moments - Institute for Healthcare Improvement

www.IHI.org/IHIForum 

DEFINING 

moments 

24TH ANNUAL 

national forum 

ON QUALITY IMPROVEMENT 

IN HEALTH CARE 

DECEMBER 9-12 

2012 

ORLANDO, FL

Health Plans Health Systems 

Hospitals 

Physician Practice 

Your healthcare organization is unique. 

At JKA we take the time to understand your goals, 

culture and capabilities. 

JKA 

Customized Lean Healthcare Solutions 

Booth # 816 

Aligned with your needs 

Quality Outcomes Lower Cost 

Increased Value Patient Satisfaction 

Consistent with your organization’s 

Leadership Team Business Objectives 

Culture Existing Capabilities 

www.johnkimconsulting.com

TABLE OF 

contents 

dear colleagues, 

Pg 

Event 

2 Agenda-at-a-Glance 

4 Keynotes 

5 Special Interest Keynotes 

12/09 sunday 

6 Learning Labs 

10 International Attendee Meeting 

12/10 monday 

11 Forum Excursions 

12 Virtual Site Visits 

13 Minicourses 

13 Scientific Symposium 

18 Welcome Reception 

18 Student and Faculty Reception 

12/11 tuesday 

20 Keynote One: Maureen Bisognano 

20 Workshops A and B 

25 Workshop C 

25 Keynote Two: Anna Deavere Smith 

19 Storyboard Reception 

19 Dine Arounds 

19 Forum After Dark 

12/12 wednesday 

31 Special Interest Breakfasts 

30 Keynote Three: Dan Heath 

30 Workshops D and E 

34 Keynote Four: Dr. Donald Berwick 

17 IHI Forum App Instructions 

36 Index by Tracks 

38 Conference Map 

40 Index by Presenter 

44 Storyboards 

52 Exhibit Hall Floor Plan 

54 Shuttle Map 

55 Conference Information 

56 Continuing Education 

56 Post-Conference Recordings 

58 Exhibitors 

I’m so thrilled to be here in Orlando this week with all of you. I hope you are as excited as I 

am for the next several days of learning, connecting, re-connecting, and sharing. All of us at 

IHI expect each National Forum to be better than the last, and yet each year it’s even better 

than we imagined. That, of course, is due to you. The growing community of improvers – 

clinicians, patients, executives, managers, and more – who gather here this week are changing 

health care…transforming it into a true health system that improves the quality of care, 

improves the health of individuals and populations, and eases the burden of costs. The pace 

of the Forum can be dizzying, but I urge all of you to pause, just for a few moments, and 

appreciate what you and your colleagues are doing for each other, and for patients everywhere. 

I have never been more proud to be part of this incredible team. 

The theme of this year’s National Forum is “Defining Moments.” My career in health care 

and improvement has been full of these moments, but I can’t remember having so many in 

just one year. Some of these moments have been big. The Supreme Court’s ruling on the 

Affordable Care Act and the US Presidential Election were shared, national events. Other 

moments, though, are smaller – not always the stuff of headlines, but no less impactful. It’s 

the Board meeting that’s transformed by a patient’s story. It’s the pharmacy developing a 

simple new protocol that eliminates errors and prevents harm. It’s the ICU team celebrating 

a year without a single central line infection. Every week, every day in fact, I see, or hear, 

or read about innovative ways to care and heal. Health care is no longer constrained by its 

walls. We’re out in our communities now – engaging everyone who shares our mission to 

improve health. We’re creating new linkages, new structures, new ways to work together. 

It’s happening all over the world, in big cities, small towns, and rural villages. These smaller 

defining moments build on each other, increasing confidence in what is possible, and 

accelerating the pace of change. 

IHI has had its own share of defining moments in 2012. Our Open School for Health 

Professions reached a major milestone: over 100,000 students and residents engaged in 

learning about improvement worldwide. With Ellen Goodman, the Pulitzer Prize-winning 

journalist, we launched The Conversation Project, a crucial initiative that is already changing 

the discussion, large and small, about how we die. Our partners in Scotland have shown 

that it is possible to change an entire country, significantly reducing mortality and harm 

nationwide. We collaborated on two new Forums – one in Cartagena, Colombia, for the 

Latin American region, and one in Auckland, New Zealand, for the Asia Pacific region. 

Here at the National Forum you’ll get to learn about all of these, and you’ll be inspired by 

the incredible people and teams who made these moments possible. 

We have an old Irish adage written on a wall back in our Cambridge office. It says, “When 

you come upon a wall, throw your hat over it, and then go get your hat.” Defining moments 

in health care are so often about climbing over walls, overcoming barriers, crossing divides, 

leaving old assumptions behind and moving forward to a new and better future. That’s what 

this week is about. Welcome to the 24th Annual National Forum. Let’s go get our hats! 

Sincerely, 

Maureen Bisognano 

President and CEO, Institute for Healthcare Improvement 

Welcome! Tweet using #IHI24Forum 

1

forum agenda 

7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 

PRE-CONFERENCE 

sunday 

12/09 

7:00 AM – 5:30 PM Registration Open Convention Center Entrance 

11:00 AM –12:00 PM 

National Forum 

Orientation 

Grand Ballroom, 

Salon 7 


monday 

12/10 


7:00 AM – 8:00 AM 


Orientation 

and Continental 

Breakfast* 


Salon 7 

8:30 AM – 4:00 PM Minicourses (lunch provided) 

8:30 AM – 4:30 PM Scientific Symposium (lunch provided) at the G Gaylord Palms Resort 

8:30 AM – 4:30 PM Virtual Site Visits (lunch provided) 

8:30 AM – 5:00 PM Forum Excursions (lunch provided) departing from the G Gaylord Palms 

* breakfast provided for Minicourse, Virtual Site Visit, Forum Excursion, 

and Scientific Symposium attendees 

CONFERENCE DAY 1 

tuesday 

12/11 


7:00 AM – 8:00 AM 


Orientation 

and Continental 

Breakfast 


Salon 7 

7:00 AM – 7:45 AM 

Partnership for 

Patients HEN 

Breakfast 

Crystal Ballroom, 

Salon D 

8:00 AM – 9:00 AM 

Keynote One: 


Cypress Ballroom 3 

9:30 AM – 2:45 PM CEO and Leadership Summit Grand Ballroom 8 

9:30 AM – 10:45 AM 

Workshop A 

10:45 AM – 2:00 PM Exhibit Hall Open 

11:15 AM – 12:30 PM 

Workshop B 

(repeat of A workshops) 


wednesday 

12/12 


7:00 AM – 8:00 AM 

Continental 

Breakfast 

7:00 AM – 

7:45 AM 

Special Interest 

Breakfasts 

8:00 AM – 9:00 AM 

Keynote Three: 

Dan Heath 


9:30 AM – 10:45 AM 

Workshop D 

10:45 AM – 2:00 PM Exhibit Hall Open 

11:15 AM – 12:30 PM 

Workshop E 

(repeat of D workshops) 

2 

24th Annual National Forum on Quality Improvement in Health Care

1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 

1:00 PM – 4:30 PM 

Learning Labs 

5:00 PM – 7:00 PM 

International Attendees Meeting 

Crystal Ballroom, Salon D 

and Convention Center Osceola C 

Resort and Convention Center 

3:30 PM – 6:30 PM Exhibit Hall Open Palms Ballroom 

4:30 PM – 7:30 PM 5th Annual Open School Chapter Congress 

sponsored by Kaiser Permanente 

G Gaylord Palms Resort, Sun Ballroom C 

3:30 PM – 6:30 PM Welcome Reception Palms Ballroom 

7:00 PM – 9:00 PM 

Faculty and Student 

Reception 

G Gaylord Palms, 

Emerald Bay Plaza 

4:30 PM – 6:30 PM Exhibit Hall Open 

Palms Ballroom 


12:30 PM – 

1:30 PM 

Lunch 

12:45 PM – 1:20 PM 

Social Media 

Lunch n’ Learn 

Crystal Ballroom 

Salon H 

1:30 PM – 2:45 PM 

Workshop C 

1:00 – 4:30 PM 

Picker Institute Special Session on 

Advancing Patient-Centered Care 

Crystal Ballroom, Salon H 

3:15 PM – 4:15 PM 

Keynote Two: 

Anna Deavere 

Smith 


4:30 PM – 6:30 PM 

Storyboard Reception 


6:00 PM – 8:00 PM 

Dine Arounds 

G Gaylord Palms Resort and 

Convention Center 

7:00 PM – 10:00 PM 

Forum After Dark 

Solaris Deck 


stay CONNECTED 

12:30 PM – 

1:30 PM 

Lunch 

1:30 PM – 2:30 PM 

Keynote Four: 

Dr. Donald Berwick 


Stay connected with IHI and your fellow National Forum attendees! 

Use the hashtag #IHI24Forum when tweeting. Be sure to follow IHI on 

Twitter, Facebook, and LinkedIn. 

Welcome! Tweet your Forum thoughts using #IHI24Forum 

3

KEYNOTES 

Keynote One: Maureen Bisognano 

Tuesday, December 11 • 8:00 AM – 9:00 AM 


Maureen Bisognano, President and CEO, 

Institute for Healthcare Improvement (IHI), is 

a prominent authority on improving health care 

systems, whose expertise has been recognized 

by her elected membership to the Institute of 

Medicine and by her appointment to The 

Commonwealth Fund’s Commission on a High 

Performance Health System, among other 

distinctions. Ms. Bisognano advises health care leaders around the 

world, is a frequent speaker at major health care conferences on quality 

improvement, and is a tireless advocate for change. She is also an 

Instructor of Medicine at Harvard Medical School and a Research 

Associate in the Brigham and Women’s Hospital Division of Social 

Medicine and Health Inequalities. Prior to joining IHI, she served 

as CEO of the Massachusetts Respiratory Hospital and Senior Vice 

President of the Juran Institute. 

Keynote Two: Anna Deavere Smith 

Tuesday, December 11 • 3:15 PM – 4:15 PM 


Anna Deavere Smith is an actress, playwright, 

and professor. Her work in the theater explores 

American character. She has won numerous 

awards, among them two Obies, two Tony 

nominations, and a MacArthur Fellowship. She 

is University Professor at New York University, 

appointed at the Tisch School of the Arts. You 

may recognize her as Nancy McNally, National 

Security Adviser on The West Wing, or as Gloria Akalitus on 

Showtime’s Nurse Jackie. Ms. Smith is said to have created a new 

form of theater in which she combines the journalistic technique of 

interviewing a diverse array of people with the art of interpreting 

their words for performance. The New York Times wrote that she 

is “the ultimate impressionist—she does people’s souls.” Her most 

recent play, Let Me Down Easy, tells the human side of the health 

care story in the United States. Ms. Smith has served as Artist-in- 

Residence in a variety of organizations, from MTV Networks to 

Grace Cathedral in San Francisco. The author of the books Letters to 

a Young Artist and Talk to Me, she has also written numerous essays 

and articles and serves on the board of the Museum of Modern Art 

and the Aspen Institute. She is founding director of Anna Deavere 

Smith Works, a nonprofit that convenes artists from around the 

world who combine artistic excellence with works that address the 

world’s most pressing problems. 

Keynote Three: Dan Heath 

Wednesday, December 12 • 8:00 AM – 9:00 AM 


Dan Heath is a Senior Fellow at Duke University’s 

CASE center, which supports entrepreneurs who 

are fighting for social good. He is the co-author 

of Switch: How to Change Things When Change Is 

Hard, which debuted at #1 on the New York Times 

and Wall Street Journal bestseller lists. The Heath 

brothers previously co-wrote the critically 

acclaimed book Made to Stick, which was named 

the Best Business Book of the Year and spent 24 months on the 

BusinessWeek bestseller list. Heath is a columnist for Fast Company 

magazine, and he has taught and consulted with organizations such as 

Microsoft, Philips, Vanguard, Macy’s, USAID, and the American Heart 

Association. Previously, Dan worked as a researcher and case writer 

for Harvard Business School, co- authoring 10 case studies on 

entrepreneurial ventures, and later served as a Consultant to the 

Policy Programs of the Aspen Institute. In 1997, Dan co-founded an 

innovative publishing company called Thinkwell, which continues to 

produce a radically reinvented line of college textbooks. 

Keynote Four: Donald M. Berwick 

Wednesday, December 12 • 1:30 PM – 2:30 PM 


Donald Berwick, MD, MPP, is the former 

President and CEO of the Institute for Healthcare 

Improvement, which he co-founded and led for 

over 20 years. In July 2010, President Obama 

appointed Dr. Berwick to the position of 

Administrator of the Centers for Medicare 

& Medicaid Services, a position he held until 

December 2011. A pediatrician by background, 

Dr. Berwick has served on the faculties of the Harvard Medical 

School and the Harvard School of Public Health and on the staffs 

of Boston’s Children’s Hospital Medical Center, Massachusetts 

General Hospital, and Brigham and Women’s Hospital. He has also 

served as Vice Chair of the US Preventive Services Task Force, the 

first “Independent Member” of the American Hospital Association 

Board of Trustees, and chair of the National Advisory Council of the 

Agency for Healthcare Research and Quality. He served two terms 

on the governing council of the Institute of Medicine, was a member 

of the IOM’s Global Health Board, and served on President Clinton’s 

Advisory Commission on Consumer Protection and Quality in the 

Healthcare Industry. Recognized as a leading authority, Dr. Berwick 

has received numerous awards for his contributions to health care 

quality and improvement. In 2005 he was appointed Honorary 

Knight Commander of the British Empire by the Queen of England 

in recognition of his work with the British National Health Service. 

Dr. Berwick is the author or co-author of four books and over 150 

scientific articles. 

4 


special interest keynotes 

workshop 

TRACKS 

A1: The Wisconsin Story 

Tuesday, December 11 • 9:30 AM – 10:45 AM 

Cypress Ballroom 3 • Sponsored by Picker Institute 

Leonard Berry, PhD, Distinguished Professor of Marketing, 

Texas A&M University, moderates a panel that includes: 

• George Kerwin, President and CEO, Bellin Health 

• Randy Linton, MD, President and CEO, Mayo Clinic Health System 

• Dean Gruner, MD, President and CEO, ThedaCare 

• Jeffrey Thompson, MD, CEO, Gundersen Lutheran Medical Center 

B1: Ensuring Equity in the Health Care Workforce 

Tuesday, December 11 • 11:15 AM – 12:30 PM 


Brian Smedley, MD, Vice President and Director, Health Policy 

Institute of the Joint Center for Political and Economic Studies 

C1: Minimally Disruptive Medicine 

Tuesday, December 11 • 1:30 PM – 2:45 PM 


Victor Montori, MD, Director, Mayo Clinic Healthcare Delivery 

Research Program and Professor of Medicine, Mayo Clinic 

D1: The Conversation Project 



Ellen Goodman, Pulitzer Prize–winning Journalist and Founder, 

The Conversation Project 

E1: The Role of Health Care in Reducing Health Disparities 

Wednesday, December 12 • 11:15 AM – 12:30 PM 


David Satcher, MD, PhD, Director, Satcher Health Leadership Institute and 

Center of Excellence on Health Disparities, Morehouse School of Medicine 

Seventy-five workshops are offered 

during the General Conference 

(December 11 and 12). The sessions 

are organized into content areas—or 

“tracks”—that follow IHI’s five strategic 

pillars. Participants can enroll in 

sessions individually or follow one of 

these strategic tracks: 

Tracks 

• Innovate 

• Raise Joy in Work 

• Motivate 

• Get Results 

• Stay Vital for the Long Haul 

Session Levels at a Glance 

The General Conference offers 

workshops for various levels of learning. 

Sessions are sorted by experience 

level throughout this guide. 

F Fundamentals Program: 

This series of sessions offers helpful 

ideas and tools for newcomers to the 

world of quality improvement. 

M Masters Program: 

For the advanced learner, this series 

of sessions provides cutting-edge 

improvement thinking from health care 

and other industries. 

S Student Program: 

Selected across a wide spectrum of topics 

and disciplines, these sessions will 

accelerate the capacity for improvement 

of health professions students who are 

new to quality improvement or new to 

the National Forum. 

P Patient Presenters: 

The sessions designated with a “P” will 

have a patient presenting as faculty. 

C Partnership for Patients: 

The sessions designated with a “C” align 

with the CMS Partnership for Patients 

initiative. 

Welcome! Tweet your Forum thoughts using #IHI24Forum 

5


sunday 

DECEMBER 9 

NATIONAL FORUM ORIENTATION 

11:00 AM – 12:00 PM 

Grand Ballroom Salon 7 

If you are new to the National Forum, we 

suggest that you attend one of the National 

Forum orientation sessions to help you 

navigate through the program and devise a 

personal learning plan. Participation in the 

National Forum orientation is free. 

LEARNING LABS 

1:00 PM – 4:30 PM 

Learning Labs offer specific “how-to” 

improvement information. These half-day 

sessions allow full engagement, discussion, 

and ample time for Q&A. 

innovate 

L1: Beacon Breakthroughs: Using Technology 

as a Driver of Innovation 

Grand Ballroom Salon 4-6 

This session will provide participants with a toolkit 

for optimizing technology in initiatives focused 

on transforming the health care system. Lessons 

from the Beacon will be presented, including 

workflow tools and guiding documents. The 

patient’s journey through the health care system 

will be explored with a focus on the key tools 

and resources necessary to enable technology to 

support emerging new care models. 

After this session, participants will be able to: 

• Describe how technology enhancements can 

lead to better patient-centered primary care 

models 

• Apply technology-based tools and resources to 

smooth the patient’s journey through the health 

care system 

Brammer, C., Senior Research Associate, University 

of Cincinnati; Kirtane, J., Director of Clinical 

Transformation, Beacon Community, Office of the 

National Coordinator; Chaufournier, R., President 

and CEO, CSI Solutions, LLC; Beasley, C., Executive 

Director, Strategic Projects, IHI 

L2: Home Health and Hospitals—Safe 

Transitions for Patients in the First 48 Hours 

Grand Cayman / Puerto Rico 

This interactive session will focus on the 

connections between the hospital and home 

health care that are necessary to support the 

smooth transition of patients and reduce 

unnecessary readmissions. Participants will 

learn about process changes used in successful 

transitions into home health care and will leave 

with practical steps they can test. 


• List process changes that support a smooth 

transition from the hospital to home health care 

• Describe characteristics of successful hospital 

and home health care partnerships 

• Identify three tests of change to improve 

transitions from the hospital 

Sevin, C., RN, Director, IHI; Sobolewski, S., RN, 

Director of Practice Improvement, Visiting Nurse 

Service of New York; Evdokimoff, M., RN, PhD, 

Consultant, M&J Associates 

L3: Unleashed, Unlocked, and Uninhibited: 

Connecting and Creating 101 F 

Crystal Ballroom Salon A-C 

Why is connecting so important? How do we 

loosen the built-in constraints on our expert 

minds? And what the heck is liberating about 

improv? This Learning Lab will focus on the 

award-winning techniques of the Innovation 

Learning Network and Kaiser Permanente’s 

Innovation Consultancy. Come play! 


• Identify key elements of smart networking 

and creativity 

• Explore several innovation techniques to 

increase the creativity of improvement projects 

McCarthy, C., Director, Innovation Learning Network, 

Kaiser Permanente; Lawson, T., Lead Designer, 

Innovation Learning Network, Kaiser Permanente 

L4: SCF Nuka System of Care: Improved 

Overall Outcomes 


Find out why many national and international 

medical systems are now looking to the 

Southcentral Foundation (SCF) Nuka System of 

Care as a way to transform a whole system of care. 

A foundation of long-term personal relationships 

backed by full open access, integration of the 

mind and body, commitment to measurement 

and quality, and a transfer of power and control to 

the patient and family has resulted in sustained, 

dramatic, documented improvements over 12 

years. The use of ER and specialty care has been 

cut in half, hospital days have dropped by over 

40%, and health outcomes as well as customer and 

staff satisfaction have dramatically improved. This 

Learning Lab will describe the SCF Nuka System 

of Care, present the ongoing story of whole-system 

transformation at Alaska Native Medical Center 

using the model, and address the model’s 

applicability to other settings. 


• Describe the SCF Nuka System of Care and 

the elements that are key to transforming a 

whole system of care 

• Articulate what a mature improvement 

infrastructure looks like after 12 years 

• Consider how the SCF Nuka System of Care 

might be applied in their setting 

Gottlieb, K., President and CEO, Southcentral 

Foundation; Eby, D., MD, Vice President of Medical 

Services, Southcentral Foundation 

L5: The Role of Multi-Specialty Maintenance 

of Certification (MOC) in Physician Quality 

Improvement Involvement M 

Crystal Ballroom Salon P-Q 

Through the Multi-Specialty MOC Portfolio 

Approval Program, board-certified physicians 

can receive MOC Part IV credit for quality 

improvement (QI) efforts they are leading or 

participating in under the supervision of an 

approved organization. This workshop will 

explore the process of engaging physicians in 

QI through the experience of several portfolio 

sponsors and describe how organizations interested 

in participating in this program can apply. 


• Provide an overview of the Multi-Specialty 

MOC Portfolio Approval Program 

• Describe the impact of the program on quality 

of care, satisfaction, and safety in a hospital 

setting 

• Recount the experiences of several organizations 

participating in the program and their 

improvements 

Graves, K., Program Manager, American Board of 

Family Medicine; Siemons, D., RN, Director, Quality 

Improvement and Clinical Outcomes, Advocate Health 

Care; Rao, S., MD, Associate Medical Director for 

Quality Improvement, Massachusetts General Hospital; 

Kowalenko, T., MD, Physician and Director of 

Continuous Professional Development, University of 

Michigan Health System; Price, D., MD, Director, 

Medical Education, The Permanente Federation; 

Harrison, R., PhD, Professor, University of Michigan 

Medical School; Bardfield, J., Program Communications 

Manager, New York State Department of Health; Brilli, 

R., MD, Chief Medical Officer, Nationwide Children’s 

Hospital; Elward, K., MD, Medical Director, Quality 

Initiatives, Medical Society of Virginia Foundation; 

Nowicki, K., Administrator, Mayo Clinic 

raise joy in work 

L6: Conversations That Promote 

Transformation 

Crystal Ballroom Salon J 

What types of conversations promote 

transformational change? This question will be 

explored in a case study of CareSouth, which 

achieved significant improvements in quality, 

financial, workforce, and patient experience 

measures after integrating leading, managing, and 

coaching conversations into day-to-day work. 

This Learning Lab will also explore how these 

conversations relate to components of a 

6 


transformational leadership model. Participants 

will think through the potential barriers and 

challenges to applying a similar model in their 

organizations. 


• Explain the CareSouth definitions of leading, 

managing, and coaching conversations 

• Compare CareSouth conversations to the components 

of a transformational leadership model 

• Use selected tools to facilitate conversations like 

those at CareSouth 

Lewis, A., CEO, CareSouth Carolina, Inc.; Baker, N., 

MD, Principal, Neil Baker Coaching and Consulting, LLC; 

Crowe, G., RN, Principal, Hamilton Consulting, LLC 

L7: Learning from Patient Stories to 

Improve Care F P 


Stories have the power to teach, convey culture, 

and make connections. This session will present 

an international project on collecting stories— 

specifically on errors that led to preventable 

harm—from the perspectives of the patient and 

family. Faculty will discuss patient case studies 

and view supplemental videos of the patient 

and family story. Faculty will guide participants 

through a structured analysis of selected cases of 

preventable harm, eliciting lessons and strategies 

for preventing such events. 


• Identify strategies to engage patients and 

families in creating solutions to address 

medical harm 

• Practice an approach to analyzing a patient 

safety event, building on the viewpoints of 

patients and families 

• Disseminate several patient empowerment 

tools related to improving the safety and quality 

of health care 

Johnson, J., PhD, Associate Professor and Deputy 

Director, University of New South Wales; Barach, 

P., MD, Professor (Level II), University of Stavanger; 

Haskell, H., President, Mothers Against Medical Error 

(MAME), and IHI Board Member 

L8: The EBAN Experience: An Equitable 

Health Collaborative 

Key West 

In a yearlong quality improvement (QI) 

collaborative, 100 ethnic community members 

and health professionals, divided into nine teams, 

improved outcomes for preventive services. 

Together they learned QI, explored the influence 

of culture on health, and redesigned care according 

to cultural preferences. Three screenplays were 

commissioned from ethnic screenwriters, filmed 

by public television, and used to stimulate 

intercultural discussion and understanding. This 

collaboration improved the experience and health 

of patients of color and created new relationships 

between individuals and their communities. 


• Develop a basic structure for a collaborative 

that engages community members in addressing 

health disparities 

• Discuss the importance of using stories to 

stimulate discussion and understanding of 

cultural preferences in health care 

• Identify the challenges as well as the 

opportunities when community members 

partner with community organizations to 

address health disparities 

Patow, C., MD, Executive Director, HealthPartners; 

Bryan, D., Director, Collaborative Learning Programs, 

HealthPartners 

L9: Innovation via Partnering with Patients P 

Vinoy 

To achieve the Triple Aim, innovative pathways 

beyond a single organization’s boundaries must be 

taken. The successful journey requires new levels 

of partnership between community members, 

patients, and clinicians. This collaborative learning 

session will explore powerful examples of innovative 

partnerships, including patient innovators, The 

Conversation Project, and an IHI Triple Aim 

site. It will also equip participants with creative 

tools, links to other people committed to personcentered 

care, and practices to achieve results 

through partnerships. 


• Describe three examples of innovative, 

person-centered partnerships 

• Identify two tools to understand and partner 

with people across health care 

• Take concrete actions to achieve 

community-wide partnerships beyond 

organizational boundaries 

Balik, B., RN, Senior Faculty, IHI and Consultant, 

Common Fire Healthcare Consulting; Hayward, M., 

Lead, Public and Patient Engagement, IHI; Webster, P., 

Improvement Advisor and Faculty, IHI 

motivate 

L10: Back to Basics: Building Essential 

QI Skills F 


So you can explain what the letters PDSA mean? 

Great! But can you run multiple PDSA tests in one 

day, recognize when a change concept is ready for 

implementation, and then sustain the improvements? 

This workshop will provide a refresher in 

Plan-Do-Study-Act for those who are stalled and 

a jump-start for those who are new to the quality 

improvement journey. Built around the Model 

for Improvement (MFI), this session will 

demonstrate how to link the three questions 

related to aim, measurement, and change concepts 

to the sequence for success. 


• Provide an overview of the MFI 

• Specify the differences between testing, 

implementing, and spreading 

• Identify key concepts and tools that should be 

part of their QI toolkit 

Lloyd, R., PhD, Executive Director, Performance 

Improvement, IHI; Taylor, J., Improvement Advisor, IHI 

L11: Dutch Health Care: Successful 

Integration Nationwide 

Sawgrass 

In the Netherlands, where professionals, patients, 

hospitals, insurers, and the health care inspectorate 

have joined forces in an integrated approach to 

improving health care, clinical auditing has become 

the cornerstone for robust, valid, and widely 

accepted quality information. Combined with 

consumer quality indices, patient-related outcome 

measurements, and financial information, these 

audits provide all stakeholders with essential 

information for organizational strategies and 

transparency. In this Learning Lab, the Dutch 

successes and struggles in improving health care 

will be analyzed and instruments for initiating 

change on a nationwide scale will be presented. 


• Build a team of stakeholders to work on 

systemwide improvement 

• Summarize the experience of teams in the 

Netherlands working on large-scale quality 

improvement 

Eddes, E., PhD, Gastrointestinal Surgeon, Dutch 

Institute for Clinical Auditing; Wouters, M., MD, 

Surgical Oncologist, Dutch Institute for Clinical 

Auditing; Schellekens, W., MD, Chief Inspector, 

Curative Health Care, Dutch Healthcare Inspectorate; 

Tollenaar, R., MD, PhD, Professor of Surgical 

Oncology, Leiden University Hospital 

L12: Improvement as an Everyday 

Leadership Philosophy 

Crystal Ballroom Salon H 

W.E. Deming’s teachings weren’t about statistics 

but about leadership. Key to these teachings is 

the understanding of variation to create work 

cultures dedicated to continual improvement, and 

the universal major waste of inappropriate data 

use. This Learning Lab will teach an elegantly 

simple approach to everyday data and the cultural 

psychology needed to lead effectively. 


• Identify process-oriented thinking as the key to 

overall organizational improvement 

• Describe two key data tools that could save up 

to 50% of executive time in meetings and at least 

one hour a day of middle management time 

• Explain several leadership mantras and simple 

tools for more effectively applying this 

leadership philosophy 

Balestracci, D., Statistician and Quality Improvement 

Specialist, Harmony Consulting, LLC 

How is your Learning Lab? Tweet your thoughts using #IHI24Forum 

7


sunday 

DECEMBER 9 

L13: Preparing Your Improvement Work 

for Publication 

Chicago/Denver 

This session will sharpen participants’ skills in 

advancing health care improvement reports 

toward scholarly publication. Working from real 

studies, participants will employ the SQUIRE 1.0 

publication guidelines in hands-on writing exercises 

to communicate key items such as improvement 

and study aims, context, results, and limitations. 

Faculty will offer timely updates on health care 

improvement science, strategies to use before the 

institutional review board (IRB), and the rigorous 

use of qualitative methods in improvement work. 

Input from participants will aid development of 

SQUIRE 2.0, the revision of these publication 

guidelines. 


• Employ writing techniques that are particularly 

applicable to scholarly improvement reports 

• Use the SQUIRE guidelines to achieve greater 

success in publication 

• Sharpen their writing skills 

Stevens, D., MD, Editor Emeritus, BMJ Quality and 

Safety, and The Dartmouth Institute; Batalden, P., MD, 

Professor, The Dartmouth Institute; Davidoff, F., MD, 

Executive Editor, IHI; Davies, L., MD, Assistant 

Professor of Surgery, Dartmouth Medical School; Ogrinc, 

G., MD, Associate Professor of Community and Family 

Medicine, White River Junction VA Medical Center 

L14: The Behavioral Health Side of Health 

Improvement M 

New York/New Orleans 

Although, as the US Surgeon General’s report 

on mental health puts it, “we cannot be healthy 

without mental health,” only 37.9% of adults with 

mental illness, according to a 2010 national survey, 

received care. The majority of people with mental 

illness seek care with primary care providers. This 

session will describe the increases in avoidable 

health care costs driven by mental illness and 

substance use disorders and explore the 

integration of mental health and substance 

use into primary health care to achieve true 

health improvement. 


• Identify why the integration of mental health 

and substance use into primary care is crucial to 

the success of health care improvement 

• Use pharmaco-practice algorithms to educate 

both primary health and mental health 

clinicians on effective management of patients 

with co-morbid conditions 

• Develop ways to improve health quality and 

outcomes through integrated care practice 

models 

Okafor, M., PhD, Director, Division of Behavioral 

Health, and Project Director, Satcher Health Leadership 

Institute; Wrenn, G., MD, Associate Project Director, 

Morehouse School of Medicine; Frye, L., MD, Instructor 

of Clinical Psychiatry, Morehouse School of Medicine 

L15: Top-Down vs. Bottom-Up Leadership M 

Crystal Ballroom Salon N 

Deming defined “fundamental knowledge” in terms 

of the difference that exists between theory and 

reality. Theory is always a simplifying abstraction. 

Reality lurks in the ugly details of front-line work 

processes. As a result, the only person who truly 

knows how a process operates is someone who 

regularly performs it. The person best positioned 

for process management and improvement is 

that front-line worker. While the concept of 

fundamental knowledge is central to the effective 

operation of any improvement team, it arguably 

achieves its most effective form in “100% 

participation models.” 100% participation is 

one of the 3 legs of Lean. This Learning Lab 

will discuss the factors that distinguish quality 

leadership, built on fundamental knowledge, from 

common management. 


• Explain the benefits of the 100% leadership 

model 

• Describe the evidence underlying reward and 

recognition systems for quality performance 

James, B., MD, Chief Quality Officer, Institute for 

Healthcare Delivery Research, Intermountain 

Healthcare, and IHI Board Member 

L16: Understanding Patient Medication 

Adherence 

Aruba/Bahamas 

Lack of medication adherence contributes to 

ineffective treatments, admissions and readmissions, 

and increased costs, but the problem continues in 

spite of the many existing approaches to improving 

adherence. In this Learning Lab, participants 

will learn about recent research and different 

techniques to motivate patients to adhere to 

medication regimens. 


• List reasons why patients do not adhere to 

medication regimens 

• Describe methods to motivate patients to 

adhere to medication regimens 

• Discuss the morbidity and costs associated with 

poor adherence to medication treatment plans 

Federico, F., RPh, Executive Director, Strategic Partners, 

IHI; Oyekan, E., PharmD, Pharmacy Quality and 

Medication Safety Leader, Kaiser Permanente National 

Offices 

L17: Using Diagnostic Tools for 

Patient Safety C 

Harbor Beach 

Many organizations have invested in safety and 

quality improvements, yet patients regularly 

continue to be harmed. Might it be that we do 

not fully understand the problem we are trying to 

fix? To succeed, improvement efforts must begin 

with the correct diagnosis of the problem and the 

development of related aims. During this session, 

participants will learn how to use several tools 

that are useful in diagnosing quality and safety 

problems in organizations and setting aims for 

improvement. 


• Describe the current diagnostic approach of 

their organization 

• Discuss the use of data gained from diagnostic 

tools to prevent, detect, and mitigate harm 

to patients 

• Appraise the usefulness of the diagnostic tools 

presented in this session in their efforts to 

improve the safety and quality of their 

organization over time 

Haraden, C., PhD, Vice President, IHI; O’Connor, P., 

PhD, Deputy Chief Executive, Healthcare Improvement, 

Scotland; Jones, K., Interim Director, Safer Care and 

Improvement Capability, NHS Institute for Innovation 

and Improvement 

L18: Eliciting Resident Projects for Boards M 

Key Largo 

This session will detail the Mayo Clinic’s experience 

in using frontline defect analysis to identify, define, 

and validate resident projects in an academic 

training institution. 


• Practice a methodology that elicits, identifies, 

and validates projects for residents in academic 

training centers 

• Engage both the leadership and the front line of 

their organization in a ground-up improvement 

project 

• Use minimal data, easily collected at the front 

line, to determine the success of resident-run 

improvement projects 

Resar, R., MD, Senior Fellow, IHI; Majka, A., MD, 

Consultant, General Internal Medicine, Mayo Clinic; 

Kautz, J., MD, Fellow, Mayo Clinic 

get results 

L19: Evaluation Design Methods for Leaders 

of QI Programming M 

Crystal Ballroom Salon K-M 

Historically, quality improvement interventions 

have not been as rigorously evaluated as other 

medical scientific methods, but it is crucial that 

health system leaders and researchers discover 

whether their work has been successful before 

sharing their findings with others. The effectiveness 

of QI interventions can be evaluated through a 

broad range of methods and approaches. 

8 


This session will use a mix of presentations 

and participatory case studies to explore those 

opportunities to better evaluate our QI 

interventions and share with others what we find 

out. Participants will be encouraged to share ideas 

about their own work in this workshop. 


• Describe two methods for evaluating 

improvement work 

• Test the effectiveness of a QI intervention both 

with and without the use of comparison groups 

• Explore approaches to collecting sound data 

Barker, P., MD, MB ChB, Senior Vice President, IHI; 

Miles, P., MD, Vice President and Director of Quality 

Improvement, American Board of Pediatrics; Mate, K., 

MD, Faculty, IHI; Parry, G., PhD, Research Scientist, IHI 

L20: Improving Transitions from the Hospital 

to Community Settings C 


The transition from the hospital to the home or 

next care setting has emerged as an important 

priority in reducing avoidable rehospitalizations. 

Hospitals play an important role in designing and 

reliably implementing effective discharge processes 

to improve this transition. This session 

will highlight four research initiatives to improve 

discharge processes in hospitals and reduce 

rehospitalizations: the STAAR initiative (IHI); 

Project BOOST (Society of Hospital Medicine, 

SHM); Project RED (Agency for Healthcare 

Research and Quality, AHRQ); and the Hospital 

to Home (H2H) initiative (IHI and American 

College of Cardiology, ACC). 


• Identify promising approaches for hospital 

clinicians and staff to improve the transition 

from the hospital to post–acute care settings 

• Compare and contrast the strategies used in the 

STAAR, Project BOOST, Project RED, and 

H2H initiatives 

• Identify the common elements of these four 

initiatives 

Rutherford, P., RN, Vice President, IHI; Williams, M., 

MD, Director, Hospital Medicine, Emory Healthcare; 

Nielsen, G., Director of Learning and Innovation, Iowa 

Health System; Jack, B., MD, Professor and Vice Chair, 

Department of Family Medicine, Boston University 

School of Medicine 

L21: Managing by Prediction 


This Learning Lab builds on our previous 

teachings about the principles of high reliability, 

situational awareness, and risk mitigation, moving 

into a discussion about embedding these 

principles in the system as a whole. Highly reliable 

care depends not only on reliable processes but 

also on a system for mitigation and process 

management that includes daily huddles, other 

process interventions, and models that use timely 

data and the collective knowledge of the patient 

and the system to predict risk. In this session, 

participants will learn how to apply the theory 

of management by prediction to support their 

organization’s evolution toward high reliability 

and align improvements in patient flow, patient 

safety, and patient experience. 


• Summarize the principles of managing 

by prediction 

• Apply the theory of management by prediction 

to accelerate transformation in safety and flow 

• Define the infrastructural and operational 

requirements of managing by prediction 

Kotagal, U., Senior Vice President, Quality/ 

Transformation, and Director, Health Policy and Clinical 

Effectiveness, Cincinnati Children’s Hospital Medical 

Center; Muething, S., MD, Assistant Vice President, 

Patient Safety, Cincinnati Children’s Hospital Medical 

Center; Ryckman, F., MD, Senior Vice President for 

Medical Operations and Professor of Surgery, Cincinnati 

Children’s Hospital Medical Center; Krier, D., Vice 

President, Family Relations, Cincinnati Children’s 

Hospital Medical Center 

L22: The Right Start: Eliminate OB Adverse 

Events F C 

Miami 

It should surprise no one that an obstetrical care 

delivery system that accepts deviation from the 

best-known medicine has a national cesarean 

section rate of 33%. The system, which tolerates 

inaccurate gestational dating, supports early-term 

scheduled delivery, and makes unreliable use of 

a high-alert medication, is designed to achieve 

exactly that result. This Learning Lab will discuss 

strategies to revamp the current system, with 

input from organizations that have made positive 

changes. 


• Discuss the definition of an adverse OB event 

• Detail the evidence in support of an obstetrical 

care delivery system that focuses on getting it 

right—starting with accurate gestational dating 

• Describe solutions that support collaborative 

care, with all stakeholders having a voice 

Gullo, S., RN, Managing Director, IHI; Cherouny, P., 

MD, Emeritus Professor, Obstetrics, Gynecology, and 

Reproduction, University of Vermont; Johnson, C., RN, 

Director of Obstetrics, Woman’s Hospital 

L23: One Year of ACOs: Incentive 

Realignment and Health Improvement 

Crystal Ballroom Salon E-F 

The term “Accountable Care Organization” was 

first used by Dr. Elliott Fisher in 2006 and went 

viral soon after. Characterized by a payment and 

care delivery model that seeks to tie provider 

reimbursements to quality metrics to reduce the 

total cost of care for an assigned population of 

patients, ACOs of various types are now up and 

running. In a one year check-up, this session will 

examine the types, hype, and market reality 

of ACOs. 


• Explain the concept of the ACO in theory and 

in practice 

• Discuss the various types of ACOs in the 

market and how they are performing 

• Identify the challenges in creating a functional 

ACO 

Orlikoff, J., President, Orlikoff & Associates, Inc.; 

Nichols, L., PhD, Director, Health Policy Program, 

New America Foundation 

L24: Integration of Research and Quality 

Improvement M 


This interactive Learning Lab will show participants 

how to combine qualitative and quantitative 

research methods in quality improvement. 

Participants should come prepared to work in 

small groups on a case study (an actual project 

that integrates research and improvement). 

Faculty will frame the research questions and 

approaches, which each group will then apply to 

the case study. Faculty will also address the issues 

and challenges raised by this series of exercises. 


• Combine qualitative and quantitative research 

methods to increase the rigor of QI projects 

• Make judgments about when to use different 

research methods in quality improvement 

Provost, L., Statistician and Senior Improvement 

Advisor, Associates in Process Improvement; Power, M., 

PhD, Director, NHS Northwest; Dixon-Woods, M., 

Professor of Medical Sociology, University of Leicester 

stay vital for the long haul 

L25: Building the Health Care Commons 

in Oregon 

Anaheim 

Responding to critical cuts in Oregon’s Medicaid 

budget, Portland metro health system leaders 

formed the Tri County Medicaid Collaborative to 

develop a regional coordinated care organization, 

the legislatively mandated accountable care 

structure that integrates physical, behavioral, 

and dental Medicaid health care. This session will 

describe how the traditional payer and provider 

competitors are co-creating new regional 

governance structures, economic and payment 

models, and an integrated delivery system to 

produce better patient and population outcomes 

at significantly lower cost. 


• Demonstrate knowledge of the enabling 

governance structures that are critical for a 

community collaborative initiative focused on 

producing optimal Triple Aim outcomes in 

a region 

How is your Learning Lab? Tweet your thoughts using #IHI24Forum 

9


sunday 

DECEMBER 9 

• Determine three to six health care service 

segments in their region that need to be 

redesigned to lower costs and improve care 

• Develop an appreciation of how nontraditional 

“engagement specialist” health care workers 

enhance and provide integration within a health 

care delivery system 

Labby, D., MD, Interim Chief Medical Officer, Tri 

County Medicaid Collaborative; Ramsay, R., Director of 

Community Care Program, CareOregon 

L26: The Cost and Quality Imperative: Setting 

Up Your Organization for Success 

Crystal Ballroom Salon D 

Reducing costs while improving quality is critical 

in today’s health care environment. This session 

will focus on tools and methods that set up your 

organization to continually take costs out of your 

system. Topics include measures and metrics, 

critical success factors, partnerships between 

financial analysts and clinicians to design projects, 

and ways of ensuring that these efforts are 

sustainable. 


• Identify four elements that are critical to setting 

their organization up for long-term success in 

reducing costs and improving value 

• Develop and prioritize a portfolio of projects 

• Define three ways to develop financial models 

and set quality metrics 

Luther, K., RN, Vice President, IHI; Schilling, L., 

RN, National Vice President, Healthcare Performance 

Improvement, Kaiser Permanente; Vitolins, S., RN, 

Director of Patient Safety and Quality Improvement, 

St. Peter’s Health Partners–Troy Division; Dascher, N., 

CEO, Northeast Health 

L27: Developing Safety and Value in 

Health Care 

Marco Island 

Health services redesign is vital to meet increased 

demand and lower costs. Providers must make 

better use of resources while improving safety and 

quality. This session will introduce the concept of 

aligning safety with patient flow as an essential 

way to manage operations by decreasing variability. 

Case studies will demonstrate that balancing cost 

and quality of care improves patient safety and 

significantly reduces costs. 


• Articulate an understanding of managing 

operations by aligning safety and patient flow 

• Describe how flow and safety are linked 

• Take steps to decrease variation in the health 

care provided by their organization 

Leitch, J., Clinical Director, Quality Unit, Scottish 

Government Health Department; Lachman, P., MD, 

Associate Medical Director and Consultant in Service 

Redesign and Transformation, Great Ormond Street 

Hospital for Children NHS Trust; Litvak, E., PhD, 

President and CEO, Institute for Healthcare 

Optimization 

L28: Maximizing the Potential to Sustain 

Your Improvements F 

Crystal Ballroom Salon G 

Health care teams around the globe have achieved 

a massive amount of change, but there is evidence 

that over one-third of these improvements are 

not sustained. Lack of sustainability significantly 

reduces the level of improvement that is achievable 

and wastes precious resources. Participants in this 

session will learn how to maximize the potential 

for sustainability of their improvement efforts. 


• Identify the key factors that affect sustainability 

of improvement 

• Assess their own improvement project, 

identifying the areas most in need of action to 

increase the likelihood of sustainability 

• Implement sustainable change within their 

organization 

Maher, L., PhD, Director for Innovation and Design, 

NHS Institute for Innovation and Improvement; 

Gustafson, D., PhD, Director, Center for Health 

Enhancement Systems Studies, University of Wisconsin 

L29: When Lightning Strikes: Responding to 

Adverse Events P 


For many organizations, their worst nightmare 

is an adverse event so serious and visible that it 

threatens the reputation of the entire enterprise. 

Would you be prepared if your organization 

were struck by such an event? In this session, 

participants will hear from faculty who have 

been involved in managing crises in their own 

organizations, and they will learn best practices 

from health care and beyond. Participants will 

learn how to plan, set priorities, and act swiftly 

and transparently while engaging all internal and 

external stakeholders. 


• Assess their organization’s level of preparedness 

to handle a serious crisis 

• Articulate the necessary elements of an effective 

crisis management plan 

• Identify the key people in their organization who 

should be involved in planning and executing an 

effective crisis management plan 

Federico, F., RPh, Executive Director, Strategic Partners, 

IHI; Sadler, B., Senior Fellow, IHI; Stewart, K., 

Clinical Director, Clinical Effectiveness Unit, Royal 

College of Physicians; Nevins, S., RN, Staff Nurse, 

North Shore Medical Center 

L30: Research Done Differently: PCORI’s 

Approach to Patient-Centered Outcomes 

Research 

St. Thomas/West Indies 

The Patient-Centered Outcomes Research 

Institute (PCORI) was authorized by Congress in 

2010 to fund research designed to improve patient 

outcomes and health quality by giving patients, 

caregivers, and clinicians the information they need 

to make better-informed health care decisions. 

Participants in this Learning Lab will learn how 

PCORI is pursuing that ambitious challenge and 

how they can get involved. 


• Describe PCORI’s origin, mission, priorities, 

and research agenda 

• Define patient-centered outcomes research and 

outline its methodology 

• Identify opportunities for quality improvement 

professionals to get involved with PCORI and 

patient-centered outcomes research 

Selby, J., MD, Executive Director, PCORI 

SUNDAY special event 

international attendee meeting 

5:00 PM – 7:00 PM • Crystal Ballroom Salon D 

All National Forum attendees from outside the United States are invited to 

take advantage of this informal opportunity to network with peers who are 

working on health systems improvements around the world, and hear about 

the strategic vision and current execution of IHI’s global work. This event will 

include light snacks and a cash bar. 

10 



7:00 AM – 8:00 AM 





navigate through the program and devise a 

personal learning plan. Participation in the 

National Forum orientation is free. 

FORUM EXCURSIONS 

8:30 AM – 5:00 PM 

With the exception of the Marriott Excursion 

(FE1), all Excursions start at the Gaylord Palms 

Resort and Convention Center. Participants will 

then be transported to their selected destination 

for a three-hour tour and presentation led by 

destination staff and IHI faculty. Afterward, 

participants will explore the lessons learned 

and their applicability to health care during an 

afternoon “deep dive” led by IHI faculty. 

FE1: Marriott World Center: Large-Scale 

Operations and Flow 

Marriott World Center, Chicago/Denver 

Participants will learn how the Marriott handles 

large volumes of visitors while still managing to 

offer superb customer service in the front office, 

adhere to tight schedules in the banquet kitchen, 

run the Hawk’s Landing Golf Club, tend to every 

detail of event and convention services, and 

manage daily housekeeping operations. 


• Identify ways of managing large-scale operations 

and flow in a non‐health care industry that can 

be compared with, and applied to, their own 

work environment 

• Recognize and analyze key concepts of operations 

and flow in different industries 

• Develop ideas for improving flow in their own 


Jacobsen, D., Director, IHI; Grebe, J., Improvement 

Advisor, IHI 

FE2: Universal Orlando ® Resort: Safety 

and Reliability 

G Gaylord Palms Resort and Convention Center, 

Captiva 

Discover how Universal’s creative team produces 

impressive stunts and spectacles while ensuring 

the safety of staff and visitors. This behind-thescenes 

look at the backstage area of park attractions 

will focus on the Universal Orlando® culture of 

“safety first.” 


• Identify safety and reliability strategies in a 

non-health care industry that can be compared 

with, and applied to, their own work 

environment 

• Recognize and analyze key concepts of safety 

and reliability in various settings 

• Develop ideas for improving safety in their own 


Griffin, F., Faculty, IHI; Berry, W., MD, Surgical 

Consultant, Harvard School of Public Health 

FE3: Central Florida Zoo: Patient Care 

and Operations 

G Gaylord Palms Resort, Sun Ballroom D 

Take a behind-the-scenes tour to learn how 

experts at the Central Florida Zoo care for their 

patients—over 400 wild animals! Participants 

will learn details of the zoo’s operations, safety 

protocols (for both humans and wildlife), and 

crisis management planning. Zoo staff will also 

share their methods for caring for, feeding, and 

managing many types of animals at once. 


• Identify ways of managing large-scale 

operations and patient care in a non-health 

care industry that can be compared with, and 

applied to, their own work environment 

• Recognize and analyze key concepts of staff 

engagement and patient care in various settings 

• Develop ideas for improving organization-wide 

operations and patient care processes in their 

own work environment 

Duncan, K., RN, Faculty, IHI; Bell-Polson, D., 

Clinical Nurse Manager, Lawrence General Hospital 

FE4: SeaWorld ® : Managing Complex Systems 

G Gaylord Palms Resort, Sun Ballroom 1-2 

This popular destination creates and successfully 

manages complex processes to care for thousands 

of animals, supports its staff, and deploys animal 

rescue operations. During a special tour, 

participants will observe the throughput, training, 

safety, and innovation systems at SeaWorld®. 


• Identify different management styles for 

complex systems in a non-health care industry 

that can be compared with, and applied to, their 

own work environment 

• Recognize and analyze key concepts of complex 

system management in various settings 

• Develop ideas for system management 

improvement in their own work environment 

McCutcheon Adams, K., Director, IHI; 

Bones, K., MSW, Director, IHI 

FE5: EA (Electronic Arts) SPORTS—Tiburon: 

Innovation and Creativity 


Learn how to innovate in a fast-paced, 

ever-changing environment from leaders in the 

video game industry as they describe ways to 

foster continuous innovation and creativity in 

the workplace. Attendees will participate in 


monday 

DECEMBER 10 

EA SPORTS—Tiburon’s new product design 

processes, learn about its methods for keeping 

pace with customer preferences, and explore its 

multidisciplinary approach to moving a concept 

through the development process by engaging 

experts to work together. EA SPORTS—Tiburon 

has succeeded in an industry where constantly 

changing technology requires nonstop adaptation 

and innovation, and as such it provides many 

parallels to the challenges of keeping pace in 

health care and remaining on the cusp of 

innovation and design. 


• Identify features of innovation and creativity 

in a non–health care industry that can be 

compared with, and applied to, their own 


• Recognize and analyze key concepts of 

innovation and creativity in various settings 

• Develop ideas for improving innovation and 

creativity in their own work environment 

Kabcenell, A., RN, Vice President, IHI; Wetherhold, J., 

Research and Development Manager, IHI 

FE6: Gaylord Palms: Joy in Work and Staffing 

Best Practices 


Customer satisfaction starts with staff satisfaction 

at this large hotel and convention center. In 

studying how the Gaylord Palms handles staffing 

assignments, manages unprofessional behavior, 

and keeps employee attrition rates lower than the 

industry standard, participants will learn best 

practices for incorporating “joy in work.” 


• Identify joy in work and staff retention strategies 

in a non-health care industry that can be 

compared with, and applied to, their own work 

environment 

• Recognize and analyze key concepts of 

employee motivation and staff engagement in 

different industries 

• Develop ideas for increasing staff satisfaction in 

their own work environment 

Dickson, E., MD, Senior Associate Dean and President, 

University of Massachusetts Memorial Medical Group; 

Gunther-Murphy, C., Director, Hospital Portfolio 

Operations, IHI 

How is your Forum Excursion? Tweet your thoughts using #IHI24Forum 

11


monday 

DECEMBER 10 

VIRTUAL SITE VISITS 

8:30 AM – 4:30 PM 

Virtual Site Visits allow attendees to gain an 

in-depth understanding of how improvement 

work is accomplished within best-practice 

organizations via virtual tours and video 

interviews with frontline staff and leadership. 

Attendees will choose two organizations to 

visit virtually. 

Morning Virtual Site Visits 

8:30 AM – 12:00 PM 

VSV1: Bellin Health 

Sawgrass 

The Bellin Health virtual site visit will focus 

on the high performance health care model. 

The model consists of aligning six dimensions: 

Strategic clarity, production system design, 

measurement system design, improvement and 

innovation, sales/marketing, and culture. This is a 

business model that aligns and deploys strategy to 

achieve strategic results. In this high-performance 

model, the shift is away from activity to an execution 

framework that maximizes organizational energy 

around the high leverage priorities that are 

necessary for achieving strategic results. In this 

presentation, the model will be detailed using a 

mix of videos and verbal discussions. 

Knox, P., Executive Vice President, Bellin Health; 

Hunt, J., PharmD, Chief Quality & Information 

Officer, Bellin Health 

VSV2: Geisinger Health System 

Vinoy 

The Geisinger Health System Virtual Site Visit 

will include a journey through their predominantly 

rural health system, from their primary care 

network to their e-ICU, emphasizing a patientcentered 

continuum of care. This Virtual Site 

Visit will showcase Geisinger’s advanced medical 

home and ProvenCare programs that leverage 

health information technology to provide reliable, 

evidenced-based, value-driven care supported by a 

dynamic climate of discovery and innovation. 

Bulger, J., DO, Chief Quality Officer, Geisinger Health 

System; Bothe, A., MD, Chief Quality Officer, 

Geisinger Health System 

VSV3: Henry Ford Health System (HFHS): A 

Journey for Performance Excellence 

Aruba/Bahamas 

In 2003, HFHS leadership decided to pursue 

organizational integration to deliver the best care 

to HFHS patients and drive sustainable growth. 

CEO Nancy Schlichting set the path toward 

improving performance throughout the system, 

selecting to adopt the Baldrige Criteria for 

Performance Excellence as a strategy for change. 

This Virtual Site Visit to HFHS offers an in-depth 

view of key changes made in the leadership system, 

workforce development and communication, strategic 

planning process, performance improvement 

tools and measures, the redesign of work systems 

and processes – including the new 200-bed Henry 

Ford West Bloomfield Hospital – and the creation 

of a culture of patient safety that helped lead to 

improved patient satisfaction, employee engagement, 

and reduction in harm events and inpatient 

mortality. Since embarking on the performance 

excellence journey, HFHS has received five 

national performance awards, including the 

Malcolm Baldrige National Quality Award in 2011. 

Conway, W., MD, Senior Vice President and Chief 

Quality Officer, HFHS and Chief Medical Officer, 

Henry Ford Hospital; Oswald, K., Senior Vice President 

and Chief Human Resources Officer, HFHS; 

Hawkins, S., Senior Vice President, Performance Excellence, 

HFHS; Voutt-Goos, M., Director, Quality Safety 

Initiative, Office of Clinical Quality and Safety, HFHS 

VSV4: Qulturum: Jönköping, Sweden 

Grand Cayman/Puerto Rico 

This Virtual Site Visit will focus on the strategic 

areas identified by the by Jönköping County 

Council as key areas to improve health care and 

increase the value of the services for patients. 

Jönköping County Council is a health care system 

with the responsibility to provide health care, 

medical treatment, and dental services for the 

residents within Jönköping County, Sweden. 

The drive for improvement within the above 

mentioned areas in the county is supported by 

Qulturum. Qulturum is a center for learning and 

transformation of care. Qulturum’s main focus is 

on facilitating improvement in patient involvement, 

prevention, cooperation, clinical improvement, 

safety, coaching teams, and designing health care 

services. 

Henriks, G., Chief Executive of Learning and 

Innovation, The County Council of Jönköping 

VSV5: North Shore Long Island Jewish 

Health System 


North Shore-LIJ (NS-LIJ) is transforming health 

care by packaging its exclusive network of providers 

with its vast inpatient and outpatient facilities and 

services to provide consumers with a full continuum 

of high quality, high value services. NS-LIJ is 

committed to innovation, continuous learning, and 

clinical excellence. In 2010, NS-LIJ was the first 

health care system in the New York metropolitan 

area to receive the National Quality Healthcare 

Award from the National Quality Forum for 

providing high quality, transparent, patientcentered 

health care. Learn more at this session! 

Jarrett, M., MD, Chief Quality Officer, NS-LIJ, Great 

Neck; Gallo, K., PhD, RN, Senior Vice President and 

Chief Learning Officer, NS-LIJ Health System 

Afternoon Virtual Site Visits 

1:00 PM – 4:30 PM 

VSV6: Shneck Medical Center 

Aruba/Bahamas 

Schneck Medical Center is a county-owned 

non-for-profit 95-bed hospital located in the 

small town of Seymour, Indiana. For several years, 

Shneck has concentrated on maintaining the delivery 

of high quality and safe care while managing 

the effects of declining reimbursement. Schneck 

uses its size as a strategic advantage and is able 

to provide a “small town touch” experience for 

patients, but is challenged with limited resources 

that could impact sustainability. This session will 

discuss how Schneck has put processes in place 

to increase stakeholder engagement and how the 

commitment to a “patient first” culture has allowed 

the organization to see improvement in quality of 

care, customer service, employee engagement, and 

financial outcomes. 

Wright, S., Director of Organizational Excellence, 

Schneck Medical Center; Dye, T., Vice President of 

Clinical Service, Schneck Medical Center 

VSV7: Southcentral Foundation 


In this Virtual Site Visit, attendees will hear the 

story of SCF’s Nuka System of Care and its 

transformational journey over the past 30 years. 

There will be a combination of video and 

photography of the physical space and employee 

and customer stories woven into the presentation 

to give a clear picture of SCF and its customerowned 

and relationship-driven Nuka System 

of Care. Additionally, there will be time for 

participants to consider what they have learned 

and discuss how they may shape their health care 

systems. 

Gottlieb, K., President and CEO, Southcentral 

Foundation; Eby,D., Vice President of Medical Services; 

Southcentral Foundation 

VSV8: Virginia Mason Medical Center 

Vinoy 

The Virginia Mason Medical Center virtual tour 

will provide participants an overview to their 

approach to improving quality and safety in 

pursuit of the perfect patient experience. The 

organizational structure, a brief history of the 

adoption of their management system, the Virginia 

Mason Production System, will be presented. 

Results they’ve achieved after 10 years and other 

current challenges will be detailed. Participants 

will hear case examples about surgical services, 

primary care clinics, and implementing leader 

standard work. 

Miller, D., Vice President and Executive Director, 

Virginia Mason Institute,Virginia Mason Medical Center; 

Patterson, S., Executive Vice President and Chief 

Operating Officer, Virginia Mason Medical Center 

12 


VSV9: Kaiser Permanente 


If you could imagine the future of health care, 

what would it look like? Kaiser Permanente is 

committed to helping shape the future of health 

care. This presentation will explore how their 

journey to transform health care began with their 

mission and the will of leadership. From there, 

they worked across the organization—from the 

front-line to executives—to develop ideas that 

improve the care they deliver. Finally, Kaiser 

Permanente executed on macro-, meso-, and 

micro-systems to drive improvements. This Virtual 

Site Visit will examine how Kaiser Permanente 

is achieving breakthrough performance for nine 

million members. 

Chase, A., Senior Vice President, Quality and Safety, 

and Co-Executive Director, CMI, Kaiser Permanente; 

Schilling, L., RN, National Vice President, Health Care 

Performance Improvement, Kaiser Permanente 

MINICOURSES 

8:30 AM – 4:00 PM 

Minicourses offer in-depth, hands-on learning 

opportunities and many take-home tools for 

implementing and sustaining change. 

innovate 

M1: IHI’s STAAR Initiative: Reducing 

Avoidable Rehospitalizations C 


IHI is leading a groundbreaking multi-state, 

multi-stakeholder initiative: STate Action on 

Avoidable Rehospitalizations (STAAR). The 

aim is to dramatically reduce rehospitalization 

rates in states and regions by supporting quality 

improvement efforts at the front lines of care 

while simultaneously working with state leaders to 

initiate systemic reforms to overcome barriers to 

improvement. This Minicourse will highlight 

the STAAR initiative’s progress to date in 

Massachusetts, Michigan, and Washington. 


• Describe common problems that contribute 

to rehospitalizations and identify promising 

approaches to reducing rehospitalizations 

• Describe the STAAR initiative’s two 

concurrent strategies to reduce avoidable 

rehospitalizations 

• Compare and contrast case studies that document 

the implementation of improvements that have 

dramatically reduced avoidable readmissions 

Rutherford, P., RN, Vice President, IHI; Coleman, E., 

MD, Director, Care Transitions Program, University of 

Colorado; Bradke, P., RN, Executive Director for Heart 

Care Services, St. Luke’s Hospital 

M2: Leading the Journey to High Reliability M 


Chief medical officers and chief quality officers can 

collaborate with other key leaders to move their 

organizations toward high reliability, focusing on 

the importance of organizational culture, process 

improvement methods, and leadership commitment. 

In this Minicourse, faculty will discuss their 

experiences and facilitate a rich discussion. 


• Describe the key characteristics of high-reliability 

organizations and methods to measure these 

characteristics 

• Reflect on their own organization’s performance 

in these areas 

• Identify effective methods for engaging key 

leadership groups 

Chassin, M., MD, President, The Joint Commission; 

Pryor, D., MD, Chief Medical Officer, Ascension Health; 

Weissberg, J., MD, Senior Vice President, Quality and 

Care Delivery Excellence, Kaiser Permanente; Yates, G., 

MD, Senior Vice President and Chief Medical Officer, 

Sentara Healthcare; Hunt, G., MD, Senior Vice President 

and Chief Medical Officer, Sutter Health; Berwick, D., 

MD, Former President and CEO, IHI; James, B., MD, 

Chief Quality Officer, Institute for Healthcare Delivery 

Research, Intermountain Healthcare, and IHI Board 

Member; Daley, J., MD, Executive Vice President and 

Chief Operating Officer, University of Massachusetts 

Memorial Medical Center; Shabot, M., MD, Senior 

Vice President and System Chief Medical Officer, 

Memorial Hermann 

M3: Courage in Health Care: Leading 

from Within 


Change calls for personal and communal courage. 

This Minicourse introduces current and emerging 

health care leaders and patient advocates to the 

principles and practices of the Center for Courage 

& Renewal® for leading from within. The Courage 

& Renewal approach supports professional 

renewal and leadership integrity. Attendees will 

learn Parker Palmer’s “Habits of the Heart,” which 

help leaders and groups hold tension in generative 

ways, support the building of relational trust, and 

promote responsible decision-making. 


• Identify three ways to foster engaged listening 

and attention 

• Implement protocols for reflection and 

connection in groups 

• Name the “Habits of the Heart” that support 

relational trust in effecting positive change 

Sherman, H., MD, Program Director, Health Care, 

Center for Courage & Renewal; Meyer, R., MD, 

Pediatrician and Medical Director, Cambridge Health 

Alliance; Schlosser, J., MD, Director, VISN 

Improvement Resource Office, VA New England 

Healthcare System 

18 TH ANNUAL INTERNATIONAL 

scientific symposium 

on improving the quality and value of health care 

monday, december 10 • 8:30 AM – 4:30 PM 

G Gaylord Palms Resort and Convention Center, 

Sun Ballroom A/B 

The Scientific Symposium features rapid-fire presentations of peer-reviewed papers, with 

an afternoon storyboard session. This program will include a keynote presentation by 

Mary Dixon-Wood, Professor of Medical Sociology, Department of Health Sciences, 

University of Leicester, UK. 

What are you talking about during your Minicourse? Tweet it using #IHI24Forum 

13


monday 

DECEMBER 10 

M4: See, Solve, Share, and Lead: 

Achieving Breakthroughs 

Marco Island 

This Minicourse will introduce the capabilities 

that lead to sustained competitive advantage for 

high-velocity organizations. Participants will learn 

to identify flagging systems and process deviations 

before reaching failure points. Faculty will 

describe how failure can be addressed, rectified, 

and converted into sources of superiority. In 

addition, presenters will share the internal dynamics 

of a high-velocity organization that ensures 

knowledge spread for relentless improvement. 


• Apply “see, solve, and share” methods to 

performance improvement 

• Differentiate complicated from complex 

systems 

McIlwain, T., MD, Vice President, Quality and Chief 

Medical Officer, St. Luke’s Episcopal Hospital; Downes, 

T., Consultant Geriatrician, Sheffield Teaching 

Hospitals; Spear, S., Senior Fellow, Massachusetts 

Institute of Technology 

M5: Health Care Innovation: Meaning, 

Strategy, Practice F 


Will “innovation” become simply another buzzword 

that comes and goes without making an enduring 

impact? Organizations that succeed in their 

innovation activities are ones that know the true 

meaning of innovation, that are deliberative in 

their strategies, and that take their efforts to a 

practical level that goes beyond exhortation. 

This theory-grounded, example-filled, interactive 

session is designed for those involved in creating 

new organizational structures for innovation in 

health care. 


• Define innovation as it applies to health care 

delivery 

• Explore various strategic directions that an 

innovation effort might take in a health care 

delivery organization 

• Describe the approach to innovation of 

leading-edge health care organizations in the 

United States and the United Kingdom 

Plsek, P., Consultant, Paul E. Plsek & Associates, Inc. 

M6: Real World Systems Innovation: 

Strategies of Four CMMI Health Care 

Innovation Challenge Grantees 


In the spring of 2012, the Center for Medicare 

and Medicaid Innovation awarded nearly 

$1 billion in Health Care Innovation Challenge 

grants to 107 projects. This interactive session 

will explore the work and strategies of six diverse 

grantees, including their distinctive issues and 

opportunities for clinical transformation, rapid 

workforce development and deployment, savings 

calculations, and scale and sustainability. 


• Draw lessons and strategies for system 

transformation through the Triple Aim that 

can be applied to their own organization or 

community 

• Review the governance and collaboration 

structures that help drive new care designs 

• Assess, compare, and contrast models for 

calculating savings 

Lewis, N., Director, IHI; Beasley, C., Executive Director, 

Strategic Projects, IHI; Labby, D., MD, Chief Medical 

Officer, Health Share of Oregon; Ramsay, R., Senior 

Manager, CareSupport and Clinical Programs, 

CareOregon; Savitz, L., PhD, Senior Scientist, 

Intermountain Healthcare; Weiss, L., Managing Director, 

High Value Healthcare Collaborative Program Office, 

The Dartmouth Institute for Health Policy and Clinical 

Practice; Johnson, T., PhD, Director, Denver Health 

and Hospital Authority; Batal, H., MD, Director, 

Denver Health and Hospital Authority; Representative 

from High Value Healthcare Collaborative Program 

Office, The Dartmouth Institute for Health Policy and 

Clinical Practice 


M7: Patient Safety: Continuing the 

Journey C F 


Improving patient safety requires acknowledging 

that there is a safety problem, developing a 

structure and process to address the gaps in care, 

using a methodology for improvement, and selecting 

appropriate process and outcome measures. At 

the end of this session, participants will be able to 

describe the structural components needed to 

improve patient safety, articulate the role of human 

factors, teamwork, and system design in these 

efforts, apply improvement methods, and build a 

just culture. 


• Discuss the components of a patient safety plan 

• Develop a safety plan for their organization 

• Describe the role of measurement in determining 

patient safety 

Federico, F., RPh, Executive Director, Strategic 

Partners, IHI; Peden, C., MD, MB ChB, Associate 

Medical Director for Quality Improvement and 

Consultant in Anaesthesia and Intensive Care, Royal 

United Hospital, Bath; Staines, A., PhD, Associate 

Professor, University of Lyon 

M8: Tools for Radical Transformation 


Health care leaders face unprecedented pressure 

during radical change. This Minicourse will 

explore ways to reform the personal language and 

habits that constrain change and will also use 

narrative practice to uncover earlier, more 

generative organizational purposes to create future 

options. Participants will practice using tools 

to recognize and transcend their personal and 

organizational constraints while enhancing their 

capacity to see and act in new ways. 


• Share a framework based in adult developmental 

and learning theory to understand key barriers 

to personal and organizational change 

• Use tools designed to promote transformation 

• Leverage individual and collective knowledge, 

hopes, and wishes to create organizations that 

can face upcoming challenges 

Taylor, J., Improvement Advisor , IHI; Crowe, G., 

RN, Principal, Hamilton Consulting, LLC; Butts, S., 

Improvement Advisor, Butts-Dion Consulting, Inc.; 

Heinrich, P., RN, Quality Improvement Consultant, 

Heinrich LLC 

M9: Engaging Physicians to Transform Care 


Improvement cannot be embedded in an 

organization’s culture without the active 

engagement of physicians. In this Minicourse, 

a comprehensive model for successful physician 

engagement—including physician compacts 

(reciprocal expectations between doctors and their 

organization)—and ways in which organizations 

can actualize this model will be described. In 

addition to discussing the critical role of physicians 

in this work, faculty will also share relevant 

perspectives from 18 of Virginia Mason’s ongoing 

efforts to improve care and efficiency through 

implementation of the Virginia Mason 

Production System. 


• Describe how urgency, shared vision, change 

sponsorship, compacts, and a comprehensive 

method can facilitate physician engagement in 

improvement 

• Address the loss of autonomy or the challenge 

to professional identity that often blocks 

physician engagement 

• Draw lessons from Virginia Mason’s experience 

that can be applied to their own organization 

Kaplan, G., MD, CEO, Virginia Mason Medical 

Center, and IHI Board Member; Silversin, J., 

President, Amicus, Inc. 

M10: From the Top: The Role of the Board in 

Quality and Safety M 


This session will describe the role of governing, 

executive, and clinical leadership in overseeing 

quality and safety through an IHI framework, 

focusing on effective integration of aims and 

outcomes (quality, cost, service, satisfaction) and 

14 


enhancement of value to achieve savings in annual 

operation costs. Mock board meetings will give 

participants the opportunity to wrestle with some 

of the most difficult problems faced by boards and 

learn about best practices to overcome them. 


• Outline a board’s role in overseeing quality and 

safety 

• List three changes that could improve the 

oversight of quality by their organization’s 

board 

• Identify three innovative best practices that 

each board could implement immediately, as 

well as specific opportunities to decrease direct 

costs while improving quality 

Reinertsen, J., MD, President, The Reinertsen Group; 

Orlikoff, J., President, Orlikoff & Associates, Inc. 

M11: Building a Clinician Peer Support 

Program F P 


Clinicians involved in an adverse event are often 

deeply affected by it, becoming “second victims” of 

the crisis. Developing a support program for these 

individuals is a key component of managing the 

crisis. During this interactive session, participants 

will learn the telltale signs of trauma, review the 

recovery stages, and begin to develop a support 

program. 


• Describe the history of second victims 

• Set the context for second victim support 

• Develop a work plan 

Kenney, L., President and Founder, MITSS; Scott, S., 

RN, Coordinator, Patient Safety, University of Missouri 

Health Care; Deen, J., RN, Patient Safety Officer, 

Catholic Healthcare Partners; Wu, A., MD, Professor 

and Director, Johns Hopkins Bloomberg School of 

Public Health; Vanhaecht, K., RN, PhD, Health 

Services Research Group, School of Public Health, 

University of Leuven 

motivate 

M12: Rallying Your Community to Improve 

Transitions C 

Key Biscayne 

Improving care transitions works best in a 

community that can align medical, nursing, and 

social services providers. In this Minicourse, 

participants will get a comprehensive overview 

of care transitions work, insights from both 

successful and stalled projects, an understanding 

of measurement challenges, and a review of 

incentives available through government initiatives. 


• Explore the strategies and experience of major 

recent initiatives to improve care transitions 

• Position themselves to improve care transitions 

in their community 

• Connect the goals of comprehensive care plans, 

community standard processes, and patient 

activation 

Lynn, J., MD, Director, Center for Elder Care and 

Advanced Illness, Altarum Institute; Brock, J., MD, 

Medical Officer, Colorado Foundation for Medical Care; 

Goroski, A., Senior Project Director, Care Transitions 

QIOSC, Colorado Foundation for Medical Care; 

Schall, M., Senior Director, IHI; Fusco, S., Director of 

Business Results and Innovation, Council on Aging of 

Southwestern Ohio; Anim, D., Assistant Vice 

President, Greater Cincinnati Health Council 

M13: One-Day School for Organizational 

Radicals 


Big change happens in health care organizations 

only through the efforts of heretics and radicals— 

those passionate individuals who are willing to 

take responsibility for change and who support 

their organization in its patient-centered mission, 

but who also challenge the status quo. Participants 

who fill this role in their organization know how 

tough it is to be an organizational radical, and in 

this Minicourse they are invited to spend an 

inspiring day with people of like mind. The session 

will explore applications of the thinking and 

practice of radical leaders that participants can use 

to achieve a “revolution” in health care quality in 

their own organization. 


• Increase their effectiveness as a leader of change 

• Build a toolkit of alternative and additional 

approaches to supporting change 

• Ignite a movement of organizational radicals in 


Bevan, H., PhD, Chief of Service Transformation, 

NHS Institute for Innovation and Improvement; 

Fenton, K., RN, Chief Nurse, University College 

London Hospital 

M14: Accelerating the Pace and Scale 

of Improvement 


Frustration with the pace and scale of health care 

improvement is widespread. Building the will 

to improve, developing and testing ideas, and 

achieving results for populations are constant 

challenges. This session will present case studies 

and experiences from organizations that have 

been leading resources and driving forces 

for systemwide, transformative health care 

improvement in their system or region. 

Participants will learn about their journeys, 

including their recent efforts to work together to 

accelerate the pace and scale of improvement both 

locally and globally. 


• Identify key requirements for becoming a 

leading resource in a system or region 

• Describe the key activities to build will, develop 

ideas, and achieve breakthrough health care 

improvement results 

Delgado, P., Executive Director, IHI; Henriks, G., 

Chief Executive of Learning and Innovation, County 

Council of Jönköping; Kotagal, U., Senior Vice President, 

Quality/Transformation, and Director, Health Policy 

and Clinical Effectiveness, Cincinnati Children’s Hospital 

Medical Center; Schilling, L., RN, National Vice 

President, Healthcare Performance Improvement, Kaiser 

Permanente; Chase, A., Senior Vice President, Quality 

and Safety, and Co-Director, CMI, Kaiser Permanente 

M15: From “Bolt-On” to “Build-In”: 

Improvement as Cultural DNA 


Most improvement efforts are driven by key 

projects whose logical results are “bolted on” work 

cultures…which then fiercely resist them. Any 

change in a work culture disturbs a puzzlingly 

obsessive desire to stay vested in current practices. 

Using a basic cognitive therapy framework, 

participants will review this phenomenon and 

learn how to transform it to drive “built-in” 

improvement. Work teams will be encouraged. 


• Apply the concept of “belief systems” to audit a 

culture and deal with the inevitable resistance 

• Depersonalize cultural resistance in their work 

culture and use new skills to implement change 

that will achieve the desired organizational results 

• Apply the wisdom of a high-level executive who 

struggles daily with these issues 

Balestracci, D., Statistician and Quality Improvement 

Specialist, Harmony Consulting, LLC; Easton, J., 

Chief Executive, Quality Improvement and Innovation 

Partnership 

M16: Is There a Perfect Heath Care System? 

Miami 

No one system has solved all of the health care 

challenges facing the world, but some have certain 

necessary elements of a solution. This Minicourse 

brings together three such systems—from Scotland, 

Alaska, and Sweden—to examine ways in which 

they could be combined into one perfect system. 

Faculty will present lessons and challenges from 

the quality journeys of these health care systems, 

and participants will learn how these lessons could 

be applied to their own system. 


• Assess the work of three high-performing 

health care systems 

• Critically and interactively discuss the work of 

health care transformation using the presented 

systems as a catalyst 

• Apply the lessons and challenges of transforming 

care for patients and families to their context 


Government Health Department; Henriks, G., Chief 

Executive of Learning and Innovation, County Council 

of Jönköping; Eby, D., MD, Vice President of Medical 

Services, Southcentral Foundation 


15


monday 

DECEMBER 10 

M17: Strategies for Facilitating Change in 

Primary Care 


Primary care practices face daunting challenges for 

transformation. Regardless of the technical nature 

of the challenge (e.g., converting to electronic 

medical records or the patient-centered medical 

home), effective facilitation of change depends on 

diagnosis of gaps. This Minicourse will present 

methods and tools for making such diagnoses, as 

well as effective intervention strategies that can 

be used by facilitators whether or not they have 

formal authority. 


• Explain how to map a change project to 

diagnose the effectiveness of current change 

management roles and alignment 

• Identify strategies for responding to gaps in 

roles and alignment, including advocacy 

• Identify strategies for skillful response to 

reactivity and resistance 

Baker, N., MD, Principal, Neil Baker Coaching and 

Consulting, LLC; Lefebvre, A., MSW, Associate Director, 

UNC–Chapel Hill; Sevin, C., RN, Director, IHI 

M18: ThedaCare’s Business Performance 

System M 


Organizations that focus on Lean improvement 

strategies face a critical question: How is 

transformational work sustained for the long 

term? ThedaCare’s lean journey, which started 

more than eight years ago, offers some answers to 

this question. Its lean management system, the 

Business Performance System, is designed to help 

managers understand their performance and meet 

their targets while developing people and building 

effective teams. This presentation will focus on 

identifying the point in the lean journey when 

a systematic management system is needed to 

sustain value stream results and create momentum 

around daily continuous improvement. 


• Experiment with the core components of 

a management system like the Business 

Performance System 

• Explain the standard work and cascades of 

information required to create and sustain a 

system of continuous improvement 

• Experiment with the integration of lean tools 

such as A3 thinking with leadership standards 

work to move an organization beyond value 

streams 

Barnas, K., Senior Vice President, ThedaCare; 

Schaffmeyer, M., COO, Care Transitions and 

Homecare Division, ThedaCare 

get results 

M19: Better Quality Through Better 

Measurement 


Good decision-making is based on systematically 

collected and analyzed data. This session will 

provide participants with a framework and 

practical recommendations for avoiding 

roadblocks in their quality measurement journeys. 

Linking measurement to improvement strategies 

will be discussed, and case studies and exercises 

demonstrating the application of measurement 

principles to health care topics will also be 

presented. 


• Distinguish between data for research, 

judgment, and improvement 

• Decide which control chart is most appropriate 

for their data 

• Link measurement efforts to improvement 

strategies 


Improvement, IHI; Scoville, R., PhD, Improvement 

Advisor and Consultant, IHI; Little, K., PhD, Principal, 

Informing Ecological Design, LLC 

M20: Beyond Basics: Using Advanced 

SPC Charts M 

Harbor Beach 

What should we do when the limits on our 

control charts are so narrow that all of the data 

fall outside them? What about seasonal factors 

or rare events? In this session, we explore more 

advanced uses for statistical process control (SPC) 

charts for health care. Presenters will address T 

and G charts for rare events data, Prime charts, 

adjustments for autocorrelation and for seasonality, 

the use of the CUSUM control charts, and more. 

We recommend that participants bring laptops to 

this Minicourse to use in data analysis. 


• Select the appropriate SPC chart for rare 

events data 

• Identify when it is most appropriate to use a 

CUSUM control chart 

• Create a variety of advanced SPC charts using 

the Excel templates provided 

Murray, S., Improvement Advisor, CT Concepts; 


Advisor, Associates in Process Improvement 

M21: Designing and Executing Large-Scale 

Interventions for Improving Perinatal and 

Infant Outcomes 

Key West 

What are the underlying drivers of maternal 

and infant mortality and morbidity, and what 

interventions are most likely to succeed in driving 

down the high rates that currently prevail in the 

United States? The improvement community has 

been working on this issue for many years in the 

US and other high-income countries, as well as 

in low- and middle-income countries, and what 

it has learned can be used to design and execute 

successful large-scale interventions for improving 

perinatal and infant outcomes. In this Minicourse, 

participants will be provided with high-level input 

from national and global experts combined with 

creative opportunities for planning and executing 

large-scale interventions to reduce perinatal 

mortality. Although NICU care is a crucial part of 

this problem, the Minicourse will focus on non- 

NICU solutions to perinatal morbidity 

and mortality. 

After this session, attendees will be able to: 

• Explain the differing epidemiology and causes 

of perinatal mortality and mortality in the 

United States and other parts of the world 

• Describe the use of driver diagrams to explore 

causes, measures, and ideas for improving 

perinatal care 

• Demonstrate familiarity with the different 

levels of the system (community, patient, 

providers, health facilities, states, nations) that 

can be targeted to improve outcomes, as well as 

possible designs (collaboratives, campaigns, 

policy change, leadership intervention) for 

effective large-scale interventions 


Bisognano, M., President and CEO, IHI; Gullo, S., 

RN, Managing Director, IHI; Homer, C., MD, CEO, 

National Initiative for Children’s Healthcare Quality 

(NICHQ) 

M22: Zero Events of Harm: Leading for 

High Reliability C 


To achieve and sustain significant improvement 

in patient safety (e.g., zero events of harm), health 

care can employ strategies from other industries 

that have proven to be highly reliable and safe. 

Reliability experts and executives from organizations 

where these strategies have been used will share 

their experiences and the lessons they have learned 

in implementing reliability principles. Lessons 

from the science of safety, implementation of a 

defined leadership method, and approaches for 

a more robust culture of safety will also be 

discussed in this Minicourse. 

16 


After this session, attendees will be able to: 

• Discuss the principles of safety and reliability 

that can help achieve zero events of patient harm 

• Contrast evidence-based leadership methods 

for building and sustaining a high-reliability 

culture 

• Design an approach to implement new 

principles in their organization 

Yates, G., MD, Senior Vice President and Chief Medical 

Officer, Sentara Healthcare; Muething, S., MD, Assistant 

Vice President, Patient Safety, Cincinnati Children’s 

Hospital Medical Center; Clapper, C., Partner and 

Chief Operating Officer, Healthcare Performance 

Improvement, LLC 


M23: Baldrige: Achieving Excellence 

and Reliability 

Key Largo 

This interactive session delves into the power of 

the Baldrige framework to enable organizations to 

sustain the highest levels of clinical, service, and 

operational excellence. Leaders from the Henry 

Ford Health System and the Studer Group who 

have recently been recognized for their success at 

implementing redefined excellence standards will 

share their experience in using Baldrige to secure 

industry role model performance. Healthcare 

Performance Improvement (HPI) will explain 

how deployment of the framework helps make 

highly reliable patient safety a sustainable reality. 

This session will also demonstrate how the 

framework serves as a unique roadmap for 

achievement of the Triple Aim. 


• Assess, compare, and contrast their 

organization’s performance against that of 

Baldrige role models and the Criteria for 

Performance Excellence 

• Describe how the Baldrige framework can 

be used to create inspired cultures and 

immediately improve performance 

• Act on the Baldrige excellence roadmap 

Ettinger, J., President and CEO, Category One Inc., and 

Alumni Member of the Board of Examiners, Malcolm 

Baldrige National Quality Award; Hawkins, S., Senior 

Vice President, Performance Excellence, Henry Ford 

Health System; Deao, C., Research and Development 

Leader, Studer Group; Yates, G., MD, Senior Vice 

President and Chief Medical Officer, Sentara Healthcare 

M24: Enhancing Primary Care Value at 

Lower Cost to the Community 


In this Minicourse, participants will design 

community health centers that honor, enhance, 

and produce value through primary care 

relationships. Building on Intermountain Health’s 

successful and sustained redesign of primary 

care through mental health integration (MHI) 

and IHI’s Triple Aim, this session will provide 

participants with a framework that defines value 

by incorporating an understanding of what really 

matters to individuals, their families, and their 

communities, describes the leadership needed to 

deliver this value, and supplies a practical 

measurement of success in meeting those values. 

Participants will engage in a collective social 

network activity that creates “out-of-the-box” 

designs for sustainable, local, social centers 

of health. 


• Build a framework for enhancing the quality of 

primary care through relational networks 

• Define the delivery system and societal costs 

that reflect the value of enhanced quality 

• Create a set of values and outcomes that make 

the most difference in the lives of individuals 

and communities 

Reiss-Brennan, B., Mental Health Integration Director, 

Intermountain Healthcare; Boudreau, K., MD, Chief 

Medical Officer, Boston Medical Center HealthNet 

Plan; Leckman, L., MD, CEO, Intermountain Medical 

Group 

M25: Global Perspectives on the Journey to 

Accountable Care 

Anaheim 

This Minicourse will explore what can be learned 

about providing accountable care by looking at 

organizations with a tradition of primary care and 

collective accountability for the quality of health 

care and total per capita costs in a population of 

patients. Is it possible to design new care systems 

to support improvements in care and inspire 

confidence that such improvements will achieve 

savings and better population health? Participants 

will be invited to try. 


• Describe a clear route to accountable care 

• Identify the successes of accountable care 

organizations from the United States, United 

Kingdom, and Mexico 

• Develop a personal action plan for their 

organization 

Crisp, N., Strategic Advisor to the CEO and Senior 

Fellow, IHI; Feeley, D., Chief Executive, Scottish 

Government Health Department; Ruelas, E., Vice 

President, National Academy of Medicine, Mexico, 

and Senior Fellow, IHI; Dowling, M., President and 

CEO, North Shore–Long Island Jewish Health System, 

and IHI Board Member; Fisher, E., MD, Director, 

Population Health and Policy, The Dartmouth Institute 

for Health Policy and Clinical Practice, and IHI Board 

Member 

IHI FORUM APP for all smartphones 

The IHI Forum EventPilot Conference App serves as your all-in-one event guide by putting 

everything you need to know right onto your mobile device. This app will enable you to: 

• Communicate with other attendees during the event 

• View Twitter updates using #IHI24Forum hashtag 

• Follow along with presentations and view PowerPoints 

• View faculty biographies 

• Refer to a map of the Marriott and the Exhibit Hall 

• Email session notes to yourself 

The IHI Forum EventPilot Conference App is available for free in the App Store and Google 

Play Market. Download yours today! For help with the app, please stop by Registration. 

To download the IHI Forum app from a smartphone or tablet: 

1. Type http://ativ.me/ihiform into your browser’s address bar or search the App store 

(for iPhone/iPad) or Google Play (for Android) and download the EventPilot 

Conference App directly from your device. 

2. When EventPilot has been installed, launch the app and enter the event code 

IHIFORUM 

For all other devices including laptops: 

1. Simply enter http://ativ.me/ihiforum into your web browser’s address bar to access 

the web app. 

Note: For optimal viewing, the IHI Forum App requires the latest version of Internet 

Explorer, Firefox, or Google Chrome 


17

MONDAY 

special events 

special half-day session 

5th Annual IHI Open School 

Chapter Congress 

Sponsored by 

4:30 PM – 7:30 PM 

G Gaylord Palms Resort and 

Convention Center, 

Sun Ballroom C 

Welcome Reception 

3:30 PM – 6:30 PM 


Active Health Presentation:Improving Quality 

and Value Across the Core Continuum 

3:30 PM – 4:15 PM 

Palms Foyer Classroom 

Learn how you can benefit from an integrated 

software solution for risk and condition 

management supporting better quality for 

individual patients and entire populations, while 

supporting communication, coordination, and 

care management needs. With 15+ years 

experience providing advanced clinical insights, 

more than 22 million patients, and a team of 

more than 30 physicians and other clinicians, 

ActiveHealth helps clients to optimize 

healthcare quality and outcomes. 

IHI Triple Aim Q&A Session 

5:15 PM – 6:00 PM 

IHI Booth #301, Palms Ballroom 

Are you interested in learning more about the 

IHI Triple Aim? Join this informal 

session with Triple Aim team members. 

Faculty and Student Reception 

7:00 PM – 9:00 PM 

G Gaylord Palms, 

Emerald Bay Plaza 

This networking event is offered specifically for 

IHI faculty, National Forum presenters, and 

health professions students. 

Picker Institute Special Session on Advancing Patient-Centered Care 

1:00 PM – 4:30 PM • Crystal Ballroom Salon H 

In this special half-day session, participants will celebrate the Picker Institute’s 

quarter-century of leadership in advancing patient-centered care with Dr. Donald Berwick, 

former CEO and President of IHI; Lucile Hanscom, Executive Director of the Picker 

Institute; Jeff Selberg, COO of IHI; Dale Shaller, Principal of Shaller Consulting; and 

Madge Kaplan, Director of Communications at IHI. Six Picker grantees will inspire 

participants to address vexing health care challenges using Always Events®, an innovative 

improvement strategy that helps providers focus on consistently delivering excellent 

patient-centered care to all patients, all the time. Dr. Berwick will lead a provocative discussion 

with several distinguished Picker Award recipients about the current and future state of 

patient-centered care. Don’t miss the session that is sure to be the talk of the 2012 Forum! 

• Always Events Grantee Panelists: Huntington, J., MD, PhD, Dartmouth-Hitchcock 

Medical Center; Parkosewich, J., RN, Nurse Researcher, and Co-Director, 

Women’s Heart Health, Yale–New Haven Hospital; Rieke, C., RN, University 

of Minnesota, Amplatz; Rockey, W., RN, Exempla; Shatz, R., DO, Director of 

Behavioral Neurology, Henry Ford Health System; Perkins, S., PhD, RN, Chief 

Nurse Executive, Anne Arundel Health System 

• Picker Award Recipients Panelists: Cleary, P., PhD, Dean, Yale School of Public 

Health; Chin Hansen, J., RN, CEO, American Geriatrics Society, and IHI Board 

Member; O’Kane, P., President, National Committee for Quality Assurance; 

Wagner, E., MD, Director, MacColl Institute for Healthcare Innovation at 

Group Health 

18 


TUESDAY special events 

Complimentary Yoga 

6:00 AM – 7:00 AM • Key Largo & Key Biscayne 

Partnership for Patients HEN Breakfast 

7:00 AM – 7:45 AM • Crystal Ballroom Salon J 

Kaiser Permanente Presentation: Making Lives Better 

Through Total Health 

10:45 AM – 11:15 AM • Palms Foyer Classroom 

At Kaiser Permanente, our organizational vision is to be a leader in 

total health by making lives better. Our integrated health care delivery 

system and commitment to preventive care empower our members 

to maximize their total health— mind, body, and spirit. In this 

presentation, we will discuss how the concept of total health speaks to 

the values of our organization and to our commitment to helping our 

members, our workforce, their families, and our communities achieve 

total health. Come learn more about total health and how you can be 

a part of it. 

Social Media 101 Lunch n’ Learn 

12:40 PM – 1:20 PM • Crystal Ballroom Salon H 

Curious about how to use Twitter and other social media sites? Grab 

your lunch and join Paul Levy, the social media-savvy former hospital 

CEO, during this informal session. 

The Conversation Project Q&A Session 

12:45 PM – 1:30 PM • IHI Booth #301, Palms Ballroom 

Come join this informal session about The Conversation Project to 

learn about the project’s mission, goals, and resources, in addition 

to learning about IHI’s plans to help organizations become 

“Conversation Ready.” 

PerfectServe Presentation: How to Improve Outcomes and 

Efficiency by Simplifying Communication Processes 

12:45 PM – 1:15 PM • Palms Foyer Classroom 

Effective communication among clinicians is essential to reliable, 

high-quality care and efficient care coordination. Yet current processes 

often break down and create delays in treatment. This session will 

describe how PerfectServe works with health systems to remove 

variability and drive process standardization, which results in 

improved outcomes and operational efficiency. 

Next Level Partners Presentation: Making Real Improvement in 

Areas of Strategic Importance 


More than ever before, it is important that impactful, game-changing 

improvements are achieved and sustained in a manner that changes 

the thought process of how care is delivered. These changes can no 

longer only be in areas that alleviate daily issues. The improvements 

must now also be impactful in areas that are strategically important 

to ensure competitive advantage within the industry requirements of 

tomorrow. Presenters in this session will share some strategy-driven 

accomplishments in their journey. 

IHI Fellowships Q&A Session 

4:30 PM – 5:00 PM • IHI booth #301, Palms Ballroom 

Are you interested in becoming an IHI Fellow? Join this informal 

session to get all of your fellowship questions answered! 

UL, LLC Presentation: Value-Based Frameworks 

4:45 PM – 5:15PM • Palms Foyer Classroom 

UL, a world leader in advancing safety, can teach you how to lead 

transformational change at your hospital. Join our discussion on how 

a value-based framework can allow you to pursue perfect safety for 

patients and staff and result in improved financial value and quality. 


4:30 PM – 6:30 PM • Palms Ballroom 

Sponsored by Elsevier 

Representatives from organizations with 

storyboards on display will be available to 

answer questions, share lessons learned, 

and network in an informal setting. 

Healthy Employees, Lower Premiums and Costs Q&A Session 

5:15 PM – 6:00 PM • IHI booth #301, Palms Ballroom 

Come learn more about a new phase of work IHI is engaged in. 

We’re working with employers, health plans, and health care 

providers to produce unexpected decreases in premiums/total costs 

through a system design that is focused on better health outcomes 

and lower costs. 

Dine Arounds 

6:00 PM – 8:00 PM • G Gaylord Palms Resort and 

Convention Center 

Join colleagues for a casual dinner at one of the many award-winning 

restaurants at the Gaylord Palms Resort and Convention Center. 

Visit the IHI Dine Around staff in the Los Angeles Room at the 

Marriott World Center on December 10 and 11 to sign up for a 

group dining experience. 


7:00 PM – 10:00 PM • Solaris Deck 

Watch a new health care-focused documentary, challenge your peers 

to an adrenaline-pumping virtual safety game, or come to connect 

with others at this fun and free new event. 

19

GENERAL 


tuesday 

DECEMBER 11 

keynote one 

8:00 AM – 9:00 AM 


Maureen Bisognano, 

President and CEO, IHI 


A1: The Wisconsin Story 

9:30 AM – 10:45 AM 


(sponsored by Picker Institute) 

Leonard Berry, PhD, Distinguished 

Professor of Marketing, Texas A&M 

University, moderates a panel that 

includes: 

• George Kerwin, President and 

CEO, Bellin Health 

• Randy Linton, MD, President and 

CEO, Mayo Clinic Health System 

• Dean Gruner, MD, President and 

CEO, ThedaCare 

• Jeffrey Thompson, MD, CEO, 

Gundersen Lutheran Medical 

Center 

B1: Ensuring Equity in the Health 

Care Workforce 

11:15 AM – 12:30 PM 


Brian Smedley, MD, Vice President 

and Director, Health Policy Institute 

of the Joint Center for Political and 

Economic Studies 


7:00 AM – 8:00 AM 





navigate through the program and devise 

a personal learning plan. Participation in 

the National Forum orientation is free and 

optional. 

rapid-fire workshops 

10 minutes, 10 slides! 

RFA: Innovations in Health Care 


Moderator: Martin, L., Executive Director, IHI 

RFB: Pioneer ACOs: After the Ink has Dried 


Moderator: Beasley, C., Executive Director, 

Strategic Projects, IHI 

A workshops 

9:30 AM – 10:45 AM 

B workshops 

11:15 AM – 12:30 PM 

All A workshop presentations 

repeat during B workshops. 

A/B WORKSHOPS 

innovate 

A2/B2: Integrating Palliative Care into the 

Emergency Department (ED) 

Aruba/Bahamas 

Palliative care initiatives have shown the natural 

evolution of integrating palliative care services 

into the ED to meet patient care needs and fulfill 

hospital imperatives to improve quality, reduce 

readmissions, and better link hospital and 

community resources. This session will explore 

current models of ED–palliative care integration, 

based on the Improving Palliative Care in the ICU 

(IPAL-ICU) initiative of the Center to Advance 

Palliative Care (CAPC). The session will 

incorporate data and case studies illustrating 

innovative, successful ED–palliative care 

integrative models designed by hospitals. 


• Identify the key characteristics of the four 

predominant models of ED–palliative care 

integration observed in the United States 

• Define the keys to successful adoption that these 

ED–palliative care models have in common 

• Develop an action plan for enhancing current 

models of ED–palliative care delivery 

Quest, T., MD, Associate Professor, Emory University 

A3/B3: Transforming Care Through the Power 

of Social Media S F 

Grand Ballroom 12-14 

As the social media revolution explodes around 

the world, creating and enhancing connections in 

unprecedented ways, the transformative change it 

makes possible can only be imagined. This session 

will inspire participants to learn how to harness the 

power of social media by getting their hands dirty 

testing common social media tools. 


• Become part of the web 2.0 revolution and 

understand the value of social media in driving 

social change 

• Identify the key components of the effective and 

innovative social media campaigns that have 

changed the world 

• Apply the POSTE method to health care 

improvement 

Krause, C., Executive Director, BC Patient Safety and 

Quality Council (BCPSQC); Puri, A., Quality Leader, 

Communications and Engagement, BCPSQC 

A4/B4: Clinical Improvement for 



Integrating clinical decision support into health care 

information technology systems can improve cost and 

quality outcomes. In addition, the health care reform 

law gives evidence-based health care an important 

role in developing accountable care organizations 

(ACOs) and patient-centered medical homes. This 

workshop will discuss how evidence-based clinical 

decision support helps organizations improve 

quality and cost outcomes across the continuum 

of care and build the clinical infrastructure for 

ACOs and medical homes. 


• Identify the potential of evidence-based clinical 

decision support to improve cost and quality 

outcomes across the continuum of care 

• Describe the role of clinical decision support in 

the creation of ACOs and medical homes 

Weingarten, S., MD, President and CEO, Zynx Health; 

Classen, D., MD, Associate Professor of Medicine, 

Senior Partner, and CMO, University of Utah 

20 


A5/B5: The VHA Medical Home Model: 

Patient-Aligned Care Teams 


In 2009, the Veterans Health Administration 

(VHA) embarked on a multi-year plan to 

transform its primary care system into a medical 

home model, which it has termed Patient-Aligned 

Care Teams (PACT). PACT is an interdisciplinary, 

team-based model that redesigns existing systems 

to increase access and clinical effectiveness by 

focusing on a readiness assessment, the construction 

of infrastructure to support implementation, 

training, measurement of progress, and promotion 

of innovation. Achievements thus far include 

reductions in admissions, urgent care visits, and 

face-to-face visits and increases in the use of 

virtual care delivery modalities. 


• Describe key components of VHA’s 

implementation plan 

• Assess the importance of measurement in 

driving organizational change 

Davies, M., MD, Chief of Staff, VA Black Hills Health 

Care System; Shear, J., National Primary Care Clinical 

Program Manager, Department of Veterans Affairs; 

Stark, R., MD, Director of Primary Care Operations, 

Department of Veterans Affairs; Schectman, G., MD, 

Deputy Chief Consultant, Primary Care, Department of 

Veterans Affairs 

A6/B6: A Human Factors Approach to Root 

Cause Analysis S F 


This workshop will provide a detailed description 

of the research, development, and deployment of 

an alternative root cause analysis investigation 

methodology based on the Human Factors 

Analysis Classification System (HFACS), which 

is often used in military and commercial aviation 

and other high-reliability industries. Presenters 

will detail the methodology, its acceptance into 

an organization’s culture, and the data used to 

identify performance improvement opportunities 

based on human behaviors. 


• Describe the development and implementation 

of the HFACS approach to root cause analysis 

• Identify ways in which HFACS can be used 

to find opportunities for system improvement 

based on human factors and behavior 

Dunning, S., RN, Risk Manager, Greenville Hospital 

System; Helmrich, G., MD, Vice Chair, Quality and IP 

Operations, Greenville Hospital System; Diller, T., MD, 

Vice President, Quality and Patient Safety, Greenville 

Hospital System; Shappell, S., PhD, Professor, 

Clemson University; Cox, S., RN, Director of Quality 

Management, Greenville Hospital System 

A7/B7: Designing and Supporting a Learning 

Health Care System 

Vinoy 

How can we better support localized, small-scale 

experimentation and innovation? A learning 

health care system requires care teams whose 

members think like “designers” and who can take 

new approaches to piloting ideas without making 

premature assessments. Faculty will share lessons 

learned from working with eight primary care 

practices to facilitate evidence-based, patientcentric 

conversations between providers and 

patients about colon cancer screening. 


• Identify four lessons to become a learning 

health care system 

• Describe two tests of change that could support 

increased experimentation in their setting 

Sevin, C., RN, Director, IHI; Schwartz, A., PhD, 

Health Care Lead, IDEO; Taylor, J., Improvement 

Advisor, IHI 

A8/B8: Better Health at Any Weight: 

Care Delivery Strategies M 

Anaheim 

In the United States, obesity poses the greatest 

threat and challenge to the health care system. 

Kaiser Permanente’s comprehensive, multisectoral 

public health approach to the obesity 

epidemic includes treatments like bariatric surgery. 

This evidence-based program integrates prevention 

and treatment to provide patients with the most 

effective program. Interventions contributing 

to success include adult weight management 

programs, community engagement, sustainment 

strategies for prevention, and end-to-end care with 

bariatric surgery. In this session, participants will 

learn about the successful spread of these practices 

to 13 hospitals. 


• Explain the risks and implications of the 

obesity epidemic 

• Identify prevention and treatment strategies 

to reduce obesity 

• Develop a plan to prevent and treat obesity with 

reliably high-quality services and programs 

Dorman, J., Director, Center for Health Care Delivery, 

Kaiser Permanente; Watson, H., Senior Consultant, 

Kaiser Permanente Regional Quality and Risk 

Management; Histon, T., PhD, Senior Manager, 

Obesity Prevention and Treatment, Kaiser Permanente 

A9/B9: Creative Breakthroughs: Collaboration 

for Innovation and Improvement F 


Collaboration for Innovation and Improvement 

is a program designed to help partners work 

together in a specially tailored learning process 

focused on improving health care for Canadians. 

Working collaboratively, health care organizations 

improve their ability to analyze the issues they face 

and develop the processes, tools, learning systems, 

and leadership they need to create and implement 

evidence-driven solutions. This interactive session 

will feature case studies illustrating team-based 

approaches to driving systems improvement, with 

robust evaluation built in. 


• Discuss how health care leaders are collaborating 

on patient involvement and chronic disease 

management approaches in the Canadian 

context, as well as to develop and sustain 

evidence-informed and systems solutions 

• Identify interprofessional, team-based strategies 

to develop local capacity for improvement 

Verma, J., Director, Collaboration for Innovation and 

Improvement, Canadian Health Services Research 

Foundation; O’Connor, P., RN, Director of Nursing and 

Chief Nursing Officer, McGill University Health Centre; 

Allen, D., RN, Director, Territorial Health Services, 

Department of Health and Social Services; Gaulton, C., 

Vice President of Performance Excellence and General 

Counsel, Capital District Health Authority 


A10/B10: The Key to Improved Outcomes: 

Workforce Development 


The relationship-based system of care for which 

Southcentral Foundation (SCF) in Alaska is well 

known has increased health outcomes, decreased 

costs, and improved customer and employee 

satisfaction. Through its innovative approach 

to workforce development (WFD), SCF aligns 

individual employee performance with 

organizational goals and objectives in support 

of SCF’s mission and vision. Its comprehensive 

WFD system integrates human resources with the 

learning and development function, supporting 

employees from initial recruitment, on-boarding, 

and management to job progressions and 

career tracks. 


• Describe SCF’s innovative approach to 

comprehensive WFD 

• Identify how SCF aligns individual employee 

performance with organizational goals and 

objectives 

• Evaluate a variety of WFD methodologies in 

terms of how they could be synthesized into 


Sappah, B., Improvement Specialist, Southcentral 

Foundation 

What workshop are you enjoying? Tweet it using #IHI24Forum 

21

GENERAL 


tuesday 

DECEMBER 11 

A11/B11: Spur Your Safety Efforts C 

Harbor Beach 

Methods for improving care should reflect the 

complexity not only of patients’ perceptions but also 

of what happens inside health care organizations. 

Leaders need new skills in uncovering the hidden 

factors that shape an organization’s culture so that 

they can better understand why things happen the 

way they do in their organization. In this session, 

participants will learn how to instill a systemic and 

interdisciplinary patient safety approach throughout 

all points of the clinical environment that can 

result in more cohesive, patient-centered care. 


• Discuss how large-scale improvement efforts 

focused on safety support the Triple Aim 

• Describe the patient experiences and cultural 

issues that affect safety performance 

• Adapt for their organization the techniques that 

facilitate rapid adoption of leading practices 

Gelinas, L., RN, Vice President and Chief Nursing 

Officer, VHA Inc. 

A12/B12: Developing and Maintaining a 

High-Performance Workforce 


Presenters from the Henry Ford Health System, 

a Malcolm Baldrige winner, will describe the 

approach to workforce selection, development, 

and management that transformed their 

organization into a high-performing workplace. 

They will demonstrate how employee engagement 

dramatically improved and share a number of 

successful approaches, including wellness programs, 

reduced employee harm, implementation of a 

just culture, leadership development, engagement 

coaching, and talent selection. 


• Identify fundamental elements of HR processes 

that contribute to a high-performing culture 

• Recognize correlations between employee 

engagement data and quality outcomes 

• Use the just culture approach to managing 

employee behaviors 

Oswald, K., Chief Human Resources Officer, Henry 

Ford Health System; Jensen, L., RN, Director, 

Organizational and HR Development, Henry Ford 

Health System 

A13/B13: Personal Mastery for 

Transformational Leadership 


People are limited in how fast and how far they 

can change their habits, role patterns, and ways 

of relating and thinking, and they often react to 

transformational change with emotional tension 

and resistance. Faced with this key limitation on 

transformational change, leaders must take on the 

difficult task of simultaneously standing firm on 

decisions and individually engaging staff members. 

This workshop will present concepts and methods 

to enhance “personal mastery,” defined as sustaining 

continuous personal learning to create desired 

results. 


• Define the nature of adaptive change challenges 

and their human dynamics 

• Identify the key elements for facilitating 

changes in habits and patterns 

• Identify ways to exercise authority that also 

help to preserve positive engagement 

Baker, N., MD, Principal, Neil Baker Coaching and 

Consulting, LLC 

A14/B14: Engaging Physicians: Insights and 

Actions for Results M 


Gaining medical staff engagement in improving 

care is a central challenge in most settings. When 

physicians fail to lead or participate actively in 

improvement initiatives, staff typically resort to 

workarounds or spend time and energy convincing 

each physician that the new way will be better 

for their patients. This session explains how to 

move physicians from the periphery to the center 

in establishing leadership for safety and quality 

improvement. 


• Describe the impact of the quality of the 

organization-doctor relationship on physician 

engagement with improvement efforts 

• Identify management attitudes and behaviors 

that enable physicians to stay on the sidelines of 

care improvement efforts 

• Describe specific behaviors and steps to 

authentically engage physicians in creating and 

achieving an institution’s quality agenda 

Silversin, J., President, Amicus, Inc. 

motivate 

A15/B15: Mastering Change in Health Care 

Organizations: Strategic Intelligence and 

Profound Knowledge 


Leaders have followers; anyone who has no followers 

is not a leader. This workshop will present an 

overview of three key ideas for how leaders can 

enlist followers to help them transform their 

health care organization. 


• List the four key concepts behind strategic 

intelligence 

• Describe the elements of profound knowledge 

• Integrate improvement into the plans of their 

organization 

Norman, C., Improvement Advisor and Consultant, 

API; Maccoby, M., PhD, President, The Maccoby Group 

A16/B16: The Disparities Leadership Program: 

Implementing Strategies to Address 

Disparities M 

Key West 

The Disparities Leadership Program (DLP) is a 

year-long executive education program designed to 

assist leaders from health care organizations with 

a strategic plan or project to eliminate racial and 

ethnic disparities in health care. Three DLP 

participants will discuss the barriers and challenges 

to implementing and advancing strategies that 

address disparities, the role of the DLP framework 

in translating research findings into implementation, 

and their successes in their approaches. 


• Recognize the root causes of disparities in 

quality of care 

• Describe the approaches taken by a hospital, a 

health plan, and a health center to identify and 

address racial and ethnic disparities 

• Discuss the challenges, successes, and next steps 

in addressing health care disparities 

Betancourt, J., MD, Director, Disparities Solutions 

Center, Massachusetts General Hospital; Tan-McGrory, 

A., Deputy Director, Massachusetts General Hospital; 

Kini, M., MSW, System Director, Diversity and Inclusion, 

Texas Health Resources; Sala, M., Assistant Director, 

University of California Davis Health System 

A17/B17: The IHI Open School: Engaging 

Learners Across Health Professions in 

Improving Care Together S F 

Sawgrass 

Quality improvement (QI) is an organization-wide 

effort involving professionals in every department 

and at every level, both clinical and nonclinical. 

Partnering with multiple disciplines and professions 

is central to any successful QI effort. For those 

who teach QI, facilitating interprofessional 

collaboration on QI projects can be daunting. In 

this interactive session, participants will learn from 

faculty who are successfully teaching students 

and/or residents across health professions how to 

improve clinical care together and who have tested 

methods for involving multiple disciplines in 

their work. 


• Explain the key strategies needed to engage 

learners from multiple professions in QI 

• Describe at least one specific activity that 

motivates learners from across health 

professions to join together to improve care 

• Give examples of IHI Open School resources 

that support quality improvement projects in 

the multi-professional context 

22 


Madigosky, W., MD, Director, Foundations of Doctoring 

Curriculum, University of Colorado; Moses, J., MD, 

Director of Safety and Quality, Department of Pediatrics, 

Boston Medical Center 

A18/B18: Customized Emergency Room 

Operational Strategies for Low Acuity 

Miami 

It is an ER flow principle that patients who need 

few or no resources should not routinely be 

kept waiting behind patients who need multiple 

resources, no matter how heavy the ER patient 

volume. This workshop will present operational 

strategies to address the problems that result in 

low-acuity patients waiting in some ERs for two 

hours or more on average. ER designs and staffing 

models that can be customized to patient volume 

and patient mix will also be outlined. 


• Describe strategies based on ER volume that 

can be implemented in their ER to efficiently 

treat low-acuity patients (levels 3,4, and 5) 

• Identify specific strategies that could be applied 

in their ER 

Nolan, K., Statistician, Associates in Process 

Improvement; Jensen, K., MD, Chief Medical Officer, 

BestPractices, Inc.; Crane, J., MD, Faculty, IHI 

A19/B19: Parents and Patients as Partners in 

QI Work c 


Everyone benefits when health care professionals 

and families work together to improve care. 

Effective and lasting change comes from the 

collaborative efforts of those who use and know 

the system and the processes best: providers, 

patients, and their families. Using the Improving 

Hearing Screening and Intervention Services 

project of the National Initiative for Children’s 

Healthcare Quality (NICHQ) as a case study, 

this session will present successful strategies 

for involving family members as driving forces 

in improving services and programs on quality 

improvement teams. 


• Identify opportunities to include parents and 

patients as meaningful partners in quality 

improvement work 

• Deploy strategies to strengthen parent-provider 

partnerships 

• Develop a plan to include family members on 

their improvement teams 

Homer, C., MD, CEO, NICHQ; Guinnee, M., PhD, 

Project Director, NICHQ; DesGeorges, J., Executive 

Director, Hands & Voices 

A20/B20: Leadership Lessons from the 

Soccer Field F 


The job of leading change in health care is 

remarkably similar to that of a coach in a sports 

setting. Using humorous and engaging anecdotes 

from coaching girls’ soccer, the presenter will 

draw lessons for leaders in health care. Though 

recommended for soccer moms and dads, this 

session will present lessons that are applicable to all. 


• Articulate the principles of servant leadership and 

their application to building high-performance 

teams 

• Encourage frontline-driven process improvement 

in an organization 

• Productively use mistakes to inform process 

improvement 

Levy, P., Author and blogger 

get results 

A21/B21: Using Global Trigger Analytics: 

Adventist Health System Collaboratives c 


Adventist Health System (AHS) gathered data 

from 25 of its hospitals using a modified version 

of the IHI Global Trigger Tool methodology 

(used to identify and track adverse events). When 

the results indicated that hypo- and hyperglycemia 

were major causes of harm across the AHS system, 

AHS designed an interhospital collaborative to 

address these issues. The Glycemic Collaborative, 

which began in June 2010, has yielded results 

demonstrating significantly improved patient 

glucose levels. 


• Identify frequent hospital-acquired adverse 

events through the use of the IHI Global 

Trigger Tool 

• Use Global Trigger data to establish priorities, 

develop action plans, and target interventions 

• Implement interhospital collaboratives to target 

specific harms and track improvement data at 

the physician and unit levels 

Frankel, A., MD, Principal, Pascal Metrics Inc.; 

Bechard, D., MD, Chief Quality and Patient Safety 

Officer, Adventist Health System; Sammer, C., RN, 

Director, Quality and Patient Safety, Adventist Health 

System; Tonkel, J., Vice President, Pascal Metrics, Inc. 

A22/B22: Combating Surgical Site Infections 

(SSIs) in Hip and Knee Arthroplasty c 


Three evidence-based practices have been shown 

to reduce SSIs following hip and knee arthroplasty 

surgery: screening patients for staphylococcus 

aureus and decolonizing carriers with nasal 

mupirocin, bathing with chlorhexidine soap, and 

using an alcohol-containing preoperative skin 

disinfectant. Participants will learn from the work 

of the IHI initiative Project JOINTS ( Joining 

Organizations In Tackling SSIs) and be shown 

how to test and implement these interventions in 

their facilities. 


• Describe the rationale behind the three new 

elements of the enhanced surgical bundle 

• Define the elements of the enhanced surgical 

bundle and identify ways to assess current 

practices for each element 

• Identify how other hospitals have implemented 

the bundle elements in their facilities and glean 

ideas that can be applied to their organization 

Duncan, K., RN, Faculty, IHI; DiGioia, A., MD, 

Medical Director and Surgeon, UPMC; Hamlin, B., 

MD, Orthopedic Surgeon, Magee-Womens Hospital, 

UPMC; Yokoe, D., MD, Hospital Epidemiologist, 

Brigham and Women’s Hospital 

A23/B23: Closing the Health Disparity 

Gap by Delivering Equitable Care in 

Diverse Settings 


Blending evidence-based clinical practice guidelines 

with discrete, culturally tailored actions has 

reduced health care disparities among a diverse 

set of patients in various geographic and clinical 

environments. Using toolkits that integrate patient 

education through video, group visits, and on-site 

demonstration, paired with provider education, 

has led to quality improvement and better care 

for patients. Participants will leave the workshop 

with the tools to develop, implement, and replicate 

similar toolkits within their health system. 


• Develop culturally tailored and patient-centered 

toolkits to improve hypertension control and 

cancer screening in minority populations 

• Describe and use strategies to increase trust 

among patients through culturally competent 

interactions and care 

Wong, W., MD, Clinical Director, Kaiser Permanente; 

Gould, B., RN, Senior Director, Quality and Hospital 

Oversight, Kaiser Permanente 

A24/B24: Running Collaboratives: The Basics 

and Beyond 

Marco Island 

Learn how to run a collaborative from the 

collective experience of hundreds of organizations 

that have used IHI’s Breakthrough Series 

Collaborative model. In this interactive session, 

participants will explore the key design features of 

the traditional collaborative model, consider when 

and how to adapt the model to their setting, and 

gather tips about what to do—and what not to 

do—to achieve their collaborative goals. 


• Apply the key design features of the Breakthrough 

Series Collaborative model 

• Identify successful adaptive methods from 

national and international collaboratives 

• Anticipate challenges and incorporate strategies 

for maximizing results 

Schall, M., Senior Director, IHI; Murray, S., Improvement 

Advisor, CT Concepts; Delgado, P., Executive Director, 

IHI; Barker, P., MD, MB ChB, Senior Vice President, IHI 


23

GENERAL 


tuesday 

DECEMBER 11 

A25/B25: Taking the Triple Aim to the 

Next Level 


HealthPartners, long an innovative leader with a 

large portfolio of Triple Aim projects, uses its 

National Quality Foundation-endorsed Total 

Cost of Care methodology to prioritize projects 

so as to achieve the best impact on the health of 

patients and to yield the greatest cost savings. 

In this session, participants will learn how 

HealthPartners customizes its projects to patients 

by applying an experience lens. 


• Implement the Triple Aim in a strategic way to 

get results efficiently 

• Develop methods within their organization 

to prioritize and customize their Triple Aim 

projects around operational goals. 

McClure, N., Senior Vice President, HealthPartners; 

Waterman, B., RN, Chief Improvement Officer, 

HealthPartners; Knudson, S., Vice President, Health 

Informatics, HealthPartners 


A26/B26: Progress Across the Sepsis 

Spectrum 


This session will provide an update on the 

progress of the North Shore-Long Island Jewish 

Health System (NSLIJ) program in improving 

the recognition and treatment of sepsis and 

severe sepsis in the Emergency Department, the 

Intensive Care Unit, and other departments. 

The discussion will cover the results and lessons 

learned from the NSLIJ-IHI collaborative effort 

to accelerate sepsis mortality reduction. 


• Discuss the challenges involved in accelerating 

the reduction of sepsis mortality across a large 

hospital system 

• Describe the key strategies that have an impact 

on sepsis recognition 

Doerfler, M., MD, Vice President, Evidence-Based 

Clinical Practice, NSLIJ; D’Angelo, J., MD, Chairman, 

Emergency Medicine, Glen Cove Hospital; Parmentier, 

D., Director of Critical Care, Telemetry Emergency, 

Glen Cove Hospital; Jacobsen, D., Director, IHI 

A27/B27: Identifying Waste in the Acute 

Care Setting 


Waste—also known as “unexplained variation”— 

is consuming, spending, or employing without 

adequate return. With health care reform’s pending 

reimbursement cuts, hospitals must identify waste 

across the full spectrum of operational and clinical 

practices within the acute care setting. This 

workshop will explore the contributions to waste 

of metrics such as staffing, throughput, hospitalacquired 

complications, overutilization, pharmacy 

utilization, length of stay, readmissions, and 

nonstandardization of high-value supply items. 


• Define key waste components and their 

potential impact on their organization 

• Determine focus areas to remove excess waste 

from their operations 

• Prioritize ways of removing waste that have a 

positive impact on the bottom line 

Miller, D., Director, Operations Support, Premier, 

Inc.; Martin, J., Senior Director, Research Operations, 

Premier, Inc. 

NETWORKING OPPORTUNITIES 

The IHI National Forum provides many networking opportunities, 

at lunches, during breaks and receptions, while doing Yoga, and on 

Twitter using #IHI24Forum. Don’t miss these networking events: 


Monday, December 10 

3:30 PM – 6:30 PM 


Complimentary Yoga 

Tuesday, December 11 

6:00 AM – 7:00 AM 

Key Largo & Key Biscayne 

Informal Networking 

Tuesday, December 11 and 

Wednesday, December 12 

7:00 AM – 7:00 PM 

Solaris Deck 

Stop by the Solaris Deck 

for informal networking 

throughout the conference. 

Social Media 101 

Lunch n’ Learn 


12:40 PM – 1:20 PM 




4:30 PM – 6:30 PM 


Dine Arounds 


6:00 PM – 8:00 PM 

NEW! 



7:00 PM – 10:00 PM 

Solaris Deck 

Special Interest Breakfasts 


7:00 AM – 7:45 AM 

The Patient and Family 

Advisor Booth 

Monday, December 10— 


Crystal Foyer 

Meet with and learn from patients who are 

collaborating with health care providers, 

systems, practices, and boards to promote 

change that matters to patients and families. 

Patient and Family Advisor 

Q&A Sessions 

Patient Family Advisory Councils: 

How to Get Started 


12:30 PM – 1:30 PM 

Finding the Right Person for your 

PFAC 


12:30 PM – 1:30 PM 

Best Practices for Engaging Patients 

and Families in Your Work 


12:30 PM – 1:30 PM 

24 


apid-fire workshops 


RFC: Partnership for Patients Best Practices c 


Moderator: Joshi, M., President, Health Research & 

Educational Trust (HRET) 

C workshops 

1:30 PM – 2:45 PM 

C Workshops do not repeat. 

C WORKSHOPS 

innovate 

C2: Innovations in Elder Care 


In 2012, IHI, with the support of the Hartford 

Foundation, convened experts from health care and 

the community to articulate the system features 

and strategy needed to achieve better experience, 

better health, and lower cost per capita among 

older adults with complex needs. This workshop 

will report on the results, including the care model 

and next steps. Workshop participants will discuss 

the findings and offer real-world tests. 


• Provide perspective on a shared and actionable 

vision for older adults with complex needs 

• Plan activities within their own work 

environments 

Wong, W., Strategic Advisor, National Medicare Strategy 

Team, and Geriatrician, Kaiser Permanente; Hansen, J., 

RN, CEO, American Geriatrics Society, and IHI Board 

Member 

C3: (Re)Imagining the Care Experience 


(Re)imagining empowers us to enhance patient 

care experiences as well as increase joy at work for 

those providing care. In this workshop, presenters 

from Kaiser Permanente (KP) will share a 

successful strategic framework for improvement 

that incorporates evidence-based practices and a 

model for innovation and reliable implementation. 

Participants will learn how ongoing efforts to 

increase KP’s focus on patient- and family-centered 

care and improve the care experience through the 

use of evidence-based practices have improved its 

HCAHPS scores. 


• Describe key elements of innovation that can 

lead to profound changes in care delivery and 

staff satisfaction 

• Apply evidence-based concepts, such as nurse 

knowledge exchange plus and hourly rounding, 

to enhance patient-centered care 

Chow, M., RN, Vice President, National Patient Care 

Services, Kaiser Permanente; Romer, D., Vice President, 

Kaiser Permanente; Burlingame, E., Senior Director, 

Service Performance and Strategy, Kaiser Permanente; 

McCarthy, C., Director, Innovation Learning Network, 

Kaiser Permanente 

C4: Health 2.0: Patients as Health Care 

Team Members 

Vinoy 

In 2009, two medical specialists from the 

Netherlands founded MijnZorgnet, a service 

provider that combines personal health record 

information and communication tools by means 

of online health communities (OHCs). OHCs 

support participation, coordination, and 

communication between patients, their caregivers, 

and their health care professionals. First evaluations 

show positive changes in care experiences. 

Participants in this workshop will learn about 

organizing care from the patient’s perspective and, 

in making patients active partners in the health 

care team, creating opportunities to address 

medical and psychosocial needs. 


• Identify tools that can be integrated into care 

delivery to stimulate patient self-management 

• Develop an implementation strategy for OHCs 

in a clinical practice from the perspective of 

health care organizations and patients 

Faber, M., PhD, Senior Research Fellow, Radboud 

University Nijmegen Medical Centre; Kremer, J., MD, 

PhD, Gynecologist, Radboud University Nijmegen 

Medical Centre 

C5: Pediatric Care Plans for Medical 

Neighborhoods M P 


Traditional care plans and care coordination have 

been focused on medical care. In this session, faculty 

will present care plans and care coordination 

developed and used by teams in the Massachusetts 

CHIPRA Medical Home Demonstration Learning 

Collaborative that include the physical, mental, 

oral, and community resources that support 

children with complex conditions. Participants will 

learn how these care plans integrate medical care 

with other elements of care and facilitate the move 

from the medical home to the medical neighborhood. 


• Identify the key elements of comprehensive care 

plans that include medical and other elements 

of care for children with complex physical and 

mental health conditions 

• Specify the role of this type of care plan from 

the perspective of the provider, the family, and 

the community 

keynote two 

3:15 PM – 4:15 PM 


Anna Deavere Smith, 

Actress, Playwright, 

and Professor 

special interest keynote 

C1: Minimally Disruptive Medicine 

1:30 PM – 2:45 PM 


Montori, V., MD, Director, Mayo 

Clinic Healthcare Delivery Research 

Program and Professor of Medicine, 

Mayo Clinic 


25

GENERAL 


tuesday 

DECEMBER 11 

• Develop a comprehensive care plan template for 

use in their own community 

Anand, S., MD, Physician Champion, National 

Initiative for Children’s Healthcare Quality (NICHQ); 

Taylor, J., Improvement Advisor, IHI; Homer, C., MD, 

CEO, NICHQ; Lind, C., Family Leader and CHIPRA 

Project Associate, Massachusetts Family Voices 

C6: SAFER: Safety Assurance Factors for 

Electronic Health Record (EHR) Resilience M 


As part of the ongoing commitment to patient 

safety in EHR-enabled health care settings, the 

Office of the National Coordinator (ONC) for 

Health Information Technology sponsored the 

2011 Institute of Medicine report Health IT and 

Patient Safety: Building Safer Systems for Better 

Care; an expert panel on the negative unintended 

consequences that may result from rapid EHR 

adoption; and a new project to develop a series 

of checklist-type instruments and best-practice 

guidance for both the inpatient and ambulatory 

settings. This project, entitled SAFER (Safety 

Assurance Factors for EHR Resilience), addresses 

several areas of risk related to the computerized 

ordering process, correct patient identification, 

clinical decision support, system-to-system 

interfaces, communication across transitions of 

care, laboratory results review, downtime events, 

and EHR safety-related human skills. 


• Explain the rationale for a multifaceted, 

socio-technical approach to safe EHR use 

• Describe the changing landscape of safety in 

EHR-enabled work systems 

• Discuss SAFER, an ONC-funded project to 

develop tools to improve safety in an 

EHR-enabled work system 

Sittig, D., PhD, Professor, University of Texas Health 

Science Center–Houston; Singh, H., Researcher, Baylor 

College of Medicine 

C7: Person-Centered Health IT— 

The Next Level 


As more and more high-performing health care 

organizations around the world focus on patientcentered 

care, the ambition to improve quality 

increases as well. Organizations are increasingly 

exploiting health information technology (IT) to 

support their efforts. Expert faculty in this session 

will help participants consider what is generalizable 

from the early adopters of health IT to support 

their own patient-centered care and improve the 

services they offer to patients. 


• Summarize the role of health IT in 

patient-centered care 

• Recount the international experience of 

patient-centered health IT 

• Identify the key elements of patient-centered 

health IT and use these elements to assess their 

organization’s progress 

Adams, L., President and CEO, Rhode Island Quality 

Institute; Robson, B., MB ChB, Medical Director, 

NHS Scotland; Hunt, J., PharmD, Chief Quality and 

Information Officer, Bellin Health 

C8: Motivating Health System Redesign: 

Using Public Data to Identify Local 

Opportunities for Improvement 


This workshop will discuss the use of publicly 

available health system performance data to identify 

opportunities for local health system improvement. 

The Commonwealth Fund’s 2012 Scorecard 

on local health system performance and its 

accompanying suite of online data tools will 

provide a framework for the discussion. Faculty 

will present examples of real-world improvement 

experiences that built on Scorecard and other 

public data to identify potential improvement 

opportunities at the system level and then will 

highlight the specific processes that benefited 

most from targeted improvement efforts and 

interventions. 


• Describe new sources of publicly available data 

that may help identify opportunities for 

improvement in their community or health system 

• Explain the use of publicly available health 

system and population health data to develop 

improvement plans 

• Think critically about data source strengths and 

weaknesses 

Radley, D., PhD, Senior Health Policy Analyst, IHI 


C9: Local Collaboratives for Engagement 

and Success 


Engaging staff across many disciplines—from 

housekeepers to physicians—can be challenging. 

This session will describe how faculty adapted the 

Breakthrough Series Collaborative model for use 

on a smaller scale—within a single hospital and 

with only two-hour meetings—and yet achieved 

significant success, both in results and with 

individual staff development. 


• Run a successful “mini-collaborative” series to 

achieve success with limited time and resources 

• Promote staff engagement at all levels and 

provide opportunities for individual 

development 

• Innovate using ideas from frontline clinical and 

nonclinical staff 

Peden, C., MD, MB ChB, Associate Medical Director 

for Quality Improvement and Consultant in Anaesthesia 

and Intensive Care, Royal United Hospital, Bath; Miller, 

J., RN, Assistant Director of Nursing, Royal United 

Hospital NHS Trust 

C10: The Human Perspective: Essential in 

Self-Dialysis P 

Key West 

In the self-dialysis setting, patient involvement 

and cooperation lead to greater understanding 

and knowledge. Self-dialysis allows patients to run 

the dialysis instead of the dialysis running their 

lives, and the result is healthier patients, a higher 

quality of life, fewer readmissions, and reduced 

infections. Participants will learn more about this 

win-win situation for patients and professionals 

as the workshop presents a unique learning model 

for self-dialysis patients. 


• Create patient-provider partnerships 

• Tailor chronic care to individual needs 

in dialysis 

Farman, C., RN, Registered Nurse, County Hospital 

Ryhov; Banck, B., RN, Deputy Chief Nurse, County 

Hospital Ryhov 

C11: Developing Physician Leaders 

Internally 


Physicians often step into leadership roles without 

a formal background in hospital operations or 

leadership skills. In this workshop, faculty will 

share lessons from an internally managed leadership 

development program designed to increase the 

pipeline of midcareer physicians prepared to 

lead change in rapidly evolving health systems. 

Participants will hear how competitively selected 

emerging physician leaders brought real-time 

problems to project instructors, certified coaches, 

and physician mentors to find solutions that 

worked in an organizational culture and 

strengthened the physician leader’s developing 

skill set. 


• Identify key components of a program to 

develop physician leaders 

• Develop practical strategies for internally 

identifying future physician leaders and helping 

them to achieve success 

Sands, K., MD, Senior Vice President, Health Care 

Quality, Beth Israel Deaconess Medical Center; 

Wasserman, A., Leadership Development Program 

Manager, Beth Israel Deaconess Medical Center; Ayoub, 

J., Director of Organizational Development, Beth Israel 

Deaconess Medical Center 

26 


C12: Measuring Improvement 


Many teams struggle to select an effective set of 

measures to track improvement without missing 

important trends or getting lost in a host of 

irrelevant data. This session will present a 

structured approach to answering the 

“measurement question,” beginning with an 

explicit theory of improvement, priorities for 

interventions, and identification of key outcome 

and process indicators. We will also review the 

relationship between outcomes, project measures, 

and PDSA measures. 


• Differentiate measurement for improvement 

from measurement for research 

• Use a driver diagram to identify key 

interventions for improvement 

• Discuss the relationship between process and 

outcome measures 

Scoville, R., PhD, Improvement Advisor, IHI 

C13: Want to Engage Patients? Let’s Talk! 

S F C P 


In this workshop, a panel of experienced consumer 

patient safety advocates will discuss their success in 

moving the patient safety bar forward by working 

with multiple stakeholders and will offer valuable 

suggestions about how to engage patients and 

families. Participants will leave this interactive 

session empowered to give patients and their 

families what they want most: To be at the center 

of the design and delivery of their care. 


• Recognize the value of patient and family 

perspectives in the design, delivery, and 

outcome of care 

• Identify effective strategies to engage patients 

and families on a variety of patient safety issues 

• Develop strategies to use patient engagement 

to improve their organization’s patient safety 

culture 

Haskell, H., President, Mothers Against Medical Error, 

and IHI Board Member; Rexford, J., Executive Director, 

CT Center for Patient Safety; Nerbonne, L., RN, 

Group Leader, NH Patient Voices 

motivate 

C14: Acting as One for One Million: 

Hoshin Planning in Saskatchewan, Canada M 


Determining goals, establishing improvement 

plans and measures, and engaging people 

throughout an organization can be challenging. 

Try doing all that for an entire provincial health 

system! Driven by an unrelenting ambition to 

achieve better health, better care, better value, and 

better teams, Saskatchewan health care providers, 

leaders, and governors are thinking and acting 

differently. This session will describe Saskatchewan’s 

emerging efforts with Hoshin Planning—a key 

chapter in their continuing story of whole system 

transformation. 


• Describe the key attributes of a strategic 

planning process that embraces continuous 

improvement principles and puts those who use 

the health system first 

• Identify how Hoshin Planning can be used 

to build a shared narrative, create inspired 

cultures, and facilitate health system 

transformation 

• Apply these tools and learnings in other health 

systems 

Brossart, B., CEO, Health Quality Council; Laurent, 

S., RN, President and CEO, Sunrise Health Region; 

Rhode, J., Chairperson, Saskatoon Health Region; 

Florizone, D., Deputy Minister, Government of 

Saskatchewan Ministry of Health 

C15: Centers for Disease Control and 

Prevention (CDC) and IHI Antibiotic 

Stewardship Pilot Testing 

Aruba/Bahamas 

This session will describe the results of pilottesting 

the practicality and ease of implementation 

of a framework developed in partnership by the 

CDC and IHI for improving patient outcomes by 

optimizing antimicrobial use. Faculty will share 

the progress and results of the initial eight pilot 

hospitals in testing recommendations designed to 

support hospitals across the country (regardless 

of size, acuity, and location) in their efforts to 

improve patient care, reduce adverse events, and 

decrease costs related to antibiotic utilization. 

Efforts to develop effective models where antibiotic 

stewardship interventions are led by specialists in 

hospital medicine will also be discussed. 


• Describe the results of pilot-testing the CDC/ 

IHI framework for reducing inappropriate 

antibiotic utilization 

• Discuss progress toward developing effective 

models of hospitalist-led antimicrobial stewardship 

initiatives 

Jacobsen, D., Director, IHI; Septimus, E., MD, Medical 

Director, Infection Prevention and Epidemiology, 

HCA; Srinivasan, A., Medical Epidemiologist, CDC; 

Flanders, S., MD, Professor of Medicine, University of 

Michigan Hospital and Health System 

C16: Transformational Leadership: 

A New Mindset 


The key to all improvement is senior leadership’s 

ability to be focused, intentional, transparent, 

and available in real time to frontline leaders and 

staff. Catholic Health Partners’ Mercy Lorain 

collaborated with IHI’s Safety Across the System 

initiative to incorporate its principles of testing 

change and spreading success into its already robust 

quality operating system and executive safety 

walk-rounds. The result has been a 

culture-changing approach to daily problem-solving 

that has demonstrated continuous improvements 

in quality, patient safety and experience, and 

throughput. 


• Develop an accountability process for 

leadership rounding and staff participation 

• Identify a quality operating system that 

integrates leadership and staff in a system of 

learning and improvement 

• Summarize clinical and leadership successes 

that can result from a new mindset 

Oley, E., RPh, President and CEO, Mercy; White, E., 

Vice President, Operations and Systems Effectiveness, 

CHP Regional Medical Center; Stephens, J., RN, 

Vice President, Quality and Post Acute Services, CHP 

Regional Medical Center 

C17: Contra Costa Health: Getting Lean— 

Designing an Engaged Ambulatory Care 

Delivery System 

Marco Island 

This session will describe key lessons learned by 

Contra Costa Regional Medical Center and 

Health Centers in its effort to transform and 

reinvent its ambulatory delivery system. Topics 

will center on empowering patient participation, 

using lean principles, and engaging leadership in 

ambulatory care redesign, including transitions 

in care, improved patient access, and creation of a 

patient-centered medical home. 


• Describe mechanisms for engaging patients and 

staff as frontline leaders in transforming the 

ambulatory care delivery system 

• Identify barriers and challenges in an 

environment of change 

• Discuss strategies to overcome these barriers in 

pursuit of developing a replicable model clinic 

Tzvieli, O., MD, Staff Physician, Contra Costa Regional 

Medical Center; Palmer, N., MD, Antioch/Brentwood 

Division Head, Department of Family Medicine, Contra 

Costa Regional Medical Center; Kotchevar, M., RN, 

Process Improvement Specialist, Contra Costa Regional 

Medical Center; Toledo, C., Population Health 

Specialist, Contra Costa Regional Medical Center 

get results 

C18: Achieving High Reliability in Health 

Care C F 


Health care organizations are adopting the high 

reliability methods used to ensure safety in other 

industries, such as commercial aviation, and 

applying them to clinical safety and quality issues. 

Called Robust Process Improvement (RPI), 

these methods offer a systematic approach to 

dissecting complex safety problems and 

subsequent deployment of focused, highly 

effective solutions. In this workshop, attendees 

will learn how RPI has been used to reduce health 

care–acquired infections, readmissions, and the 

risk of wrong-site surgery. 


27

GENERAL 


tuesday 

DECEMBER 11 


• Articulate the difference between best practices, 

one-size-fits-all solutions, and the targeted 

solutions developed through RPI 

• Replicate results achieved by other 

organizations using RPI methods 

• Develop an approach to involve physicians as 

leaders in RPI 

Vandiver, A., Director and Master Black Belt, The Joint 

Commission; Benedicto, A., Executive Vice President, 

Support Operations and Chief of Staff, The Joint 

Commission; Pujols McKee, A., MD, Executive Vice 

President and Chief Medical Officer, The Joint Commission 

C19: Applying Lean in a Skilled 

Nursing Facility F 

Anaheim 

Virginia Mason Medical Center uses Lean—also 

known as the Toyota Production System(TPS)— 

in managing and fundraising for Bailey-Boushay 

House, a skilled nursing facility and a national 

model of care for people with HIV/AIDS and 

other end-of-life issues. The TPS tools have been 

deployed at Bailey-Boushay House to create 

visibility, promote standardization, and eliminate 

defects in processes, including medication 

administration, supply ordering, food tray delivery, 

special events, and major gift work. 


• Describe the use of Lean principles to improve 

clinical and administrative functions in 

long-term care 

• Identify the role of Lean principles in enhancing 

fund development and relationship building 

with major donors 

Vanderhoef, M., President, Virginia Mason Foundation, 

Virginia Mason Medical Center; Knowles, B., Executive 

Director, Bailey-Boushay House, Virginia Mason 

Medical Center 

C20: How to Succeed with a Comprehensive 

Harm Reduction Initiative C 


This workshop will reveal the secret sauce involved 

in achieving national best practice in reducing 

patient and employee harm. Success factors will 

be shared from three different perspectives. First, 

participants will learn how Henry Ford Health 

System achieved a 31% reduction in all cause 

harm events and a 40% reduction in hospital 

mortality systemwide. Then best practices from 

high-performing hospital engagement networks 

(HENs) will be discussed in the Centers for 

Medicare and Medicaid Services demonstration. 

Finally, participants will learn from the experience 

of Michigan Keystone’s critical access hospitals. 


• Share implementation process for a successful 

large-scale harm reduction campaign 

• Identify opportunities for smaller critical 

access hospitals 

Conway, W., MD, Senior Vice President and Chief 

Quality Officer, Henry Ford Health System; Jordan, J., 

Deputy Director, Partnership for Patients, Centers for 

Medicare and Medicaid Services; Watson, S., Senior 

Vice President, MHA Keystone Center 

C21: Eliminating Hospital-Associated 

Infections (HAI): Can It Be Done? C 

Harbor Beach 

Like polio and other infections, hospital-associated 

infections can be eliminated. To do so, we must 

implement evidence-based medicine, align incentives 

and legislation, standardize measurement and 

reporting, and develop local collaborations. 

Working with these strategies, many communities 

and states, such as Tennessee, have overcome 

barriers. Ultimately, we must create a vision of 

a health care system with sustainable HAI 

elimination programs so that HAIs become rare. 


• Convince health professionals that we can 

create a health care system with a sustainable 

HAI elimination program 

• Deploy strategies such as aligning incentives 

and using innovative models for knowledge 

transfer to eliminate HAIs in their setting 

Jain, M., MD, Medical Director of Quality Improvement, 

Quality Improvement Organization; Cardo, D., MD, 

Director, Centers for Disease Control and Prevention 

C22: How Can Payers Drive Quality in Large 

Health Systems? 


Health financing reforms are a powerful tool to 

expand access to care and improve the quality of 

care for a country’s population. A range of tools 

are at the disposal of payers to drive quality— 

quality planning, quality control, and quality 

improvement all have a role to play. But how do 

payers integrate and implement these strategies 

and measure their effectiveness? This workshop 

will describe how different countries have 

approached this question, and a panel discussion 

will give participants an opportunity to hear from 

those who are in the “hot seat” of decision-making. 


• Explain the role of public and private payers in 

improving the quality of health systems 

• Describe two tools available to payers to 

monitor and improve quality 


Mate, K., MD, Faculty, IHI 

C23: Memorial Hermann’s Zero Harm 

Journey C 

Sawgrass 

This workshop will describe Memorial Hermann’s 

(MH) journey toward becoming a high reliability 

organization. Although all MH employees receive 

formal training in high reliability behaviors, this 

journey represents a culture change rather than 

a set of new techniques. MH’s goal is zero harm 

to patients. Participants will learn how MH 

celebrates when hospitals reach annual milestones 

of zero hospital-acquired infections and about its 

handling of patient safety indicators and serious 

safety events. 


• Describe high reliability principles and 

practices that are critical to quality and safety 

• Recognize leadership and patient care behaviors 

that protect patients from harm 

Wolterman, D., President and CEO, Memorial 

Hermann; Shabot, M., MD, Senior Vice President and 

System Chief Medical Officer, Memorial Hermann; 

Cannon, D., Memorial Board Chair, Memorial Hermann 


C24: How Do We Know What We 

Don’t Know? M 


Organizations frequently ask, “what will go wrong 

next?” This workshop presents a methodology, 

developed at Cedars-Sinai Medical Center with 

IHI faculty and based on frontline analysis, that 

enables organizations to answer that question 

predictively and proactively. 


• Summarize the ways in which small common 

frontline defects can cause major safety events 

• Use a methodology to detect small frontline 

problems using anchoring questions 

Resar, R., MD, Senior Fellow, IHI; Luther, K., RN, 

Vice President, IHI; Kashiwagi, D., MD, Hospitalist, 

Mayo Clinic; Romanoff, N., MD, Vice President of 

Medical Affairs, Cedars-Sinai Medical Center 

C25: The IACT Program: Medical Disclosure 

and Transparency F 


When unexpected adverse medical events occur, 

patients and doctors need a safe and supportive 

process for disclosure and transparency to help 

them cope with the resulting physical, emotional, 

and financial stress. In the aftermath of such an 

event, the organization needs to improve process 

and system design to make care safer. In this 

workshop, participants will hear the perspectives 

of a patient and a family member. The IACT 

(Integrated Accountability and Collaborative 

Transparency) Program, a powerful disclosure 

model, will also be explained and shared. 

28 



• Explain the emotional, physical, and 

reputational harm that often results from 

medical errors for patients, families, and health 

care professionals 

• Describe the potential psychological impact 

of litigation on patients and health care 

professionals 

• Understand the potential outcomes and remedies 

possible with the IACT Program as opposed to 

the court system 

Scott, J., MD, Director of Healthcare ADR Innovation, 

Carolina Dispute Settlement Services; Micalizzi, D., 

Pediatric Patient Safety Advocate and Consultant, Task 

Force for Child Survival and Development 

C26: The Eye of the Storm: Emergency 

Response to Hurricanes 

Miami 

During the first hurricane to hit the New York 

metropolitan area in 26 years, employees and 

physicians from the North Shore–Long Island 

Jewish Hospital System established a safe haven for 

more than 1,300 patients, outside nursing home 

residents, and others seeking shelter. Participants 

will learn about the extraordinary display of 

leadership, teamwork, and advanced emergency 

preparedness that allowed nearly 1,000 patients 

from Staten Island Hospital, Southside Hospital, 

and other hospitals and nursing homes to be 

safely evacuated. 


• Describe the steps necessary to ensure the safety 

of patients, employees, and the community 

during multiple emergency hospital evacuations 

• Discuss the role of the emergency command 

center and the vital aspects of ongoing internal 

and external communication 

Jarrett, M., MD, Chief Quality Officer, North Shore– 

Long Island Jewish Hospital; Solazzo, M., Executive 

Vice President and COO, North Shore–Long Island 

Jewish Hospital 

C27: Patient-Centered Leaders as 

Value Creators 


This session focuses on the game-changing and 

market-differentiating potential of leaders seeking to 

create high-value care. Deploying the transformative 

power of a value creation system—bolstered by 

force-multiplying staff engagement—leaders are 

able to establish a solid business case. Mayo Clinic’s 

experience will be shared as one that demonstrates 

a hard-dollar financial return on leadership 

development, social capital, and quality 

infrastructure investment. 


• Establish a solid case that quality is a business 

strategy, not an expense 

• Describe the transformative power of the Mayo 

Clinic value creation system 

• Articulate the game-changing potential of 

growing social capital 

Swensen, S., MD, Medical Director, Leadership and 

Organization Development, Mayo Clinic 

GREEN INITIATIVES 

IHI continues to make a concerted effort to reduce the environmental impact of the 

National Forum and all IHI events. In year seven of this effort, you may notice the 

following changes: 

• All presentations made available to IHI by presenters before the conference 

will be available on www.IHI.org to participants. Participants need to log in 

and then click on “My IHI” at the top of the screen, navigate to “My Enrollments 

and Certificates,” and find the link under “24th Annual National Forum on 

Quality Improvement in Health Care” for “Materials/Handouts.” Paper 

handouts will not be provided for any session. If you would like paper 

handouts, please print your materials before your arrival or visit a printing 

kiosk in the Los Angeles meeting room. 

• The entire meeting space will have high-speed wireless Internet access. We 

encourage participants to bring their laptops to their sessions to take notes and 

view presentations. Meeting rooms will be set up with work tables whenever 

possible. 

• IHI works with the conference center to eliminate waste from paper and 

plastic food packaging and to use local and organic food products whenever 

possible. 

• Food not consumed by attendees will be donated to a local food bank. 

• Exhibit Hall giveaways and other meeting supplies that are not distributed will 

be donated to local elementary and middle schools. 

• Recycling containers will be made available for recyclable meeting materials 

and catering items. 

• Transportation to the airport at the close of the conference will be available to 

attendees in an effort to offset our carbon footprint by ride-sharing. 

We encourage you to stop by the registration desk to give us your feedback on how 

we can continue to reduce the IHI National Forum’s impact on the environment. 


29

GENERAL 


wednesday 

DECEMBER 12 

keynote three 

8:00 AM – 9:00 AM 


Dan Heath, 

Best-selling Author and 

Senior Fellow, Duke 

University CASE Center 


D1: The Conversation Project 

9:30 AM – 10:45 AM 



Ellen Goodman, Pulitzer Prizewinning 

Journalist and Founder, 

The Conversation Project 

E1: The Role of Health Care in 

Reducing Health Disparities 

11:15 AM – 12:30 PM 



David Satcher, MD, PhD, Director, 

Satcher Health Leadership Institute 

and Center of Excellence on Health 

Disparities, Morehouse School 

of Medicine 

rapid-fire workshops 


RFD: Creating the Culture for Innovation 


Moderator: Kabcenell, A., Vice President, IHI 

LATE BREAKING SESSION: Out of the Blocks: 

Strategies for a Post-Election Era 


In November, leaders in health policy and health care 

gathered in Washington at an IHI event to respond 

to this fact: What has been interpreted by many as 

a status quo election is anything but for health care. 

The election confirmed that the Accountable Care 

Act and reform will accelerate. Conversations and 

perspectives shared by political and health leaders at 

the November event were informative and sobering, 

inspiring and energizing. In this session, hear what 

the insiders and leaders are currently predicting and 

planning, and start to make your own strategy for 

the change on the horizon. 


• Analyze the strategies and tactics shared by leaders 

from ACOs, hospitals, physicians groups and 

safety net organizations for 2013 and beyond. 

• Plan an approach that will help them meet the 

most pressing challenges for their organization. 

Moderator: Pugh, M., Principal, MDP Associates, and 

Senior Faculty, IHI 

D workshops 

9:30 AM – 10:45 AM 

E workshops 

11:15 AM – 12:30 PM 

All D workshop presentations 

repeat during E workshops. 

D/E WORKSHOPS 

innovate 

D2/E2: Political Pressure: A Barrier to Safety 

in Health Care Systems P 

Harbor Beach 

Numerous high-profile inquiries in the United 

Kingdom, the Netherlands, Australia, and the 

United States have revealed subtle and overt external 

pressures that enable and support unsafe care. 

Understanding these political pressures to execute 

a government policy regardless of evidence on quality 

of care is essential to transforming health care 

systems. This workshop will review the key findings 

and recommendations from these inquiries and 

identify ways to overcome the barriers to 

improvement being replicated around the world. 


• Identify the barriers that have contributed to 

patient harm in national inquiries and appreciate 

the influence of external political pressures 

• Review the professional commitment to protect 

patients 

• Articulate the consequences of a culture of 

blame and secrecy and its effect on patient safety 

Jarman, B., PhD, Senior Fellow and Emeritus 

Professor, Imperial College London; Bailey, J., Founder 

of Cure, NHS; Barach, P., MD, Professor, University of 

Stavanger 

D3/E3: Delivering Value with Experience- 

Based Design of Care F 


In this workshop, participants will learn how to 

apply the new experienced-based design that 

improves care experiences and may be the new 

operating system for health care. The workshop will 

demonstrate how to tap into existing resources and 

co-design care with patients, families, and caregivers 

to improve outcomes and efficiencies while reducing 

waste and cost. Participants will also learn how to 

identify opportunities for improvement, develop 

solutions, and operationalize changes that transform 

care and change cultures. 


• Develop a new operating system for care 

delivery that puts the patient at the center 

• Co-design care delivery by viewing all care 

through the eyes of patients, families, and 

caregivers 

Di Gioia, A., MD, Medical Director and Surgeon, 

UPMC; Giarrusso, M., RN, Director of Patient and 

Family Centered Care, University of Pittsburgh 

D4/E4: Pursuing the Triple Aim: Seven 

Innovators Show the Way to Better Care, 

Better Health, and Lower Costs 


The Triple Aim is both an IHI program and an idea, 

and for an increasing number of organizations 

it is their “true north.” No one organization 

anywhere has fully achieved the goal, yet many are 

well along the pathway to success. This session will 

discuss seven innovators from various parts of the 

United States whose work helps them in their journey 

toward the Triple Aim, defined as simultaneously 

improving the experience of care, improving the 

health of a population, and decreasing per 

capita costs. 


• Describe the thinking that led to the development 

of the Triple Aim 

• Discuss the results and experiences of several 

organizations that have pursued the Triple Aim 

Bisognano, M., President and CEO, IHI; Kenney, C., 

Author 

30 


special interest breakfasts 


Network with colleagues and discuss a variety of improvement 

topics over breakfast! Special Interest Breakfasts (SIBs) are 

informal group conversations led by an expert facilitator. 

SIB1: Force Multiplier: Using Constraints Management to Take 

Operational Excellence to Dramatic New Levels 


Facilitators: Halder, R., MD, Rear Admiral, US Navy (Ret), Executive Medical 

Consultant, NOVACES, LLC; Makaroff, J., Senior Business Consultant, 

NOVACES, LCC; Ross, T., RN, Lean Six Sigma Program Coordinator, 

St. Alexius Medical Center 

SIB2: Managing Overutilization of Inpatient High-Tech Imaging: 

The Next Generation UM for Your Third Largest and Fastest 

Growing Cost Center 


Facilitators: Seidelmann, F., MD, Founder, CMO, and Chairman of 

Neuroradiology, Radisphere National Radiology Group; Seidelmann, S., 

CEO, Radisphere National Radiology Group; Schlissberg, H., Chief 

Strategy Officer, Radisphere National Radiology Group 

SIB3: Interprofessional Education and Quality Improvement 


Facilitator: Schoenbaum, S., MD, Special Advisor to the President, Josiah 

Macy Jr. Foundation 

SIB4: Mejorando la Calidad de la Salud en Latinoamérica: 

Diálogos y Visiones 

Miami 

Facilitators: Ruelas, E., MD, Vice President of the National Academy of 

Medicine and Senior Fellow, IHI; Delgado, P., Executive Director, IHI 

SIB5: Mapping Your Performance and Reaching for the Best: 

The Commonwealth Fund’s WhyNotTheBest.org 


Facilitator: Audet, A., MD, Vice President, Health System Quality and 

Efficiency, The Commonwealth Fund 

SIB6: Children’s Hospitals Working Together to Eliminate 

Serious Harm 


Facilitator: Muething, S., MD, Vice President for Safety, James M. Anderson 

Center for Health Systems Excellence, Cincinnati Children’s Hospital 


SIB7: Using Technology to Bridge the Gap Between Hospitals, 

Payers, and Patients 


Facilitators: Merlino, J, MD, Chief Experience Officer, Cleveland Clinic; 

Dolin, J., Co-Founder, Emmi Solutions 

SIB8: Sustainability and the Healthy Hospital Initiative 


Facilitators: Sadler, B., Senior Fellow, IHI; Wadwha, S., Director, Healthier 

Hospitals Initiative 

SIB9: New Frontiers in Pursuing the IHI Triple Aim 


Facilitators: Beasley, C., Executive Director, Strategic Projects, IHI; 

Lewis, N., Director, IHI 

SIB10: The Conversation: Starting with You 


Facilitators: Hayward, M., Lead, Patient and Family Engagement, IHI; 

Luther, K., RN, Vice President, IHI; McCannon, J., MD, Research Fellow 

in Medicine, Massachusetts General Hospital; McCutcheon Adams, K., 

LICSW, Director, IHI 

SIB11: Fellowship Opportunities at IHI 


Facilitator: Goldmann, D., MD, Senior Vice President, IHI 

SIB12: The Path to Clinical Integration and Physician Alignment 

Marco Island 

Facilitators: Kaneski, T., RN, Manager, Clinical Integration, Edward Hospital; 

Smith, B., DO, Vice President of Clinical Integration and Chief Medical 

Officer, Edward Hospital 

SIB13: Influencing Change: How Do You Develop a Personal and 

Organizational Practice? 

Harbor Beach 

Facilitators: Sevin, C., RN, Director, IHI; Baker, N., MD, Principal, Neil 

Baker Coaching and Consulting, LLC 

SIB14: AHRQ Health Care Innovations Exchange: Innovations and 

Tools to Improve Quality and Reduce Disparities 

Sawgrass 

Facilitator: Gray, L., Research Associate, WESTAT 

SIB15: Equity, Diversity, and Inclusion in Health Care: The Time 

is Now 


Facilitators: Clark, C., MD, Lead for EMR Benefit Realization, Bon Secours 

Health System; Coghill, Y., National Lead, Leadership for Equality, National 

Health Service, United Kingdom 

SIB16: Passport Special Interest Breakfast 

Vinoy 

Facilitator: Duncan, K., RN, Faculty, IHI 

SIB17: Alternative Workforces to Improve Patient Health 


Facilitators: Garson, A., MD, Chairman, The Grand-Aides Foundation; 

King, S., Managing Partner, Starfield Consulting and Special Advisor, South 

Georgian Bay Collaborative; Behforouz, H., MD, Executive Director, PACT 

Project, Partners in Health; Sarker, S., Chief of Staff to the CEO, Health 

Leads 

SIB18: Provider-Specific Challenges to Improving Quality and 

Reducing Cost 

Aruba/Bahamas 

Facilitators: Gundling, R., Vice President, Healthcare Financial Practices; 

Mulvany, C., Technical Director, Healthcare Financial Management 

Association 

SIB19: Determining Operational Barriers to Optimized 

Organizations 


Facilitators: Longe, M., Director, AHA Solutions; Simpson, S., Senior Field 

Representative, AHA Solutions 


31

GENERAL 


wednesday 

DECEMBER 12 

D5/E5: A National Platform for Spurring 

Innovation Spread 


The United States faces challenges around 

affordability, access, and disparities in health care 

that cannot be met without transformative change. 

Organizations need to spread innovations and 

learn from each other quickly, while embracing the 

information age. As an integrated delivery system 

with eight autonomous multi-specialty medical 

groups, Kaiser Permanente (KP) has developed 

a national structure for identifying and spreading 

quality improvement best practices and innovations. 

Learn how this experience provides KP with a 

platform to accelerate improvements in affordability 

and efficiency. 


• Draw lessons from KP’s experience that can be 

applied within their own organization 

• Implement a structure to spread best practices 

in quality improvement 

• Translate this structure to accelerate 

improvements in affordability and efficiency 

Compton-Phillips, A., MD, Associate Executive 

Director of Quality, Kaiser Permanente; Young, S., MD, 

Senior Medical Director, Care Management Institute, 

The Permanente Federation, LLC 

D6/E6: Building a Global Learning Network 

S F 

Miami 

This interactive session will describe the theories 

underpinning networks and explore their 

application in health care through the lens of 

real-life network development efforts. Strategies 

for building effective networks and optimizing 

value for network members will be identified by 

drawing from theory, examples, and experience in 

the room. 


• Describe the theory underpinning networks 

• Apply network theory in health care 

• Identify key factors to consider when developing 

networks, drawing from the experiences of 

those who developed the IHI Open School for 

health professionals 

Delgado, P., Executive Director, IHI; Bartley, A., RN, 

Quality Improvement Consultant and Faculty, IHI; 

Gray, J., MD, PhD, Director, Ko Awatea, New Zealand, 

Counties Manukau District Health Board; Ruelas, E., 

Vice President, National Academy of Medicine, Mexico, 

and Senior Fellow, IHI; Lee, C., CEO, Changi General 

Hospital, Singapore 

D7/E7: Implementing Accountable Care M 


Although health care organizations are facing an 

uncertain future, several themes are emerging: 

reimbursement; the need to build the capability 

to manage populations; and, adding to the 

complexity, the need to understand the unique 

opportunity presented by each of the various 

payer segments. This session will focus on 

developing a comprehensive payer strategy that 

positions health care systems to be successful in 

the evolving marketplace. 


• Develop a comprehensive payer strategy plan 

for accountable care 

• Define an accountable care strategy consistent 

with their organizational mission and vision 

• Develop an implementation plan for an 

accountable care strategy that defines 

populations and measurable aims 

Knox, P., Executive Vice President, Bellin Health; 

Kerwin, G., President and CEO, Bellin Health; 

Dietsche, J., CPA, CFO, Bellin Health 

D8/E8: Re-Think Health: New Approaches to 

the Triple Aim 


No one organization has achieved the Triple Aim. 

Our only sustainable option is to rethink the 

health system. Re-Think Health’s action-research 

projects engage diverse groups of regional leaders 

using proven processes of leadership development 

and social change that complement clinical 

approaches to reform. Project participants and 

researchers will share stories of the impact and 

results to date for Re-Think Health, focusing on 

community organizing among citizens, system 

dynamics modeling among diverse stakeholders, 

and stewardship of shared goals among regional 

leaders. 


• Rethink what it takes to achieve the IHI Triple 

Aim in their organization and community 

• Consider how citizen engagement, systems 

thinking, and multi-stakeholder stewardship 

can complement current Triple Aim strategies 

• Plan one follow-up action to explore at a 

community or regional level to complement 

current Triple Aim efforts 

Fisher, E., MD, Director, Population Health and Policy, 

Dartmouth Institute for Health Policy and Clinical 

Practice, and IHI Board Member; Immediato, S., 

Project Leader, Re-Think Health/Fannie E. Rippel 

Foundation; Hilton, K., Director, Organizing for 

Health, Re-Think Health/Leading Change Project 

at Harvard University; Foster, R., MD, Senior Vice 

President, Quality and Patient Safety, South Carolina 

Hospital Association 

D9/E9: Executing Population Health Projects 

Vinoy 

This session will focus on population health 

projects within the context of the Triple Aim. 

Faculty will discuss a framework for population 

health projects and what they are learning from 

the Triple Aim community. 


• Explain a framework for working on population 

health projects in a community 

• Share examples of what this looks like in the 

Triple Aim community 

Whittington, J., MD, Faculty, IHI 

D10/E10: Clinical Microsystems + Coaching = 

High Performing Microsystems and Desired 

Outcomes 


Meeting leadership strategic improvement goals is 

a challenge. Field experience and research findings 

point to the importance of coaching in helping 

front-line teams assess their current state. 

Coaching can also help teams establish a rhythm 

and create processes directed at strategic 

improvement and explicit goals. 


• Define a clinical or supporting microsystem 

• Describe how to assess a clinical microsystem 

• Design a developmental program for the 

front-line team 

Godfrey, M., RN, Co-Director and Instructor, The 

Microsystem Academy at The Dartmouth Institute for 

Health Policy and Clinical Practice 


D11/E11: Building a Foundation for 

Evidence-Based Care 


Motivating physician compliance with clinical 

care standards is complex and difficult, and many 

organizations struggle with implementation. 

This session teaches six key insights—gleaned 

from over 100 physician interviews—into how to 

achieve widespread buy-in to an evidence-based 

performance improvement infrastructure. Several 

case studies will be shared to illustrate motivational 

concepts, including a firsthand account from the 

DRG Cost Efficiency Project at Danbury 

Hospital, which engaged over 25 physician leaders 

to transform care quality in meaningful ways 

across eight diagnoses. 


• Analyze and identify the most common 

demotivators that inhibit acceptance of clinical 

care standards 

• Leverage motivational tools to enlist physician 

support for performance improvement 

infrastructure 

• Integrate tactics into a multifaceted strategy 

for motivating widespread compliance with 

care standards 

32 


Boston, C., RN, Managing Director, Advisory Board 

Company; Miller, M., Chief Medical Officer, Western 

Connecticut Health Network 

D12/E12: Transforming Cancer Care by 

Redesigning the Patient Process Together 


Three health care systems in the southern part of 

Sweden have redesigned care for cancer patients 

by making clear promises to patients and involving 

them in every step of the care chain. Inspired by 

modern information logistics ideas, proactive 

patient safety work, and positive deviance examples, 

these initiatives have led to very promising results. 

In this workshop, participants will learn how 

measuring the results in a value compass 

dashboard has made results visible. 


• Describe the importance of patient involvement 

and value-based improvements 

• Demonstrate effective screening methods, 

highlighting a population-care approach 

Henriks, G., Chief Executive of Learning and Innovation, 

County Council of Jönköping; Bergeling-Thorell, M., 

Developing Leader, Orthopedic Clinic 

D13/E13: Is Compliance the Right Tool for 

Cultural Transparency? M 


Preparing for an accreditation survey every three 

years is not an adequate way for organizations to 

maintain safe patient care practices. Nor should 

they wait until they get into trouble. This 

presentation will focus on the real-world journey 

of the William W. Backus Health System, which 

moved from getting ready for inspection to 

embracing measurement and transparency as 

the path to safe, quality care. That journey began 

when leadership embraced external scrutiny as a 

vehicle for validating care quality and safety. 


• Change organizational culture from a defensive 

mode about external evaluations to an “always 

on, bring it on” culture to validate quality and 

safety in care 

• Consider how to save their organization millions 

of dollars in punitive and litigation costs 

Gutbezahl, C., MD, CEO, Compass Clinical Consulting; 

Thompson, B., Assistant Vice President, Organizational 

Excellence, William W. Backus Hospital; Shea, P., MD, 

Chief Medical Officer, William W. Backus Hospital 

D14/E14: Frontline Staff Driving Safety 

Across the System C 


At Mercy Hospital, frontline staff use multiple 

small tests of change, weekly data review, and 

continual interdepartmental spread to influence 

their evolving safety culture. This workshop will 

focus on best practices to test and implement 

strategies to achieve significant results, including 

reductions in falls, 100% surgical case debrief, 

consistent surgical antibiotic redosing, and more 

meaningful leadership involvement. Participants 

will learn how widespread staff participation has 

generated cultural improvements in patient 

experience scores and employee engagement. 


• Describe the importance of attention, 

understanding, connection, and tempo in 

realizing rapid, significant change 

• Identify benefits of small tests of change and 

ways in which frontline staff can capitalize 

on these benefits to drive monumental 

improvements 

• Discuss improvements related to falls prevention, 

antibiotic redosing, surgical case debriefs, 

handoffs, and more 

Wells, D., RN, Registered Nurse, Mercy Health Partners; 

Ziegler, M., MD, Anesthesiologist, Mercy Hospital 

Anderson; Shelley, K., RN, Nurse Manager, Mercy 

Hospital Anderson; Maupin, J., RN, Director of 

Quality Services, Mercy Hospital Anderson; Herron, 

C., RN, Nurse Manager, Mercy Hospital Anderson 

motivate 

D15/E15: Improving Quality and Reducing 

Costs with Palliative Care P 


This workshop will review specific palliative care 

delivery models in a range of care settings (home, 

hospital, office practice, nursing home) and the 

evidence that improved quality-of-life and survival 

outcomes have markedly reduced the need for 

hospitalization. Faculty will share proven tools for 

establishing or improving a palliative care program 

and provide technical assistance. 


• Create a work plan and timeline for a palliative 

care model that fits their care setting and the 

needs of their seriously ill patients and their 

families 

• Access professional training options to prepare 

their workforce 

Meier, D., MD, Director, Center to Advance Palliative Care 

D16/E16: Best Practices: IHI Spread and 

Network Methodology F 


Based on our work in collaboratives, campaigns, 

virtual courses, and more, we at IHI have learned 

a lot about what works (and what doesn’t) when 

spreading content to a large audience. This session 

will provide an overview of network theories, 

suggested content sequencing principles, and 

spread tools that can assist participants with 

their work. The lessons shared in this workshop 

will enable participants to provide their hospitals 

with content delivered in a more structured and 

predictable way, engage in more proactive and 

meaningful communication, and maintain higher 

energy across many large initiatives. 


• Identify several strategies to develop and 

support a network 

• Describe practical tools that can be used to 

spread clinical elements throughout a network 

• Articulate several key network theories 

Duncan, K., RN, Faculty, IHI; Gunther-Murphy, 

C., Director, Hospital Portfolio Operations, IHI; 

O’Rourke, K., Network Manager, IHI 

D17/E17: How to Turbo-Charge Health Care 

Improvement C 


More than any other factor, energy makes the 

difference between improvement activities that 

are sustained over the long term and those that 

fizzle out. Energy fuels high performance. In this 

workshop, faculty will share powerful methods 

to unleash the latent energy for change within an 

organization, that will increase the pace and scale 

of improvement. 


• Summarize why energy is critical to leading 

improvement activities 

• Liberate the natural energy and vitality of the 

workforce and service users for the cause of 

high-quality care 

• Use models and frameworks for analyzing and 

building energy for change 

Bevan, H., PhD, Chief of Service Transformation, 

NHS Institute for Innovation and Improvement 

D18/E18: Building an Integrated Approach to 

Improvement with Lean, Six Sigma, and the 

Model for Improvement S F 


What approach to quality improvement does your 

organization follow? Lean? Six Sigma? The Model 

for Improvement? All have value, and yet many 

organizations send mixed messages to their 

employees, telling that one approach will be 

followed this month, then adopting another 

approach the next month. Such messages lack 

what Deming called “constancy of purpose.” This 

workshop will help participants clarify the 

similarities and differences between the three 

approaches and provide a framework for organizing 

their overall quality improvement strategy. 


• Describe the similarities and differences 

between Lean, Six Sigma, and the Model for 

Improvement 

• Determine the approach or approaches most 

appropriate for their organization 

• Initiate a plan to build an integrated quality 

improvement strategy 


Improvement, IHI; Luther, K., RN, Vice President, 

IHI; Zak, H., President and COO, ThedaCare Center 

for Healthcare Value 


33

GENERAL 


wednesday 

DECEMBER 12 

keynote four 

1:30 PM – 2:30 PM 


Donald Berwick, MD, MPP 

Former President and CEO, 

IHI 

D19/E19: Presenting Data: Please, No More 

Red, Yellow, or Green! 


It’s vital that senior leaders and board members 

view key measures of their organization’s status 

in ways that further their ability to ask pivotal 

questions, draw valid conclusions, and make 

insightful decisions. Often senior leadership is 

presented with data for system-level measures in 

a tabular summary or in other relatively flat ways 

that are of limited utility for learning. Participants 

will learn the latest in how to powerfully display 

measures that senior executives can understand. 


• Explain why tabular and color methods to 

display measures are inadequate for learning 

by leaders 

• Identify the key design elements for 

presentation of an effective family of measures 

for learning 

• Analyze a vector of measures 

Murray, S., Improvement Advisor, CT Concepts; 


Advisor, Associates in Process Improvement 

D20/E20: Ensuring a Positive Surgical 

Experience via Optimal Communication M 


Are the perceptions of what providers believe that 

patients and their families need to know during the 

surgical experience valid? Is the type and quality 

of the information shared through the process 

relevant, timely, and clearly communicated? This 

interactive workshop will offer attendees the 

opportunity to interact with members of a surgical 

team to answer these critical questions and to 

listen to what patients need. 


• Identify the best ways to guide surgical team 

members toward optimal communication with 

patients and their families 

• Develop ways to change patient education from 

disease-centered to patient-centered 

Healy, G., MD, Professor, Harvard University Medical 

School; Guglielmi, C., RN, Perioperative Nurse Specialist, 

Beth Israel Deaconess Medical Center; Rodriguez, 

M., President, Association of Surgical Technologists; 

Cammarata, B., MD, Clinical Assistant Professor of 

Anesthesiology, Tucson Medical Center 

get results 

D21/E21: A Systems Perspective on Medical 

Professionalism 


To date, much of the research on medical 

professionalism has focused on the individual 

physician. However, researchers have increasingly 

realized that professionalism is influenced by 

many additional factors, such as the physician’s 

practice environment, organizational leadership, 

and market forces. This session will feature 

research on the systems perspective on professionalism, 

discuss the implications of this framing for 

organizational leaders, and provide strategies for 

linking professionalism and quality improvement. 


• Identify the multiple influences on physician 

professionalism 

• Link professionalism to quality improvement 

Wolfson, D., Executive Vice President and COO, 

ABIM Foundation; Hafferty, F., PhD, Associate Director, 

Program in Professionalism and Ethics, Mayo Clinic 

D22/E22: Practical Guidance for Measuring 

the Triple Aim 

Sawgrass 

Since the Triple Aim was introduced in 2008, it 

has become the organizing framework for the US 

national quality strategy, as well as for the 

strategies of many health organizations around 

the world. However, these organizations still 

struggle with measuring the outcomes related to 

execution of the Triple Aim. In this session, an 

expert panel representing a broad range of 

organizations will share their experiences and 

provide advice on successful practices for 

measuring the Triple Aim. 


• Measure the Triple Aim in their organizations 

• Summarize case studies of how organizations 

have successfully integrated Triple Aim 

measurement into learning systems to improve 

organizational performance 

Stiefel, M., Senior Director, Care and Service Quality, 

Kaiser Permanente; Ramsay, R., Director of Community 

Care Program, CareOregon; Dinneen, M., MD, PhD, 

Director, Office of Strategy Management, Department 

of Defense; Hester, J., PhD, Senior Adviser, Centers for 

Medicare and Medicaid Services 

D23/E23: Lessons from Scotland’s 

Quality Journey 


Five years ago, the political leaders, the clinicians, 

and the managers of Scotland’s health care system 

set out on an ambitious journey to reduce mortality 

and harm. Their success has led to a more 

ambitious and broader approach to health care 

quality beyond safety. This session will describe 

what Scotland did, the methods it used, and the 

lessons learned. This interactive session will give 

participants the opportunity to apply these 

lessons to their own context. 


• Assess the impact of a national quality 

improvement change program 

• Discuss the application of the lessons from 

Scotland to their own context 

• Apply the lessons learned in Scotland to their 

work to achieve change at scale 


Government Health Department; Feeley, D., Chief 

Executive, Scottish Government Health Department 

D24/E24: Lives Saved, Costs Safely Reduced: 

QUEST ® Year Four M 

Aruba/Bahamas 

Over four years, QUEST® member hospitals 

will have saved more than 24,820 lives and 

$4.5 billion. If all hospitals across the country 

achieved these gains, an estimated 87,250 lives 

and $34 billion could be saved each year. With 

more than 290 hospitals across 40 states treating 

approximately 2.3 million patients annually, 

QUEST uses collaboration to speed performance 

improvement in six domains: cost of care, mortality, 

evidence-based care, harm, patient experience, and 

the newest addition, readmissions. 


• Describe the key characteristics and attributes 

of a high-performing hospital 

• Discuss the critical importance of the roles 

played by collaboration, knowledge transfer, and 

transparency in rapid performance improvement 

• Give examples of organizations that have 

achieved a top level of performance 

Scott, C., RN, Service Line Vice President, Quality and 

Safety, Premier, Inc.; Nelson, E., Director, Population 

Health Measurement Program, The Dartmouth 

Institute for Health Policy and Clinical Practice; 

Bankowitz, R., MD, Chief Medical Officer, Premier, 

Inc.; Vincent, M., RN, Vice President of Performance 

Improvement, Saint Joseph Health System 

34 


D25/E25: Louisiana Birth Outcomes 

Initiatives (BOI)—Improving Quality, Care, 

and Cost C F 

Anaheim 

Chief among the goals of the Birth Outcomes 

Initiative is creating a sustainable infrastructure 

for addressing birth outcomes. Louisiana has 

a blueprint for action that focuses on system 

changes, including improved quality of maternity 

and neonatal care with an eye to reducing 

elective deliveries prior to 39 weeks’ gestation. 

To achieve this goal, the supported Louisiana 

hospitals joined the IHI Perinatal Improvement 

Community 

in September 2011. Participants will learn 

from these key stakeholders what has been 

accomplished so far. 


• Describe the Louisiana BOI and its goals 

• Consider engaging hospitals at the state level 

in a shared goal to eliminate elective deliveries 

as the first step in a plan to improve quality 

and safety and reduce cost 

Gullo, S., RN, Managing Director, IHI; Alletto, M., 

Deputy Director, Louisiana Birth Outcomes Initiative, 

Louisiana Department of Health 

WEDNESDAY special events 

Simpler Healthcare Presentation: Lean Leadership Immersion 

for Health Care 

10:45 AM – 11:15 AM • Palms Foyer Classroom 

You may know Lean tools are only part of the solution to transforming your entire 

workplace. What do you know about the pivotal role leaders play in getting beyond use 

of the tools and changing the behavior of the entire organization? What is the essential 

short list of things leaders do to make the difference in capturing the hearts and minds 

of all employees? Come find out in this 30 minute session led by Simpler Healthcare. 

Radishphere National Radiology Group Presentation: 

Why Radiology is Desperate for Quality Standards 


With Radiology being the third largest health care spend category and touching nearly 

every patient and major disease category, shouldn’t radiology be in the forefront of your 

quality efforts? Come learn how standards-based radiology can ensure diagnostic 

accuracy, appropriate imaging utilization, and ultimately improve patient safety. 

D26/E26: Orchestrating a Symphony: 

Preventing Falls C 

Marco Island 

This workshop presents the practice changes 

implemented in the North Shore–Long Island 

Jewish Health System to reduce falls and harm 

from falls, with IHI’s improvement model used 

as a framework. An interdisciplinary team 

designed and piloted the implementation of four 

changes, spread them systemwide, and achieved 

a 30% 

reduction in falls. This workshop will also 

highlight a toolkit, implementation, lessons 

learned, and next steps. 


• Identify four interventions to reduce falls 

• Implement a program at their facility to 

further reduce harm from falls 

Thomas, L., PhD, RN, Vice President, System 

Nursing Research, North Shore–Long Island Jewish 

Hospital, New Hyde Park; Rabinowitz, M., PhD, 

RN, Manager for Nursing Initiatives, North Shore– 

Long Island Jewish 

Hospital; Mazzapica, D., RN, Corporate Manager of 

Nursing Initiatives, North Shore–Long Island Jewish 

Hospital, Lake Success 


D27/E27: Dealing with the Global Cost and 

Quality Challenge 


Health care systems in every country of the world 

are facing the challenge of providing access to 

high-quality care from constrained budgets. The 

National Health Service (NHS) in the United 

Kingdom is working to generate £20 billion of 

efficiencies while improving quality. Already over 

£8 billion has been delivered, with quality markers 

improving. In this session, faculty will describe the 

need for all systems to address these challenges; 

outline those areas of improvement with the most 

potential for delivering quality and efficiency 

improvements together; discuss the NHS change 

model for driving large-scale change; and provide 

personal leadership lessons for the next stage of the 

quality journey. 


• Articulate which improvement interventions 

deliver improvements in both quality and cost 

efficiency in health care systems 

• Assess the success of the NHS large-scale 

change model in delivering required 

improvements 

• Employ personal leadership development 

interventions 

Easton, J., Chief Executive, Quality Improvement and 

Innovation Partnership 

D28/E28: Talent Management: Developing 

Clinical and Administrative Leaders to Lead 

the Quality and Safety Agenda M C 


To ensure that it remains the top hospital of the 

decade, Virginia Mason embarked on a rigorous 

process to ensure that current and future 

physician and administrative leaders support a 

quality and safety vision. The key attributes of this 

process are transparency and a systems approach. 

The presenters of this session will discuss their 

belief that this is a critical step for the organization, 

the ways it supports their succession planning 

needs, and its key components. They will also give 

advice to those who wish to take a similar approach. 


• Describe the Virginia Mason talent 

management purpose, process, and results 

• Summarize the key tools and standard work 

used to support the process 

• Apply the lessons learned by Virginia Mason in 

developing their own similar process 

Kaplan, G., MD, CEO, Virginia Mason Medical Center, 

and IHI Board Member; Tachibana, C., RN, Vice 

President and Chief Nursing Executive, Virginia Mason 



35

track INDEX 

innovate 

L1 

L2 

L3 

L4 

L5 

M1 

M2 

M3 

M4 

M5 

M6 

A2/B2 

A3/B3 

A4/B4 

A5/B5 

A6/B6 

A7/B7 

A8/B8 

A9/B9 

C2 

C3 

C4 

C5 

C6 

C7 

Beacon Breakthroughs: 

Using Technology as a Driver 

of Innovation 

Home Health Care: An Essential 

Component of the Healthcare System 

Unleashed, Unlocked, and 

Uninhibited: Connecting and 

Creating 101 

SCF Nuka System of Care: 

Improved Overall Outcomes 

The Role of MOC in Physician 

QI Involvement 

IHI’s STAAR Initiative: Reducing 

Avoidable Rehospitalizations 

Leading the Journey to High Reliability 

Courage in Health Care: Leading 

From Within 

See, Solve, Share, and Lead: 

Achieving Breakthroughs 

Healthcare Innovation: Meaning, 

Strategy, Practice 

Real World Systems Innovation: 

Strategies of Four CMMI Health 

Care Innovation Challenge Grantees 

Integrating Palliative Care in the ED 

Transforming Care Through the 

Power of Social Media 

Clinical Improvement for 


VHA Medical Home Model: 

Patient-Aligned Care Teams 

A Human Factors Approach to 

Root Cause Analysis 

Designing and Supporting a Learning 

Health Care System 

Better Health at Any Weight: 

Care Delivery Strategies 

Creative Breakthroughs: Collaboration 

for Innovation and Improvement 

Innovations in Elder Care 

(Re)Imagining the Care Experience 

Health 2.0: Patients as Health Care 

Team Members 

Pediatric Care Plans for Medical 

Neighborhoods 

SAFER: Safety Assurance Factors 

for EHR Resilience 

Person-Centered Health IT— 

The Next Level 

C8 

D2/E2 

D3/E3 

D4/E4 

D5/E5 

D6/E6 

D7/E7 

D8/E8 

D9/E9 

D10/E10 

Motivating Health System Redesign: 

Using Public Data to Identify Local 

Opportunities for Improvement 

Political Pressure: A Barrier to 

Safety in Health Care Systems 

Delivering Value with Experience- 

Based Design of Care 

Pursuing the Triple Aim: Seven 

Innovators Show the Way to Better 

Care, Better Health, and Lower Costs 

A National Platform for Spurring 

Innovation Spread 

Building a Global Learning Network 

Implementing Accountable Care 

Re-Think Health: New Approaches 

to the Triple Aim 

Executing Population Health Projects 

Leveraging New Technologies 

for Improvement—Disruptive 

Innovations in Health Care 


L6 Conversations That Promote 

Transformation 

L7 Learning from Patient Stories to 

Improve Care 

L8 The EBAN Experience: An 

Equitable Health Collaborative 

L9 Innovation via Partnering with 

Patients 

L30 Patient Centered Outcomes 

Research Institute 

M7 Patient Safety: Continuing the 

Journey 

M8 Tools for Radical Transformation 

M9 Engaging Physicians to 

Transform Care 

M10 From the Top: The Role of the 

Board in Quality and Safety 

M11 Building a Clinician Peer Support 

Program 

A10/B10 The Key to Improved Outcomes: 

Workforce Development 

A11/B11 Spur Your Safety Efforts 

A12/B12 Developing and Maintaining a 

High-Performance Workforce 

A13/B13 Personal Mastery for 

Transformational Leadership 

A14/B14 Engaging Physicians: Insights and 

Actions for Results 

C9 Local Collaboratives for 

Engagement and Success 

C10 The Human Perspective: Essential 

in Self-Dialysis 

C11 Developing Physician Leaders 

Internally 

C12 Measuring Improvement 

C13 Want to Engage Patients? Let’s Talk! 

D11/E11 Building a Foundation for Evidence- 

Based Care 

D12/E12 Transformation of Cancer Care by 

Redesigning the Patient Process 

Together 

D13/E13 Is Compliance the Right Tool for 

Cultural Transparency? 

D14/E14 Frontline Staff Drive Safety 

Across the System 

motivate 

L10 Back to Basics: Building Essential 

QI Skills 

L11 Dutch Healthcare: A Succesful 

Nationwide Integration 

L12 Improvement as an Everyday 

Leadership Philosophy 

L13 Preparing Your Improvement Work 

for Publication 

L14 The Behavioral Health Side of 

Health Improvement 

L15 Top-Down vs. Bottom-Up Leadership 

L16 Understanding Patient Medication 

Adherence 

L17 Using Diagnostic Tools for 

Patient Safety 

L18 Eliciting Resident Projects for Boards 

M12 Rallying Your Community to 

Improve Transitions 

M13 One-Day School for Organizational 

Radicals 

M14 Accelerating the Pace and Scale of 


M15 From “Bolt-On” to “Build-In”: 

Improvement as Cultural DNA 

M16 Is There a Perfect Health Care 

System? 

M17 Strategies for Facilitating Change in 

Primary Care 

M18 ThedaCare’s Business Performance 

System 

A15/B15 Mastering Change of Health Care 

Organizations: Strategic Intelligence 

and Profound Knowledge 

36 


A16/B16 Implementing Strategies to 

Address Disparities 

A17/B17 The IHI Open School: Engaging 

Learners across Health Professions in 

Improving Care Together 

A18/B18 Customized ER Operational 

Strategies for Low Acuity 

A19/B19 Parents and Patients as Partners in 

QI Work 

A20/B20 Leadership Lessons from the 

Soccer Field 

C12 

C14 

C15 

Measuring Improvement 

Acting as One for One Million: Hoshin 

Planning in Saskatchewan, Canada 

CDC-IHI Antibiotic Stewardship 

Pilot Testing 

C16 Transformational Leadership: A New 

Mindset 

C17 Contra Costa Health: Getting Lean— 

Designing an Engaged Ambulatory 

Care Delivery System 

D15/E15 Improving Quality and Reducing Costs 

with Palliative Care 

D16/E16 Best Practices: IHI Spread & Network 

Methodology 

D17/E17 How to Turbo-Charge Healthcare 


D18/E18 Building an Integrated Approach to 

Improvement with Lean, Six Sigma, 

and the Model for Improvement 

D19/E19 Please, No More Red, Yellow, or Green! 

D20/E20 A Positive Surgical Experience—You’re 

Not Alone 

get results 

L19 

L20 

L21 

L22 

L23 

L24 

M19 

M20 

Evaluation Design Methods for 

Leaders of QI Programming 

Improving Transitions from the Hospital 

to Community Settings 

Managing by Predicition 

The Right Start: Eliminate OB Adverse 

Events 

One Year of ACOs: Incentive 

Realignment and Health Improvement 

Integration of Research and Quality 


Better Quality through Better 

Measurement 

Beyond Basics: Using Advanced 

SPC Charts 

M21 Designing and Executing Large-Scale 

Interventions for Improving Perinatal 

and Infant Outcomes 

M22 Zero Events of Harm: Leading for 

High Reliability 

A21/B21 Using Global Trigger Analytics: 

AHS Collaboratives 

A22/B22 Combating SSIs in Hip and Knee 

Arthroplasty 

A23/B23 Closing the Health Disparity Gap by 

Delivering Equitable Care in Diverse 

Settings 

A24/B24 Running Collaboratives: The Basics 

and Beyond 

A25/B25 Taking the Triple Aim to the Next Level 

C18 Achieving High Reliability in Health Care 

C19 Applying Lean in Skilled Nursing 

Facility 

C20 How to Succeed with a Comprehensive 

Harm Reduction Initiative 

C21 Eliminating HAI: Can It Be Done? 

C22 How Can Payers Drive Quality in 

Large Health Systems? 

C23 Memorial Hermann’s Zero Harm 

Journey 

D21/E21 A Systems Perspective on Medical 

Professionalism 

D22/E22 Practical Guidance for Measuring the 

Triple Aim 

D23/E23 Lessons from Scotland’s Quality Journey 

D24/E24 Lives Saved, Costs Safely Reduced: 

QUEST Year Four 

D25/E25 Louisiana BOI- Improving Quality, 

Care, and Cost 

D26/E26 Orchestrating a Symphony: 

Preventing Falls 


L25 

L26 

L27 

L28 

L29 

L30 

Building the Health Care Commons 

in Oregon 

The Cost and Quality Imperative: 

Setting Up Your Organization for 

Success 

Developing Safety and Value in 

Healthcare 

Maximize the Potential to Sustain 

Your Improvements 

When Lightening Strikes: Responding 

to Adverse Events 

Research Done Differently: PCORI’s 

Approach to Patient-Centered 

Outcomes Research 

M23 Baldrige: Achieving Excellence and 

Reliability 

M24 Enhancing Primary Care Value at 

Lower Cost to the Community 

M25 Global Perspectives on the Journey to 


A26/B26 Progress Across the Sepsis Spectrum 

A27/B27 Identifying Waste in the Acute 

Care Setting 

C24 How Do We Know What We 

Don’t Know? 

C25 IACT Program: Medical Disclosure 

and Transparency 

C26 The Eye of the Storm: Emergency 

Response to Hurricanes 

C27 Patient-Centered Leaders as Value 

Creators 

D27/E27 Dealing with the Global Cost and 

Quality Challenge 

D28/E28 Talent Management: Developing 

Clinical and Administrative Leaders to 

Lead the Quality and Safety Agenda 

students 

A3/B3 Transforming Care through the Power 

of Social Media 

A6/B6 A Human Factors Approach to Root 

Cause Analysis 

A17/B17 The IHI Open School: Engaging 

Learners across Health Professions in 

Improving Care Together 

C13 Want to Engage Patients? Let’s Talk! 

D6/E6 Building a Global Learning Network 

D18/E18 Building an Integrated Approach to 

Improvement with Lean, Six Sigma, 

and the Model for Improvement 

37

D 

N 

Patient and 

Family Advisor 

booth 

This way to the North Tower 

11 

3 

Bookstore 

Registration 

Changes & 

Badge Edits 

First Aid 

Conference 

Information 

38 


Exhibit Hall & 

IHI Cafe 

Storyboards & 

Luggage Storage 

Keynote Room 

Entrance 

Registration 

Presenter 

Prep Room & 

Lounge 

Shuttles 

Shuttle Service To: 

Gaylord Palms Resort & Convention Center 

Courtyard Marriot Lake Buena Vista 

Hotel Spring Hill Suites by Marriott 

Caribe Royale 

Buena Vista Suites 

More details in Shuttle Map on page 54. 

To Access Complimentary 

wireless internet: 

1. Select “view available wireless 

networks” and connect to the 

“ibahn_conference” wireless 

network 

2. Open a new web browser and type 

“ibahn” into the address bar 

3. Enter code “0869A5” 

39

presenter INDEX 

A 

Adams, Laura..........................................C7 

Allen, Donna....................................A9, B9 

Alletto, Michelle.......................... D25, E25 

Anand, Shikha........................................C5 

Anim, Dora...........................................M12 

Ayoub, Joanne........................................C11 

B 

Bailey, Julie........................................D2, E2 

Baker, Neil.................. L6, M17, A13, B13 

Balestracci, Davis........................L12, M15 

Balik, Barbara.......................................... L9 

Banck, Britt-Mari..................................C10 

Bankowitz, Richard.................... D24, E24 

Barach, Paul...............................L7, D2, E2 

Bardfield, Joshua..................................... L5 

Barker, Pierre..................... L19, M21, A24 

....................................B24, C22, D16, E16 

Barnas, Kim..........................................M18 

Bartley, Annette................................D6, E6 

Batalden, Paul........................................ L13 

Beasley, Carol......................... L1, M6, RFB 

Bechard, Douglas........................ A21, B21 

Bell-Polson, Deborah...........................FE3 

Benedicto, Anne Marie........................C18 

Bergeling-Thorell, Mari.............. D12, E12 

Berry, Leonard.........................................A1 

Berwick, Donald....................................M2 

Betancourt, Joseph...................... A16, B16 

Bevan, Helen.....................M13, D17, E17 

Bisognano, Maureen............. M21, D4, E4 

Bones, Kate............................................FE5 

Boston, Carol............................... D11, E11 

Boudreau, Karen..................................M24 

Bradke, Peg.............................................M1 

Brammer, Craig....................................... L1 

Brilli, Richard.......................................... L5 

Brock, Jane............................................M12 

Brossart, Bonnie....................................C14 

Bryan, Debra........................................... L8 

Bulger, John.......................................VSV2 

Burlingame, Esther.................................C3 

Butts, Sue................................................M8 

C 

Cammarata, Brian....................... D20, E20 

Cannon, Deborah.................................C23 

Cardo, Denise........................................C21 

Chase, Alide............................ M14, VSV9 

Chassin, Mark........................................M2 

Chaufournier, Roger............................... L1 

Cherouny, Peter..................................... L22 

Chow, Marilyn.........................................C3 

Clapper, Craig......................................M22 

Classen, David..................................A4, B4 

Coleman, Eric.........................................M1 

Compton-Phillips, Amy..................D5, E5 

Conway, William..................... VSV3, C20 

Crane, Joseph............................... A18, B18 

Crisp, Nigel...........................................M25 

Crowe, Ginna.................................. L6, M8 

D 

Daley, Jennifer........................................M2 

D’Angelo, John............................. A26, B26 

Dascher, Norman.................................. L26 

Davidoff, Frank..................................... L13 

Davies, Michael................................A5, B5 

Davies, Louise....................................... L13 

Deao, Craig...........................................M23 

Deen, Jana.............................................M11 

Delgado, Pedro........................... M14, A24 

..................................................B24, D6, E6 

DesGeorges, Janet....................... A19, B19 

Dickson, Eric.........................................FE6 

Dietsche, James................................D7, E7 

Digioia, Anthony.......... A22, B22, D3, E3 

Diller, Thomas..................................A6, B6 

Dinneen, Michael........................ D22, E22 

Dixon-Woods, Mary............................ L24 

Doerfler, Martin.......................... A26, B26 

Dorman, Jann...................................A8, B8 

Dowling, Michael.................................M25 

Downes, Tom.........................................M4 

Duncan, Kathy................... FE3, A22, B22 

............................................RFC, D16, E16 

Dunning, Sharon.............................A6, B6 

Dye, Tammy......................................VSV6 

E 

Easton, Jim.........................M15, D27, E27 

Eby, Doug......................................L4, M16 

Eddes, Eric............................................. L11 

Elward, Kurtis......................................... L5 

Ettinger, Joel.........................................M23 

Evdokimoff, Merrily............................... L2 

F 

Faber, Marjan..........................................C4 

Farman, Christian.................................C10 

Federico, Frank...........L29, L16, M7, RFC 

Feeley, Derek......................M25, D23, E23 

Fenton, Katherine................................M13 

Fisher, Elliott......................... M25, D8, E8 

Flanders, Scott......................................C15 

Florizone, Dan.......................................C14 

Foster, Richard.................................D8, E8 

Frankel, Allan....................A21, B21, RFD 

Frye, Liz................................................. L14 

Fusco, Sharon.......................................M12 

G 

Gallo, Kathleen.................................VSV5 

Gaulton, Catherine..........................A9, B9 

Gelinas, Lillee.............................. A11, B11 

Giarrusso, Michelle..........................D3, E3 

Goldmann, Don.......................... D10, E10 

Goodman, Ellen..................................... D1 

Goroski, Alicia.....................................M12 

Gottlieb, Katherine................................. L4 

Gould, Bernice............................ A23, B23 

Graves, Kevin.......................................... L5 

Gray, Jonathon..................................D6, E6 

Grebe, Joan............................................FE1 

Gruner, Dean...........................................A1 

Guglielmi, Charlotte................... D20, E20 

Gullo, Sue....................................L22, M21 

............................................RFC, D25, E25 

Guinnee, Meghan....................... A19, B19 

Gunther-Murphy, Christina......FE6, D16 

................................................................E16 

Gustafson, David.................................. L28 

Gutbezahl, Cary.......................... D13, E13 

H 

Hafferty, Frederic........................ D21, E21 

Hamlin, Brian............................. A22, B22 

Hansen, Jennie Chin..............................C2 

Haraden, Carol...................................... L17 

Harrison, Richard Van........................... L5 

Haskell, Helen................................L7, C13 

Hawkins, Susan..................... VSV3, M23 

Hayward, Martha................................... L9 

Healy, Gerald............................... D20, E20 

Heinrich, Pat..........................................M8 

Helmrich, George............................A6, B6 

Henriks, Goran............M16, M14, VSV4 

...................................................... D12, E12 

Herron, Carrie............................. D14, E14 

Hester, James............................... D22, E22 

Hilton, Kate.....................................D8, E8 

Histon, Trina....................................A8, B8 

Homer, Charles..........M21, A19, B19, C5 

Hunt, Gordon........................................M2 

Hunt, Jacquelyn..........................VSV1, C7 

I 

Immediato, Sherry...........................D8, E8 

J 

Jack, Brian.............................................. L20 

Jacobsen, Diane.........FE1, A26, B26, C15 

Jain, Manoj.............................................C21 

James, Brent...................................L15, M2 

Jarman, Brian....................................D2, E2 

Jarrett, Mark............................ VSV5, C26 

Jensen, Laurie.............................. A12, B12 

Jensen, Kirk................................. A18, B18 

Johnson, Cheri....................................... L22 

Johnson, Julie........................................... L7 

Jones, Kate............................................. L17 

Jordan, Jack............................................C20 

K 

Kabcenell, Andrea.................................FE4 

Kaplan, Gary.......................M9, D28, E28 

Kashiwagi, Deanne...............................C24 

Kautz, Jordan........................................ L18 

Kenney, Charles...............................D4, E4 

Kenney, Linda.......................................M11 

Kerwin, George........................ A1, D7, E7 

Kini, Mina.................................... A16, B16 

Kirtane, Janhavi....................................... L1 

Knowles, Brian......................................C19 

Knox, Peter......................... VSV1, D7, E7 

Knudson, Susan.......................... A25, B25 

Kotagal, Uma...............................L21, M14 

Kotchevar, Miles...................................C17 

Kowalenko, Terry.................................... L5 

Krause, Christina.............................A3, B3 

Kremer, Jan..............................................C4 

L 

Labby, David.......................................... L25 

Lachman, Peter..................................... L27 

Laurent, Suann......................................C14 

Lee, Chien Earn...............................D6, E6 

Lefebvre, Ann.......................................M17 

Leitch, Jason.............L27, M16, D23, E23 

Levenback, Charles............................. RFD 

Levy, Paul..................................... A20, B20 

Lewis, Ann............................................... L6 

Lewis, Ninon..........................................M6 

Lind, Cristin............................................C5 

Linton, Randall.......................................A1 

Little, Kevin..........................................M19 

Litvak, Eugene....................................... L27 

Lloyd, Robert...........L10, M19, D18, E18 

Loehrer, Saranya..................................RFC 

Luther, Katharine......L26, C24, D18, E18 

Lynn, Joanne.........................................M12 

M 

MacCoby, Michael...................... A15, B15 

Madigosky, Wendy...................... A17, B17 

Maher, Lynne........................................ L28 

Majka, Andrew...................................... L18 

Martin, John................................ A27, B27 

Martin, Lindsay....................................RFA 

Mate, Kedar..................................L19, C22 

Maupin, Janice............................. D14, E14 

Mazzapica, Denise...................... D26, E26 

McCarthy, Chris.............................. L3, C3 

McClure, Nancy.......................... A25, B25 

McCutcheon Adams, Kelly..................FE4 

McIlwain, Thomas.................................M4 

McNair, Scott...................................... RFD 

Meier, Diane................................ D15, E15 

Meyer, Rob.............................................M3 

Micalizzi, Dale Ann..............................C25 

Miles, Paul............................................. L19 

Miller, Douglas............................ A27, B27 

Miller, Joanne..........................................C9 

Miller, Matthew.......................... D11, E11 

Miller, Diane......................................VSV8 

Montori, Victor.......................................C1 

Moses, James............................... A17, B17 

Muething, Stephen.....................L21, M22 

Murray, Sandra.................. M20, A24, B24 

...................................................... D19, E19 

N 

Nelson, Eugene........................... D24, E24 

Nerbonne, Lori......................................C13 

Nevins, Suzanne................................... L29 

Nichols, Len.......................................... L23 

Nielsen, Gail.......................................... L20 

Nolan, Kevin............................... A18, B18 

Norman, Clifford........................ A15, B15 

Nowicki, Kelly......................................... L5 

O 

O’Connor, Patricia.................. L17, A9, B9 

Ogrinc, Greg.......................................... L13 

Okafor, Martha..................................... L14 

Oley, Edwin...........................................C16 

Orlikoff, Jamie....................................... L23 

O’Rourke, Kate........................... D16, E16 

Oswald, Kathy............................. A12, B12 

Oyekan, Elizabeth................................ L16 

P 

Palmer, Nancy.......................................C17 

Parmentier, Darlene.................... A26, B26 

Parry, Gareth......................................... L19 

Patow, Carl............................................... L8 

Patterson, Sarah................................VSV8 

Peden, Carol....................................M7, C9 

Plsek, Paul..............................................M5 

Power, Maxine....................................... L24 

Price, David............................................. L5 

Provost, Lloyd..........L24, M20, D19, E19 

Pryor, David............................................M2 

Pugh, Michael..........................................LB 

Pujols McKee, Ana...............................C18 

Puri, Ajay..........................................A3, B3 

Q 

Quest, Tammie.................................A2, B2 

R 

Rabinowitz, Myrta...................... D26, E26 

Radley, David..........................................C8 

Ramsay, Rebecca................ L25, D22, E22 

Rao, Sandhya........................................... L5 

Reiss-Brennan, Brenda........................M24 

Resar, Roger..................................L18, C24 

Rexford, Jean.........................................C13 

Rhode, Jim.............................................C14 

Rita, Suzanne.......................................RFC 

Robson, Brian..........................................C7 

Rodriguez, Margaret.................. D20, E20 

Romanoff, Neil......................................C24 

Romer, Deborah......................................C3 

Ruelas, Enrique..................... M25, D6, E6 

Rutherford, Patricia......................L20, M1 

Ryckman, Frederick.............................. L21 

S 

Sadler, Blair........................................... L29 

Sahney, Vinod............................. D10, E10 

40 


Sammer, Christine...................... A21, B21 

Sands, Kenneth.....................................C11 

Sappah, Barbara.......................... A10, B10 

Satcher, David................................ L14, E1 

Schaffmeyer, Maryjeanne....................M18 

Schall, Marie...................... M12, A24, B24 

Schectman, Gordon.........................A5, B5 

Schellekens, Wim................................. L11 

Schilling, Lisa................ L26, M14, VSV9 

Schlosser, James......................................M3 

Schwartz, Amy.................................A7, B7 

Scott, Jessica..........................................C25 

Scott, Carolyn.............................. D24, E24 

Scott, Susan..........................................M11 

Scoville, Richard......................... M19, C12 

Selby, Joe................................................ L30 

Septimus, Edward.................................C15 

Sevin, Cory......................L2, M17, A7, B7 

Shabot, M. ............................................C23 

Shappell, Scott.................................A6, B6 

Shea, Peter................................... D13, E13 

Shear, Joanne....................................A5, B5 

Shelley, Kristin............................ D14, E14 

Sherman, Hanna....................................M3 

Siemons, Donna...................................... L5 

Silversin, Jack....................... M9, A14, B14 

Singh, Hardeep.......................................C6 

Sittig, Dean..............................................C6 

Sobolewski, Sally.................................... L2 

Solazzo, Mark.......................................C26 

Spear, Steven..........................................M4 

Srinivasan, Arjun..................................C15 

Staines, Anthony....................................M7 

Stark, Richard..................................A5, B5 

Steed, Airica........................................ RFD 

Stephens, Jim.........................................C16 

Stevens, David....................................... L13 

Stewart, Kevin....................................... L29 

Stiefel, Matthew.......................... D22, E22 

Swensen, Stephen.................................C27 

T 

Tachibana, Charleen................... D28, E28 

Tan-Mcgrory, Aswita.................. A16, B16 

Taylor, Jane...............L10, M8, A7, B7, C5 

Thomas, Lily................................ D26, E26 

Thompson, Jeffrey...................................A1 

Thompson, Bonnie..................... D13, E13 

Toledo, Cheryl.......................................C17 

Tollenaar, Rob....................................... L11 

Tonkel, Jackie............................... A21, B21 

Torres, Trissa........................................RFB 

Tzvieli, Ori.............................................C17 

V 

Vanderhoef, Michael.............................C19 

Vandiver, Alex.......................................C18 

Vanhaecht, Kris....................................M11 

Verma, Jennifer................................A9, B9 

Vincent, Mary Ann..................... D24, E24 

Vitolins, Susan...................................... L26 

W 

Wasserman, Amy..................................C11 

Waterman, Beth.......................... A25, B25 

Watson, Heather..............................A8, B8 

Watson, Sam.........................................C20 

Webster, Patty......................................... L9 

Weingarten, Scott............................A4, B4 

Weissberg, Jed........................................M2 

Wells, Dominique....................... D14, E14 

White, Eli..............................................C16 

White, Suzanne...................................RFB 

Whittington, John...........................D9, E9 

Williams, Mark..................................... L20 

Wolfson, Daniel.......................... D21, E21 

Wolterman, Dan...................................C23 

Wong, Winston........................... A23, B23 

Wong, Warren.........................................C2 

Wouters, Michel.................................... L11 

Wrenn, Glenda..................................... L14 

Wright, Suzanna...............................VSV6 

Wu, Albert............................................M11 

Y 

Yates, Gary.........................M23, M2, M22 

Yokoe, Deborah........................... A22, B22 

Z 

Zak, Helen.................................. D18, E18 

Ziegler, Mark............................... D14, E14 

Quality care requires 

clear communication. 

Improve your communication 

climate with C•CAT. 

All aspects of quality care depend upon effective, patient-centered 

communication. Learn how your organization is doing. Developed 

by the American Medical Association and a multi-stakeholder group, 

the Communication Climate Assessment Toolkit (C•CAT) provides: 

• A 360° assessment of organizational aspects related to communication 

• Validated, benchmarked results to help develop targeted 

QI interventions 

• Seven NQF-endorsed measures of health disparities and 

cultural competence 

Trained consultants will help plan your assessment, interpret results and 

develop specific improvement plans. Stop by booth 1213 today to 

learn how you can improve communication for your patients! 

ama-assn.org/go/ccat 

ccat@ama-assn.org 

© 2012 American Medical Association. All rights reserved. 

41

storyboards 

Storyboard Reception • Tuesday, December 11 • 4:30 PM – 6:30 PM • Palms Ballroom 

innovate 

Pediatric Pain Management During 

Short-Term Procedures 

Abington Memorial Hospital 

Kelly Cummings, M.J. 

kcummings@amh.org 

TeleICU Ventilator Rounds Improve 

Mechanical Ventilation 

Advanced ICU Care 

Thomas Kalb, MD 

tkalb@icumedicine.com 

Integrated Care for Frail Older People 

Advancing Quality Alliance 

Elizabeth Bradbury 

elizabeth.bradbury@srft.nhs.uk 

Improving Things that Matter in 

EMS Systems 

American Medical Response 

Scott Bourn, PhD 

Scott.Bourn@amr.net 

Reducing Utilization Management 

(UM) Denial Rates and Healthcare 

Costs for MaineCare Medicaid 

APS Healthcare 

Eric Altman, MA 

ealtman@apshealthcare.com 

Meta-Management: Management for 

Management Using Production Flow 

Unit Chart (PFUC) 

Aso Iizuka Hospital 

Hiromi Ando, MD, PhD 

hando1@aih-net.com 

Designing an Integrated Medication 

Management System 

Beth Israel Deaconess Medical Center 

Samantha Ruokis 

sruokis@bidmc.harvard.edu 

Interdisciplinary Team Bedside 

Rounding Improves Efficiency, Safety, 

and Satisfaction 

Boulder Community Hospital 

Eugene Chu, MD 

echu@bch.org 

Mental Health Training and Tools 

Improve Physician and Patient Care 

and Experience, Changing Attitudes 

British Columbia Medical Association 

Rivian Weinerman 

rivian.weinerman@viha.ca 

Mobile Technology: Improving 

People’s Lives by Helping 

Manage Diabetes 

Chartered Health Plan Inc. 

Mark R. Fracasso, MD 

mfracasso@whealthcare.com 

Improving Seizure Education and 

Discharge Planning for Children 

Hospitalized with Epilepsy or Seizures 

Children’s Hospital Colorado 

Ann Boyer, MD 

ann.boyer@childrenscolorado.org 

Peer Review to Peer Action: Our Road 

to High Reliability 

Columbia St. Mary’s Hospital 

Antonio Salud II, MD 

asalud@columbia-stmarys.org 

Implementation of a Novel 

Peri-Operative Pharmacist Driven 

Anticoagulation Assessment Service 

Concord Hospital 

Regina Kavadias, PharmD 

rkavadia@crhc.org 

Pharmacy Anticoagulation Service: 

Improving Efficacy and Transitions of Care 

Concord Hospital 

Regina Kavadias, PharmD 

rkavadia@crhc.org 

Aggressively Using Portable UV Light 

Disinfection Creates Significant 

Reduction in Environmentally-Related 

Health Care Associated Infections 

Cooley Dickinson Hospital 

Daniel English 

daniel_english@cooley-dickinson.org 

20,000 Days Campaign 

Counties Manukau District Health Board 

Diana Dowdle 

Diana.dowdle@middlemore.co.nz 

Using Technology to Facilitate Timely 

Care of the Septic Patient: Lactic Acid 

Alert System 

Covenant Health System 

Jamie Roney, RN 

jroney@covhs.org 

Improving the Process of Same-Day 

Appointment Triage in a Family 

Medicine Outpatient Clinic 

Dartmouth Hitchcock Medical Center 

Thomas Leeson, DO 

thomas.a.leeson@hitchcock.org 

Patients’ Love Shines on the 

Physician Transient Trouble Time 

EGPRN; NAPCRG / member 

Sofica Bistriceanu, MD, PhD 

sofica.bistriceanu@yahoo.com 

Nursing Home Guidance: Reducing 

Inappropriate Hospital Admissions for 

the Terminally Ill at End of Life 

NHS South of England 

Sarah Baines 

sarah.baines@oxfordhealth.nhs.uk 

Improving the Emergency 

Department Culture Follow Up 

Process for Discharged Patients 

Florida Hospital 

Diana Vetterick, RN 

diana.vetterick@flhosp.org 

Supporting Team (MD + RN) Rounding 

Forsyth Medical Center 

Trina Seals, RN 

tseals@novanthealth.org 

An ICU Patient-Family Communication 

(PFC) Pilot: It is Not Only About End of Life 


A. Joseph Layon, MD 

ajlayon@geisinger.edu 

Checklists and Quality Outcomes— 

Correlation or Causation? 




HAIs and Thermally Injured Patients— 

Chlorhexidine Gluconate Baths Work 




Weight Loss is Not One Size Fits All 

Gundersen Lutheran Health System 

Andrea Erickson, RD 

adericks@gundluth.org 

Developing a Fall Risk Prevention 

Strategy for Postpartum Patients 

Hartford Hospital 

Deborah Gingras, RN 

dgingras@harthosp.org 

Gone in 90 Minutes: A Multidisciplinary 

Approach to Improve Discharge 

Efficiency and Family Satisfaction 

Hawaii Pacific Health 

James Lin, MD 

jclin@hawaiipacifichealth.org 

Low Acuity Initiative ED PASTE 

Performance Improvement Initiative 

Heartland Health 

Tami Meier, RN 

tamara.meier@heartland-health.com 

Missouri’s Effort to Show You Great 

Care: Project ED PASTE Performance 

Initiative 

Heartland Health 

Tami Meier, RN 

tamara.meier@heartland-health.com 

The Importance of Hospital 

Surveillance in the IPSG Monitoring: 

Patient Identification 

Instituto Nacional de Traumatologia e 

Ortopedia Jamil Haddad 

Marcio Niemeyer-Guimaraes 

muracio@gmail.com 

An Impact Analysis of Enhanced 

Recovery for Colorectal Surgery 

Interior Health Authority 

Ron Collins, MD 

drron.collins@interiorhealth.ca 

The “Green” Side of Patient Safety 

Jesse Brown VA Medical Center 

Laurie Blum-Eisa, RN 

Laurie.Blum-Eisa@va.gov 

Care Transitions: Building a Community 

Dream Team to Reduce Readmissions 

John Dempsey Hospital 

Wendy Martinson, RN 

wmartinson@uchc.edu 

Disaster Prepardeness: Keeping Our 

Children Safe in the Event of a Disaster 


Sarah Koshy, RN 

Sarah.X.Koshy@kp.org 

Solving Screening Mammogram Access 


Sonya Weise 

sonya.e.weise@kp.org 

Patient Centered Medical Home: A Vision 

for Progressive Transformational Change 

Kaiser Permanente Riverside Medical Center 

Callisha.A.Bell@kp.org 

Impact of Interdisciplinary Collaboration 

on HCAHPS Pain Scores by Enhancing a 

Decentralized Pharmacy Model 

Kimball Medical Center 

Sandra Richardson, PharmD 

srichardson@barnabashealth.org 

Appropriateness of the Utilization of 

Hospital Resources in Saudi Arabia: 

Implications for Health Quality 

King Saud University 

Saad Alghanim, PhD 

sagksu@gmail.com 

Paving The Way With Process Innovation 

King’s Daughters Medical Center 

Tara McFann 

tara.mcfann@kdmc.net 

Experiences of Lung-Cancer Care — 

Perspectives of Patients and Significant 

Others 

Landstinget Dalarna 

Osterlund Efraimsson 

eoe@du.se 

Patients Contacts with PHC Regarding 

Specific Lung-Cancer Symptoms 

Landstinget Dalarna 

Osterlund Efraimsson 

eoe@du.se 

Coiled Urinary Drainage Tubing Does 

Not Increase the Risk of UTI 

Marmara University 

Zeynep Kubilay, MD 

zepella@hotmail.com 

Improving the Reliability of Care 

Coordination and Reducing Hospital 

Readmissions in an Academic Medical 

Center (STAAR) 

Massachusetts General Hospital 

Jocelyn Carter, MD 

jcarter0@partners.org 

Patient Safety Reporting System: 

Innovative Uses 


Ruth Bryan, RN 

rbryan@partners.org 

Using a Web-Based Standardized 

Clinical Encounter to Evaluate Providers’ 

Ability to Assess Risk of Suicide 

Massachusetts General Hospital, 

Psychiatry Academy 

Lydia Chevalier 

lchevalier@partners.org 

Clinical Decision Support Tools for 

Improved Population Outcomes at 

Point of Care 

Mayo Clinic 

Dawn Francis 

francis.dawn1@mayo.edu 

Spreading Innovation Across ICUs: 

A Systems Approach 

Mission Hospitals 

Laurie Downs, RN 

laurie.downs@msj.org 

Clinical Initiative to Improve 

Transitions in Care for the Frail Elderly 

with Dementia 

Monmouth Medical Center 

Joan Wills, RN 

jwills@barnabashealth.org 

Innovating Care: Rapid Cycle Design of 

an Express Admission Unit 

Mount Sinai Hospital 

Kate Van Den Broek, RN 

kvandenbroek@mtsinai.on.ca 

42 


Improving Quality Through an Innovative 

Health Home 

MultiCare Health System 

Ashley Keays, DO 

ashley.keays@multicare.org 

Challenges in Evaluating and Selecting 

Readmission Measures for Use as 

National Consensus Standards 

National Quality Forum 

Alexis Morgan 

aforman@qualityforum.org 

Improving the Use of Topical Anesthetic 

Prior to IV Placement in the Pediatric 

Emergency Department 

New York Presbyterian Hospital 

John Babineau, MD 

jb2358@columbia.edu 

Supporting the Implementation of 

Advance Care Planning in Care Homes in 

the Westongrove Area 

NHS Education South Central 

Joanna Withers, MB ChB 

joanna.withers@nhs.net 

Innovation in Same Day Emergency Care 

NHS Institute for Innovation and 


Carolyn Robertson, RN 

carolyn.robertson@institute.nhs.uk 

Successful Innovation—Can Health Care 

Learn From Business? 

NHS South of England 

Tricia Woodhead 

pwoodhead@nhs.net 

Health Behavior Change—Where the 

Rubber Meets the Road 

Chris Sarfaty, MSW, LICSW 

csarfaty@comcast.net 

Optimizing Inpatient Glycemic Control: 

A Journey of Process, Knowledge, and 

Culture 

North Memorial Medical Center 

Shelley Weier, MD 

susan.schumacher@northmemorial.com 

Developing an SNF Affiliate Network: 

Improving Care Across the Continuum 

North Shore Long Island Jewish 

Health System 

Maureen E. McClusky 

mmcclusk@nshs.edu 

When It Comes to Quality Kids are 

Not Small Adults: Creating a Pediatric 

Service Dashboard 

North Shore Long Island Jewish 

Health System 

Linda Jendresky 

LJendresky@nshs.edu 

Empowering the Perioperative Staff 

Improve Patient Safety 

North Shore University Hospital 

Martha Nicholson 

mnichols@nshs.edu 

Quality as a Driver of CME Activities 

North Shore-LIJ Health System 

Fiona H Levy, MD 

flevy@nshs.edu 

Transforming Care for the Elderly in 

Nursing Homes 

Northern Ireland HSC Safety Forum 

Janet Haines-Wood 

janet.haines-wood@setrust.hscni.net 

A Suicide Risk Assessment Resource 

for Health Care 

Ontario Hospital Association 

Cyrelle Muskat 

cmuskat@oha.com 

Supporting and Sustaining Recovery in 

Transition from Hospital to Home: Learning 

Through the Patient Experience 

Ontario Shores Centre for Mental 

Health Sciences 

Beth Brannon, RN 

brannonb@ontarioshores.ca 

Asynchronous Web Visits for the 

Follow-up of Chronic Conditions: 

A Pilot Study 

Partners Healthcare 

Ronald Dixon, MD 

rdixon@partners.org 

Improving Glycemic Outcomes 

Presbyterian Hospital/Novant Health 

Clinical Improvement 

John Gardella, MD 

jegardella@novanthealth.org 

Improved Satisfaction with a Team 

Approach to Pediatric Emergency Care 

Primary Children’s Medical Center 

Douglas Nelson, MD 

doug.nelson@hsc.utah.edu 

The Accelerating Clinical Transformation 

for Creating Value and Controlling Cost 

in Cardiology 

Providence Health and Services 

Xiaoyan Huang, MD 

xiaoyan.huang@providence.org 

Applying International Learning to 

Drive Person-Centred Care Locally 

Public Health Wales 

Alan Willson, MD 

Alan.Willson@wales.nhs.uk 

Making Quality the Heart of Your 

Business—The Experience in Wales 


Alan Willson 


A3 Methodology: Reducing IV Catheter 

Related Events 

Rutland Regional Medical Center 

Denise Simpson 

dsimpson@rrmc.org 

Patient Tracking Through 

Perioperative Care 

Saint Joseph’s Health Care London 

Karen Rogers, RN 

karen.rogers@sjhc.london.on.ca 

The Role of Navigation and Patient 

Education in the Treatment of Patients 

with Head/Neck Cancers 

Samaritan Hospital Cancer Treatment 

Center St. Peter’s Health Partners 

Sabrina Mosseau, RN 

mosseaus@nehealth.com 

Santa Clara Valley Medical Center 

Quality Improvement Initiative: 

Implementation of Health Reform Act 

Santa Clara Valley Medical Center 

Alan Travasso 

Vickie.Wilson@hhs.sccgov.org 

Enhancing Care & Reducing 

Readmissions for CHF Patients: 

The Role of the Primary Care Team 

Sentara Healthcare 

Anthony Hardt, MD 

abhardt@sentara.com 

Eliminating Falls for High Fall Risk 

Patients in the Emergency Department 

Singapore General Hospital 

Ho Soo Ling 

mone.mone.zaw@sgh.com.sg 

Fall Not! 


Neela Kanagasundaram 


Order Up 


Lee Chee Woei 


Synergy: A Multiple Antimicrobial 

Combination Testing Method 


Andrea Kwa 


Health Literacy and Pediatric Family- 

Centered Care: Improving the Safety 

and Efficiency of the Pre-Surgical 

Experience 

Steven and Alexandra Cohen 

Children’s Medical Center 

Gloria Collura, RN 

gcollura@nshs.edu 

Improving Charge Capture, Productivity 

Tracking, and Staff Satisfaction 

The Christ Hospital 

Victoria Roelker 

victoria.roelker@thechristhospital.org 

Targeting Zero Safety Events 

The Christ Hospital Health Network 

Kim Biery, RN 

kimberly.biery@thechristhospital.com 

Hybrid Learning to Support Chronic 

Care Redesign 

The Dartmouth Institute for Health Policy & 

Clinical Practice/Dartmouth College 

Alice Andrews, PhD 

alice.andrews@dartmouth.edu 

Naming Conventions for Trauma 

Activation, Unidentified, and Mass 

Casualty Incident Patients 

Truman Medical Center 

Teresa Lienhop, RN 

tlie4@aol.com 

Reducing Patient Turnaround Time in the 

Emergency Dept: A Multi-Year Experience 

UHS 

Srikanth Poranki, PhD 

srikanth_poranki@uhs.org 

Developing and Implementing a 

Positive Leadership Program 

University Health Network 

Kathi Sabo, RN 

Kathy.sabo@uhn.ca 

Discharge Navigators: Providing 

Transitional Support and Acute Care to 

Post-Surgical Patients After Discharge 


Carolyn Plummer, RN 

carolyn.plummer@uhn.ca 

Nurses for Tomorrow: A Strategic Nursing 

Resource Analysis Approach to Proactive 

Health Human Resource Management 


Carolyn Plummer, RN 

carolyn.plummer@uhn.ca 

Within the S.C.O.P.E. of Patient Care: 

A Primary Care Integration Project 

and Evaluation 


Mary Kay McCarthy, RN 

marykay.mccarthy@uhn.ca 

Improving Care for Severely Injured 

Children in Wessex 

University Hospital Southampton NHS 

Foundation Trust 

Kate Pryde 

katepryde@nhs.net 

Cost-Effectiveness Analysis of Textile 

Technology in Preventing Methicillin- 

Resistant Staphylococcus Aureus 

University of Central Florida 

Ning Zhang, MD, PhD 

ning.zhang@ucf.edu 

Creating a Just Culture: Error and Near 

Miss Reporting System for Nursing 

Students 

University of San Francisco 

Elizabeth Cooper, RN 

eecooper@usfca.edu 

Antimicrobial Stewardship at MD 

Anderson Cancer Center 

University of Texas, MD Anderson 

Cancer Center 

Kenneth Rolston, MD 

krolston@mdanderson.org 

Reduction in Pediatric Mortality Rates 

by Analysing Mortality Cases 

University of the Free State (Family 

Medicine Department) 

Lesley Thembelani, MB, ChB 

bhebhelt@gmail.com 

University of Wisconsin Health 

Industrial Engineering Student Program 

University of Wisconsin Medical Foundation 

Elizabeth Strutz 

elizabeth.strutz@uwmf.wisc.edu 

Code Triage: A Modeling of Rapid 

Response Team in Ambulatory Care 

VA Medical Center 

Evelinda Camacho, RN 

evelinda.camacho@va.gov 

Community Living Center: Military 

Honors Ceremony—Preserving Dignity 

in Death 

VA Medical Center 

Evelinda Camacho, RN 

evelinda.camacho@va.gov 

Implementation of an Electronic 

Early Warning System: The Sum Equals 

Lives Saved 

Virginia Commonwealth University 

Health System 

Renata Sampson, RN 

rsampson@mcvh-vcu.edu 

Sustainable Effective Implementation of 

a Surgical Pre-Procedural Checklist: An 

Attestation Format for all Team Members 

Virginia Mason Medical Center 

Farrokh Farrokhi, MD 

nsrfrf@vmmc.org 

Destroying the State of Sepsis 

Washington Hospital Center 

Sally Gutierrez, RN 

sally.b.gutierrez@medstar.net 

Improving Obstetrical Rapid Response 

Teams Using Multidisciplinary Simulation 

and Family Models 

Wellspan Health 

Eileen Garavente, MD 

egaravente@wellspan.org 

Which storyboard did you enjoy? Tweet it using #IHI24Forum 

43

storyboards 

Storyboard 

Reception • Tuesday, December 11 • 4:30 PM – 6:30 PM • Palms Ballroom 

Improving Surgeon Documentation 

Practices to Reduce Coding Errors 

in PSI-15 

Wellspan, York Hospital 

Virginia Wesner 

vwesner@wellspan.org 

Using ACS NSQIP to Monitor 

Success and Failure in Changes 

to SCIP Measures 




Using the Surgeon Champion Model 

to Improve Surgical Care Improvement 

Project Compliance at York Hospital 




The Agency for Healthcare Research 

and Quality Health Care Innovations 

Exchange 

Westat 

Laura Gray 

LauraGray@Westat.com 

Redesign of the Medicine Program: 

Blending Theory and Method for 

Groundbreaking Results 

Windsor Regional Hospital 

Theresa Morris, RN 

theresa_morris@wrh.on.ca 

The Time Out Project and Culture of 

Safety at Woodhull Hospital, NYC 

Woodhull Medical and Mental Health 

Center (Health and Hospitals 

Corporation) 

Minda Aguhob 

maguhob@gmail.com 


Covenant Care—Empowering 

Employees Through Philanthropy 


Paula Miser 

bthornton@covhs.org 

Frontline Engagement in a 6S Project in 

a Busy Operating Room: 1 “S” at a Time 


Pat Reeves, RN 


Improving Suture Safety Outside the 

Operating Room 


Leslie Zun, MD 

zunl@sinai.org 

Developing the Sheffield 

Microsystem Coaching Academy 

Sheffield Teaching Hospitals 

Tom Downes 

tom.downes@sth.nhs.uk 

Reducing Staff Calls from 

Patient Rooms 


Khoo Kian Boon 


Chronic Disease Management: A Staff 

Driven Evidence Based Care Model at 



Karen Riddell, RN 

karen_riddell@wrh.on.ca 

motivate 

Trauma Alert Activation by 

Emergency Medical Services 


Kelly Cummings 


Using Technology and Environmental 

Design to Create a Safe, Personalised, 

and Meaningful Patient Journey 

Bupa Cromwell Hospital 

Jan McGuinness 

jan.mcguinness@cromwellhospital.com 

Healthy Northeast: Community 

Transformation Led by Residents 

Community Solutions 

Catherine Craig 

ccraig@cmtysolutions.org 

hk2020 


Coralyn Dillard, RN 


Flourishing a Culture for Continuous 

Improvement in Health Care and Social 

Services in Sweden 

Famna - Swedish Association for Non-Profit 

Health and Social Service Providers 

Thomas Schneider, PhD 

thomas.schneider@famna.org 

Using Simulation to Demonstrate the 

Power of Improvement Methodologies 

for Clinical Laboratories in Resource- 

Limited Settings 

Global Health Consulting BCM 

Barbara McKinney, MD 

bcmpathdoc@me.com 

Implementation of a Post-Hospital 

Discharge Follow-Up Appointment 

with a Pharmacist Within an Internal 

Medicine Clinic 

Gundersen Lutheran Medical Center 

Michael Meyers, PharmD 

memeyers@gundluth.org 

Perinatal Mood and Anxiety Disorder 

Screening and Rapid Response Team 


Jean Krause 

jmkrause@gundluth.org 

Establish a Center for Patient Safety 

and Quality: Improving Regional Patient 

Safety Promotion and Medical Quality 

Japan Association for Development of 

Community Medicine 

Masahiko Ishikawa, MD 

masahikois@jadecom.jp 

Leadership Embraces the Culture of 

Quality Improvement at the Department 

of Public Health 

Los Angeles County - Department of 

Public Health 

Quan Truong 

qtruong@ph.lacounty.gov 

5S in the LPCH NICU 

Lucile Packard Children’s Hospital 

Danielle Scapa 

dscapa@LPCH.org 

Children’s Care Value Stream Re-Design 

National Healthcare Group Polyclinics 

Lim Voon Hooi, RN 

Voon_Hooi_LIM@nhgp.com.sg 

Creating a Culture of Physician 

Excellence—Physician Excellence 

Committee 

NCH Healthcare System 

Michael Vickers, MD 

mvickers@nasamri.com 

Accurate Daily Weights in CHF Patients 

North Shore Medical Center 

Prashanth Mopala, MD 

pmopala@partners.org 

A Roadmap to Joint Commission 

Certification for Palliative Care 

North Shore University Hospital 

Dana Lustbader, MD 

Lustbader@nshs.edu 

Hypothermia Blankets in the ICU: An 

Ice Age Practice? 

Northwestern Memorial Hospital 

Inge LeBlanc, RN 

ingeleblanc@hotmail.com 

Applying International Learning to 

Drive Person-Centred Care Locally 

Public Health Wales/1000 Lives Plus 

Alan Willson, PhD 

sarah.puntoni@wales.nhs.uk 

Stories for Improvement—A National 

System-Wide Learning Approach 




Developing Internal Professional 

Standards in the Emergency Department 

Safety Forum 

Levette Lamb, RN 

levette.lamb@setrust.hscni.net 

iLead: A Quality and Patient Safety 

Support Program 

Sunnybrook Health Sciences Centre 

Brigette Hales 

brigette.hales@sunnybrook.ca 

Heart Failure: Stop the Revolving Door 

UConn Health Center 

Jason Ryan, MD 

jaryan@uchc.edu 

Collaborative Approach Improves Quality 

Measures of Symptom Management 

in the Michigan Oncology Quality 

Consortium 

University of Michigan Health System 

Katherine Abstoss 

kabstoss@umich.edu 

Development of a PDSA Cycle to 

Improve Diabetes Care in a Resident 

Continuity Clinic 

Washington Univ-School of Medicine 

Emily Fondahn, MD 

fondahne@gmail.com 

Structured Debriefings Following 

Trauma Cases Improve Perceptions of 

Team Communication 

Wesley Medical Center 

Gina Berg, PhD 

gberg@kumc.edu 

Structured Debriefings Improve 

Perceptions of Quality of Care 

Wesley Medical Center 

Gina Berg, PhD 

gberg@kumc.edu 

Use of WHO International Health 

Promoting Hospital Standards to 

Improve Healthcare 

PA Regional Network; Saint 

Vincent College 

Carla Zema, PhD 

carla.zema@stvincent.edu 

get results 

ETC to MICU Communication of Patient 

Care at the Bedside 




Preventing Unnecessary Radiation: 

The Days Since Program 




Improving Cancer Outcomes Through 

Value-Based Commissioning 

ACCA 

Sharon Cannaby 

sharon.cannaby@accaglobal.com 

Accreditation Canada Leading Practices: 

Recognizing Innovation, Sharing 

Knowledge, and Improving Health Care 

Accreditation Canada 

Christopher Dean 

christopher.dean@accreditation.ca 

Utilizing Sepsis Bundle to Reduce 

Mortality in ED Patients: AHS 

Collaboratives 

Adventist Health System 

Joanie White 

joanie.white@ahss.org 

Right Time, Healthy Babies Playbook: 

Initiating an Improvement Project 

Across Institutions 

Affiliated Community Medical Center, 

Dartmouth College 

Kathryn Duevel, MD 

kathrynd@acmc.com 

Improving the Timeliness of Discharge 

Documentation to Accelerate Housekeeper 

Response Time to Clean a Room 

All Children’s Hospital 

Julie Messick, RN 

Julie.Messick@allkids.org 

Recommendations for Implementing 

Lean: Findings from Five Case Studies 

American Institutes for Research 

Kathryn Paez, RN, PhD 

kpaez@air.org 

Cardiac Arrest: A Change Package to 

Save Lives 

American Medical Response 

Lynn White 

Lynn.White@emsc.net 

Development of a Global EMS Trigger 

System for Identifying Adverse Events 

in the Prehospital Environment 

AMR 

Mike Verkest 

mike.verkest@amr.net 

44 


Improve Member Access to FUH 

Within 7 Days for TX Medicaid and IL 

Commercial Populations 


Eric Altman 


Transitions of Care: Reducing Hospital 

Inpatient Admissions in Pennsylvania’s 

High Risk, High Cost Medicaid Population 


Eric Altman 


Large Scale Surgical Improvement in 

Britsh Columbia, Canada 

BC Patient Safety and Quality Council 

Marlies van Dijk, RN 

mvandijk@bcpsqc.ca 

Journey Through the Misadventures of 

Chemotherapy 


May Adra, PharmD 

madra@bidmc.harvard.edu 

Preventing Patient Harm: A Tale of 

Two Hospitals 

Beth Israel Deaconess Medical Gns 

Kenneth Sands, MD 

ksands@bidmc.harvard.edu 

Reducing Incontinence Associated 

Dermatitis using the VA-TAMMCS 

Improvement Model 

Birmingham VA Medical Center 

Debra Litton, RN 

littonr@charter.net 

Value Based Purchasing is Here, Now 

How Do You Deal With It? 

Blanchard Valley Regional Health System 

Timothy Teyner 

tteyner@bvhealthsystem.org 

Reducing Medication Requests to 

Improve Nursing and Pharmacy Efficiency 

Bridgeport Hospital 

Teresa Papstein, RPh 

dtpaps@bpthosp.org 

Getting to a Better Place, Raising 

Employee Opinion Scores, by Establishing 

a Nursing Conflict Resolution Group 

Brigham and Women’s Hospital 

Marianne Cummings, RN 

mcummings2@partners.org 

Impact of Bedside Barcoding on 

Medication Errors in a 150-Bed 

Rehabilitation Hospital 

Burke Rehabilitation Hospital 

Thomas Grandville, PharmD 

tgrandvi@burke.org 

Improving the Discharge Process: 

Journey from Paper to Electronic 

Cancer Treatment Center of America 

Susan M. Eckhardt 

laurentp@icmcvi.com 

Lean Tools in Everyday Life 


Kathryn Doran 


Sleep Deprived? Overlooked and 

Undertreated 


Michele Szkolnicki 


Physicians on the LSS Journey 

Cancer Treatment Centers of America® at 

Eastern Regional Medical Center 

Precious Laurent 


Optimization of On-Site Guest 

Accommodations 

Cancer Treatment Centers of America® at 

Eastern Regional Medical Center 

Ahmed Ayad 

Ahmed.Ayad@ctca-hope.com 

Better Together: The Power of 

Carolinas Health Care System Working 

Together to Reduce Early Elective 

Deliveries 

Carolinas HealthCare System 

Deana Williams 

Deana.williams@carolinas.org 

Diabetes Management Care Redesign 


Zeev Neuwirth, MD 

Zeev.Neuwirth@carolinashealthcare.org 

Lipid Management for Ischemic Vascular 

Disease Patients: A Performance 

Improvement Team Approach 


Lisa Hebert 

Lisa.hebert@carolinashealthcare.org 

Striving to Keep Patients Healthy 

at Home: Reducing Avoidable 

Rehospitalizations in Home Health 


Lori Drewery, RN 

lori.drewery@carolinashealthcare.org 

Reducing Lab Specimen Mislabeling to 

Prevent Potential Patient Harm 

Cedars-Sinai Medical Center 

Edward Seferian, MD 

edward.seferian@cshs.org 

How Can We Improve Patients’ Knowledge 

and Understanding About Side Effects of 

Medicines? 

Chelsea and Westminster NHS 


Vanessa Marvin, PharmD 

vanessa.marvin@chelwest.nhs.uk 

Improving Discharge Efficiency and 

Effectiveness for Asthma Patients Using 

the Electronic Health Record 


Amy Tyler, MD 

amy.tyler@childrenscolorado.org 

Improving Hospital Discharge Summary 

Content and Routing Timeliness to the 

Primary Care Provider 


Mark Brittan, MD 

mark.brittan@childrenscolorado.org 

Hand off of Information: Our Medication 

Reconciliation Journey 

Children’s Specialized Hospital 

Lorraine Quatrone 

LQuatrone@childrens-specialized.org 

Establishing a Portfolio of Quality 

Improvement Projects in Pediatric 

Surgery Through Advanced 

Improvement Leadership Systems 

Cincinnati Children’s Hospital 


Christina Williams 

christina.williams@cchmc.org 

Imaging Institute Critical Results 

Development 

Cleveland Clinic Health System 

Bonnie Wildman, RN 

wildmab@ccf.org 

Patient Engagement Technology Sets 

Expectations for a Hospital Stay and 

Improves HCAHPS Scores 

Cleveland Clinic Health System 

James Merlino, MD 

merlinj@ccf.org 

Reduction of Third and Fourth Degree 

Lacerations During Vaginal Delivery 

Community Medical Center 

Donna Cetroni, RN 

dcetroni@barnabashealth.org 

I Am Waiting for the Results of My 

Child’s Labwork…and Waiting 

and Waiting 

Connecticut Children’s Medical Center 

Sandra Riccardino, RN 

Sriccar@ccmckids.org 

Improvement of Regulatory Compliance 

Through Care Enhancement Teams 

Courtemanche & Associates 

Judy Courtemanche, RN 

elizabeth@courtemanche-assocs.com 

Frontline Staff Implement Tollgates in 

Lean 6S Project in Equipment Distribution 


Bruce White 


Modified Early Warning Scoring Tool 

Conceptualization: Identifying the 

Patient At-Risk for Deterioration 


Jamie Roney, RN 

jroney@covhs.org 

Race for the BEST: Achieving Higher 

Standards for Pain Management and 

Patient Experience 


Karen Dean, RN 


Show Me a Medical Home: 

Transformation in Missouri 

CSI Solutions 

Laurel Simmons 

lsimmons@spreadinnovation.com 

Chiropractic and Oncology 

Rehab Integration 

Cancer Treatment Centers of America 

(CTCA) 

Karen Gilbert 


Crash Cart Update 

CTCA 

Tiffany Vaughan 


Maximizing Lab Storage 

CTCA 

Adetola Akinwande 


Peripherally Inserted Central Catheter 

Line Appointments 

CTCA 

Stephanie Pagliaroni 


Pharmacy Kaizen 

CTCA 

Heather Cole 


Pre-Scheduling of Radiation 

Oncology Consults 

CTCA 

Peyton Williams-Veal 


Quality of Life Coordination of Care 

CTCA 

Tracy Tetzner 


Respiratory Therapy and Oncology 

Rehabilitation Program 

CTCA 

Dawn Fortner 


The Danish Safer Hospital Programme 

Danish Society for Patient Safety 

Beth Lilja, MD 

beth.lilja@patientsikkerhed.dk 

Coffee + Potluck + Data = Healthy 

Mom & Baby on a Shoestring Budget 


Michele Lauria, MD 

Michele.lauria@hitchock.org 

Evidenced-Based Care—Why are we 

Still Struggling? 

Datix Ltd., United Kingdom 

Daniel L. Cohen, MD 

dcohen@datix.co.uk 

Quality in Health Care: A Four 

Dimensional View of the Elephant 

Datix Ltd., United Kingdom 

Daniel L Cohen, MD 

dcohen@datix.co.uk 

Using a Classification System to 

Reduce Medication Errors & Improve 

Medication Safety 

Deaconess Hospital 

Darla Vote, RN 

darla_vote@deaconess.com 

Improving Pre-Hospital Care for 

Patients with Heart Attack or Stroke 

—Ambulance Cardiovascular Quality 

Initiative 

East Midlands Ambulance Service 

Deborah Shaw 

debbie.shaw@emas.nhs.uk 

Physician Orders for Scope of 

Treatment Pilot Program 

Edward W Sparrow Hospital 

Carolyn Stramecki 

carolynstramecki@yahoo.com 

Accountable Post-Surgical Care: 

Reducing Defects in Postoperative 

Gastrostomy Tube Care 

Emory University 

Sarah Hill, MD 

sarahjoyhill@gmail.com 

Saying Boo to the Flu: Improving 

Health Care Worker Immunization 

Rates in a Community Health System 

Excela Health 

Denise Addis, RN 

daddis@excelahealth.org 

A Multidisciplinary Approach to the 

Elimination of Neurosurgical Site 

Infection 

Excela Health Latrobe Hospital 

Joan Grote 

jgrote@excelahealth.org 

Implementation of a Nurse Driven 

Collaborative: Sepsis Protocol in a 

Community Hospital Setting 

Flagler Hospital 

Kelly Reyna, RN 

kelly.reyna@flaglerhospital.org 

ED XR TAT 

Florida Hospital 

Jaison Abraham 

jaison.abraham@flhosp.org 

Improving Glycemic Outcomes 

Forsyth Medical Center/Novant Health 

Clinical Improvement 

Patrick Healy, MD 

pkhealy@novanthealth.org 

Reduction of Unnecessary Therapy by 

Respiratory Care in the Adult Population 

Through Patient Driven Protocols 


Joseph Mlinarich 

jjmlinarich@geisinger.edu 


45

storyboards 

Storyboard 


Introduction of VTE Risk Assessment 

in a Large Acute Hospital with a Target 

of 90% 

Gloucestershire Hospital NHS 


Andrew Seaton, RN 

andrew.seaton@glos.nhs.uk 

Improvement in Hand Hygiene Compliance 

Greenville Hospital System University 


Tom Diller, MD 

tdiller@ghs.org 

A Novel, Comprehensive, Multimodal 

Analgesic Regimen for Joint 

Replacement Surgery 

Greenwich Hospital 

Mark Chrostowski, MD 

mark.chrostowski@greenwichhospital.org 

Improved Outcomes with Minimally 

Invasive Coronary Artery Bypass 

Grafting 


Prem Rabindranauth, MD 

prabindr@gundluth.org 

Integrated Transfusion Reduction 

Initiative: Impact Among Patients 

Undergoing Surgery for Colorectal 

Cancer 


Joshua Froman, MD 

sbshapir@gundluth.org 

The Road Home: A Pediatric Practice’s 

Journey to Develop a Patient Centered 

Medical Home 


Steven Manson, MD 

srmanson@gundluth.org 

The Effect of Periodic Rounding 

on Fall Prevention in High-Risk 

Emergency Department Patients 

Hartford Hospital Geriatrics 

Christine Waszynski 

cwaszyn@harthosp.org 

Streamlining Emergency Department 

Patient Flow Through a Targeted 

Patient Assessment Area 

Health Sciences North 

Shannon Clarke, RN 

shclarke@hsnsudbury.ca 

High Complexity: Methodology for 

Definition and Measurement in Private 

Hospitals 

Hospital Israelita Albert Einstein 

Paula Kiyomi Onaga Yokota, RN 

paulak@einstein.br 

Ease My Pain 

Howard University Hospital 

Hemamalini Karpurapu, MD 

hkarpurapu@gmail.com 

Impact of Patient-Centered Medical 

Homes on Cost and Utilization of 

High-Risk Members 

Independence Blue Cross 

Ravi Chawla 

Ravi.Chawla@ibx.com 

Patient-Centered Medical Home 

Impact on Chronically Ill Commercial 

Health Plan Members 


Ravi Chawla 


Patient-Centered Medical Home 

Impact on Health Plan Members with 

Diabetes 


Ravi Chawla 


Patient-Centered Medical Homes 

Reduce Inpatient Admissions and 

Expenditures for Chronic Members 


Ravi Chawla 


Specialist Reviews for Patients at the 

Institute of Mental Health Within 24 

Hours of Admission 

Institute of Mental Health, Singapore 

Hong Choon Chua, MD 

hong_choon_chua@imh.com.sg 

Falls in Hospital Environment: The 

Importance of Event Notifications 



Marcio Niemeyer, MD 


Effective Critical Laboratory Tests 

Communication Based on The Joint 

Commission International Patient 

Safety Goal No.2 



Marcio Niemeyer, MD 


Improve Prescription Capture Rate 

International Capital and Management 

Company 

Chenery Kinemond 

rodrigueza@icmcvi.com 

Reducing Imaging Turnaround Time 

International Capital Management 

Company 

Sherina Khiani 


Costs vs. Values: Lessons for 

Transforming Global Health Systems 

Ivey International Centre for Health 

Innovation, University of Western Ontario 

Karin Schnarr 

kschnarr.phd@ivey.ca 

I-Aguirre sm Quality Model: 

Successful Sustained Results 

Jackson Health System 

Roboam Aguirre, RN 

Roboam@aol.com 

Redesigning Case Management 

Jewish Hospital Kenwood 

Tiffany Coyle 

tcoyle@health-partners.org 

The Right Focus for Health Care 

Leaders 

jmakaroff@novaces.com 

Jason Makaroff 

jmakaroff@novaces.com 

Hospital Operating Room Turnover 

Time Reduction 

Kaiser Foundation Hospital 

Debra Brown 

debra.l.brown@kp.org 

ICU Restraint Documentation 

Compliance Improvement 


Debra Brown 


Improve Quietness of the Hospital 

Environment 


Debra Brown 


Medi-Cal Treatment Authorization 

Request Submission Time Reduction 


Debra Brown 


Reducing UTIs in GYN NSQIP Surgical 

Patients 


Debra Brown 


From Sea Level to Summit: One Team’s 

Climb to Excellence Begins in Fast Track 


Julie West, Sherri Austin 

julie.a.west@kp.org 

How a High-Performing Unit-Based 

Team Sustained and Spread Best 

Practices to Improve Colorectal Cancer 

Screening 


Vicky McCloskey 

vicky.j.mccloskey@kp.org 

Kaiser Permanente Proactive Physician 

Office Support 


Grace Chiang 

grace.h.chiang@kp.org 

Northwest Region, Histology Lab 

Unit Based Team Turnaround Time— 

Phase Two 


Lolita Burnette 

Lolita.B.Burnette@kp.org 

Frontline Staff and Management 

Engagement Drive Quality Outcomes 

Kaiser Permanente Medical Group 

Joan Mah 

Joan.Mah@kp.org 

The Kaiser Permanente Labor 

Management Partnership: Building 

Improvement Capacity at the Front 

Lines of Care 

Kaiser Permanente San Diego 

Jenny Button 

Jenny.Button@kp.org 

Reducing High Alert Medication Errors 

Kaiser Permanente, South San Francisco 

Alicia Eyherabide, RN 

alicia.eyherabide@kp.org 

Intensive Care Unit Ventilator-Associated 

Pneumonia Rate Reduction 

King’s Daughters Medical Center 

Tara McFann 

tara.mcfann@kdmc.kdhs.us 

A National Collaborative to Prevent 

Central Line Associated Bactaraemia 

Ko Awatea 

Suzanne Proudfoot, RN 

suzanne.proudfoot@middlemore.co.nz 

Reducing Surgical Site Infections 

Legacy Health 

Lori Fedje, RD 

lfedje@lhs.org 

Fall Prevention: SCUBA Dive for 

Patient Safety 

Legacy Mount Hood Medical Center 

Molly Schmitz 

mschmitz@lhs.org 

Striving for Zero IV Pump Errors— 

A Unique Approach 

Lehigh Valley Health Network 

Kristie Lowery, RN 

Kristie.Lowery@lvhn.org 

Continuous Quality Improvement: 

A Shared Governance Model that 

Maximizes Agent-Specific Knowledge 

London Health Sciences Centre 

Vanessa Burkoski, RN 

vanessa.burkoski@lhsc.on.ca 

Improving Transitions of Care in the 

MaineHealth System: The Value of a 

Community Based Approach 

MaineHealth 

David Bachman, MD 

bachmd@mainehealth.org 

CHRONIC Chronic Problem List 

Implementation Plan: A Process 

Management Success Story 

Mayo Clinic Health System - Eau Claire 

Donn Dexter, MD 

dexter.donn@mayo.edu 

Hearts2Home with One Voice: Involving 

a Patient and Family Advisory Council in 

Reducing Cardiac Readmissions 

Mayo Clinic Rochester 

Carmen Kane 

kane.carmen@mayo.edu 

Best Care Begins with Access to 

Neonatal Intensive Care 

McMaster Children’s Hospital 

Sumesh Thomas 

spthomas@mcmaster.ca 

Near Misses Ignite Our Journey to a 

Happily Ever After 

Mercy Tiffin Hospital 

Karen Gill, RN 

karen_gill@mhsnr.org 

Strategic Processes Utilized to 

Decrease Percentage of Elective 

Scheduled Procedures in L&D 

MidState Medical Center 

Rose Vitale, RN 

rvitale@midstatemedical.org 

Collaborative Initiative to Manage 

Heart Failure Patients, Decreasing 

Readmission Rates and Improving 

Quality of Life 

Monmouth Medical Center 

Sharon Holden, RN 

sholden@barnabashealth.org 

Fall Reduction Efforts on a Geri-Psych Unit 

Mount Auburn Hospital 

Dorothea Devanna, RN 

ddevanna@mah.harvard.edu 

Improving the Hand Off Process 


Leslie Zun, MD 

zunl@sinai.org 

Reduction of Turnaround Time for 

Patients with Upper and Lower Limb 

Injuries in NHG Polyclinics 

National Healthcare Group 

Poh Hia Lim, MD 

euan_ph_lim@nhgp.com.sg 

46 


Reduce the Time Taken for Admission 

of DEM Patients to National Heart 

Centre Singapore Wards 

National Heart Center 

Foong Jia Yi 

foong.jia.yi@nhcs.com.sg 

Improve Compliance to Surgical Site 

Infection Bundle to Reduce Infections 

and Readmissions 

National University Hospital, Singapore 

Bhuvaneshwari Mohan Kumar 

bhuvaneshwari@nuhs.edu.sg 

Adverse Drug Event Huddle Interventions: 

Management Through a Web-Based 

Collaboration Platform 

Nationwide Children’s Hospital 

Dorcas Lewe, RN 

dorcas.lewe@nationwidechildrens.org 

Fever/Neutropenia—Time to 

Antibiotics Reduction 


Mike Cummings 

mike.cummings@nationwidechildrens.org 

Increasing the Identification of 

Childhood Obesity Within a Hospital- 

Based Primary Care Network 


Jim Gallup 

james.gallup@nationwidechildrens.org 

Pediatric Perioperative Hypothermia: 

A QI Approach 


Mike Fetzer 

mike.fetzer@nationwidechildrens.org 

Personalized Reminder Calls: Do They 

Impact Attrition Rates in an Outpatient 

Setting? 


Amanda Wodzisz, RN 

amanda.wodzisz@nationwidechildrens.org 

Back to Sleep: SIDS Prevention in the 

NICU 


Catherine Ravelo, RN 

catherine.ravelo@nchmd.org 

Bar Code Scanning in Labor and 

Delivery 


Robin Piaggione, RN 

robin.piaggione@nchmd.org 

Bug Busters: Stopping Hospital- 

Acquired C-Diff in its Tracks 


Erica Szczepkowski, RN 

erica.szczepkowski@nchmd.org 

Child Friendly Discharge Information 


Catherine Ravelo, RN 

catherine.ravelo@nchmd.org 

Dysphagia Screening for Prevention of 

Aspiration Pneumonia 


Merna Martian, RN 

merna.martian@nchmd.org 

Fall Prevention Strategies for the 

Acute Rehabilitation Patient 


Maria Feola, RN 

maria.feola@nchmd.org 

Hurry Up and Wait! Improving Delays 

in Medication Administration 


Erica Szczepkowski, RN 

erica.szczepkowski@nchmd.org 

Hospital Transporter Job Cancellations 


Magaly Del Valle 

magaly.delvalle@nchmd.org 

Hypergylcemic Control in Cardiac 

Surgical Patients 


Tricia Sutton, RN 

Patricia.Sutton@nchmd.org 

Immersive Simulation: Quality Patient Care 

Through Teamwork and Communication 


Diana Trupiano, RN 

Diana.Trupiano@nchmd.org 

Implementation of a Basal Bolus Insulin 

Program in a Community Hospital Setting 


Kim Thorp, RPh 

Kim.Thorp@nchmd.org 

Implementing Change of Shift Walking 

Rounds to Improve Communication 

and Handoffs 


Barbara Ryan, RN 

barbara.ryan@nchmd.org 

Improving Stroke Discharge Education 


Elizabeth Flick, RN 

elizabeth.flick@nchmd.org 

Improving Time to Therapeutic Vancomycin 



kim.thorp@nchmd.org 

Managing Costs to Medicare 

Reimbursement Rates for Drug 

Eluting Stent Cases 


Christopher Vasta 

christopher.vasta@nchmd.org 

Mother-Baby Discharge Education 


Robin Piaggione, RN 

robin.piaggione@nchmd.org 

No Passing Zone: Improving Response 

to Patient Needs 


Marcia Swasey, RN 

marcia.swasey@nchmd.org 

Oncology Nurses Improve 

Communication about Medications 


James O’Neil 

james.oneil@nchmd.org 

Palliative Care: An Interdisciplinary 

Approach for Best Outcomes 


Gwen Kolegue, RN 

gwen.kolegue@nchmd.org 

Patients Perception of Nurse 

Communication 


Kristin Miller, RN 

kristin.miller@nchmd.org 

Preventing Catheter-Associated Urinary 

Tract Infections by Using Evidence 


Maureen Baldia, RN 

maureen.baldia@nchmd.org 

Preventing Slips, Trips, and 

Broken Hips 


Laraine McNeese, RN 

laraine.mcnesse@nchmd.org 

Qualitative Analysis of Central Line Care 

in the Medical/Surgical Setting 


Theresa Lynch Morrison, PhD, RN 

theresa.morrison@nchmd.org 

Reducing Harm from Anticoagulant 

Therapy 



kim.thorp@nchmd.org 

S.O.S—Suspect Onset of Sepsis 


Jon Kling, RN 

jonathan.kling@nchmd.org 

Sleeping Soundly...Healing Finally 


Jessica D’Agostino, RN 

jessica.dagostino@nchmd.org 

Talk to Me 


Kevin Smith, RN 

Kevin.Smith@nchmd.org 

Targeting Pain Management: Improving 

Documentation and HCAHPS Scores 


Erin Raney, RN 

erin.raney@nchmd.org 

Multi-Disciplinary Bedside Rounds: 

Improving Communication and 

Teamwork to Enhance Patient 

Engagement and Discharge Planning 


Amy Silverstein 

abs9021@nyp.org 

Quality Improvement in the ED With 

Quality Fellows 


Melaney Gordon, RN 

meg9009@nyp.org 

Rapid Improvement Event in the Infusion 

Center at NYU Langone Center for 

Musculoskeletal Care 

New York University Langone 


Kathleen Murphy 

kathleen.murphy2@nyumc.org 

GRASP-AF: How a Simple Piece of 

Audit Software Helped Prevent 90 

AF-Related Strokes in England 

NHS Improvement 

Ian Robson 

ian.robson@improvement.nhs.uk 

Medication Reconciliation: Reducing 

the Risk 

Patricia King 

ncrose2002@yahoo.com 

Orthopedic Care Standard and Related 

Infections 

North Shore - LIJ Health System 

Donna Armellino, RN 

darmelli@nshs.edu 

Anticoagulation Safety: 

A Comprehensive Program 

NorthShore University Hospital 

David Rosenberg, MD 

lraghunauth@nshs.edu 

Discharge Before Noon Challenge to 

Improve Medicine Service Throughput 

NYU Langone Medical Center 

Katherine Hochman, MD 

katherine.hochman@nyumc.org 

Evidenced Based Care for Hospitalized 

Diabetics: Preventing Morning 

Hypoglycemia 

Our Lady of Lourdes Regional 


Cecile Broussard , RN 

broussardc@lourdesrmc.com 

Improving Oral Health by Decreasing 

Time Since Last Hygiene Visit 

Park Dental 

Todd W. Marshall 

jlind@parkdental.com 

Fast Track Extubation Guidelines for 

Select Cardiac Surgery Patients 

Penn Presbyterian Medical Center 

Joseph DiMartino, RN 

joseph.dimartino@uphs.upenn.edu 

Hand Hygiene: Empowering the Patient 


Lauren Fagan, RN 

lauren.fagan@uphs.upenn.edu 

Improving the PPMC Critical Values 

Notification Process 


Adam McMullen 

adam.mcmullen@uphs.upenn.edu 

Please Stay....You Are Important 


Allen Fasnacht 

allen.fasnacht@uphs.upenn.edu 

Providing Safe Meals to Hospital 

Inpatients 


Lee Erickson, MD 

lee.erickson@uphs.upenn.edu 

Safety Checklist Targeting Patient- 

Controlled Analgesia Pumps and Case 

Studies 

Physician-Patient Alliance for 

Health & Safety 

Michael Wong 

mike.ppahs@gmail.com 

Empowering Nurses Through 

Releasing Time to Care 

Providence Portland Medical Center 

Candice Hoag, RN 

candice.hoag@providence.org 

Pursuing Sustainable High Quality 

Care: Jönköping County Council 




Integration of Two International Models 

of Accreditation in a System 

Rede de Hospitais Sao Camilo 

Daniela Akemi Costa 

daniela.akemi@saocamilo.com 

Patient Education Plan: Our Experience 

in Sao Camilo Hospital 




VAP Bundle: A Success Story 




Redesigning the ED Patient Flow to 

Improve Time: An Experience in Brazil 

Rede D’OR Sao Luiz Analia Franco 

Carlos Augusto Dias, MD 

cadias@me.com 

Implementation of Best Practice: 

Reduction of Cesarean Section 

Surgical Site Infection 

Roper St. Francis Healthcare 

Kelly Walker, RN 

Kelly.Walker@rsfh.com 

Worth The Wait: Reduction in < 39 

Weeks Elective Deliveries 

Roper St. Francis Healthcare 

Kelly Walker, RN 

Kelly.Walker@rsfh.com 

Economic Burden of MRSA, 

Clostridium difficile, and Vancomycin- 

Resistant Enterococci in Hospitals 

S2 Statistical Solutions, Inc. 

Peter Mallow 

peterm@s2stats.com 


47

storyboards 

Storyboard 


Adverse Events Rate Used as Strategic 

Indicator 

Sao Camilo 

Fabio Peterlini, MD 

peterlini@uol.com.br 

Sao Camilo Hospital Survey on Patient 

Safety Culture: A Brazilian Experience 

Sao Camilo 

Fabio Peterlini, MD 

peterlini@uol.com.br 

Releasing Time to Care: A Nursing 

Lean Journey 

Saint Charles Health System 

Karen Fitzgerald, RN 

kfitzgerald@stcharleshealthcare.org 

Help! We’re Falling and We Can’t Get 

Up—Falls Reduction 

Saint Luke’s Hospital 

Samir Doshi, MD 

sdoshi@saint-lukes.org 

Pre-Operative Testing of Elective 

Surgical Patients’Adherence to NICE 

Guidelines 

Salisbury NHS Trust 

Matthew Taylor 

mgt102@gmail.com 

Relational Coordination: A Foundation 

for Improving Organizational Health 

Salus Global Corporation 

Nancy Whitelaw, RN 

nwhitelaw@salusgc.com 

Process Improvement Through a 

Leadership Academy 

San Francisco General Hospital 

Thomas Holton, RN 

thomas.holton@sfdph.org 

Implementing the Care Transitions 

Intervention Coaching Tool to Improve 

Program Tracking 

Scott & White Healthcare 

Angie Hochhalter, PhD 

ahochhalter@swmail.sw.org 

PICC Effectiveness: Visions and Targets 

Seton Healthcare Family 

Gwen Irwin, RN 

girwin@seton.org 

First Steps in Quality Improvement: A 

Multidisciplinary Outpatient Team’s 

Experience 

Sheffield Teaching Hospitals 

Jenkins Sarah, MB ChB 

sarah.jenkins@sth.nhs.uk 

Benefit of Active Surveillance Methods 

to Reduce Rate of HAI MRSA in High- 

Risk Populations 

Shepherd Center 

Susan Bowen 

Susan_Bowen@shepherd.org 

Clinical Surveillance Profiles and 

Operational Tracking Boards Identify 

At-Risk Patients: Improving Care 

Quality and Outcomes 

Silver Cross Hospital 

Jeff Softcheck 

jsoftcheck@silvercross.org 

Ease Overcrowding in the Emergency 

Department by Reducing Time of 

Patients to Reach Inpatient Ward 


Norizan Bte Jaafar 


To Improve Hand Hygiene Compliance 

Rate Before Patient Contact 


Lim Tee Cheng Christina 


Driving Quality Performance Across an 

Organization Using Hospitalist RNs 

Sound Physicians 

Dianna Budgeon, RN 

dbudgeon@soundphysicians.com 

A Multidisciplinary Approach to 

Reduce Readmissions 


Marina Farah, MD 

mfarah@soundphysicians.com 

Interdisciplinary Event Review 

Committee: A Successful Impact on 

Catheter-Associated Urinary Tract 

Infections 

St Luke’s Episcopal Health System 

Karen K. Myers, RN 

kmyers@sleh.com 

A System Approach to Improving Care 

of the Patient Exhibiting Alcohol 

Withdrawal Symptoms 

St. John Hospital and Medical Center 

Erica Terry, RN 

Erica.Terry@stjohn.org 

We Are Human First, Expert Second: 

Healing Without Harm, Journey to a 

Safe Culture 

St. John Hospital and Medical Center 

Marietta Aluia, RN 

Marietta.Aluia@stjohn.org 

Reducing Readmissions Within 30 Days 

for Patients with CHF and/or COPD 

St. Joseph’s Health Centre 

Ivan Yuen 

yueniv@stjoe.on.ca 

Working Through the Workaround for 

Safe HIT Adoption 

Sunquest Information Systems 

JoAnne Scalise, RN 

JoAnne.Scalise@gmail.com 

How a Vascular Access Team Eliminated 

CLABSI in PICC Lines for Over Six Years 

Sutter Roseville Medical Center 

Sophie Harnage, RN 

harnagsa@sutterhealth.org 

Impact of Regular Line Rounds in a 

Pediatric Hematology/Oncology Unit 

Texas Children’s Hospital 

Brigitta Mueller, MD 

bumuelle@txch.org 

Measuring the Implementation of Shared 

Decision Making Within the NHS 

The Advancing Quality Alliance 

Lesley Massey 

Emma.J.Walker@srft.nhs.uk 

Child and Family Relations: Building 

Positive Relationships with Patients, 

Families, and Staff 

The Hospital For Sick Children 

Marie Pinard, RN 

marie.pinard@sickkids.ca 

13 Strategies for Patient Safety and 

Joint Commission Compliance for 2013 

The Joint Commission 

Patricia Adamski, RN 

padamski@jointcommission.org 

Thinking Outside the Survey: 

Intracycle Monitoring 


Barbara Buturusis, RN 

bbuturusis@jointcommission.org 

Reinventing ED Patient Flow 

The Miriam Hospital 

Denise Brennan, RN 

dbrennan@lifespan.org 

Need for Pediatric Microsystem in 

Shared-Service Blood Bank 

The Stephen and Alexandra Cohen 

Children’s Medical Center of New York 

Kathy Albert, RN 

kalbert@nshs.edu 

Time Out Challenge: Doing it Right 

Every Time 

The Stephen and Alexandra Cohen 

Children’s Medical Center of New York 

Kathy Albert, RN 

kalbert@nshs.edu 

A Multidisciplinary Approach to Reduce 

Ventilator Associated Pneumonia 

Thomas Jefferson University Hospital 

Brian Glynn 

brian.glynn@jeffersonhospital.org 

An H2H Quality Strategy to Reduce 

Readmissions 

Tucson Medical Center 

Brenda Carle, RN 

brenda.carle@tmcaz.com 

Early Ambulation Reduces VTE 

Following TKR 

UHC 

Marilyn Szekendi, PhD, RN 

szekendi@uhc.edu 

Harm Scale Reliability in Patient 

Safety Events 

UHC 

Tammy Williams, RN 

williams@uhc.edu 

Reducing Door to Balloon Time 

UHS 



Reducing Operating Room Turnover Time 

UHS 



Streamlining Congestive Heart Failure 

Discharge Process 

UHS 



Safe Surgery for Children: Validation of 

a Preoperative Checklist 

Universidade Federal de Sao Paulo 

Maria Angelica Peterlini, RN, PhD 

maria.angelica@unifesp.br 

Bundle to Reduce Catheter-Related 

Bloodstream Infection in a Brazilian 

Neonatal Intensive Care Unit 


Mavilde Pedreira, RN, PhD 

mpedreira@unifesp.br 

Hand Hygiene and Patient Safety: 

Concepts and Practices During 

Undergraduate Training 


Mavilde Pedreira, RN, PhD 

mpedreira@unifesp.br 

Hand Hygiene Promotion in a Pediatric 

Intensive Care Unit in Brazil 


Aline Belela-Anacleto 

alinebelela@uol.com.br 

An Interprofessional Collaborative 

Approach to Standardized Workflow 

and Improved Efficiencies in General 

Internal Medicine Program 


Mary Kay McCarthy, RN 

marykay.mccarthy@uhn.ca 

Improving the Quality of Team 

Communication Through CRM Training 

and Coaching 

University of Colorado Hospital, 

Anschutz Medical Center 

Catherine Kleiner, PhD, RN 

catherine.kleiner@uch.edu 

The Rapid Assessment Zone 

University of Florida 

Nate Lisenbee, MD 

nate4085@ufl.edu 

Reducing Misidentified and Unlabeled 

Specimens in an Academic Medical 

Center 

University of Maryland Medical Center 

Joshuha Ayres 

jayres1@umm.edu 

UMass Memorial Medical Center: 

Developing a Regional STEMI 

Collaborative 

University of Massachusetts 

Memorial Medical Center 

Jay Cyr, RN 

jay.cyr@umassmemorial.org 

UMass Memorial Medical Center: EMS 

—The Link to Expediting STEMI Care 

University of Massachusetts 

Memorial Medical Center 

Jay Cyr, RN 

jay.cyr@umassmemorial.org 

Sustainable Excellence at Penn 

Medicine: Building Capability and 

Capacity for Improvement 

University of Pennsylvania 

Kristi Pintar 

kristi.pintar@uphs.upenn.edu 

An Evidence-Based Practice Center in 

an Academic Medical Center Supports 

Continuous Quality Improvement 

University of Pennsylvania Health System 

Joel Betesh, MD 

joel.betesh@uphs.upenn.edu 

Elder PAC – Providing All-Inclusive 

Care 

University of Pennsylvania Health System 

Susan Foster, RN 

susan.foster2@uphs.upenn.edu 

Standardized Reporting and Analysis 

of Safety and Quality Measures 

Edgewater Technology, Inc. 

Ryan Hayden 

rhayden@edgewater.com 

PIIA: Skin to Skin Contact to Promote A 

Smooth Transition to Extrauterine Life 

University of Pennsylvania - 

Pennsylvania Hospital 

Pamela Power, RN 

Pamela.Power@uphs.upenn.edu 

48 


SCIP-Card 2 Beta Blocker Compliance 


University of Pennsylvania Hospital 

Ann Marie Morris, RN 

morrisa@uphs.upenn.edu 

Building a Culture of Sustainable 

Quality and Process Improvement in 

an Academic Setting 

University of Texas MD Anderson 

Cancer Center 

Elizabeth Comcowich Garcia, RN 

elizgarcia@mdanderson.org 

Improvement of the Chemotherapy 

Preparation Process to Improve 

Patient Safety in the Gynecologic 

Oncology Center 

University of Texas MD Anderson 

Cancer Center 

Judith Smith, PharmD 

jasmith@mdanderson.org 

Power Gradients and Hand Hygiene: 

Risky Business 

University of Texas Southwestern 


Eleanor Phelps, RN 

eleanor.phelps@utsouthwestern.edu 

Reducing Deep Sternal Wound Infections 

Using the DMAIC Framework 

University of Texas Southwestern 

University Hospitals 

Philip Greilich MD 

Philip.greilich@utsouthwestern.edu 

Improving Effectiveness, Promoting 

Efficiency: The EMR-based Pathway for 

Pressures Ulcer Prevention, Detection, 

and Treatment 

UT Southwestern University Hospital 

Eleanor Phelps, RN 

eleanor.phelps@utsouthwestern.edu 

Developing Leadership Skills for 

Improvement Work 

VA Boston Health Care System 

Jacqueline Spencer, MD 

jacqueline.spencer3@va.gov 

Integrating the Care of High Users of 

the Emergency Department 

Vancouver Coastal Health Authority 

Veneranda Dettmers 

veneranda.dettmers@vch.ca 

A Combined Quality System to Promote 

Shared Accountability in a Large 

Health Care Organization 

Vancouver Island Health Authority 

Martin Wale 

martin.wale@viha.ca 

Reducing Avoidable Readmissions 

Effectively: A Minnesota Campaign 

VHA Upper Midwest 

Deborah Brown, RN 

debrown@vha.com 

Waste Reduction in Operating Room 

Instruments by Application of the 

Virginia Mason Production System 


Farrokh Farrokhi, MD 

nsrfrf@vmmc.org 

Improving Family’s Overall Rating of 

Hospice Care: A Team Effort 

VNA HealthCare 

Tara Green, RN 

tgreen@vnahealthcare.org 

Leaping Away from Sliding Scale 

Insulin: A System Wide Approach to 

Improving Glucose Control 

Wellspan Health 

Molly Walbrown, PharmD 

mwalbrown2@wellspan.org 

Implementation of High Value 

Enhanced Recovery Surgery 

Pathways Across London, England 

Whittington Hospital NHS Trust 

Martin Kuper 

martinkuper@hotmail.com 

Improving and Sustaining Safe Patient 

Flow Through a Multidisciplinary 

Approach Between the MICU and ED 

Yale New Haven Health System 

Jennifer Ghidini 

jennifer.ghidini@ynhh.org 

Making Patient Satisfaction Data 

Meaningful to Physicians and Staff 

Children’s Hospital of Pittsburgh 

Jillian Williams 

williamsje5@upmc.edu 

Patient and Family Centered Care 

Approach to Readmissions— 

Does it Work? 

Magee-Womens Hospital of UPMC 

Judith Herstine 

jherstine@magee.edu 

PFCC M/P: Co-Designing Patient and 

Family Care Experiences 

PFCC Innovation Center of UPMC 

Meghan Kelley 

hilkoml@upmc.edu 

PFCC M/P: Creating an Urgency to 

Drive Change 


Carolyn Drummond 

drummondca@mail.magee.edu 

The Shadow Knows! Seeing Care 

Through the Eyes of Patients and 

Families 


Patricia Embree 

embreepl@upmc.edu 

Reengineering Workflows to Enhance 

Patient- and Family-Centered Care: 

Applying Industrial Engineering 

Principles in the ED 

UPMC 

David Bertoty, RN 

bertotyda@upmc.edu 

Orthopaedic Spine Surgery Postoperative 

Flight Plan 

UPMC Presbyterian Hospital 

Mary Beth Pais, RN 

paismb@upmc.edu 

Preventing Readmission Through Good 

Discharge Planning 


Mary Beth Pais, RN 

paismb@upmc.edu 

The PFCC Patient /Family Advisory 

Council-In Real Time 


Joseph Dominick, RN 

dominickjt@upmc.edu 


Diffusion of the Continuous 

Improvement Mindset 


Shannon Mills 

samills@bidmc.harvard.edu 

Decrease Catheter-Associated Urinary 

Tract Infections 

Central DuPage Hospital 

Bushra Khan 

Bushra.Khan@CadenceHealth.org 

Establishing a Portfolio of Quality 

Improvement Projects in Pediatric 

Anesthesia 

Cincinnati Children’s Hospital 


Anna Varughese, MD 

anna.varughese@cchmc.org 

Searching for the Ideal 

Regulatory Model 


Judy Courtemanche, RN 

elizabeth@courtemanche-assocs.com 

Using the IHI Waste Reduction Tool to 

Realize Frontline Savings 

Erasmus Medical Centre, The Netherlands 

Marije Hansen-Stoffer 

m.stoffer@erasmusmc.nl 

Partnering Up—Partnership for Patients 

Franciscan St. Margaret Hospital 

Zak Boswell 

zakary.boswell@franciscanalliance.org 

Early Identification and Treatment 

of Sepsis 

Franciscan St Margaret Hospital 

Zak Boswell 


Emergency Heart Attack Analysis Tool 


Zak Boswell 


Getting to Zero: CLABSI and VAP 


Zak Boswell 


Improving the Admission and 

Discharge Processes 


Zak Boswell 


Medical Fitness Association Certification: 

Exercise is Medicine 


Zak Boswell 


Patient Satisfaction: Spreading 

Best Practice 


Zak Boswell 


Preventing CAUTI: Revisiting a Previous 

Patient Safety Initiative by Adopting a 

Partnership Approach 


Zak Boswell 


Purdue University Student Partnership 


Zak Boswell 


Reducing Costs While Improving 

Quality 


Zak Boswell 


Reducing Hospital Acquired Pressure 

Ulcers from the HRET/IHA Initiative 


Zak Boswell 


Reducing Readmissions Together 


Zak Boswell 


Staying Ahead of Falls 


Zak Boswell 


Training Employees to Lead in Quality 



Zak Boswell 


WorkingWell Partnership: Achieving 

Performance Excellence and Earning 

an Award in the Process 


Zak Boswell 


Implementation of a Mandatory 

Influenza Vaccination Program 

Greenville Hospital System University 


Tom Diller, MD 

tdiller@ghs.org 

Identifying and Categorizing Quality 

Improvement Training Needs of 

Health Care Staff 

Hamad Medical Corporation 

Ihab Seoudi, PhD 

iseoudi@hmc.org.qa 

Establishing a Strategic Lean 

Infrastructure with Respect to 

Multisite Alignment 

Hartford Health Care Corp 

Mohamed Saleh 

msaleh@harthosp.org 

How to Make Change Sustainable: 

Strategies and Innovation 

HealthPartners 

Marcella De La Torre, 

marcella.x.delatorre@healthpartners.com 

Implement Medication Therapy 

Management in Cardiology Clinic 

Improves Quality of Patient Care 

Hennepin County Medical Center 

Yun Lu, PharmD 

yun.lu@hcmed.org 

Increasing Patient Volume by 

Improving the Patient Experience in a 

Family Planning Clinic 

John Snow, Inc. 

Jennifer Kawatu, RN 

jkawatu@jsi.com 

Lean Principles Applied to Hospital 

Facility Layout to Improve Flow and 

Quality of Care 

Juran Healthcare 

Brian Stockhoff, PhD 

bstockhoff@juran.com 

Increasing Use of the Child’s Weight 

in Pediatric Prescriptions in a Primary 

Health Care Setting 

National Healthcare Group Polyclinics 

Xiaoli, King, RN 

Rachel_king@nhgp.com.sg 

To Improve and Standardize the Recall 

Process for Patients with Abnormal 

Diagnostic Results 

National HealthCare Group Polyclinics 

Kunwar Bir Singh 

Kunwar_bir_singh@nhgp.com.sg 

Reducing Complications Arising from 

Central Venous Catheter Insertion 

by Standardizing Training and 

Credentialing 


Bhuvaneshwari Mohan Kumar 

bhuvaneshwari@nuhs.edu.sg 


49

storyboards 

Storyboard 


Transforming Patient Experience: 

The Essential Guide 

NHS Institute for Innovation 

and Improvement 

Sam Hudson 

sam.hudson@institute.nhs.uk 

Transforming Leadership Development 

in Health Care 

Novant Health Corporate Learning and 

Development 

Debbie Kiser, RN 

dgkiser@novanthealth.org 

National University Hospital: 

Transforming Care at the Bedside 


Siew Tin Teng 

siew_tin_teng@nuhs.edu.sg 

Impact of the Antimicrobial Stewardship 

Program on Patient Safety in Singapore 

General Hospital 


Tay Ming Ming Daniel 

daniel.tay.m.m@sgh.com.sg 

In Situ Simulation: Testing Responses 

in the Real World with Real Teams 


Adam Wendling, MD 

awendling@anest.ufl.edu 

Accelerating New RN Graduate 

Performance Improvement Engagement 

with Mentoring 

Versant RN Residencies 

Jean Shinners, PhD, RN 

jshinners@versant.org 

Reduction of Inappropriate Parenteral 

Nutrition Use: Outcomes with Team 

Collaboration 

Winchester Medical Center 

Susan Lessar, RD 

slessar@valleyhealthlink.com 

student storyboards 

Check it Out! Can a Post-Procedure 

Checklist Improve Quality in 

Interventional Radiology? 

Boston Medical Center/ 

Boston University School of Medicine 

Alec Kherlopian 

akherl@bu.edu 

Development of the Student Retention 

Committee at Covenant School of Nursing 


LeeAnn Fabry, RN 


The Error of Omission: A Study of Inpatient 

Hospital Team Task Accountability 

Mayo Clinic 

Daniel Chan, MD 

chan.daniel@mayo.edu 

Empirical Evaluation of Hand Hygiene 

Compliance Perceptions and Behaviors 

North Carolina State University 

Venkitasubramanian Akshay 

akshay_v_s@hotmail.com 

Family Medicine Residency Improvement 

Curriculum: Longitudinal Instruction for 

Clinical Learners 

Oregon Health Sciences University and 

Portland State University 

Paige Hatcher 

paigehatcher.md@gmail.com 

IHI Open School UK Conference 2012: 

Students, Academics, and Professionals 

Promote “Small Change, Big Impact” 


Alan Willson 


Improving Quality of the Discharge 

Process: Common Themes Among 

Interdisciplinary Inpatient Units 

University of Alabama School of Nursing 

Natalie Wilson 

nataliewilson@uab.edu 

University of Cincinnati IHI Open 

School Chapter: Self-Management 

Clinic Improves Community Health 

University of Cincinnati 

Grace C. Miller 

milleg2@mail.uc.edu 

The Medically Homeless: How 

Transitions of Care Issues are Magnified 

in the Uninsured Patient 

University of Colorado School of Medicine 

Racheal Gilmer 

Racheal.gilmer@ucdenver.edu 

Medical Students as Informed Observers 

of the Health Care System 

University of Connecticut Health Center 

Bruce Gould, MD 

gould@uchc.edu 

The Rapid Assessment Zone (RAZ) 


Nate Lisenbee 

nate4085@ufl.edu 

Venous Air Embolism: A Web-Based 

Simulation for the Education of the 

Pathophysiology, Management, and 

Prevention 


Linda Le-Wendling, MD 

lle@anest.ufl.edu 

What Happens to Patients When They 

Leave Our Office? Coordinating Care in 

a Safety-Net Health System 


Martin Wegman 

mwegman@ufl.edu 

Improving the Bone Health Screening 

of Premature Infants 

University of South Florida 


Alexandra Printz 

aprintz@health.usf.edu 

Pilot Program Offers Interactive Open 

School Discussion Forum 

University of South Florida 


Christopher Centonze 

usfhigopenschool@gmail.com 

2012: IHI Open School San Antonio 

Chapter 

The University of Texas Health Science 

Center at San Antonio and Trinity University 

Thomas Methvin 

methvin.thomas@gmail.com 

The Medical Student Safety Attitudes 

and Professionalism Survey 

The University of Texas Medical School at 

Houston and Baylor College of Medicine 

Tyler Williams 

stephen.t.williams@uth.tmc.edu 

Assessing Patient Safety Attitudes in 

Undergraduate Nursing Students 

University of Toronto 

Margaret Saari, RN 

margaret.saari@utoronto.ca 

Redefining Success: Building Capacity 

in Interdisciplinary Collaboration and 

Quality Improvement 

University of Toronto 

Margaret Saari, RN 

margaret.saari@utoronto.ca 

Vanderbilt Health Care 

Improvement Group 

Vanderbilt University 

Scott Hagan 

scott.l.hagan@vanderbilt.edu 

Improving Patient Flow in the 

Outpatient Cancer Clinic 

Wayne State University 

Kimberly Ku 

kku@med.wayne.edu 

Wayne State University IHI Open 

School Chapter 

Wayne State University 

Kimberly Ku 

kku@med.wayne.edu 

picker institute always 

events grantees 

SMART Discharge Protocol: A Pilot 

Study to Standardize the Discharge 

Process in an Acute Care Hospital 

Anne Arundel Medical Center 

Sherry Perkins, PhD, RN 

kandersen1@aahs.org 

Hardwiring “Always Events” from 

Nurse Orientation to Patient and 

Family Centered Care 


Jon Huntington, MD, PhD 

Jonathan.T.Huntington@hitchcock.org 

Patient Family Advisor Engagement 

in Simulated Learning Interventions 

to Improve the Quality of Physician- 

Patient Communication 

Dartmouth-Hitchcock Medical Center 

Marc Bertrand, MD 

marc.bertrand@hitchcock.org 

Increasing Patient Participation in 

Comfort and Pain Control 

Exempla Saint Joseph Hospital 

Wendy Rockey, RN 

rockeyw@exempla.org 

Dementia Screening for Senior 

Patients 

Henry Ford Health System 

Rhonna Shatz, DO 

Rshatz1@hfhs.org 

ISHAPED: Developing a Patient-Centered 

Approach to Handoffs 

Inova Health System 

Mary Ann Friesen, PhD, RN 

maryann.friesen@inova.org 

Always Use Teach-Back 

Iowa Health System 

Gail A. Nielsen 

Nielsega@ihs.org 

The “Always Responsive” Quality 

Demonstration Project 


Gaurdia Banister, PhD, RN 

gbanister@partners.org 

Project PARIS: Parents and Residents 

in Session: Teaching Family-Centered 

Care in a Training Program 

Mount Sinai Medical Center 

Christine Low, MSW 

christine.low@mountsinai.org 

Same Page Transitional Care: Creating 

a Template for Optimal Transitions 

Planetree 

Michael Lepore, PhD 

mlepore@planetree.org 

Improving Patient and Family Centered 

Care for Hospitalized Patients with 

Dementia: Partner with Me 

University of California San Francisco 


Carla Graf, RN 

carla.graf@ucsfmedctr.org 

MyStory: A Multifaceted Initiative to 

Capture Each Pediatric Patient’s Story 

to Provide Personalized Care 

University of Minnesota Medical Center 

Cheristi Cognetta-Rieke, RN 

ccognet1@fairview.org 

Transplant Guardian Angels and 

Trauma Team Texting 

UPMC 

Deborah Maurer 

maurerd@upmc.edu 

Premature Life Transitions: An End-of-Life 

and Bereavement Care Program for 

Neonates and Families 

Yale New Haven Health System 

Janet Parkosewich, RN 

janet.parkosewich@ynhh.org 

50 


Forum Fortune 

You’ve Got to Play to Win 

Visit each of these Forum Fortune Booth Sponsors, get their stamp or signature, and return your completed card to IHI Registration by 

11:30 AM on Wednesday, December 12. The drawing will be on Wednesday, December 12 at 1:00 PM at the IHI Booth (#301). You must 

be present to win. Prizes include Kindles®, a Wii Fit, Visa® and Amex Giftcards, an iPad, and a free registration to the 2013 National Forum, 

among others. You need stamps for each of these sponsors. 

Active Health Management 

Booth #1206 

Blue Jay Consulting 

Booth #817 

Dialog Medical 

Booth #707 

Isabel Healthcare 

Booth #417 

Masimo 

Booth #1101 

MEDCONCERT, a Division of CECity 

Booth #801 

Premier Healthcare Alliance 

Booth #401 

Skylight Healthcare Systems 

Booth # 1454 

AHA Solutions 

Booth #206 

Care Team Connect 

Booth #815 

GE Healthcare 

Booth #223 

Mediware 

Booth #513 

Rapid Modeling Corp 

Booth #522 

VigiLanz Corporation 

Booth #1100 

Amphion Medical Solutions 

Booth #113 

Datix & UHC 

Booth #1212 

Healthstream 

Booth #1013 

Joint Commission Resources 

Booth #1400 

MCN Healthcare 

Booth #316 

Milliman Care Guidelines 

Booth #806 

SEERhealth, LLC 

Booth #108 

Zynx Health 

Booth #1107 

Name: 

Organization: 

Email: 

51

exhibit hall floor plan 

52 


IPSE 

Interprofessional 

Patient Care 

Scholarly Inquiry 

Education 

Institute for Patient Safety Excellence 

Improve Patient Care. Reduce Medical Error 

The emerging field of Patient Safety is revolutionizing healthcare in the 21st 

century. Here’s your opportunity to join—and lead—that revolution. Take your 

institution to the next level in patient safety with UIC’s innovative, interdisciplinary 

online programs. 

Make a Difference in Patient Safety 

Created by the top-ranked Institute for Patient Safety Excellence and 

the College of Medicine at University of Illinois at Chicago, the Patient 

Safety Leadership master’s degree and certificate programs give 

individuals and institutions a direct path to developing 

a culture of patient safety in their organizations. 

Choose from the following: 

• Master’s Degree in Patient Safety Leadership 

• Graduate Certificate in Patient Safety, Error Science and Disclosure 

• Graduate Certificate in Patient Safety Organizations 

(866) 772-2268, option 1 │ www.go.uic.edu/PSL │ info@online.uic.edu 

PSL_1.3.indd 1 

10/5/2012 11:37:39 AM 

53

shuttle map 

54 


information 

Shuttle Service to Other Hotels 

During the conference, IHI will provide National 

Forum participants with complimentary shuttle 

transportation to the Marriott World Center. 

Shuttles will run every 10 to 20 minutes from the 

following locations: 

• Gaylord Palms Resort and Convention 

Center 

• Courtyard Marriott Lake Buena Vista Hotel 

• Marriott Village Spring Hill Suites 

• Caribe Royale 

• Buena Vista Suites 

See opposite page for shuttle map. 

Shuttle Operating Hours 

Sunday, December 9, 6:30 AM – 10:00 PM 

Monday, December 10, 6:30 AM – 10:00 PM 

Tuesday, December 11, 6:30 AM – 10:00 PM 

Wednesday, December 12, 6:00 AM – 4:00 PM 

IHI will also provide complimentary shuttle 

service from the Marriott World Center to 

Orlando International Airport on the last day 

of the General Conference, Wednesday, December 

12, from 12:00 PM to 4:00 PM. 

Exhibit Hall Hours 

The 2012 Exhibit Hall includes snack stations, 

an IHI café for meeting and relaxing, and over 

130 exhibitors. The exhibit hall will be open in 

the Palms Ballroom during the following times: 


3:30 PM – 6:30 PM 


3:30 PM – 6:30 PM 


10:45 AM – 2:00 PM 

4:30 PM – 6:30 PM 


4:30 PM – 6:30 PM 


10:45 AM – 2:00 PM 

National Forum Bookstore 

Located in the Crystal/Grand Foyer, the National 

Forum Bookstore features books written, edited, 

or recommended by our world-renowned faculty. 

It will be open during the following times: 

• Monday, December 10, 7:30 AM – 6:00 PM 

• Tuesday, December 11, 7:30 AM – 6:30 PM 

• Wednesday, December 12, 7:30 AM – 1:30 PM 

Many of the National Forum Bookstore authors 

will host book signings. These events are listed 

at the bookstore and on Twitter using 

#IHI24Forum. 

Business Center 

Located next to the Palms registration desk in 

the Crystal Foyer, the full-service business center 

offers professional printing services as well as 

shipping, receiving, copying, and faxing. Business 

Center hours are: 

• Monday – Friday, 7:00 AM – 6:30 PM 

• Saturday – Sunday, 8:00 AM – 4:00 PM 

Health Center 

The health center is a separate building on the 

Marriott World Center property, located beyond 

the pool. It is a fully equipped athletic facility with 

indoor and outdoor pools, a full spa, whirlpools, 

and saunas. The health center is open 24 hours, 

with an attendant from 6:00 AM until 10:00 PM. 

Use of the fitness center is complimentary for 

overnight guests. 

Checkout 

Checkout from at the Marriot World Center is 

at 11:00 AM. If you are staying at the Marriott, 

please see the hotel bell staff about storing any 

luggage after checkout. If you are staying at one of 

our additional hotel properties, you will be notified 

where to check your luggage by IHI shuttle staff. 

Emergencies 

If for any reason there is an emergency during the 

National Forum, you may dial “0” on any hotel 

phone to request assistance from the operator or 

“55555” to connect directly to the Loss Prevention 

Department. IHI Blue Shirt and Marriott World 

Center staff are also available to assist. 

Guests 

We are excited that family and friends are 

accompanying many of you. We regret that hotel 

space can accommodate only registered participants 

at the keynote presentations, general sessions, and 

meal functions. Your guests are welcome to join 

you at the National Forum receptions. Please see 

IHI staff at the registration desk for a guest 

ribbon and name badge. 

Message Board/Job Postings 

You may place job postings as well as messages for 

other attendees on a corkboard located next to the 

registration desk. 

Messages and Faxes 

If you are staying at the Marriott World Center, 

your telephone messages will go directly to your 

room. If a caller identifies you as being with the 

National Forum, urgent messages will be posted 

on the message board located next to the National 

Forum registration desk near the Convention 

Center entrance. Marriott World Center contact 

numbers are: 

• Phone: (407) 239-6411 

• Guest Fax: (407) 239-6164 

Name Badges 

Please wear your name badge throughout the 

National Forum and carry your list of registered 

sessions with you. This is your ticket into the 

conference and all sessions. 

Safety and Security 

Please do not leave any personal belongings 

unattended in meeting rooms. IHI is not 

responsible for lost or stolen items. 

55

information 

Continuing Education 

Attendees of the 24th Annual National Forum on 

Quality Improvement in Health Care will learn 

how to: 

• Recognize habits that support quality 

health care and apply the basic principles for 

improving them 

• Define ways to reduce suffering and improve 

health 

• Develop an understanding of how to 

transform an organization 

• Identify elements for creating a culture 

of change that will lead to continuous 

improvement 

In support of improving patient care, the Institute 

for Healthcare Improvement is accredited by the 

American Nurses Credentialing Center (ANCC), 

the Accreditation Council for Pharmacy Education 

(ACPE), and the Accreditation Council for 

Continuing Medical Education (ACCME) to provide 

continuing education for the health care team. 

The National Forum carries a maximum of 

19.25 contact hours for physicians, nurses, and 

pharmacists. 

This activity will be submitted to the National 

Association of Healthcare Quality for CPHQ CE 

credit and to the National Association for Social 

Workers for social worker credits. 

All National Forum Learning Labs, Minicourses, 

and General Conference sessions offer ANCC, 

ACPE, ACCME, and CPHQ credits. 

All sessions offer pharmacy contact hours except 

the following: L1, L5, L11, L18, L22, M21, M24, 

RFA, RFB, A2/B2, RFC, C11, C19, RFD, RFE, 

D15/E15, D25/E25. Please note that all keynotes, 

special interest keynotes, virtual site visits, and 

forum excursions do not offer pharmacy contact 

hours. 

Sessions that offer NASW social worker 

credits: L2, L4, L6, L7, L8, L9, L10, L14, L20, 

L25, L29, M1, M3, M8, M11, M12, M17, M23, 

A2/B2, A5/B5, A8/B8, A13/B13, A15/B15, 

A16/B16, A17/B17, A19/B19, A20/B20, 

A23/B23, A25/B25, C2, C4, C5, C9, C10, 

C13, C19, C25, C26, D4/E4, D8/E8, D9/E9, 

D12/E12, D15/E15, D25/E25 

How to receive a certificate of credit: 

To be eligible for a continuing education certificate, 

attendees must complete the online evaluation 

within 30 days of the continuing education activity. 

If circumstances prevent you from completing 

the survey by the specified deadline, please email 

info@IHI.org before this time period expires. 

After this time period, you will be unable to 

receive a continuing education certificate. 

Go to www.IHI.org/certificatecenter. (If you are 

not logged into the website, you will be redirected 

to the log-in screen. Once you are logged in, you 

will be redirected back to the Certificate Center.) 

Click on the “24th Annual National Forum” link 

that appears under the “Create Certificate” header. 

Select the type of credits you wish to receive from 

the drop-down list and then click “Submit.” 

Review your enrollment and click “Continue.” 

Take the surveys associated with each of the 

sessions you attended and for which you wish to 

receive credits by selecting “Take Survey Now” 

next to the session. 

Once you have completed all of the associated 

surveys, “Generate Certificate” will be activated. 

Click on this button to generate a PDF file of 

your certificate that you can print or save to your 

computer. 

post-forum session RECORDINGS 

IHI knows that attendees of the National Forum General Conference often wish to 

attend each and every workshop session rather than having to pick from the many 

wonderful courses offered by exceptional faculty. If you attended the National Forum 

General Conference in person, you will have free access to recorded audio synched 

with PowerPoint slides for every General Conference workshop as well as keynote and 

special interest keynote video and audio. Registered attendees will receive an email in 

early January with access information. 

Please note: IHI will have video cameras and photographers at the National Forum. We 

may capture your image for use on IHI TV at the Forum, on the IHI website, or in other 

IHI materials. 

56 


Your Quality 

Department 

doesn’t have to 

go it alone! 

Join Passport and receive a 

comprehensive set of online tools 

to accelerate your improvement efforts 

and engage staff at your hospital. 

The exclusive benefits of a yearlong membership for $5,000 include: 

• Unlimited participation in Expeditions—three-month, web-based programs led by 

expert faculty and designed to address your organization’s highest improvement priorities 

• Registration for Leading Quality Improvement: Essentials for Managers—a six-month 

virtual program designed to teach your middle managers the skills they need to lead 

improvement at your organization 

• A 25% IHI Open School online course subscription discount 

• Other tools, including on-demand podcasts, videos, and presentation materials 

Join the hundreds of other Passport members—become a member today! 

Network with current members and learn more at the Special Interest Breakfast on 

Wednesday, December 12 or ask for more information at the IHI booth in the Exhibit Hall. 

57

exhibitors 

Acesis 

Booth #1440 

2047 Old Middlefield Way 

Mountain View, CA 94043 

(708) 702-7759 

jstanaszek@acesis.com 

www.acesis.com 

Acesis empowers healthcare systems 

to better manage the clinical and 

operational processes necessary to 

deliver true accountability across the 

continuum of care, all via our real-time, 

cloud-based, collaborative software. 

ACP - American College of Physicians 

Booth #1208 

190 N. Independence Mall West 

Philadelphia, PA 19106 

(800) 523-1546 

custserv@acponline.org 

www.acponline.org 

The American College of Physicians 

(ACP) is the world’s largest medical 

specialty society with the attention 

of more than 100,000 internists, 

subspecialists and hospitalists. 

GOLD SPONSOR 

Booth #1206 

1333 Broadway, 4th Floor 

New York, NY 10018 

(212) 651-8200 

sales@activehealth.net 

www.activehealth.com 

ActiveHealth Management is a national 

leader in providing integrated population 

health management solutions that 

improve health outcomes and lower 

medical costs. Join us in the Palms Foyer 

Classroom on Monday for our 

presentation on Improving Quality 

and Value across the Care Continuum 

from 3:30 PM – 4:15 PM. 

Advanced ICU Care 

Booth #812 

999 Executive Parkway, Suite 210 

St. Louis, MO 63141 

(866) 394-6100 

info@icumedicine.com 

www.icumedicine.com 

Advanced ICU Care®, the nation’s 

largest independent provider of tele-ICU 

services, combines experienced 

intensivist-led teams, sophisticated 

technology and evidence-based best 

practices to improve patient care and 

safety in the ICU. 

Agency for Healthcare Research and 

Quality (AHRQ) 

Booth #1006 

540 Gaither Road 

Rockville, MD 20850 

(301) 427-1364 

www.ahrq.hhs.gov 

Within the Department of Health 

and Human Services, the Agency for 

Healthcare Research and Quality is 

the lead Federal agency charged with 

improving the quality, safety, efficiency 

and effectiveness of health care for all 

Americans. AHRQ supports research 

to improve the quality of health care 

and promote evidence based-decisions. 

Aging with Dignity 

Booth #1209 

PO BOX 1661 

Tallahassee, FL 32302 

(888) 594-7437 

fivewishes@agingwithdignity.org 

www.agingwithdignity.org 

National nonprofit organization: created 

the Five Wishes advance directives 

used by 35,000 organizations including 

hospices. Available in 26 languages 

and Braille. New online resources, 

adolescent/young adult and pediatric 

versions. 

AHA Solutions, Inc. 

Booth #206 

155 North Wacker Drive, Suite 400 

Chicago, IL 60606 

(800) 242.4677 

solutions@aha.org 

www.aha-solutions.org 

AHA Solutions, Inc. is a resource 

to hospitals pursuing operational 

excellence. As an American Hospital 

Association (AHA) member service, 

AHA Solutions collaborates with 

hospital leaders and market consultants 

to conduct product due diligence and 

identify solutions to hospital challenges. 

AICML 

Booth #104 

221 Athabasca Hall 

Edmonton Alberta T6G 2EB 

CANADA 

(780) 492-4828 

info@aicml.ca 

www.aicml.ca 

AICML offers rule-based scheduling 

for MDs, nurses, and ancillary services. 

Automated schedule building that 

integrates financial analytics, best 

practices (as required) and schedule 

validation for compliance while 

optimizing FTE allocations. 

American Academy on Communication 

in Healthcare 

Booth #1014 

201 E. Main St., Suite 1405 

Lexington, KY 40507 

(859) 514-9150 

info@AACHonline.org 

www.AACHonline.org 

The American Academy on 

Communication in Healthcare (AACH) 

improves healthcare effectiveness by 

providing education, research and 

practice focused on communication and 

relationships for clinicians, patients, 

families, and healthcare teams. 

American College of Healthcare 

Executives 

Booth #1203 

1 N. Franklin Street, Suite 1700 


(312) 424-9400 

contact@ache.org 

www.ache.org 

The American College of Healthcare 

Executives is an international professional 

society of more than 40,000 healthcare 

executives who lead hospitals, healthcare 

systems, and other health care 


American College of Surgeons 

National Surgical Quality 

Improvement Program 

Booth #1300 

633 N. Saint Clair Street 

22nd Floor 

Chicago, IL. 60611-3211 

(312) 202-5607 

www.acsnsqip.org 

The American College of Surgeons 

National Surgical Quality Improvement 

Program (ACS NSQIP®) is the first 

nationally validated, outcomes-based 

program to measure and improve the 

quality of surgical care and reduce costs. 

American Heart Association/American 

Stroke Association 

Booth #103 

7272 Greenville Avenue 

Dallas, TX 75231 

(800) AHA-USA-1 

accreditation@heart.org 

www.heart.org 

Evidence-based treatment guidelines 

improve patient outcomes. To learn 

more about our continuous quality 

improvement programs and new 

certification and accreditation 

opportunities visit us at Booth 103 or 

www.heart.org/quality 

American Medical Association— 

Communication Climate Assessment 

Toolkit (C-CAT) 

Booth #1213 

515 N. State St. 


(312) 464-5000 

ccat@ama-assn.org 

www.ama-assn.org/go/ccat 

The AMA presents C•CAT, a 

360-degree assessment tool to identify 

strengths/weaknesses in organizations’ 

communication. Results are used to 

develop tailored QI interventions to 

create an environment that fosters 

effective, patient-centered communication. 

Amerinet, Inc. 

Booth #1442 

Two CityPlace Drive 

Suite 400 

Creve Coeur, MO 63141 

customerservice@amerinet-gpo.com 

www.amerinet-gpo.com 

Amerinet, a leading national healthcare 

solutions organization, enriches 

healthcare delivery for members through 

resources, guidance, and support 

that help lower costs, raise revenue and 

champion quality. Learn more, 

www.amerinet-gpo.com. 

Amphion Medical Solutions 

Booth #113 

8301 Excelsior Drive 

Madison, WI 53717 

(888) 830-2644 

sales@amphionmedical.com 

www.amphionmedical.com 

Amphion Medical Solutions is a 

premier provider of technology-driven 

transcription and coding services. 

Whether you need a technology 

platform or outsourcing services, 

Amphion can help. 

Ascent Clinical Quality Improvement 

Booth #808 

35 South Glencoe Street, Suite 100 

Denver, CO 80246 

(303) 618-4366 

rmay@ascentcqi.com 

www.ascentcqi.com 

Ascent CQI helps good hospitals 

become great hospitals. Our experienced 

clinical teams work with your physicians 

and staff to make real and lasting 

changes to improve your clinical quality. 

58 


Avatar International 

Booth #906 

1000 Primera Blvd., Suite 3144 

Lake Mary, FL 32746 

(800) 282-8274 

info@avatar-intl.com 

www.avatar-intl.com 

BMJ Group 

Booth #817 

BMA House, Tavistock Square 

London, WC1H 9JR, UK 

+44 (0) 20 7387 4410 

support@bmjgroup.com 

group.bmj.com 

BMJ Group empowers clinicians and 

organisations to improve patient outcomes 

with a wide range of products and 

services from the BMJ Quality & Safety 

journal to BMJ Quality programmes. 

CHG Hospital Beds 

Booth #112 

1020 Adelaide St. South 

London, ON, N6E 1R6 CANADA 

(519) 963-4010 

vleach@chgbeds.com 

www.chgbeds.com 

Spirit Select was designed to make the 

lives of patients and healthcare workers 

safer and easier. Contact us today for 

more information! 

Creative Healthcare 

Booth #712 

7033 E. Greenway Parkway, Suite 180 

Scottsdale, AZ 85254 

(480) 473-2525 

mm@creative-healthcare.com 

www.creative-healthcare.com 

Creative Healthcare is the leading 

provider of Lean and Six Sigma project 

consulting and training deployment for 

the health care industry. For more 

information, visit the Creative Healthcare 

website at www.creative-healthcare.com. 

Baldrige Performance Excellence Program 

Booth #115 

100 Bureau Drive, MS 1020 

Gaithersburg, MD 20899 

(301) 975-2036 

baldrige@nist.gov 

www.nist.gov/baldrige 

The Baldrige Program promotes organizational 

excellence through assessment, 

feedback, and sharing best practices. 

The Program is currently celebrating 

its 25th year of managing the Malcolm 

Baldrige National Quality Award. 

BD 

Booth #1012 

1 Becton Drive 

Franklin Lakes, NJ 07417 

(201) 847-6800 

customer_support@bd.com 

www.bd.com 

BD features a broad array of healthcare 

worker and patient safety engineered 

products; needles and syringes, IV 

catheters, anesthesia needles and trays, 

sharps disposal, skin preps, scrubs, and 

flush syringes. 

BlueBin, Inc. 

Booth #1017 

4616 25th Avenue, NE #764 

Seattle, WA 98105 

(206) 321-8192 

www.bluebininc.com 

BlueBin specailizes in Lean supply chain 

soultions for health care organizations. 

We install a robust system called 

Demand Flow that immediately 

increases patient focus, cuts cost, and 

eliminates waste. 

Blue Jay Consulting, LLC 

Booth #1422 

200 S. Orange Ave. #2160 

Orlando, FL 32801 

(407) 210-6570 

mark.feinberg@bluejayconsulting.com 

www.bluejayconsulting.com 

We are pleased to be the top provider 

of enhanced interim leadership and 

process improvement solutions for 

emergency departments throughout the 

country. 

Canadian Patient Safety Institute 

Booth #907 

10235 101 Street, #1414 

Edmonton, Alberta T5J 3G1 

CANADA 

(866) 421-6933 

info@cpsi-icsp.ca 

www.patientsafetyinstitute.ca 

The Canadian Patient Safety Institute 

(CPSI) is a not for profit organization 

that exists to raise awareness and 

facilitate transformation in patient 

safety. CPSI reflects the desire to close 

the gap between the healthcare we have 

and the health care we deserve. 

Care Team Connect 

Booth #815 

518 Davis Street, Suite 230 

Evanston, IL 60201 

(877) 736-4631 

info@careteamconnect.com 

www.careteamconnect.com 

Powering Care Coordination, 

readmissions and ACO/PCMH 

programs by aligning hospitals, 

community providers and family to deliver 

the right care to the right patient at the 

right time. That’s Care Team Connect. 

Center to Advance Palliative Care 

Booth #209 

1255 Fifth Avenue, Suite C2 


(212) 201-2670 

hallia.baker@mssm.edu 

www.capc.org 

Center to Advance Palliative Care 

(CAPC) provides health care professionals 

with tools, training, and technical 

assistance necessary to start/sustain 

successful palliative care programs in 

hospitals and other health care settings. 

Chameleon Corporation 

Booth #1113 

625 Bakers Bridge, Suite 105 

Franklin, TN 37067 

(615) 656-3280 

matt@chameleonwhiteboard.com 

www.chameleonwhiteboard.com 

The Chameleon is a first-of-its-kind 

interchangeable whiteboard designed 

to tackle ever-changing information. 

Chameleon creates better perceptions 

while facilitating better Top Box/ 

CAHPS scores, thereby promoting 

patient-centered care. 

Commonwealth Fund 

Booth #312 

1 East 75th Street 


(212) 606-3800 

info@cmwf.org 

www.commonwealthfund.org 

The mission of The Commonwealth 

Fund is to promote a high-performing 

health care system that achieves better 

access, improved quality, and greater 

efficiency, particularly for society’s most 

vulnerable populations. 

Conifer Health Solutions 

Booth #1418 

140 Fountain Parkway, Suite 500 

St. Petersburg, FL 33716 

(877) CONIFER 

success@coniferhealth.com 

www.coniferhealth.com 

Conifer Health Solutions provides 

Revenue Cycle Management and Patient 

Communications services to more 

than 250 hospitals and health systems 

nationwide. 

Cooper Signage & Graphics 

Booth #217 

2405 Lance Court 

Loganville, GA 30052 

rcooper@carefinding.com 

www.carefinding.com 

Wayfinding and Signage Solutions. 

We are AHA endorsed. Randy Cooper 

wrote the book: Wayfinding For 

Healthcare Best Practices For Today’s 

Facilities. 


Booth #908 

PO Box 23659 

Charlotte, NC 28227 

(704) 573-4535 

info@courtemanche-assocs.com 

www.courtemanche-assocs.com 

Courtemanche & Associates is a 

nationally recognized healthcare 

consulting firm that provides regulatory 

compliance assessment, evaluation, 

recommendations, education, postsurvey 

assistance, and ongoing support 

for health care leaders, administrators, 

and practitioners. 

Customer Feedback Systems, LP 

Booth #1115 

16600 Dallas Parkway, Suite 419 


(972) 447-0090 

hlawrence@cfs-northamerica.com 

www.cfs-northamerica.com 

A leader in on-sight patient experience 

technology, Customer Feedback 

Systems, identifies patient’s perceptions 

and truths about their experience. Our 

system is user-friendly, immediate, and 

proven to capture hidden truths vital to 


Dartmouth College - Master of Health 

Care Delivery Science degree program 

Booth #622 

37 Dewey Field Rd 

Hanover, NH 

(603) 646-1222 

george.newcomb@dartmouth.edu 

www.mhcds.dartmouth.edu 

Designed for working professionals, 

Dartmouth’s 18-month Master of 

Health Care Delivery Science degree 

program equips students with new 

knowledge and skills to lead the vital 

changes occurring in health care today. 

Datix Ltd & UHC 

Booth #1212 

155 North Wacker Drive, Suite 4250 


(312) 803-4991 

sales@datix.co.uk 

www.datixusa.com 

Patient safety and risk management 

software that enables users to spot 

trends as adverse events occur and 

reduce future harm by prioritizing risks 

and putting in place corrective actions. 

DebMed 

Booth #116 

2730 West Tyvola Road, Suite 200 


(866) 783-0422 

info@debmed.com 

www.debmed.com 

The DebMed® GMS (Group Monitoring 

System) is the world’s first group 

monitoring system to report hand hygiene 

compliance rates in real-time based on the 

World Health Organization’s (WHO) 

“Five Moments for Hand Hygiene.” 

Which exhibit booths did you visit? Tweet it using #IHI24Forum 

59

exhibitors 

Department of Defense Patient Safety 

Program 

Booth #914 

7700 Arlington Blvd, Suite 5101 

Falls Church, VA 22042 

(703) 681-0064 

patientsafety@tma.osd.mil 

www.health.mil/dodpatientsafety 

DoD Patient Safety Program focuses on 

creating a culture of safety and quality 

by providing products, services, and 

training to build trust, transparency, 

teamwork, and communication within 

the Military Health System. 

Dialog Medical, a Standard Register 

Healthcare Company 

Booth #707 

30 Perimeter Park Drive 

Atlanta, GA 30341 

(800) 482-7963 

enterprise@dialogmedical.com 

www.dialogmedical.com 

Dialog Medical’s iMedConsent 

application produces easy-to-understand, 

procedure-specific consent forms, 

discharge instructions and patient 

education materials. Trusted by over 

200 hospitals, iMedConsent enhances 

safety, manages risk, ensures compliance, 

and lowers costs. 

Dimensional Insight 

Booth #600 

60 Mall Road 

Burlington, MA 01803 

(781) 229-9111 

sales@dimins.com 

www.dimins.com 

Dimensional Insight offers an end-toend 

business intelligence platform for 

data integration, reporting/analytics, 

and dashboards. The Diver Solution, 

3-times Best-in-KLAS, helps hundreds 

of hospitals implement BI initiatives 

faster and more cost effectively. 

DNV Healthcare, Inc. 

Booth #512 

463 Ohio Pike 

Cincinnati, OH 45255 

www.dnvaccreditation.com 

Dr. Foster Intelligence 

Booth #1016 

Smithfield Street 

London, EC1A 9LA UK 

+44 20 7332 8800 

info@globalcomparators.com 

www.globalcomparators.com 

The challenges facing health care 

systems transcend national boundaries. 

Dr. Foster’s Global Comparators is an 

elite benchmarking and improvement 

network that helps the world’s leading 

hospitals. Leading hospitals, leading 

quality. 

ECRI Institute 

Booth #516 

5200 Butler Pike 

Plymouth Meeting, PA 19462 

clientservices@ecri.org 

www.ECRI.org 

ECRI Institute is an independent 

nonprofit that researches the best 

approaches to improving patient care. 

Our unbiased, evidence-based research, 

information, membership program, and 

educational services help you to lead 

your organization in assessing and 

addressing safety, quality and risk 

management challenges. For more 

information, visit www.ecri.org. 

Edgewater Technology Inc. 

Booth #1003 

200 Harvard Mill Square, Suite 210 

Wakefield, MA 01880 

(781) 246-3343 

makewaves@edgewater.com 

www.edgewatertechnology.com 

Excellence. Creativity. Responsiveness. 

Value. Innovation. Flexible Services. 

Extensible Solutions. Enthusiastically 

Satisfied Customers. Decades Focused 

in Healthcare. Great Technology. 

Experienced Experts. Let us show you. 

Visit Edgewater at booth #1003. 

Edwards Lifesciences 

Booth# 1001 

One Edwards Way 

Irvine, CA 92614 

(949) 250-2500 

www.edwards.com 

Edwards Healthcare Provider Solutions 

is your expert advisor in clinical process 

improvement. Programs include the 

Sepsis Management Program and 

Post-Surgical Recovery Program focused 

on reducing critical complications in 

your hospital. 

Elsevier / MEDai 

Booth #612 

4901 Vineland Road, Suite 450 

Orlando, FL 32811-7192 

(321) 281-4480 

ProviderAnalytics@Email.Elsevier.com 

www.medai.com 

Elsevier/MEDai combines predictive analytics, 

data mining, and clinical outcomes 

analysis to empower the delivery of quality 

care, enhance chronic care management 

and improve operational efficiencies. 

Learn more at www.MEDai.com. 

Endur ID Incorporated 

Booth #1207 

8 Merill Industrial Drive, Unit 4 

Hampton, NH 03842 

(603) 758-1488 

info@endurid.com 

www.endurid.com 

Endur ID will be presenting our Patient 

Identification Solutions. Endur ID’s 

solution includes wristband media and 

software. Endur ID wristbands are in 

color, are waterproof, easy to produce 

and comfortable. 

Eventium 

Booth #1216 

N6586 Rolling Meadows Drive 

Fond du Lac, WI 54937 

(414) 939-8735 

Joan.Haizlip@eventiumusa.com 

www.eventiumusamcom 

Provider of evidence-based solutions 

for the health care continuum, including 

clinical pathways, patient education, 

stoplight tools and disease management 

programs. 

FastCare Development 

Booth #1205 

215 N. Webster Ave. 

Green Bay, WI 54305-3400 

(920) 433-7872 

jjolso@bellin.org 

www.FastCare.com 

Bellin started the FastCare retail health 

clinic model in 2006. FastCare partners 

with local health care systems to provide 

convenient and economical health care 

services for many basic health conditions. 

FlexSim Software Products, Inc. 

Booth #823 

1577 N. Technology Way 

Orem, UT 84097 

(801) 224-6914 

sales@flexsim.com 

www.flexsim.com 

An industrial simulation world leader, 

FlexSim Software Products, Inc. 

captured seniority in health care systems 

simulation through the ground-up 

design of FlexSim HC, the analytical 

world’s most powerful health care 

modeling tool. 

Forward Health Group, Inc. 

Booth #706 

44 East Mifflin Street, Suite 601 

Madison, WI 53703 

(608) 729-7530 

info@forwardhealthgroup.com 

www.forwardhealthgroup.com 

Forward Health Group, a health 

care measurement company, turns 

fragmented clinical and administrative 

health care data, stored in multiple 

disparate systems, into actionable 

information that drives population 

health improvement. 

GE Healthcare 

Booth #223 

N16 W22419 Watertown Road 

Waukesha, WI 53186 

(877) 438-4788 

geeducation@ge.com 

www.gehealthcare.com/education 

GE Healthcare’s new Fetal Heart Rate 

Monitoring Program and Nursing 

Library of Online Education with more 

than 50 courses help clinicians stay 

current with best practices and optimize 

patient care. 


Booth #1112 

100 N. Academy Ave 

Danville, PA 17822 

(570) 214-9725 

ckbagwell@geisinger.edu 

www.geisinger.org 

Geisinger Health System has been 

nationally recognized for innovative 

practices and quality care. A mature 

electronic health record connects a 

comprehensive network of 4 hospitals, 

38 community practice sites and more 

than 900 Geisinger primary and 

specialty care physicians. 

Global Novations 

Booth #1436 

200 West Street 

Waltham, MA 02451 USA 

info@globalnovations.com 

www.globalnovations.com 

Global Novations, a Korn/Ferry 

International company, is a consulting 

and employee development firm focused 

on helping the world’s top organizations 

optimize their talent management and 

inclusion efforts. Our unique approach— 

talent optimization—is a fusion of 

research-driven employee development 

and inclusion strategies that address the 

needs of today’s global organizations. 

GP Strategies 

Booth #1402 

6095 Marshalee Drive, Suite 300 

Elkridge, MD 21075 

(888) 843-4784 

info@gpstrategies.com 

www.gpstrategies.com 

GP Strategies is a global performance 

improvement company driven to solve 

your business challenges, perform at the 

highest level and make a greater impact 

on the world around you. 

60 


HCPro, Inc. 

Booth #107 

75 Sylvan St., Suite A-101 

Danvers, MA 09123 

(781) 639-1872 

customerservices@hcpro.com 

www.hcpro.com 

With more than 20 years of experience, 

HCPro, Inc. is a leading provider of 

integrated information, education, 

training, and consulting products and 

services dedicated to improve the 

quality of care. 

i2i Systems 

Booth #901 

3663 N. Laughlin Road 

Santa Rosa, CA 

(866) 820-2212 

salesinfo@i2isys.com 

www.i2isys.com 

i2i Systems is a leader, pioneer and 

12-year success story in providing 

Population Health Management 

solutions, currently serving over 1,000 

health care facilities across 31 states. 

Isabel Healthcare 

Booth #417 

1710 Hermitage 

Ann Arbor, MI 48104 

(734) 332-0612 

info@isabelhealthcare.com 

www.isabelhealthcare.com 

Isabel Healthcare provides diagnosis 

support to clinicians worldwide. As a 

point-of-care diagnosis decision support 

and knowledge management solution, 

Isabel assists with getting the diagnosis 

correct quickly—improving testing and 

treatment. 

Krames Staywell 

Booth #1108 

780 Township Line Road 

Yardley, PA 19507 

(866) 722-4377 

info@kramesstaywell.com 

www.kramesstaywell.com 

Healthier Hospitals Initiative 

Booth #216 

12355 Sunrise Valley Drive, Suite 680 

Reston, VA 20191 

(703) 860-9790 

info@healthierhospitals.org 

www.healthierhospitals.org 

The Healthier Hospitals Initiative is a 

call-to-action providing free resources 

for the entire industry to join the shift 

to a more sustainable business model 

and address the health/environmental 

impacts. 

HealthStream, Inc. 

Booth #1013 

209 10th Avenue South, Suite 450 

Nashville, TN 37203 

(615) 301-3100 

contact@healthstream.com 

www.healthstream.com 

Over half of US hospitals use 

HealthStream’s research, learning, 

simulation, and talent management 

solutions to improve outcomes. Learn 

how we support better healthcare 

quality and experiences at 

www.healthstream.com. 

HQI Partners 

Booth #902 

2966 South Church Street #247 

Burlington, NC, 27215 

(336) 395-1420 

tonysummerlin@hqipartners.com 

www.hqipartners.com 

HQI Partners is a national provider of 

core measure abstraction and quality 

Improvement consulting services. Our 

vision is to support our clients in the 

delivery of perfect care. 

HyGreen, Inc. 

Booth #903 

3630 SW 47th Avenue 

Gainesville, FL 32608 

(877) 574-9473 

info@hygreen.com 

www.hygreen.com 

The HyGreen Hand Hygiene Recording 

and Reminding System records all hand 

hygiene events and reminds health 

care workers to wash when they forget, 

increasing patient safety and improving 

outcomes. 

ICNet Systems 

Booth #205 

4320 Windfield Road, Suite 200 

Warrenville, IL 60555 

(630) 836-8073 

info@icnetsystems.com 

www.icnetsystems.com 

ICNet® is the global leader for infection 

surveillance, antimicrobial stewardship 

and adverse drug event, core measures 

and reporting software in daily use 

at over 1000 hospitals. Our focus is 

enhancing patient safety and quality. 

Institute for Healthcare Improvement (IHI) 

Booth #301 

Institute for Safe Medication Practices 

Booth #105 

200 Lakeside Drive, Suite 200 

Horsham, PA 19044 

(215) 947-7797 

jogle@ismp.org 

www.ismp.org 

ISMP is devoted entirely to medication 

error prevention and safe medication 

use. The organization is respected 

worldwide as the premier resource for 

impartial, timely, and accurate 

medication safety information. 

Intelligent InSites 

Booth #909 

102 Broadway 

Fargo, ND 58102 

(701) 893-2000 

info@intelligentinsites.com 

www.intelligentinsites.com 

We help health care organizations 

optimize operations by transforming 

automatically-collected data into 

actionable intelligence and real-time 

operational insights, enabling our 

customers to reduce costs, deliver better 

care, and improve patient satisfaction. 

John Kim and Associates: Lean 

Healthcare 

Booth #816 

3917 Kathleen Way 

Davenport, IA 52807 

(563) 650-3822 

www.johnkimconsulting.com 

An industry leading Lean health care 

consulting company specializing in 

the design, development and 

implementation of Lean programs 

customized to the needs of health 

systems, hospitals, physician practices 

and health plans. 

Joint Commission Resources 

Booth #1400 

1515 W. 22nd Street, Suite 1300W 

Oak Brook, IL 60523 

(630) 268-7400 

info@jcrinc.com 

www.jcrinc.com 

Joint Commission Resources ( JCR) 

offers a full spectrum of resources to 

help health care professionals provide 

safe and efficient patient care through 

consulting services, education programs, 

publications and multimedia products. 

DIAMOND SPONSOR 

Booth #507 

1800 Harrison Street - 24th floor 

Oakland, CA 94612 

(510) 625-5667 

keith.b.paulsen@kp.org 

www.kp.org 

Kaiser Permanente is committed to 

helping shape the future of health care 

by focusing on the total health of our 9 

million members and the communities 

we serve. 

Join us in the Palms Foyer Classroom on 

Tuesday for our presentation on Total 

Health from 10:45 AM – 11:15 AM. 

Lapekas & Associates—Performance 

Excellence Consulting 

Booth #517 

N8882 1225th Street 

River Falls, WI 54022 

(704) 957-6307 

patlapekas@me.com 

www.lapekasconsulting.com 

Consulting and coaching services 

focused on helping organizations 

and leaders achieve higher levels of 

performance excellence, every day, 

with every customer interaction. 

Loyola University Chicago Niehoff 

School of Nursing 

Booth #117 

2160 S. First Avenue, 

Maguire Bldg. 105, Room 2840 

Maywood, IL 60153 

(708) 216-9101 

aweatherford@luc.edu 

www.luc.edu/nursing 

Loyola University Chicago announces 

new HRSA supported post-masters 

Doctorate of Nursing Practice (DNP) 

program – healthcare quality using 

education in safety and technology 

(H-QUEST) – focusing on outcomes 

management/quality/safety or 

health care informatics. 

Masimo 

Booth #1101 

40 Parker 

Irvine, CA 92618 

(949) 297-7000 

www.Masimo.com 

A key medical technology innovator, 

Masimo is responsible for the invention of 

award-winning noninvasive technologies, 

medical devices, and a wide array of 

sensors that are revolutionizing patient 

monitoring in various care settings. 

Master Business Operational 

Excellence for Healthcare 

Booth #1106 

110 Pfahl Hall, 280 W Woodruff Ave 

Columbus, OH, 43215 

(614) 247-2556 

Mick.15@osu.edu 

www.fisher.osu.edu/MBOE 

12-month program teaching operational 

excellence to improve: value streams; 

end-to-end physical and information 

flow; and patient safety and satisfaction, 

while reducing waste. Includes distance 

learning format. 


61

exhibitors 

MCN Healthcare 

Booth #316 

1777 S Harrison Street, Suite 405 


(800) 538-6264 

pam.gustafson@mcnhealthcare.com 

www.mcnhealthcare.com 

MCN Healthcare is a leading provider 

of healthcare regulatory compliance 

solutions including policy management, 

policy library, and StayAlert! – e-mail 

notification of regulatory changes and 

implementation tools. Visit us at 

www.mcnhealthcare.com. 


a division of CECity 

Booth #801 

285 Waterfront Drive E, Suite 100 

Homestead, PA 15120 

(888) 669-7444 x 314 

www.medconcert.com and 

www.cecity.com 

MedConcert®...Healthcare’s premier 

social cloud-based platform that 

meaningfully connects all stakeholders 

to cost-effectively measure performance, 

scale continuous quality improvement, 

align professional and financial incentives, 

enable lifelong-learning, and support 

enterprise-wide care coordination. 

Medical Simulation Corporation 

Booth #1002 

4643 S. Ulster Street, #650 


(303) 483-2800 

HealthcareGroup@medsimulation.com 

www.medsimulation.com 

Medical Simulation Corporation strives 

to improve healthcare economic and 

clinical outcomes through accelerated 

adoption of evidence-based medicine. 

MSC’s solutions are designed for health 

care providers across the continuum 

of care. 

Mediware 

Booth #513 

11711 W. 79th St. 

Lenexa, KS 66214 

(888) MEDIWARE 

info@mediware.com 

www.mediware.com 

Mediware is a leading provider of 

specialized health care solutions. With 

the InSight performance mangement 

solution from Mediware, it’s easier 

than ever to do the right thing. 

Call 888-Medware today. 

Medkinetics, LLC 

Booth #1104 

124 First Street South, Suite 200 

Franklin, TN 37620 

(615) 599-1627 

Info@Medkinetics.com 

www.medkinetics.com 

Medkinetic’s Quality Performance 

Improvement System is the industry 

leading physician peer review system. 

The QPI system to addressing quality 

concerns, and having decision making 

tools to make quality improvement 

changes. 

Memory Jogger 

Booth #1438 

8 E Industrial Way, Suite 3 

Salem, NH 03079 

(603) 890-8800 

www.memoryjogger.org 

GOAL/QPC’s critical tools for 

improvement and excellence are brought 

to you through our Memory Jogger 

series. They drive home on-site 

workshop learning through a 

combination of lecture, case studies, 

and hands-on activities. 

Meridian Leadership Institute 

Booth #1117 

125 Half Mile Road, Suite 200 

Red Bank, NJ 07701 

(732) 933-2749 

info@meridianleadershipinstitute.com 

www.meridianleadershipinstitute.com 

Spark creative energy to drive and 

achieve outstanding results! The 

Meridian Leadership Institute provides 

dynamic, experiential training and 

coaching programs to grow leaders and 

teams throughout your organization. 

Midas+ Solutions 

Booth #701 

4801 East Broadway Boulevard, 

Suite #335 

Tucson, AZ 85711 

(800) 737-8835 

Midas.sales@acs-inc.com 

With approximately 1,500 clients, 

Midas+ Solutions is the preferred 

health care quality outcomes improvement 

partner. Our clients outperform 

the median national hospital quality 

scores for value-based purchasing and 

other pay-for-performance programs. 

Milliman Care Guidelines 

Booth #806 

901 Fifth Avenue, Suite 2000 


(206) 389-5300 

eric.kapust@milliman.com 

www.careguidelines.com 

Milliman® Care Guidelines® helps you 

drive effective care by providing fast 

access to global, validated best practices 

so you can apply your clinical expertise 

and make decisions with confidence. 

MindMixer 

Booth #1215 

1111 North 13th Street, Suite 101 

Omaha, NE 68102 

(402) 830-0854 

www.MindMixer.com 

MindMixer is an online engagement 

tool that enables your patients, employees, 

and physicians to become contributors. 

Ideas, voices, and perspectives are 

shared to facilitate better conversations 

that yield actionable results. 

Minitab 

Booth #212 

1829 Pine Hall Road 

State College, PA 16801 

(814) 238-3280 

sales @minitab.com 

www.minitab.com 

Minitab is the leading provider of powerful 

and easy-to-use quality improvement 

software worldwide. Companies rely on 

Minitab software, training and services 

to help them achieve world-class quality. 

MEDIA SPONSOR 

Modern Healthcare 

www.modernhealthcare.com 

Mom’s Meals 

Booth #1008 

718 SE Shurfine Drive 

Ankeny, IA 50021 

(866) 825-6067 

dj.wilder@momsmeals.com 

www.momsmeals.com 

Mom’s Meals is a home-delivered meal 

provider specializing in providing nutritious, 

fresh meals to seniors nationwide. 

We prepare, package and deliver ready 

to heat and eat meals directly to a 

senior’s doorstep. 

Morrisey Associates, Inc. 

Booth #1308 

222 S. Riverside Plaza, Suite 1850 


www.morriseyonline.com 

sales@morriseyonline.com 

Morrisey offers a comprehensive suite 

of web-based credentialing and care 

management applications. The Chicagobased 

company was established in 1987 

and currently has more than 900 health 

care customers. 

National Database of Nursing Quality 

Indicators 

Booth #222 

3901 Rainbow Blvd., MS 3060 

Kansas City, KS 66160 

(913) 588-1691 

ndnqi@kumc.edu 

www.nursingquality.org 

NDNQI® is the only national, nursing 

quality measurement program that 

provides hospitals with unit-level 

performance reports with comparison to 

regional, state, and national benchmark 

data. Currently, NDNQI has over 

1,700 participating hospitals that use 

NDNQI data to improve patient safety 

and quality of care. 

National Initiative for Children’s 

Healthcare Quality (NICHQ) 

Booth #314 

30 Winter Street, 6th Floor 

Boston, MA 02108 

(617) 391-2700 

info@nichq.org 

www.NICHQ.org 

NICHQ is an independent, not-forprofit 

organization that works to better 

children’s health and healthcare through 

quality improvement. 

National Patient Safety Foundation 

Booth #912 

268 Summer Street, Sixth Floor 

Boston, MA 02210 

(617) 391-9908 

dcoletta@npsf.org 

www.npsf.org 

NPSF, an independent not-for-profit 

501(c)(3), has been pursuing one mission 

since its founding in 1997 — to improve 

the safety of care provided to patients. 

National Research Corporation 

Booth #213 

1245 Q Street 

Lincoln, NE 68508 

(402) 475-2525 

klounsbery@nationalresearch.com 

www.nationalresearch.com 

National Research Corporation has 

brought data-driven visibility to patientcentered 

care for 30 years. Today, its focus 

on empowering customer-centric health 

care across the continuum transcends 

patient-centered care to incorporate 

families, communities, employees, and 

other stakeholders. This integration of 

metrics and analytics uncovers insights 

for effective performance improvement, 

quality measurement, and more. 

62 


NAVEX Global 

Booth #523 

6000 Meadows Drive, Suite 200 

Lake Oswego, OR 97035 

(866) 297-0224 

info@navexglobal.com 

www.navexglobal.com 

NAVEX Global is the trusted global 

ethics and compliance expert for more 

than 8,000 clients in over 200 countries. 

We serve more than 500 health care 

clients with PolicyTech, our AHAendorsed 

policy management solution. 

GOLD SPONSOR 

Booth #1000 

P.O. Box 492 

Simsbury, CT 06070 

(877) NLP-Lean (657-5326) 

mholland@nl-p.com 

www.nl-p.com 

The NLP team is an industry leader 

in health care rapid-cycle process 

improvement, strategy deployment, and 

the associated transfer of knowledge to 

continuously refine your culture of high 

performance independently. 

Join us in the Palms Foyer classroom 

for our presentation on Making Real 

Improvement in Areas of Strategic 

Importance on Tuesday from 

2:45 PM – 3:15 PM. 

Nihon Kohden America, Inc. 

Booth #100 

90 Icon Street 

Foothill Ranch, CA 92610 

(800) 325-0283 

info@nkusa.com 

www.nkusa.com/monitoring 

Nihon Kohden’s Defensive Monitoring 

strategy with the Prefense TM Early 

Detection and Notification System TM 

notifies hospitals when patient conditions 

start to deteriorate and enables quicker 

interventions to prevent in-hospital 

complications. 

PLATINUM SPONSOR 

Booth #607 

145 Community Drive 

Great Neck, NY 11021 

(516) 465-8000 

NorthShore-LIJQuality@nshs.edu 

northshorelij.com 

North Shore-LIJ is the nation’s thirdlargest, 

non-profit, secular healthcare 

system, serving more than seven million 

people throughout the NYC metro 

area. We partner with IHI and others to 

improve patient care through research 

and education. 

NOVACES, LLC 

Booth #900 

650 Poydras Street, Suite 2320 

New Orleans, LA 70130 

(504) 544-6888 

dsmith@novaces.com 

www.novaces.com 

NOVACES is a management consulting 

firm that inspires organizations to create 

cultures of performance excellence and to 

solve their toughest challenges by focusing 

on processes, project management, and 

leadership. 

Novia Strategies / Novia Solutions 

Booth #913 

13029 Danielson Street, Suite 200 

Poway, CA 92064 

(866) 747-4200 

info@novia-inc.com 

www.novia-inc.com 

Novia Strategies provides consulting 

services to health care organizations in 

operations improvement, clinical resource 

management and balancing cost 

and quality. Novia Solutions, an interim 

management firm, provides experienced 

leaders for hospitals. 

Nuance 

Booth #601 

1 Wayside Road 

Burlington, MA 01803 

(781) 565-5000 

www.nuance.com 

Nuance intelligently bridges clinical 

documentation, CDI, coding, 

compliance and quality with clinical 

language understanding solutions. We 

help organizations improve efficiency, 

achieve the highest levels of clinical 

accuracy and appropriate reimbursement 

for the care provided so caregivers can 

focus on what’s most important: Taking 

care of patients. 

Outcome, a Quintiles Company 

Booth #1420 

201 Broadway 

Cambridge, MA 02139 

(888) 526-6700 

provider@quintiles.com 

www.outcome.com 

Outcome, a Quintiles Company, is a 

leading provider of web-based quality 

measurement systems for qualityimprovement 

(QI), pay-for performance, 

reimbursement, accreditation, and 

certification programs. 

MEDIA SPONSOR 

www.psqh.com 

Pascal Metrics 

Booth #614 

1025 Thomas Jefferson Street NW, 

Suite 420 East 

Washington, DC 20007 

(202) 333-9090 

info@pascalmetrics.com 

www.pascalmetrics.com 

Pascal Metrics is a Patient Safety 

Organization (PSO) offering patient 

safety and performance improvement 

services that reduce all-cause harm and 

associated costs using real-time data. 

PeraHealth, Inc. 

Booth #1456 

1520 South Boulevard, Suite 228 


(866)362-0001 

www.perahealth.com 

PeraHealth provides real-time alerting 

of a patient’s current condition by 

trending their most current clinical 

assessments. PeraHealth repurposes 

your EHR information helping 

clinicians respond and intervene sooner 

to changing patient status, improving 

patient safety. 

Performance Logic, Inc. 

Booth #613 

901 SE Oak St., Suite 205 

Portland, OR 97214 

(888) 407-1705 

info@performancelogic.com 

www.performancelogic.com 

Performance Logic PPM is a 

comprehensive, web-based project 

portfolio management tool designed 

specifically to enable health care 

organizations to manage projects in 

IT, clinical, and operational areas with 

real-time performance tracking. 

Perinatal University LLC 

Booth #204 

745 Kingston Drive 

Virginia Beach, VA 23452 

(757) 631-8837 

ccurran@perinatalu.org 

www.perinatalu.org 

Perinatal University improves patient 

safety by focusing on perinatal competency 

and excellence. Our 3 phase online 

Proficiency Education System offers a 

comprehensive analysis of key perinatal 

knowledge, criticial thinking, and skills 

analysis for system transparancy. 

Physician Wellness Services 

Booth #809 

5000 W 36th Street, Suite 230 

Minneapolis, MN 55416 

(888) 892-3861 

alison.anderson@ 

workplacebehavioralsolutions.com 

www.PhysicianWellnessServices.com 

Physician Wellness Services provides 

a coordinated, comprehensive and 

confidential suite of services—physician 

EAP, physician intervention services, 

and training and consulting—designed 

specifically for physicians and 

organizations that employ them. 

Phytel, Inc. 

Booth #415 

11511 Luna Road, Suite 600 


(800) 559-3057 

phytelsales@phytel.com 

www.phytel.com 

Phytel population health solutions 

empower providers and care teams with 

actionable tools to analyze variances in 

care, improve care transitions, engage 

patients, and enhance quality. Phytel’s 

registry has 25 million patients across 

leading health systems. 


Booth #922 

11 Main Street, 4th Floor 

Camden ME 04843 

(888) 680-7500 

info@pickerinstitute.org 

www.pickerinstitute.org 

Picker Institute is an independent 

nonprofit organization dedicated to 

advancing patient-centered care and 

the Always Events® initiative to assure 

an optimal healthcare experience for 

patients and families, every time. 


63

exhibitors 

Pivotal Resources 

Booth #306 

1646 N. California Blvd., Suite 520 

Walnut Creek, CA 94596 

(925) 975-0500 

healthcare@pivotalresources.com 

www.pivotalresources.com/services/ 

healthcare/ 

Pivotal Resources are specialists in 

helping leaders, managers, and front-line 

staff through transformations. For 

19+ years, our customized Change 

Leadership consulting/training QI 

services positively impacts efforts for 

Triple Aim results. 

PowerDMS Suite 

Booth #1005 

PO Box 2468 

Orlando, FL 32802 

(800)749-5104 

sales@powerdms.com 

www.powerdms.com 

PowerDMS Suite is an industry leading, 

total software solution to compliance 

management. With its seamless approach 

to document life cycle, e-signature 

management, and rich training course 

development tools, compliance can 

be realized. 

PQ Systems 

Booth #606 

210 B East Spring Valley Road 

Dayton, OH 45458 

(800) 777-3020 

sales@PQsystems.com 

www.PQsystems.com 

PQ Systems is dedicated to helping 

health care providers improve quality 

and comply with JCAHO standards. 

Our highly-regarded products 

include CHARTrunner®Lean and 

CHARTrunner®, the leading PI charting 

software solutions for health care. 

Premier Healthcare Alliance 

Booth #401 

13034 Ballantyne Corporate Place 


(877) 777-1552 

solutioncenter@premierinc.com 

www.premierinc.com 

Premier is a performance improvement 

alliance of more than 2,600 U.S. hospitals 

and 86,000-plus other sites using the 

power of collaboration and technology to 

lead the transformation to coordinated, 

high-quality, cost-effective care. 

Press Ganey 

Booth #407 

404 Columbia Street 

South Bend, IN 46601 

(800) 232-8032 

info@pressganey.com 

www.pressganey.com 

For 25 years, Press Ganey has been 

committed to providing insight that 

allows health care organizations to 

improve the quality of care they provide. 

QI Macros Lean Six Sigma SPC 

Software for Excel 

Booth #101 

2253 S. Oneida Street, Suite 3D 


(303) 756-9144 

info@qimacros.com 

www.qimacros.com 

QI Macros Lean Six Sigma SPC 

Software for Excel simplifies process 

improvement for pareto charts and 

control charts. Contains 90+ templates 

including fishbones and flowcharts. 

Used by 3,000+ hospitals. $199/copy. 

QR Systems Inc (QRS) 

Booth #923 

100 Arbors Lane, Suite A 

Woodbridge, Ontario L4H 1A1 

CANADA 

(289) 371 0224 

jason.uppal@qrs3e.com 

www.clinicalMessage.org 

clinicalMessage is designed to improve 

quality and economics of care in both 

PCMH and hospital wards. 

Quantros Inc. 

Booth #805 

475 Sycamore Drive 

Milpitas, CA 95035 

(877) 782-6876 

info@quantros.com 

www.quantros.com 

Quantros is a leading provider of 

software-as-a-service applications and 

related services to advance healthcare 

quality and safety performance through 

advanced business intelligence and data 

management. 

GOLD SPONSOR 

Booth #1201 

3700 Park East 

Beachwood, OH 44122 

(866) 437-7237 

info@radispheregroup.com 

www.radispheregroup.com 

Radisphere is the largest and fastest 

growing national radiology group in the 

United States with 150 radiologists and 

35 exclusive hospital clients in 11 states. 

Join us on Wednesday, December 12 

from 12:45 PM – 1:15 PM in the 

Palms Foyer Classroom for our 

presentation “Why Radiology is 

Desperate for Quality Standards” 

Rapid Modeling Corporation 

Booth #522 

8044 Kimbee Drive 

Cincinnati, OH 45244 

(513) 624-6629 

nlee@rapidmodeling.com 

www.rapidmodeling.com 

RMC specializes Lean and Six Sigma 

for healthcare design. RMC’s product 

lines include TimeStudyRN/MD and 

Layout-iQ, and are used in Transforming 

Care at the Bedside (TCAB) and 

Releasing Time to Care (RTC). 

ReadyPoint Systems 

Booth #904 

40 Burton Hills Blvd #150 

Nashville, TN 37215 

(615) 656-5290 

wmorrow@readypointsystems.com 

www.readypointsystems.com 

ReadyPoint is focused on helping 

hospitals improve the processes that 

increase quality and safety of care. By 

automating core processes and training 

your people to them, ReadyPoint’s 

services rapidly simplify a complex – yet 

critical – area of hospital operations. 

RF Surgical Systems, Inc. 

Booth #714 

3326 160th Ave SE, Suite 220 

Bellevue, WA 98008 

(425) 283-0678 

info@rfsurg.com 

www.rfsurg.com 

RF Assure and RF Surgical Detection 

Systems bring innovation, simplicity, 

confidence, and compliance to hospitals 

by providing an easy to use, accurate 

system for detecting and preventing 

retained surgical sponges. 

RL Solutions 

Booth #501 

One Broadway, 14th Floor 

Cambridge, MA 02142 

(888) 737-7444 

sales@rlsolutions.com 

www.rlsolutions.com 

RL Solutions designs innovative 

healthcare software for patient feedback, 

incident reporting & risk management, 

infection surveillance and claims 

management. We have over 1,100 

clients, including 9 of the top 10 in the 

country, according to US News & World 

Report. 

Sage Products Inc. 

Booth #1007 

3909 Three Oaks Road 

Cary, IL 60013 

(800) 323-2220 

customerservice@sageproducts.com 

www.sageproducts.com 

Sage Products’ simple interventions 

include Comfort Bath® Cleansing 

Washcloths, Prevalon® Heel Protector, 

Prevalon® Turn and Position System, 

Toothette® Oral Care, Comfort Shield® 

Barrier Cream Cloths and Sage® 2% 

CHG Cloths. 

SEERhealth 

Booth #108 

1600 Parkwood Circle SE, Suite 600 

Atlanta, GA 30339 

(770) 767-3900 

info@seerhealth.com 

www.SEERhealth.com 

SEERhealth develops solutions, 

incorporating professional services and 

cloud-based technology, to modernize 

quality assurance for organizations 

within healthcare. 

Sheridan Healthcare, Inc. 

Booth #713 

1613 N. Harrison Parkway, Suite 200 

Sunrise, FL 33323 

(877) 707-4545 

onesolution@shcr.com 

www.sheridanhealthcare.com 

Sheridan Healthcare, Inc. is a hospitalbased, 

multispecialty practice 

management company that provides 

comprehensive service-line management 

for anesthesia, radiology, emergency 

medicine, neonatology, and other 

pediatric subspecialties. 

64 


Sigma Breakthrough Technologies Inc. 

Booth #717 

123 N. Edward Gary, Second Floor 

San Marcos, TX 78666 

512-353-7489 

info@sbtimail.com 

www.sbtionline.com 

Returning millions to hospital systems 

nationwide, SBTI delivers performance 

and process improvement deployments 

utilizing Lean and Six Sigma methodology. 

From cycle time to DNFB, SBTI 

understands the environment and 

delivers. 

GOLD SPONSOR 

Booth #413 

(336) 283-4060 

mattesons@simpler.com 

www.simpler.com 

Simpler Healthcare is the world leader 

in Lean transformation. With its 

proprietary Simpler Business System®, 

our sensei have delivered the fastest and 

most enduring transformations at more 

than one hundred health care provider 

networks around the world. 

Join us in the Palms Foyer classroom for 

our presentation on Lean Leadership 

Immersion for Health Care from 

10:45 AM – 11:15 AM on Wednesday. 

Skylight Healthcare Systems 

Booth #1454 

10935 Vista Sorrenty Parkway, Suite 350 

San Diego, CA 92130 

(858) 523-3700 

contact@skylight.com 

www.skylight.com 

Skylight Healthcare is the pioneer of 

interactive patient care systems. From 

pre-admission through post-discharge, 

we help you address patients’ needs for 

education, services, and essential information 

that enhance their experience. 


Booth #915 

1123 Pacific Avenue 

Tacoma, WA 98402 

(800) 850-9665 

info@soundphysicians.com 

www.soundphysicians.com 

Sound Physicians is a leading hospitalist 

organization that combines proven 

clinical processes, a web-based workflow 

platform, and a passion for making a 

difference to improve quality, satisfaction 

and financial performance. 

The Advisory Board Company 

Booth #313 

2445 M Street NW 

Washington D.C. 20037 

(202) 266-6639 

crimson@advisory.com 

www.advisory.com 

Global research, technology, and 

consulting firm partnering with 

150,000 leaders in 3,100+ healthcare 

organizations. We provide strategic 

guidance, actionable insights, web-based 

software solutions, and comprehensive 

implementation and management 

services. 

The Compliance Team 

Booth #308 

PO Box 160 

Spring House, PA 19477 

(215) 654-9110 

rdunning@thecomplianceteam.org 

www.thecomplianceteam.org 

The Compliance Team leads in hospital 

accreditation and quality initiatives for 

patient safety & experience with plain 

language standards, expert mentoring, 

checklists, and electronic benchmarking. 


Booth #200 

One Renaissance Boulevard 

Oakbrook Terrace, IL 60181 

(630) 792-5690 

drutkowski@jointcommission.org 

www.jointcommission.org 

The Joint Commission, the gold standard 

in health care evaluation, accredits and 

certifies more than 19,000 health care 

organizations in order to help provide 

quality health care to the public. 

Organizations experience an educative 

survey process but also have access to 

tools to help tackle health care’s most 

challenging issues. 

The Wellness Network 

Booth #916 

N27 W23539 Paul Road, Suite 100 

Pewaukee, WI 53072 

(888) 219-4678 

tpc@thewellnessnetwork.tv 

www.thewellnessnetwork.tv 

The Wellness Network (TWN) owns 

The Patient Channel & The Newborn 

Channel; most comprehensive in-hospital 

health network in the US. TWN also 

partners with Joint Commission 

Resources Quality & Safety Network. 

Thermo Scientific 

Booth #114 

8365 Valley Pike 

Middletown, VA, 22645 

(800) 232-3342 

peggy.rogers@thermofisher.com 

www.thermoscientific.com\aboutsepsis 

The Thermo Scientific’s 

B•R•A•H•M•S line of immunoassays 

facilitate earlier diagnosis of diseases 

and better control of therapy, thus 

enabling doctors to improve patient 

outcomes. 


Booth #201 

6200 S. Syracuse Way, Suite 300 

Greenwood Village, CO 80111 

(919) 474-6082 

christine.tankersley@truvenhealth.com 

www.truvenhealth.com 

For over 30 years, Truven Health 

Analytics has delivered clinical 

information, analytic tools and 

benchmark solutions to hospitals and 

clinicians. Realize opportunities for 

improving quality, efficiency and patient 

outcomes at www.truvenhealthcom. 

GOLD SPONSOR 

Booth #1404 

333 Pfingsten Road 

Northbrook, IL 60062 

(877) 854-3577 

OpEx@ul.com 

www.ul.com/lean 

UL’s Center for Continuous Improvement 

& Innovation is committed to providing 

health care leaders the knowledge and 

tactics to foster a culture of continuous 

improvement to deliver higher value for 

patients and families. 

Join us in the Palms Foyer Classroom 

on Tuesday from 4:45 PM – 5:15 PM 

for our presentation on value-based 

frameworks. 

University of Michigan Lean 

Healthcare Training, Coaching, 

and Professional Development 

Booth #813 

Integrative Systems and Design 

University of Michigan 

2401 Plymouth Road Suite A/B 

Ann Arbor, MI 48105 

(734) 647-7190 

www.cpd.engin.umich.edu 

meonline@umich.edu 

Lean healthcare experts of the 

world-class University of Michigan 

Health System and the College of 

Engineering help develop the skills, 

training, and coaching to plan, launch, 

and sustain lean health care 


University of St. Thomas Health Care 

MBA 

Booth #814 

1000 LaSalle Avenue, TMH455 


(651) 962-4135 

medmba@stthomas.edu 

www.stthomas.edu/healthcaremba 

AACSB- and CAHME-accredited 

MBA for experienced professionals 

from throughout the healthcare 

industry. Utilizing on-campus/online 

distance learning, the program develops 

the leadership foundation for addressing 

the Triple Aim. 


65

exhibitors 

University of Tennessee (UT) Center for 

Executive Education 

Booth #917 

1000 Volunteer Boulevard, 

603 Haslam Business Bldg. 

Knoxville, TN 37996 

(865) 974-5001 

ExecEd@utk.edu 

ExecEd.utk.edu 

UT offers CME-certified programs 

and the nation’s #1 physician executive 

MBA; delivers custom Lean 

health care, Lean ED, Lean OR, and 

Lean for Outpatient Settings courses; 

and orchestrates on-site PI/ QI events. 

Verge Solutions 

Booth #715 

P.O. Box 394 

Mt. Pleasant, SC 29465 

(843) 628-4168 

ashley@verge-solutions.com 

www.verge-solutions.com 

Verge offers web-based products 

that streamline processes towards the 

improvement of hospitals and 

health care systems: Regulatory and 

Accreditation Compliance, Incident 

Management, Claims, Patient Relations, 

Credentialing, and Committee 

Management. 

Versus Technology 

Booth #615 

2600 Miller Creek Road 

Traverse City, MI 49684 

info@versustech.com 

www.versustech.com 

Versus offers RTLS for locating patients, 

staff, and equipment in real-time, 

including state-of-the-art integrated 

hand hygiene systems. Versus optimizes 

processes, streamlines patient flow, and 

improves all areas of clinical compliance. 


Booth # 307 

VigiLanz Corporation 

Booth #1100 

5775 Wayzata Boulevard, Suite 970 


(855) 525-9078 

connect@vigilanzcorp.com 

www.vigilanzcorp.com 

VigiLanz real-time software-as-a-service 

surveillance solutions for infection control, 

pharmacy and quality programs enable 

expedited NHSN submission, HAI 

tracking, robust analysis, reports, and 

antimicrobial stewardship, optimizing 

clinical outcomes and efficiencies. 

Virginia Mason Institute 

Booth #1424 

1100 Ninth Avenue 


(206) 341-1600 

VMInstitute@vmmc.org 

VirginiaMasonInstitute.org 

Experience-based learning in the 

Virginia Mason Production System. 

Meet our faculty to learn how your 

organization can improve quality and 

safety for patients, eliminate waste, and 

improve staff satisfaction. 


Booth #1406 

351 N Sumneytown Pike 

North Wales, PA 19454 

www.vreehealth.com 

contactus@vreehealth.com 

Vree Health, a wholly-owned subsidiary 

of Merck & Co., Inc., is dedicated to 

developing technology-enabled services 

that address the needs of patients, 

family caregivers, hospitals, and other 

health care providers. 

Zynx Health 

Booth #1107 

10880 Wilshire Boulevard, Suite 300 

Los Angeles, CA 90024 

(855) 367-ZYNX 

info@zynx.com 

www.zynxhealth.com 

Zynx Health provides evidence-based 

clinical decision support solutions. 

With Zynx, providers “dare to be better” 

and improve outcomes, enhance safety, 

and lower costs every day. 

Visit www.zynxhealth.com or 

call (855) 367-ZYNX. 

THANK YOU to our 

non-exhibiting SPONSORS 

www.perfectserve.com 

220 East Las Colinas Blvd. 

Irving, Texas 75039 

(800) 842-5146 

customerservice@vha.com 

www.vha.com 

VHA Inc., is a national network of 

not-for-profit health care organizations. 

VHA leverages its expertise in analytics, 

contracting, consulting and networks 

helping members achieve their 

operational, clinical and financial 

objectives. 

WhiteCloud Analytics 

Booth #106 

225 N. 9th Street, Suite 200 

Boise, ID 83702 

(208) 991-9370 

info@whitecloudanalytics.com 

www.whitecloudanalytics.com 

NEW 

PRODUCT 

WhiteCloud Analytics solutions and 

services enable health systems to harness 

the power of their data to address 

complex challenges and deliver more 

efficient, higher-quality health care. 

www.healthcareinnovation.us/journal 

www.centerfortransforminghealthcare.org 

66 


acknowledgements 

thank you TO OUR CHAIRS 

IHI would like to thank the National Forum co-chairs for their extraordinary effort and commitment in developing the program for 

the 2012 National Forum: 

Alide Chase 

Senior Vice President of Quality and Safety and 

Co-Executive Director, CMI, Kaiser Permanente 

Paula Johnson, MD 

Head, Mary Horrigan Connors Center for Women’s 

Health and Gender Biology and Chief, Division of 

Women’s Health, Brigham and Women’s Hospital 

Enrique Ruelas, MD 

Vice President, National Academy of Medicine, Mexico 

Gilbert Salinas 

Director of Patient-Centered Care, Rancho Los Amigos 

National Rehabilitation Center 

All planning committee members and persons influencing the content of the National Forum program have disclosed all relevant financial relationships with any 

commercial interest to the Institute for Healthcare Improvement. 

IHI would like to thank our board of directors 

for their ongoing support and guidance 

James M. Anderson, 

Advisor to the President 

Cincinnati Children’s 

Hospital Medical Center 

Cincinnati, OH 


President and CEO 

Institute for Healthcare 


Cambridge, MA 

Michael Dowling 

President and CEO 

North Shore – Long Island 

Jewish Health System 

Great Neck, NY 

Elliott S. Fisher, MD, MPH 

Director for Population 

Health and Policy 

The Dartmouth Institute 

for Health Policy and 

Clinical Practice 

Lebanon, NH 

Terry Fulmer, PhD, 

RN, FAAN 

Dean, Bouvé College of 

Health Sciences 

Northeastern University 

Boston, MA 

A. Blanton Godfrey, PhD 

Dean and Professor 

College of Textiles 

North Carolina State University 

Raleigh, NC 

Jennie Chin Hansen 

CEO 

American Geriatrics Society 

New York, NY 

Helen Haskell 

Founder and President 

Mothers Against Medical Error 

(MAME) 

Columbia, SC 

Brent C. James, MD, MStat 

Chief Quality Officer 

Executive Director, Institute for 

Healthcare Delivery Research 

Intermountain Healthcare 

Salt Lake City, UT 

Gary S. Kaplan, MD 

Chairman & CEO 


Seattle, WA 

Arnold Milstein, MD, MPH 

Medical Director 

Pacific Business Group 

on Health 

San Francisco, CA 

Dennis S. O’Leary, MD 

President Emeritus 


Oakbrook Terrace, IL 

Rudolph F. Pierce, Esq. 

Attorney (Of Counsel) 

Goulston & Storrs, PC 

Washington, DC 

Nancy L. Snyderman, 

MD, FACS 

Chief Medical Editor, 

NBC News 

Associate Professor of 

Otolaryngology, University 

of Pennsylvania 

New York, NY 

Diana Chapman Walsh, 

MS, PhD 

President Emerita 

Wellesley College 

Wellesley, MA 


67

68 


MARK YOUR CALENDARS FOR NEXT YEAR’S 

25th Annual National Forum 

on Quality Improvement in Health Care 

DECEMBER 8-11, 2013 

ORLANDO, FL 

Stay connected with IHI and your fellow National Forum Attendees 

until next December by following us on: 

FACEBOOK LINKEDIN TWITTER 

69

IMPROVE QUALITY. 

IMPROVE VALUE. 

Data-Driven Solutions for Better Health Outcomes 

We understand the vision of providing patients with the highest 

quality of care and value of services. It was that vision that founded 

ActiveHealth Management over 15 years ago. 

Before Triple Aim was a major initiative, ActiveHealth was already 

dedicated to improving quality of care, reducing costs and improving 

the health of populations. We offer proven solutions and strategies 

to help organizations achieve success with their Triple Aim goals. 

Take three steps towards your Triple Aim goals while at the 

National Forum conference: 

1. Get the facts. Learn about the results we can deliver. 

Visit us at booth #1206. 

2. See how it’s done. Join our 30 minute session 

on Monday, December 10, 2012 3:30pm – 4:15pm, 

“Improving Quality & Value Across the Continuum.” 

3. Get Access. Scan the QR code, or visit 

activehealth.com to gain insight from our experts. 

70 


Statistical Software 

It’s easy to achieve all your quality improvement goals when you analyze your data with Minitab 16. 

Thousands of world-class companies choose Minitab because it has the tools they need and is easy 

to use, thanks to features like an interactive Assistant that guides you through your analysis. 

Don’t just improve your business – transform it. 

www.minitab.com 

Minitab Inc. provides exceptional sales, technical support and training for Minitab 16. 

For more information, visit www.minitab.com

72 24th Annual National Forum on Quality Improvement in Health Care File: 16126 IHI Forum Conference Guide Ad - 2012 

Size: 7.5” x 10” 

North Shore-LIJ and IHI 

Continue Their Partnership 

to Improve Patient Care 

North Shore-LIJ Health System is proud to continue its partnership with IHI. Our special 

collaboration draws on the health system’s leadership in clinical excellence and the 

research being conducted at The Feinstein Institute for Medical Research. 

As our partnership grows, North Shore-LIJ and IHI work together to enhance 

processes that can be used across our health system and then introduced worldwide. 

Our areas of focus include: 

• Early sepsis diagnosis and treatment resulting in reduced mortality 

• Pioneer sponsor of the “Conversation Project” to encourage people to 

begin to talk about their wishes for end-of-life care 

• Improving care for patients with advanced illness 

• Establishing a Quality Academy at our corporate university, Center for 

Learning and Innovation, to develop and embed organizational 

improvement capabilities 

• Launching an IHI Open School Chapter for medical students to acquire 

healthcare improvement skills. 

To learn more, visit us at Booth #607 in the Exhibit Hall or online at northshorelij.com.

as a HealtHcare leader, 

wHat issues in your 

organization keeP you 

uP at nigHt? 

➜ 

➜ 

do you know How 

to address tHeM? 

stakes are HigH, 

so can you afford 

just anotHer ‘good 

try’ tHis tiMe? 

When your organization needs more than just a good effort. When 

you need guaranteed, reliable and sustainable results, quickly… 

you need to take it to the NEXT LEVEL. 

Partnering improvement examples: 

• 40 min 

• 

• 

➜ 

➜ 

• 

➜ 

• 

• 

➜ 

➜ 

➜ 

in aVerage or turn-oVer time 

C-seCtion infeCtion rate from 17% to 0 

reVenue CyCLe CHarge CaPture by $1.8m 

sCiP-7 ComPLianCe rate from 20% to 100% 

bed PLaCement time by 23% 

CentraL steriLe ProCess time by 50% 

key differentiators: 

• No minimum time for 

engagement 

• Results guarantee 

• Structured client 

development process to 

ensure knowledge transfer 

Mike Holland 

Vice President – Lean Healthcare 

NEXT LEVEL Partners ® , LLC 

mholland@nl-p 

(212) 632-0070 

www.nl-p.com 

• 

➜ 

instrument set inVentory by $146K 

Please come see us in BootH #1000 at the iHi forum • december, 9-12, 2012 • orlando, fl 

73

N O R T H W E S T E R N U N I V E R S I T Y 

The Time is Now. 

Take the Lead. 

PROGRAM DIRECTORS: 

Kevin Weiss, MD, MPH 

Professor of Clinical Medicine 

Feinberg School of Medicine 

Northwestern University 

Donna Woods, EdM, PhD 

Associate Professor 

Feinberg School of Medicine 

Northwestern University 

GUEST FACULTY INCLUDE: 

James Battles, PhD 

Agency for Healthcare Research 

& Quality (AHRQ) 

Carmella Bocchino 

America’s Health Insurance Plans 

Helen Burstin, MD, MPH 

National Quality Forum 

Martin Hatlie, JD 

Partnership for Patient Safety 

Julie Johnson, MSPH, PhD 

University of New South Wales 

L. Gregory Pawlson, MD, MPH 

Blue Cross Blue Shield Association 

Derek Robinson, MD, MBA 

American Hospital Association 

Kathleen Sutcliffe, PhD, MSN 

University of Michigan 

Ross School of Business 

Robert L. Wears, MD, MS 


and Imperial College London 

Graduate Programs in 

Healthcare Quality and Patient Safety 

Master of Science degree in Healthcare Quality and Patient Safety: 

A two-year, part-time degree program which focuses on the knowledge, skills, and methods 

necesary for improving healthcare delivery systems. It is designed for both clinical and 

non-clinical professionals currently working in the healthcare setting who want to focus 

their career development on these important areas in healthcare. 

Faculty Development Program in Healthcare Quality and Patient Safety: 

A one-year program designed for faculty who wish to develop the educational tools, 

methods, and curricular approaches for integrating healthcare quality and patient safety 

into the medical education curriculum. 

Certificate Program in Healthcare Quality and Patient Safety: 

A one-year program designed for the learner who wants to acquire a comprehensive 

overview of these fields. 

The above programs are all part-time and do not require Chicago residence. 

Students are required to travel to our Chicago campus for a series of classroom-based 

intensive sessions. 

Introducing the new 

PhD Program in Healthcare Quality and Patient Safety 

A full-time doctoral program designed to educate 

the next generation of healthcare quality and patient 

safety innovators, practitioners, and researchers. 

For more information, please contact 

Meetal Acharya at MastersIHS@northwestern.edu 

or by phone at 312-503-5533. 

Please visit our website at: 

www.northwestern.edu/ihs/education 

THE GRADUATE SCHOOL 

• 

FEINBERG SCHOOL 

OF MEDICINE 

74 

“The need for leadership in health care has never been greater…” 

— from The Institute of Medicine report, Crossing the Quality Chasm 


notes 

76 


2-R633_HCQ_GenSpaceAd_FPcolor_FINAL_Layout 1 10/12/12 1:50 PM Page 1 

Circulation: Cardiovascular 

Quality and Outcomes 

The catalyst to turn outstanding science into actions to 

improve health and health care for the public 

Download the iPad 

app for a print-like, 

full-text experience 

Read and search 

with ease on your Internetenabled 

smartphone 

circoutcomes.ahajournals.org 

EDITOR 

Harlan M. Krumholz, MD, SM 

A digital subscription includes access to Circulation: Cardiovascular 

Quality and Outcomes online and on your iPad ® . 

SUBMIT YOUR MANUSCRIPT 

http://circoutcomes-submit.aha-journals.org 

4.906 

With an Impact Factor of 4.906, Circulation: 

Cardiovascular Quality and Outcomes ranks 

19th among 117 journals in the Cardiac & 

Cardiovascular Systems subject category. It is the 

#1 journal dedicated to quality of cardiovascular 

care and related patient outcomes. 

2011 Journal Citation Reports® (Thomson Reuters, 2012) 

RAPID PUBLICATION ONLINE WITHIN 4 WEEKS OF ACCEPTANCE 

Join the AHA * 

Call: 1-800-787-8984 (United States) 

+1-301-223-2307 (Rest of World) 

Visit my.americanheart.org/membership 

Subscribe † 

Call: 1-800-638-3030 (United States) 

+44 (0) 20 7981 0525 (Europe) 

+1-301-223-2300 (Rest of World) 

Visit http://lww.com/circoutcomes 

* 

Premium Professional Plus Members receive full access to all 11 AHA journals online and for their iPad as a benefit of membership. Premium Professional, Early Career, and 

Student/Trainee Members have limited access to journals and features as indicated by their selected level. Full access options are available for each level of membership when 

you join. To have access to the iPad edition, Members with online journal benefits must indicate Circulation: Cardiovascular Quality and Outcomes as one of their online selections. 

† 

Non-member individual and resident digital subscriptions — online and iPad edition — are ordered via LWW. Institutional online access is available via Ovid. 

Visit www.ovid.com or contact your Ovid Sales Representative directly. Print subscriptions are no longer available. 

Apple and iPad are trademarks of Apple Inc., registered in the U. S. and other countries. App Store is a service mark of Apple Inc. 

77

Cox on Communications 

Jack Cox, MD, MMM • Chief Quality Officer, Hoag Hospital • Author and industry expert on wellness, medical 

management, quality improvement, physician engagement and product evaluation • Centrally involved in the hospital’s 

strategic partnership with PerfectServe • Here, from a recent interview, are a few jewels from Dr. Cox. 

On physician-to-physician collaboration: 

“Improved physician collaboration is important because of the 

complexity and acuity of patient illnesses. Facilitating timely 

and complete communication among physicians leads to 

quicker patient care and lower lengths of stay. Currently, CMS 

and others payers focus on readmission rates and transitions 

of care. Optimizing physician-to-physician communication, 

especially the communication between inpatient physicians and 

primary care physicians, leads to smoother transitions and fewer 

readmissions.” 

On care coordination: 

“Healthcare is truly a team sport and that has never been more 

true than today. In a hospital, the ability for teams of physicians 

and caregivers to seamlessly communicate care plans and react 

to rapidly changing patient conditions is absolutely key 

for best patient care. A lack in communication 

coordination leads to treatment delays, medical 

errors, provider and patient frustration, longer 

hospital stays and potentially poorer clinical 

outcomes; cost of care and safety are also 

compromised. PerfectServe has provided 

us with a communication platform that 

allows for more comprehensive and 

timely team coordination. Our results 

speak for themselves.” 

On communication across 

the continuum: 

“Most of our med-surg patients are 

admitted to our hospitalist team. In 

addition, most of our patients have 

multiple subspecialists caring for them. 

Having a communication platform that 

allows hospitalists to communicate 

with primary care physicians or 

schedule follow-up care with a 

subspecialist as a part of the 

transition of care has been absolutely 

key. It has led to a decrease in 

readmissions and an improvement 

in care transitions.” 

On process improvement: 

“Our organization is focused on performance improvement 

in clinical outcomes, service and cost of care. Communication 

is the infrastructure for any good clinical process. A platform 

that can facilitate improved communication among clinical 

team members is critical. For example, with a stroke patient, 

there is a narrow window of opportunity to assess the patient 

and intervene to optimize the clinical outcome. We have used 

PerfectServe as the communication platform to mobilize a 

diverse team of clinicians which may include imaging techs, 

radiologists, neurologists, interventional neuro-radiologists and 

neurosurgeons, as well as other intervention team members.” 

On nurse-to-physician communication: 

“Nurse-to-physician communication, especially given the diverse 

number of subspecialists taking care of any given patient, 

was a challenge for us. PerfectServe has given our 

nurses an optimal way to reach physicians using 

one contact number and thus eliminating the 

burden of shifting through reams of paper 

to find who is currently on call or 

providing coverage. This has led to 

improved nursing satisfaction, more 

nursing time to spend with patients, 

less confusion and a better process of 

care. Physicians are also more 

satisfied knowing they don’t have to 

update each patient floor with their 

call schedules.” 

On PerfectServe: 

“We are pleased with what PerfectServe 

does to simplify and streamline our 

communication needs. It is a platform 

that will only expand on its capabilities 

and continue to improve 

communication across 

the continuum of 

care.” 

www.perfectserve.com 

1-877-844-7728 

PerfectServe: Communication Smart Enough for Medicine

moments - Institute for Healthcare Improvement

Create successful ePaper yourself

Delete template?

Save as template?