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  • How I Became a Patient Advocate
    became involved in patient safety I go to the day that changed my life This began with the video interview IHI recorded in my home in Wisconsin about two and a half years ago When Jo Ann Endo and Alan Olasin of IHI came to talk to me for Projects JOINTS I had just come home from a rehab facility after having my right leg amputated above the knee due to a MRSA infection I got from a knee replacement Before this life changing event I had my dream job as an educational administrator The hardest thing I ever had to do was give up this work It was like a door closed on a part of my life that I deeply cared about I did not think anything would ever matter to me again IHI s interview was absolutely what I needed at this time in my life because it provided an opportunity to tell my story People around the country and even the world used the video to start conversations about joint infections and many other safety issues Learning that so many organizations were using my story to help others led to a new focus for me I now work with the Wisconsin Hospital Association and others to teach organizations about the importance of patient engagement I do not want anyone else to experience what I did because of infection By continuing to share my story I feel I am moving toward this goal What mattered to me changed because of this infection New doors have opened for me The people at IHI gave me the courage to tell my story at a time when I was very low in my life They asked me What matters to you on a day when I needed someone to ask me that question I would not be doing what I do today without that special interview This is a good week to say a special thank you to IHI and especially to Jo Ann and Alan for helping to give me a voice Today I ask all of you What matters to you Tell your story so that together we can change health care and make it safer for everyone Tags Patient Safety Infection Healthcare Associated HAI Engage Patients and Families in Improvement Communication Blog Home Older Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by Ginny Moore 3 9 2015 2 01 53 PM Rosie is an inspiration to all Her dedication and passion will help others as they provide care and receive care Thank you for all you do Rosie Best Ginny Moore loading Did you find this user comment useful people found this user comment useful Report This Show More Comments Loading You are about to report a violation of our Terms of Use All reports are strictly confidential Reason Select One Contains profanity or violence Spam Defamatory Illegal Unlawful

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=125 (2016-02-01)
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  • Engaging the “Patient” in Patient Safety
    the monitor to see my heart rate in the 40s while lifting my hand to try to get the attention of my nurse or anyone else who could see me The next thing I knew there were people surrounding my bed and my nurse was thumping on my chest Shortly after they welcomed me back I learned that my left foot looked funny because my left hip was dislocated I needed to return to the OR within the hour I will never forget the stressed look on my wife s face and the tears streaming down my cheeks as I rolled back down the hallway I learned later that both my code event and need for repeat surgery were due to the level of my anesthesia but there are things I noticed during my hospitalization that may also have also contributed While I have a great relationship with my surgeon to this day no one ever asked about my view of what happened on that November morning or told me if they reviewed the event in detail to help prevent it from occurring again in the future Shouldn t we do more to engage patients when it comes to patient safety When police investigate an automobile accident don t they speak to the drivers How many times in a given week do we receive surveys about our purchasing experiences online or in a store Whether it is to investigate an incident or to improve a product or service everyone seems to care about the opinion of the customers or participants It is vitally important that we do the same thing in health care Our patients have a perspective we can only truly capture by asking them But how do we do it This is a difficult question to answer because one solution does not fit all clinical environments For example my patients can t tell me what they think since they are all infants but their parents certainly can We have found unique ways to engage families in event investigation and our process improvement work at the hospital In some instances our patients work elsewhere in the institution These are the easiest patients to routinely incorporate into your efforts as they already have a vested interest and don t have to travel far We have held focus groups with the families of former patients and surveyed current ones The hospital s patient safety steering committee also includes two patient representatives While how we engage patients and families in safety and improvement efforts very much depends on the context we need their input regardless of the situation In quality improvement work we use the phrase nothing about us without us to describe the need to incorporate all relevant disciplines when working on a project As we celebrate Patient Safety Awareness Week we need to remember how important it is to include our patients as well Tags Patient Safety Quality Improvement Engage Patients and Families in Improvement Communication Blog Home Older Average

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=124 (2016-02-01)
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  • Tools to Support Patient Engagement (and Patient Safety)
    care He is faculty for the IHI Patient Safety Executive Development Program and co chaired a number of IHI Patient Safety Collaboratives The theme of this year s National Patient Safety Awareness Week March 8 14 is United in Safety The goal is to focus on patient engagement and emphasize the importance of the relationship between providers and patients and their families In honor of this week I d like to highlight some of the resources IHI has developed for care providers middle managers executives boards and others to encourage patient and family engagement Patient Agenda Form During IHI s AHRQ funded work on PROMISES Proactive Reduction of Outpatient Malpractice Improving Safety Efficiency and Satisfaction Project we made a number of resources and tools available to participants One is a patient agenda form that guides communication about the following topics What concerns would you like us to focus on today Please list any prescriptions you may need refilled today Please list any specialists you have seen and tests you have had recently Improving Office Visit Communication Another helpful resource describes strategies to improve communication between providers and patients during the office visit Developed by Leana Wen MD author of When Doctors Don t Listen How to Avoid Misdiagnoses and Unnecessary Tests these strategies include E stablish an active partnership Focus on the diagnosis Listen Understand every test ordered Self Management Support Toolkit To support patients and families in the day to day management of chronic conditions IHI developed the Partnering in Self Management Support A Toolkit for Clinicians The concepts and tools in this toolkit give busy clinical practices tested resources and tools to help patients effectively manage their condition and sustain healthy behaviors Keeping patients engaged and informed leads to safer care Respect for patient wishes and involving them

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=46 (2016-02-01)
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  • Patient Safety Awareness Week: Dr. Edita Falco's Story
    lawyers These days patient safety is a very hot topic and everyone seems to be interested But as Dr Leape said the hard work has just begun Fifteen years after To Err Is Human was published we have not produced significant advances in spite of many efforts We need future generations to commit to the well being of the patient and patient safety and to deliver high quality health care Like ethics patient safety isn t just another subject you have to study in school but a professional obligation Medical students and young doctors need to understand why we make mistakes recognize system failures evaluate their communication skills and most of all be concerned about the dignity and well being of the patient Providers must learn to say I am sorry and take responsibility for their actions It s not easy Most of the responsibility is ours older doctors transfer many things through the hidden curriculum Our attitudes mean a lot We must examine ourselves first in order to send the right message We have to have faith that at some point in the future the work of so many people of goodwill is going to bear fruit La Semana de Seguridad Del Paciente La Historia de Dra Edita Falco Debo confesar que tuve una privilegiada e inesperada experiencia En el año 2002 concurrí al Congreso de la AAP un evento que duraba dos días y medio muy intensos donde esperaba recoger mucha información Cuando anunciaron una conferencia sobre seguridad del paciente pensé en una monótona exhibición de estadísticas administrativas y miré de soslayo la puerta para evadirme pero afortunadamente no lo hice Fue una grata sorpresa la aparición de un señor con gran capacidad de comunicación que cautivó a la audiencia desde el primer momento Exhibió un video en el que se iba mostrando una cantidad de pequeñas fallas que determinaron un desastre final en el nacimiento de un niño Era nada menos que Lucian Leape Pero aun no tenía cabal comprensión de lo que representaba Al año siguiente lo reencontré en el congreso de la APSA y allí el tema me sedujo por completo Conservo como un tesoro su conferencia y el PowerPoint que luego se publicó Nos introdujo en la fisiopatología del error en el diseño de sistemas un mundo nuevo y fascinante en el que encontraba la explicación a muchos problemas que hasta ese momento no había siquiera reconocido como tales Meses después en mi país propuse hablar del tema Lo que fue bastante resistido al inicio hasta que finalmente anunciamos una conferencia a donde fueron dos médicos y muchos abogados Ahora es un tema vastamente conocido pero como dijo el Dr Leape el trabajo duro recién comienza Quince años después de publicado To Err Is Human abundan artículos que destacan cifras de estancamiento en la reducción de los errores a pesar de los esfuerzos realizados La seguridad debería considerarse como algo intrínseco e irremplazable en la atención al paciente Así como la ética la seguridad

    Original URL path: http://www.ihi.org/education/ihiopenschool/blogs/_layouts/ihi/community/blog/itemview.aspx?List=9f16d15b-5aab-4613-a17a-076c64a9e912&ID=164 (2016-02-01)
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  • Including the Patient Voice on Patient Safety Committees
    Center in Springfield Massachusetts two patients have full membership on the Patient Safety Committee The process used to recruit and train them could be a model for others Baystate established its Patient and Family Advisory Council PFAC in 2010 As early discussions centered on patient safety issues the Patient Safety Committee focused on how to begin a conversation with patients about helping to prevent harm The committee asked that a safety champion attend a PFAC meeting and this dialogue resulted in two patients joining the Safety Committee in 2012 and I am delighted to be one of those advisors Orientation was essential for a smooth transition and effective collaboration Both the Safety Committee and the patient advisors needed preparation for this partnership to be productive The chair of the Patient Safety Committee facilitated discussions that helped the members recognize the value of patient and family contributions Committee members became willing to forgo assumptions in lieu of hearing directly from patients and their families Watch a brief video about simple ways to improve patient care I n addition the chair of the Safety Committee met with the two patient advisors prior to our first committee meeting We reviewed the time commitment and expectations We addressed definitions language and tools used by the Safety Committee and familiarized ourselves with current topics of discussion Most importantly assigned mentors paired up with the patient advisors to clarify issues and answer questions as they came up during committee meetings Our work has evolved A third patient advisor now serves on an ad hoc patient falls committee and others have served on root cause analysis teams As one of those first two patient advocate recruits I feel that this partnership has worked beautifully and productively Of course I hope my input has been helpful to the organization but I do know my experience has been beneficial to me personally I have become a better consumer of health care and a better patient On December 2 2014 I participated in a panel discussion to help celebrate the re launch of the Betsy Lehman Center for Patient Safety and Medical Error Reduction in Boston To prepare I asked the Baystate Medical Center Patient Safety Committee if having patients on the committee had changed the way they conduct their meetings One committee member said Well yes Not in our discussions I mean we don t filter our comments just because you are here but we do look to your input to guide our decisions and remind us that our work impacts our patients I guess that says it all Tags Patient Safety Person and Family Centered Care Engage Patients and Families in Improvement Communication Blog Home Older Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments Show More Comments Loading You are about to report a violation of our Terms of Use All reports are strictly confidential Reason Select One Contains profanity or

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=123 (2016-02-01)
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  • Fellows Snapshot: Sahar Al-Asam, BDM, MSD, CAGS, 2014-2015 Hamad Medical Corporation-IHI Fellow
    MSD CAGS 2014 2015 Hamad Medical Corporation IHI Fellow What brought you here to your IHI Fellowship I have always been interested d uring my career in how to be someone who provides good practice in general I always wanted to be a good dentist a good practitioner and health care provider I ve worked hard through my whole learning journey and reached the point where I became part of the administration in my department Now I have spent about five or six years in this position gaining experience in the work of administration But I began thinking that with more knowledge of quality improvement I could do better I started to look back over my past work to learn What could I have done better How could I improve my performance How could we provide better care in my department So I started exploring quality improvement programs and degree programs in health care administration opportunities for seeking more knowledge And then the Hamad Medical Corporation Fellowship program was announced as part of the strategic partnership with IHI It seemed like a great opportunity for me to learn more about quality improvement so I applied was accepted and now I am here What s one thing you ve learned already I ve gained so much knowledge but one thing I ve learned that I will take home with me is how to involve my patients in our practice more It has not been a priority for us in the past but I believe we can do so and it would be a major improvement It s important to me because I feel that I was taught as a practitioner to really try to understand patient needs What can I do better for you in my practice what matters to you from your perspective I will definitely take this home and start to implement it immediately What s something that has surprised you One thing is how many strategic partners IHI is working with and that within every partnership is a whole world of work It s about safety improvement capability patient centered care and so on Just the work involved with one area of one of the strategic partner organizations is so complex The partners themselves are very different organizations so that alone is a challenge Given how small IHI is this has really surprised and impressed me Something else I was surprised but very glad to learn about is IHI s work in the Africa region These are people who really have limited resources to provide care to patients so it s such important work What are you most excited about I would love to take all the knowledge I have gained during my fellowship particularly in the Improvement Advisor program which I think is very powerful something I think each and every IHI Fellow should complete I have learned so much from this program in terms of how to work with data how to motivate people how to

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=113a95c2-dffe-41ec-abee-93b4088068ac&ID=24 (2016-02-01)
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  • Why You Should Be Curious about PDSAs
    on the floor to show the dance steps making the footprints different colors to differentiate the right foot from the left one numbering the footprints in the order of the steps taping the footprints to the floor so they don t move around George figures out how to teach Bill and others how to dance Running PDSA cycles comes naturally Children use the PDSA approach all the time without even knowing it You use it too Have you ever tried to take a different route to work to see if there was less traffic tried to exercise more tried to learn how to use your new smartphone tried to learn a new hobby or tried to get a baby to sleep through the night Then you ve been running PDSA cycles We re teaching it to students in IHI s Open School courses Now can we expand the PDSA approach beyond ourselves to interactions with others at work maybe even in our families amongst our friends and in our communities How can we make it go viral What if everyone in the world knew how to run PDSA cycles and approached change through this lens Could you imagine the evening news Community clashes over XYZ issue but decided to run a series of tests to learn what solution will work best in our town Yes we can learn what happened in this community and that community but testing through PDSA cycles helps us determine what s going to work in our community in our local context If everyone knew how to run PDSA cycles whenever something doesn t go as planned people have differing opinions on how to proceed on some issue or we see an opportunity to make something better we would get out of the conference room or the debate and say Let s run a test and learn Perhaps that s a bit of a stretch but I m testing this approach now with my children with everything from building Lego towers to using the potty to our morning routine so we can get out of the house faster I ll let you know how it goes So PDSA cycles is my answer to Maureen s question What is the one improvement idea you think everyone in the world should know What would be your answer Tags Improvement Capability Plan Do Study Act PDSA Model for Improvement Quality Improvement Improvement Methods and Tools Blog Home Older Average Content Rating 1 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by Vickie Kamataris 4 15 2015 10 51 46 AM We use PSDA ever day in every work area by every member of the staff from my LSS Black Belts to the housekeeping and dietary staff The results are captured on our Key Performance Indicator boards our version of Lean Management for Daily Improvement We call it Rapid Cycle Change and are beginning to add A3

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=122 (2016-02-01)
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  • Transforming Diabetes Care in a High-Risk Community
    our clinic s systems and processes For the past five months we have been working on a project to implement the Diabetes Mellitus Clinic Bundle DMCB which consists of A1c labs average blood sugar drawn at least twice a year or as needed Urine microalbumin drawn yearly Bun Creatinine levels drawn yearly Blood pressure check done yearly or as needed Foot exam done yearly or as needed Eye exams done yearly or as needed I dentifying safe practices 1 treating hypoglycemia 2 sick day protocols 3 dealing with hyperglycemia 4 safe usage and disposal of insulin and needles Appointments with dieticians and nurse educators for diabetes self management support Patients who attend the DMCB clinic are those identified as being at risk for complications related to diabetes When patients arrive at our clinic we review their diabetes labs with them We evaluate them for any acute conditions hypoglycemia hyperglycemia visual impairment and give them a foot exam In addition to their evaluation we provide direct access to appointments with our ophthalmologists nutritionists diabetes educators and podiatrists to ensure they are receiving quality care to prevent long term health complications related to poor control of blood sugars We track all DMCB patients in our databases and a nurse follows up with each patient to ensure they receive adequate care This ensures we provide ongoing support to assist patients towards improved glucose control We are starting to see some positive results For example one of our patients had an average blood sugar in the low 300s After two months in our program we redrew her A1c and it came out between 6 7 average 130 150 This is a drop of 4 5 A1c points and dramatically decreases her risk of having a stroke heart attack and microvascular complications associated with diabetes UKPDS Study on Diabetes With continuing ongoing support we hope to maintain her blood sugar numbers and assist her with challenges that may affect her glucose control Our DMCB project has shown improvements in the number of patients completing their diabetes labs We are currently in the process of taking what we ve learned from our first project and spreading it to our family practice clinics at West County For example we are sharing the program training guidelines we ve developed which include details on how to conduct an orientation with nursing staff teach the curriculum conduct one on one coaching with nurses and provide constructive feedback We are also sharing the work we designed for each phase of clinic development to help staff and preceptors follow quality of care standard processes Without access to modern health care my grandparents never received quality care to prevent complications from diabetes They didn t have the opportunity to learn from a certified diabetes educator Getting their hemoglobin A1c checked or having regular foot exams were never options because they lived in underserved areas Now however others do not have to suffer the fate of my grandparents By establishing quality programs and improving

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=121 (2016-02-01)
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