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Monday, August 17, 2009

Participation in the Preconference Symposium on Patient Safety Officer
training is mandatory for those in the Patient Safety Certificate Program.

8:00 a.m. Registration Commences
Preconference Symposium Faculty:
  • Paul Barach, MD, MPH, Professor, Center for Patient Safety, University of Utrecht, Netherlands, and Associate Professor, University of South Florida, Sydney, Australia (Co chair)
  • Julie K. Johnson, MSPH, PhD, Associate Professor and Deputy Director, Centre for Clinical Governance Research, Faculty of Medicine, University of New South Wales, Sydney, Australia (Co chair)
  • Davis Balestracci, MS, Principal, Harmony Consulting, LLC, Portland, ME
  • Gwen Sherwood, PhD, RN, FAAN, Professor and Associate Dean for Academic Affairs, School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC
Presentation Material (Acrobat)
9:00 a.m. Welcome and Introduction
Paul Barach, MD, MPH (Co chair)
9:15 a.m. Mental Models and Framing of Safety and Quality
Julie K. Johnson, MSPH, PhD (Co chair)
9:30 a.m. Small Group Discussion about the 5 Pre-Conference Questions
  • What are the most important patient safety issues facing your institution?
  • How does the culture of your institution affect your ability to implement change?
  • What are 3 patient safety initiatives that you've read about, heard about, or seen that you believe will make an impact in your institution?
  • What are 3 patient safety initiatives you would like to implement in the next year?
  • Describe the composition of the team that will be necessary to accomplish each of those initiatives in your institution.
Handout Material (Acrobat)
9:45 a.m. Debriefing from Small Group Discussion
Gwen Sherwood, PhD, RN, FAAN
10:00 a.m. The Patient Safety Core Curriculum and Introduction to Lewis Blackman Story
Paul Barach

Handout Material (Acrobat)
10:15 a.m. Break
10:45 a.m. Small Group Discussion of Lewis' Story (a Pre-Analysis)
11:15 a.m. Debriefing from Small Group Discussion: How Are We Thinking about Safety Now?
Julie K. Johnson
11:30 a.m. Lunch on Your Own
1:00 p.m. Data "Insanity": The Silent Improvement Killer -- Part 1
Davis Balestracci
  • Systems and Processes
  • The "assumptions" they never tell you about...that invalidate most of the statistics you've learned!
  • Process-oriented thinking
  • Are you using special cause strategies?
  • "Plot the dots!" -- Run charts and analysis
  • What are the common cause strategies?
  • What would you do with data like this now?
Presentation Material (Acrobat)
1:30 p.m. Engaging Leaders -- From Turf Wars to Appreciative Inquiry, Principles of Leadership for Quality and Safety
Gwen Sherwood
2:00 p.m. Small Group Exercise

Gwen Sherwood
2:15 p.m. Debriefing from Small Group Exercise
2:30 p.m. Group Discussion
Davis Balestracci and Paul Barach
  • How does your organization react to, report, and analyze "incidents?"
  • Have you ever considered "safety" in a process-oriented context?
  • Have you, with the best of intentions, been using "special cause" strategies?
  • Could you "plot the dots" to see whether you have been successful?
  • Does this material suggest situations in your organizations that might respond better to "common cause" strategies?
3:00 p.m. Break
3:30 p.m. Data "Insanity": The Silent Improvement Killer -- Part 2
Davis Balestracci
  • Eradicating the myth of "trends"
  • Quick review of common cause strategy: Clearing up a common misconception
  • "Owning" the "Learning and Growth" sub-business of your organization
  • Statistics in a quality improvement perspective
Presentation Material (Acrobat)
4:00 p.m. Final Discussion about the Lewis Blackman Story
Paul Barach and Julie Johnson
  • What have we learned, how would we approach our analysis differently?
  • Facilitated Group Discussion (Topics to consider: disclosure, leadership, qualitative methods for learning about safety)
4:15 p.m. Real World Dilemmas in Quality and Safety
Participants and Faculty
  • What are the day-to-day issues that members of the audience face?
  • What are the strategies for addressing them?
4:30 p.m. Concluding Comments, Questions and Post-Colloquium Examination Logistics
5:00 p.m. Adjournment

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