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Physician and clinical leaders from Inova Health System recognized a significant opportunity to save lives and improve care in a system that has more than 4000 patients with sepsis annually. Through this interactive session, you will learn how Inova clinical leaders used improvement science to impact sepsis mortality through early identification of clinical deterioration using early warning score tools and rapid intervention by a multidisciplinary team. Participants will engage with the leaders who designed the intervention algorithm; led the educational sessions using low-fidelity simulation; monitored the improvement; and integrated the role of intensivists, advance practice providers, rapid response nurses, and clinical nurses both onsite and through the teleICU.

After this presentation you will be able to:

1. Describe the use of performance improvement tools to reduce sepsis mortality.
2. Explain how Inova Health System leveraged teamwork and relationship building to improve early identification of sepsis.
3. Describe the use of simulation and teleICU as tools to promote compliance with the sepsis bundle for the treatment of sepsis.

Methods, Tools and Frameworks: The intrinsic ability of the healthcare system to adjust its functioning prior to, during, or following changes and disturbances so that it can sustain required operations under both expected and unexpected conditions is resilient behavior fostering Safety II. Healthcare workers routinely confront evolving situations and constantly adapt their performance. In organizations, because this effort results in success, it is rarely uncovered. This Learning Lab will focus on the successful transition of Safety II from theoretical constructs to executing Resilience Engineering in a healthcare environment. The audience should be individuals with an understanding of QI methodology and high reliability principles. Didactic material will include a common language for resilience engineering, Safety 1, Safety 2, and high-reliability organizational principles. Theater-based improv exercises focused on team adaptability will increase both personal skills and the ability to teach others the resilience potentials (anticipate, monitor, respond, and learn). Using simulation of everyday success, learners will recognize and appreciate complexity in healthcare systems, with an understanding for work as imagined vs work as done. The reality of the efficiency-thoroughness tradeoff with competing obligations will be highlighted. Value to participants is multifactorial. Instructors will explicitly describe theory and subsequent practical applications. Instruction will include interactive engagement with the audience to highlight specific examples of resilient behavior from their own experiences. We will share our institutional experience of the development and implementation of “Advancing Quality and Safety: Resilience Engineering in Healthcare” educational paradigm that engaged team members from the bedside to the executive level.

After this presentation you will be able to:

1. Describe the presence of organizational resilience as a source of safety in healthcare.
2. Develop the resilience potentials of anticipate, monitor, respond and learn as a strategy to reduce harm and increase the likelihood of optimal outcomes.
3. Implement resilience interventions in their own hospitals.

Patient communication impairment is associated with preventable adverse events and patient and family distress. The Study of Patient-nurse Effectiveness with Assisted Communication Strategies framework supports communication with patients who are unable to speak. We will present the assessment pathway, best practices with “low tech” tools, an electronic tablet communication application, and an implementation guide. Nurses, physicians, respiratory and rehabilitation therapists, patient advocates, and patient experience coordinators will benefit from case examples, demonstrations, and hands-on practice.

After this presentation you will be able to:

1. Identify communication assessment parameters, categories of patient communication impairment, and the impact on patient-provider communication in acute-critical care settings.
2. Identify appropriate patient communication tools or strategies based on assessment parameters according to an evidence-based communication framework.
3. Describe steps for implementation and quality measurement of communication framework at your home institution.

Built around the Model for Improvement, this session will demonstrate how to put into practice the model’s three key questions about setting aims, establishing measures, and selecting changes to drive successful improvement work. This course will provide a refresher for those who are stalled in their improvement efforts and a jump-start for those who are new to the quality improvement journey.

After this presentation you will be able to:

1. Describe the elements of the Model for Improvement.
2. Identify the necessary elements to develop an aim statement and identify a family of measures
3. Explain how to develop high-leverage change ideas and conduct effective Plan-Do-Study-Act cycles.

10,000 people turn 65 every day and are likely already a growing portion of the people served in your health system. The care of older adults is often complex and, too often, includes unwanted care or results in harms. The harms are experienced most acutely by older adults and their family care givers. But our health system care teams may lose their own joy in work and health systems costs are increasing. In 2016, The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA), launched the Age-Friendly Health Systems initiative. The 4Ms Framework of an Age-Friendly Health System is evidence-based and reliably implementable across health care settings: What Matters: Know and align care with each older adult’s specific health outcome goals and care preferences including, but not limited to, end-of-life care, and across settings of care. Medication: If medication is necessary, use age-friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation across settings of care. Mentation (Mind): Prevent, identify, treat, and manage dementia, depression, and delirium across care settings. Mobility: Ensure that older adults move safely every day to maintain function and do What Matters. Join us in this workshop to draw from the experience of five pioneer health systems and begin mapping your own journey to safe, reliable, evidence-based care of older adults.

After this presentation you will be able to:

1. Understand the 4Ms framework as essential elements of evidence based, high-quality care of older adults (What Matters, Medication, Mentation and Mobility)
2. Understand opportunities for local adaptation of the 4Ms and examples of how different systems have put those into place
3. Articulate impact of asking and acting on What Matters to older adults as the starting place of care of older adults
4. Understand how to integrate asking and acting on What Matters across different ethnicities, cultures and religions
5. Take initial steps to your journey of becoming an Age-Friendly Health System and specifically how to engage leadership in this journey

The Spreading Community Accelerators through Learning and Evaluation (SCALE) initiative uses Improvement Science (IS) tools, methods, and approaches to improve well-being in communities in order to strengthen collaboration with stakeholders; commence innovative improvement projects and develop sustainable systems that focus on equity. Core teams comprised of institutional leaders, improvement coaches and community participants will share how adaptation of key frameworks and IS tools can facilitate systems change in SCALE communities. The aim of this session is to share knowledge gained from the evaluation of SCALE and demonstrate how best to adapt IS tools tools in community settings. Participants will leave with concrete tools and approaches to collaborate with stakeholders in their community to improve health, well-being, and equity. Outline 1. (10 min buffer) 2. Introduce our team and SCALE initiative 3. Introduce Race, Racism, and Equity (RRE) and IS Framework and Tools 4. Overview of IS tools and findings from SCALE (SCALE Evaluation Team) a. RRE and Community Engagement b. Improvement Science and Measurement c. Community of Solutions Skills and Community Transformation Mapping 5. Hands on activities with participants: examples from SCALE communities using IS tools, modifications, and how they address equity and strengthen collaboration a. Race, Equity and Inclusion Training and the Race Equity Map (Melvin Jackson, Raleigh North Carolina) b. Community Transformation Map and Journey Mapping (Will Douglas, Tenderloin District, San Francisco) c. IS Tools, Driver Diagrams, Model for Improvement (Becky Henry, Maricopa County, Arizona) d. IS tools, Trauma Informed Community Engagement (Amy Turk, Downtown Women’s Center, Los Angeles)

After this presentation you will be able to:

1. Identify lessons learned from community processes and a range of models to address equity.
2. Demonstrate how IS tools/methods have been adapted by SCALE communities to work toward health equity and facilitate community collaboration.
3. Practice how to apply IS tools using an equity lens with session participants in their own communities.

This Learning Lab provides a structured approach to high-velocity improvement, including tools and methodology. Expert faculty will challenge attendees’ thinking and simulate the critical skills required for high performance. Learning will be enriched with examples of digital solutions that enable rapid identification and real-time connectivity. The following case studies with data will be shared: The translation of Toyota theory to achieve redesign of care systems for Older Adults, including the concept of ‘Flipped Discharge’; The Baldrige Award–winning Charleston Area Medical Center sustained transformation of reducing deferrals and increasing revenue while improving staff satisfaction and patient experience.

After this presentation you will be able to:

1. Identify why system complexity requires us to take a methodical approach to system design, operation, and improvement.
2. Be able to identify specific applications of translated Toyota tools and methodology to achieve graceful care.
3. Access credible data and results of transformational redesign of complex systems, including older adult care.

This interactive session will offer 10 tips for improvement and practical techniques from successful improvement programs around the world. We will discuss key QI methods, collaboration, and networking, as well as creating conditions for change, co-designing with patients and families, measuring what matters, understanding your context, and sustaining gains. Examples include diverse patient populations with a focus on reducing inequities. Everyone, including presenters, will pledge to test one new idea and leave with a plan.

After this presentation you will be able to:

1. Identify tried and tested QI techniques that can accelerate improvement efforts in context for all health populations.
2. Discuss and explain best practices in driving improvement, including using a learning system and coaching tools to achieve results in co-designing change with patients and families.
3. Develop a plan to test one new idea from the top tips after the session.

Quality Improvement (QI) is the common ground between physicians and administrators. Engaging physicians in quality improvement allows them to engage in the larger health care system and make it a constantly improving enterprise. This session will describe a bottom-up approach to developing a QI program and QI capability. Participants will learn about the multi-year journey of Physician Quality Improvement (PQI), a grassroots, physician-led QI program in British Columbia, Canada, and use learnings and stories from this example to develop their own path forward. We will focus on identifying key success factors, the succession of priorities in a resource-constrained system, the tensions that develop running an entrepreneurial program within a hierarchical system, and identifying what success looks like at the various stages of evolution.

After this presentation you will be able to:

1. Identify the key factors needed to run a successful grassroots QI program.
2. Define a multi-year progression of evolving priorities in a grassroots QI program.
3. Identify some of the key tensions when running an entrepreneurial program within a hierarchical system.

Teaching statistical improvement concepts need not be boring nor didactic. Some of last century’s greatest quality ambassadors developed games to help improvement leaders experience important concepts first-hand, such as common versus special cause variation, experimentation, variation reduction, and process tampering. This workshop runs several of these classic games to help attendees experience and internalize ‘thinking like a statistician’ in a pragmatic way. Join us for Deming’s red bead game, Nelson’s funnel experiment, Box’s helicopter exercise, and other games.

After this presentation you will be able to:

1. Explain key concepts of special cause variation, variation reduction, and process tampering.
2. Describe the value of control charts and designed experiments.
3. Describe key statistical thinking concepts important to health care management and improvement.

Dave, Janet, and Kathy have led the popular Leading Quality Improvement (LQI) virtual program at IHI for six years, with more than 7,000 participants to date. There have been many lessons learned along the way, and the dialogue with health care managers in the United States and around the world has been very valuable, enriching the learning and improving the curricula for future participants. In this highly interactive session, we will explore some of the basics for leading quality programs as a manager in the trenches based on attendee feedback. We will explore time management, self awareness, coaching techniques, effective problem solving, communication, and other skills. Through didactic instruction, reflection, and sharing we will help you build your skills to drive quality improvement.

After this presentation you will be able to:

1. Identify your opportunities for growth and development as a frontline leader in quality improvement.
2. Develop the skills as a manager to successfully engage yourself and your team in quality improvement.
3. Connect with like-minded colleagues to share stories and insights for mutual learning.

An essential and strategic activity for improving quality and safety is a strong quality planning process. How do you learn about the need of those you serve? How do you understand the current performance of your system to meet their needs? What informs you to decide to innovate or improve? In this session, learn from Tampa General Hospital’s journey as they use IHI’s approach to quality planning as a launch pad to building leadership will, defining what’s the right work to do, and mapping the path forward.

After this presentation you will be able to:

1. Explain the strategic opportunity of a comprehensive quality planning process
2. Describe an example of a comprehensive quality planning process and key learning from that example.
3. Introduce the concept of quality planning as part of your strategy

What can large health systems learn from efforts to transform whole country health systems to deliver safer care? Recently, three seminal reports challenged health systems around the world to prioritize quality. This session shares results from work in Mexico, Ethiopia, Scotland, Ghana, and Nigeria – countries at various points in their National Quality Strategy journeys – including a framework for countries and large systems seeking to develop a Quality Strategy and accompanying systems for management and learning.

After this presentation you will be able to:

1. Understand recommendations from recent global reports advocating health systems delivering quality care and better outcomes, and their relevance to quality in large health systems in all economies.
2. Explain how the framework can be used to guide development of improved Quality Strategies for large health systems.
3. Describe how to implement Quality Strategies using an integrated quality management approach.

All of us, no matter where we work in our organizations, will be confronted with situations where things have gone wrong: A patient has been harmed by an adverse event. You witness a colleague berating a peer. A news story breaks about a serious quality lapse at your organization, and a neighbor asks how such a thing could have happened. Regardless of what chair we occupy, we all need the confidence to act appropriately and effectively. This confidence stems from understanding the psychological barriers to speaking up and having strategies for overcoming these concerns. In addition, health care workers need to know what specific things they can say when these situations arise. The “transparency bundle” is a set of attitudes and skills that can facilitate effective responses. This session will draw on emerging work on transparency in health care and integrate new insights from social and cognitive psychology to illustrate the critical role that every health care worker can play in promoting transparent responses to breakdowns in care.

After this presentation you will be able to:

1. Describe the critical role that each of us should play in responding to care breakdowns with confidence and transparency, regardless of the role we play in our organization.
2. Explain how feelings of fear and embarrassment can undermine our confidence to act with transparency and three strategies to overcome these concerns.
3. Demonstrate actions we can take and things we can say when faced with a spectrum of care breakdowns requiring a transparent response.

Modern provider organizations need ways to empower physicians to make optimal clinical decisions while stewarding scarce resources. In this interactive session, exchange insights with your peers on how to talk to physicians about cost, avoid common pitfalls, and learn from successful techniques used by other health care organizations. Dive into case-studies based on real-life scenarios. Discuss techniques to leverage the “7 Cs” that drive clinical decisions: Compassion, Curiosity, Community, Clarity, Conversation, Competition, and Compensation.

After this presentation you will be able to:

1. Describe methods for incorporating unblinded peer comparisons, curated recent case reviews, and group reflections on practice variation to accelerate learning, drive quality improvement, and reduce waste.
2. List strategies and tactics that leverage intrinsic drivers of behavior change and supplement extrinsic drivers.
3. Identify common pitfalls of individual physician feedback (e.g., dubious attribution, severity adjustment, and unactionable data).

In this highly interactive session, you will explore the story of the rapidly growing ‘What matters to you?’ (#WMTY) movement. The WMTY approach has become an international movement for improvement and a way of reframing the relationship between caregivers and patients and families — as well as reconnecting staff with their original purpose as caregivers. Thousands of participants around the world are now creating significant change in individual lives and playing an important role in re-orientating the work of health and social care systems — benefiting patients, families, and staff.

After this presentation you will be able to:

1. Explain why “WMTY” is such a powerful re-orientating approach and describe powerful examples of impact.
2. Develop next steps for testing and implementing the WMTY approach in your own work and gain practical experience with tools and methods to help.
3. Identify key factors that have allowed the WMTY movement to grow and flourish internationally, including differences emerging between countries and cultures.

Beyond physical harm, patients can also experience non-physical harms in the course of care, including negative impacts on emotions, trust, and therapeutic relationships that can have long-lasting consequences. To improve the quality and safety of care, organizations can strive to prevent such harms by pursuing a more reliable "practice of respect." During this session, we will shine a light on non-physical harms and experiences of disrespect. Using a case-based approach and leveraging the Root Cause Analysis and Action (RCA2) framework and existing systems for assessing and tracking preventable harm, participants will practice identifying, analyzing, and constructively discussing such incidents. Participants will also explore the central role of patient and family engagement in designing and implementing successful and sustainable improvement and the intersections between this work and just culture, equity, and organizational operations. By interacting with real cases, participants will leave with practical experience and concrete ideas about how to get started when they return to their organizations.

After this presentation you will be able to:

1. Describe a framework that utilizes existing institutional resources and processes for capturing, assessing, and tracking patient and family experiences involving non-physical harms and disrespect.
2. Apply the framework to a series of cases and discuss the optimal methods of designing and implementing initiatives to improve the patient and family experience.
3. Explore a roadmap for moving toward a more reliable practice of respect, including the necessary organizational elements.

Health care consumers want experiences that speak to their individual values and preferences. Yet, most health care lags far behind other industries, from entertainment to education, in providing truly customized service experiences. In 2018, the Institute for Healthcare Improvement partnered with NRC Health to develop models of “mass customization” for health care – providing relatively personalized services without overwhelming investments in new resources. This session will review the results of this research, which studied both out-of-industry organizations like Netflix and health care organizations like Novant Health in North Carolina to develop a detailed roadmap for organizations that aspire to effect mass customization. The session will also review an innovative program from Region Jonkoping County, Sweden, where leaders have introduced a co-designed “patient compact” to ensure alignment between care experience and patient goals and preferences. The compacts, tested in 54 units, has demonstrated results in increasing patient engagement. This model offers a foundational approach to customizing care.

After this presentation you will be able to:

1. Distinguish between mass customization and related concepts like person-centered care
2. Learn how large consumer-centered companies outside of health care, like Netflix, produce customized experiences
3. Understand how to work toward customization through an advanced patient compact model, with review of an in-depth case study from Region Jonkoping County, Sweden

This session will describe the theory of how to apply quality improvement (QI) skills in order to improve health outcomes, experience of care, and cost of care for a population segment (i.e., pursue the IHI Triple Aim). We will walk attendees step-by-step through how you can use your existing QI skills in service of population health improvement, identifying the steps where this differs from traditional QI work. We will incorporate examples to illustrate the theory from the work of Community Solutions and East London NHS Foundation Trust, both of whom are using QI and the Triple Aim framework to improve outcomes, experience, and cost for whole populations.

After this presentation you will be able to:

1. Explain how to apply quality improvement principles in service of achieving the Triple Aim for populations.
2. Identify areas where the Triple Aim approach differs from standard quality improvement work.
3. Develop confidence to start applying quality improvement to a population segment.

The Indiana Rural Health Association (IRHA) works with communities impacted by behavioral health needs including substance use disorder, suicide, depression, and anxiety. IRHA created the Crossroads Partnership for Telehealth (Crossroads), funded by the Health Resources and Services Administration, which has implemented telehealth programs to increase access. This session will discuss the steps involved, including technology selection, workflow, and billing support. The team will share tools to measure program success and strategies for quality improvement.

After this presentation you will be able to:

1. Identify potential opportunities to implement tele-behavioral health.
2. Describe strategies to implement a tele-behavioral health program
3. Identify steps to successfully run a tele-behavioral health program.

Patients with a behavioral health emergency often confront over-crowded emergency departments that are ill-equipped to meet their needs. Taking the patient perspective, this session will share the work of an 18-month IHI Learning Community that tested new ways to care for patients in the emergency department and to connect them more effectively with community resources. Participants will learn about successes, challenges, and ideas for how to make meaningful improvements in their own systems.

After this presentation you will be able to:

1. Describe how to incorporate the patient and family perspective into the redesign of ED care
2. Understand key changes to improve care in the ED for individuals with behavioral health needs
3. Understand key components of a coordinated system of behavioral health care

Improving outcomes and narrowing equity gaps for children in poverty can be overwhelming. We created the multi-sector All Children Thrive Learning Network with parents and community-based partners to achieve city-wide child health improvement goals. Network goals, defined in partnership with stakeholders across the hospital-community continuum, include reduced infant mortality and preterm birth, narrowed child health gaps between high and low morbidity neighborhoods, and increased child readiness for and success in school. Through this Network, we are harnessing the ideas, talents, and inherent motivation of community stakeholders to break down silos and accelerate the pace of improvement for Cincinnati’s 66,000 children. Our main strategies are devised to hold ourselves accountable to all children in our community (not just those that walk through our doors); build will and effective partnerships with stakeholders, including families; identify and mitigate social risk; expand quality improvement capabilities across sectors; and employ actionable data to inform improvement strategies while addressing social and economic causes at the root of child health disparities. This session will provide attendees with our roadmap. We will highlight strategies to produce a learning system, including design, measurement, coproduction, and quality improvement capability building. Using an interactive, case study approach, presentations will be made by parents, healthcare providers and community partners. Time will be allocated for participants to envision impacting their own communities through discussion of goals, strategies, and lessons learned.

After this presentation you will be able to:

1. Describe insights gleaned from a city-wide learning network which aims to reduce infant mortality and preterm birth, narrow child health gaps between high and low morbidity neighborhoods, and increase a child’s readiness for and success in school.
2. Apply Cincinnati’s population health roadmap, inclusive of key interventions and actions, to workshop attendees’ current or planned initiatives.
3. Understand Cincinnati’s implementation strategies, with a focus on building meaningful hospital-community relationships, expanding community QI capabilities, and adding an equity lens to data to inform interventions.

Critical gaps exist in the data that enables organisations to identify current and emerging risks to patient safety. Safety failures continue to occur in health services worldwide. In order to combat this, we need to rethink how safety risks are identified. In this session we explore how, with data organisations already collect, risks to patient safety can be identified and care improvements can be directed. This session will deliver a framework for identifying and analysing non-traditional patient safety data to drive healthcare improvement. The framework encompasses such data as patient feedback, medico-legal claims, sentinel events, reports to government clinical councils, practitioner regulator notifications, care volume, and more to identify and address current and emerging safety risks. This session assumes no QI knowledge, and would be suitable for everyone from consumers and students to system managers. Beyond the provision of a framework, in this session we will share our own experience of implementing routine monitoring of non-traditional patient safety data. This will include a discussion of what worked and what didn’t, challenges in enacting the framework, and strategies to engineer prospective data-sharing agreements.

After this presentation you will be able to:

1. Deliver a clear framework for attendees to identify sources of underused safety risk data in their own organisations in an interactive design-thinking activity during the session.
2. Provide a road-map for participants on how to incorporate these data into routine safety risk monitoring systems in their organization.
3. Give insight on how participants can implement and measure improvements to patient safety and patient centred care by incorporating lessons from data feeds including patient complaints, medicolegal claims, practitioner notifications and more, and sell this change to managers and system leaders within 6 months following the conference.

Go backstage at Universal Orlando® and learn how the stunt team ensures the safety of staff and visitors during high-risk stunts. Learn how the team addresses reliability during hand-offs and staffing changes and how it handles unexpected events. Hear directly from actors and see stunts demonstrated backstage and performed live.

After this presentation you will be able to:

1. Explain how safety and reliability concepts from a non-health care setting can be applied to health care.
2. Recognize and analyze key concepts of safety and reliability.
3. Develop ideas for improving safety in your own work environment.

Get a behind-the-scenes look at how Orlando Health System has fostered the deep engagement of its clinicians, staff, and patients through a focus on teamwork and results. Participants will visit Orlando Regional Medical Center, a Level 1 trauma center, and Arnold Palmer Medical Center, which includes one of the nation’s largest neonatal intensive care units. Learn how Orlando Health's quality structure helped providers deal with the events of the Pulse Nightclub tragedy.

After this presentation you will be able to:

1. Describe the structures that build the deep engagement of clinicians and staff.
2. Discuss the leadership behaviors that can deepen the engagement of staff and patients and lead to great results in care delivery.
3. Develop two strategies that can improve engagement at any institution.

The health care workforce experiences high rates of physical and psychological harm, despite adverse consequences for productivity, turnover, morale, and patient outcomes. We will introduce a comprehensive, proactive approach, including leadership, hazard identification, risk management, and performance measurement. Faculty will share tools, measures, and lessons learned from health care systems with success in improving workforce safety. This session will focus on slip/trips/falls, patient handling, and workplace violence and welcomes executives, leaders, and staff.

After this presentation you will be able to:

1. Describe the impact of workforce harm on patients, families, the health care team, and organizational performance.
2. List leading causes, metrics, and solutions for addressing workforce harm, including slips, trips, and falls; musculoskeletal injury; and workplace violence.
3. Explain approaches to integrate recommendations into an organization’s assessment, reliable management, and improvement of workforce safety.

Every 9 minutes, someone dies due to a wrong or delayed medical diagnosis. Hear how one health system is using a change package, Improving Diagnosis in Medicine, as a framework for organizational change. Presenters will share tools, implementation strategies, and examples of learning from diagnostic error, creating reliable diagnostic processes, engaging patients and families, improving cognitive performance, and using teaming for accurate diagnosis. Small group exercises will support plans for change at your home institution.

After this presentation you will be able to:

1. Describe one organization's strategy for reducing harm from delayed and missed diagnosis.
2. Describe two ways to adapt current patient safety processes to improve diagnosis.
3. Describe two tools that could be introduced to your organization to reduce harm from diagnostic error.

In this Excursion, participants will learn how the Marriott World Center expertly handles the flow of large volumes of visitors yet offers superb customer service in the front office, efficiently and safely feeds an average of 1 million plates per year, runs a golf club, tends to every detail of event and convention services, manages the logistics and tracking of Lost & Found, and manages daily housekeeping operations. Employee retention and recognition will also be discussed.

After this presentation you will be able to:

1. Identify at least 5 new ideas to borrow from large-scale operations in different functions of the hotel industry.
2. Consider application of ideas for improving your own work environment.
3. Develop next steps and action plans for testing new ideas in your own operations.

The nonprofit Second Harvest Food Bank of Central Florida collects, stores, and distributes donated food to more than 550 feeding partners in six counties. After a 2004 hurricane, the Food Bank improved its disaster preparedness and response, enabling it to provide more than 1 million meals and serve as the staging ground for other food banks during a 2018 hurricane. Excursion participants will engage in dynamic discussion with executive management to learn about the strategic planning, management, and daily operations of a community-based organization that addresses social determinants of health through food security. Participants will also volunteer for two hours at the Food Bank, an experiential learning opportunity that provides time to ask questions of frontline workers.

After this presentation you will be able to:

1. Examine a user-centered design approach to strategic planning, operations, and disaster preparedness and response.
2. Discuss place-based strategies to address food insecurity and related determinants of health at scale.
3. Identify at least three ways an organization can improve its disaster preparedness efforts.
4. Discuss service learning, via small group conversation, with frontline workers.
5. Apply ideas gathered from an out-of-industry organization ready for testing and spread in any organization.

Experienced change-makers know to expect the unexpected when leading improvement. So why does traditional quality improvement (QI) training focus almost exclusively on technical tools built to foster statistical control? How are we systematically training the psychology component, or the art of improvement, from Deming’s System of Profound Knowledge? For the last three years, ICSI has taught more than 3000 physicians, leaders, and staff an adaptive approach to QI that marries the Model for Improvement to improvisation. Improvisation, or “improv,” provides a framework for collaboration and experimentation that complements traditional QI methods. In this high-energy, hands-on workshop, you’ll discover how an improvisational approach can change the conversation about improvement, activate your team, and accelerate your work. Learn the Rules of Quality Improv(e), explore the Simple Tools to Re-Ignite Change Toolkit, and have fun practicing techniques that can be easily applied to your toughest improvement challenges.

After this presentation you will be able to:

1. Explain how an improvisational mindset and adaptive engagement methods can complement existing quality improvement models.
2. Describe the Rules of Quality Improv(e) and the Simple Tools to Re-Ignite Change Toolkit and how to apply them.
3. Use easy-to-learn tools and techniques that foster teamwork, collaboration, and courageous quality improvement.

What are the key considerations when planning a large scale change programme? What are the common pitfalls you can avoid with a scale up method? What elements do you have to just let play out and how do you balance the inevitable tensions and challenges that arise? We present learning from the development and running of a large scale change programme (in Maternity and Neonatal care) in England over the last 2.5 years. The programme has a national footprint and is currently focused on five clinical interventions aiming to improve safety and outcomes, reduce variation and provide high quality healthcare experience. The programme maintains a focus on system enablers including culture, capability, processes, measurement and person-centered care to support improvement. We will discuss the challenges of balancing these enablers against the clinical interventions. In addition, this programme nests within a larger maternity transformation programme with significant ambition, rich with similar and/or competing initiatives. We present how we working to prevent duplication, spread learning between initiatives and increase alignment. We will undertake a number of exercises with participants to illustrate how you can navigate some of these challenges when setting up, refining and scaling your large scale change programme

After this presentation you will be able to:

1. Develop an understanding of how to choose change ideas (and how to develop them); the need for a strategy to balance an explicit focus on vital system enablers against a clear clinical focus and how we balance the political and clinical drivers when developing and running large scale quality improvement programmes
2. Develop and understanding of how we can design a robust scale up process and how we build into this consideration of infrastructure, population size, funding, measurement and execution theory.
3. Develop an understanding of the need to ensure alignment and synergy between improvement initiatives to prevent duplication of effort and potential confusion with clinical teams when developing and running large scale quality improvement programmes

This Excursion will give participants an opportunity to learn how Gaylord Palms, a large hotel and convention center, improved its operating margin, increased customer satisfaction, enhanced workforce morale, and reduced employee attrition by focusing on employee satisfaction and joy in work.

After this presentation you will be able to:

1. 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 environments
2. Recognize and analyze key concepts of employee motivation and staff engagement in different industries
3. Develop ideas for increasing staff satisfaction in your own work environment

Teaching interprofessional health care team members empathic and reflective communication skills has informed a highly interactive board game to practice and reinforce communication skills that result in improved communication, better relationships, and a better workplace. The game uses theory and knowledge about empathic and non-judgmental communication using PEARLS© and the Ladder of inference. Players throw the dice and can land on “Pearls” and Ladder boxes that require the player to take a card from the Pearl or Ladder card deck to then respond to personal and professional scenarios using PEARLS© or the Ladder of inference. A communication coach provides support and encouragement during the game. All players are winners as a result of the cooperative play and learning.

After this presentation you will be able to:

1. Describe and provide examples of PEARLS© and Ladder of inference to demonstrate understanding of empathic communication and "jumping to conclusions" in stressful situations.
2. Develop and increase confidence in the use of new communication skills as a result of practice to enhance communication and relationships in the workplace.
3. Engage in cooperative, supportive discussion within a safe environment by all players as each player attempts to respond to communication scenarios using new communication skills.

Is your Board Quality Oversight dated and tired? Are you looking for strategies to renew your board’s commitment to quality and improve your organization’s performance? Is it time to refresh your board quality work to be current with best practice? This Breakthrough Boardroom session is designed for Trustees and senior leaders to evaluate and advance their board oversight of quality to be up to date with current leading practices. This session will refresh participants’ understanding of the components of Board oversight of quality using the Framework for Board Oversight of Quality. This Framework, which was introduced by IHI last year, was developed by a panel of governance, leadership, and quality experts. Participants will evaluate their current board quality practices using the Framework and Governance of Quality Assessment tool to identify areas of opportunity for improving board governance of quality. The session will be led by governance and quality experts. This session will be led by experts in governance and quality and will offer tactical and practical ideas for your board, with specific examples of leading systems and case studies of current board quality work. Participants will leave with a game plan for improvement in their board’s oversight of and commitment to quality.

After this presentation you will be able to:

1. Summarize the IHI Framework for Board Governance of Quality
2. Assess board governance of quality using the Governance of Quality Assessment
3. Identify opportunities for your board to improve oversight of quality

This Excursion will give participants discuss connections between the game of golf and health care. PGA and LPGA professionals, instructors, and fitness experts will lead discussions and exercises focusing on behavioral health, improvement science, joy in work, and leadership. Participants will also have an opportunity to implement tests of change with their own golf game.

After this presentation you will be able to:

1. Identify strategies and techniques to reduce stress in the workplace.
2. Discuss leadership behaviors that can deepen staff engagement and improve outcomes.
3. Describe training techniques for a thriving learning environment that will maximize productivity and reduce burnout.

Two health systems developed data-driven processes to improve value. At Providence St. Joseph Health (PSJH), system-wide infrastructure supported leaders making changes. In ambulatory care, Northwell Health proactively identifies vulnerable populations and links them with care. At PSJH, we reduced cost per case with constant or improved outcomes. Clinicians felt more accountable for outcomes and costs. At Northwell, we’ve empowered users to take ownership, improved star rating performance, increased incentive bonus capture, and reduced patient out-migration.

After this presentation you will be able to:

1. Describe the role of senior clinical and operational leaders in framing the shift to value based care and resourcing transformation initiatives.
2. Describe barriers and enablers for clinical engagement as experienced by two large community health systems with diverse physician practice structures.
3. Illustrate the importance and relevance of data analytics in supporting and monitoring ongoing improvement work.
4. Practice viewing real-life data and developing action plans to achieve clinical practice change

This Excursion will go "backstage" at the Central Florida Zoo, a community-based organization engaged in the care of very special "patients." Participants will learn key concepts from this non-health care setting that can be applied to staff and patients in their own work environments: preventative care techniques, community and staff engagement, efficient safety processes, and ways to stay competitive as a community facility with many large competitors nearby.

After this presentation you will be able to:

1. Recognize and analyze key concepts of staff engagement and patient care in various settings.
2. Develop ideas for improving organization-wide operations and patient care processes in any work environment.
3. Identify ways of managing complex facility operations and customer (or patient and family) care in a non-health care industry that can be compared with, and applied to, any work environment.

Many current responses to the opioid crisis focus on the immediate overdose and short-term survival, rather than addressing the need for long-term prevention and treatment strategies across a community. Experiences from around the country suggest that successfully addressing the opioid crisis requires multiple stakeholders across a community to work together, building new partnerships and developing creative strategies to prevent and treat opioid use disorder. This interactive session will highlight the innovative work of four approaches in Wisconsin, Ohio, New York, and Indiana. Each team will demonstrate the importance engaging disparate partners in a multi-pronged, community-wide approach that includes work on community engagement and education, education and training for clinicians, peer recovery coaches, enhancing access to Medication Assisted Treatment, and more. In the first part of the session, participants will hear a range of perspectives on successes, failures, and lessons learned. Patients stories will be shared from a diverse group including individuals in recovery, clinicians, a social worker and a fire chief. The second part of the session will break into small groups to share learning and challenges among participants and discuss specific, actionable strategies and tools.

After this presentation you will be able to:

1. Explain the importance of a community-wide approach to addressing the opioid crisis
2. Describe different strategies and tools being used in communities around the country
3. Communicate the ability to adapt approaches with peers, clinicians, researchers and health system leaders

The Framework for Safe, Reliable and Effective Care describes the interdependencies of culture, systems, leadership, patient partnership and staff engagement and is being used globally by individuals, teams, organizations and systems in service of improved outcomes for patients. While many organizations are working on all these areas in some way, work tends to exist in silos. In this session we’ll describe the Framework and the associated tools including a diagnostic tool that participants can apply to their own work settings. We’ll also hear case study examples from organizations using this Framework in practice. Participants will get the opportunity to reflect and apply the tools and the Framework to their personal and organizational journey including identifying aspects of whole system safety that they might like to focus on when they return to work.

After this presentation you will be able to:

1. Explore approaches to improve patient safety & quality based on the Framework for Safe, Reliable and Effective Care
2. Understand the relationship between culture and learning system based on lessons learned from a case study
3. Develop a plan to apply the elements of the framework on a project that you are leading in your area of responsibility

This highly interactive session is designed to further develop your improvement coaching skills by putting them to work in a safe learning environment. Role plays, scenarios, and exercises will help you gain insights and learn techniques to help your improvement teams build confidence, enhance capability, and drive success.

After this presentation you will be able to:

1. Practice skills in the art of coaching improvement leaders and teams.
2. Explain how to help teams own their work and develop their own insights and solutions.
3. Create a coaching engagement game plan using the insights you’ve gained throughout the day.

Many people encounter roadblocks along the quality measurement journey. Major milestones include selecting measures, developing operational definitions, building data collection plans, and understanding variation. This session provides guidance on navigating those roadblocks and building a measurement system that works, with an emphasis on understanding variation conceptually and statistically with run and control charts. Through case studies and exercises, we will explore the application of measurement principles to health care and ultimately link measurement to improvement.

After this presentation you will be able to:

1. Explain why you measure.
2. Identify useful measures (e.g., operational definitions, sampling, and stratification).
3. Identify key steps for making and interpreting run and control charts.

Health Systems are working towards improving health outcomes by embracing healthcare equity. This workshop will move from the history of racism in the U.S. and racialized medicine to building and operationalizing two frameworks for working towards healthcare justice. Through incorporating didactic, experiential and interactive methods, and integrating the concepts of building will, ideas and execution, this session will explore how health systems are perpetuating disparities and ways to move forward. Two organizations that are integrating healthcare equity into complex healthcare systems will be featured. Work that further develops the “Eliminate Racism and Other Forms of Oppression” component of the IHI paper, Achieving Health Equity: A Guide for Healthcare Organizations will be presented. You will leave understanding the basis for healthcare equity, how to communicate the need for this work to your organizations, and more confident in your ability to develop strategies for implementation. This session features work by UW Medicine, the Cambridge Health Alliance, and the Institute for Healthcare Improvement.

After this presentation you will be able to:

1. Understand the racialized history of medicine. Appreciate “how we got here” and use that knowledge to foster drive and passion for anti-racism and anti-oppression work.
2. Identify key components of frameworks/blueprints for advancing equity and healthcare justice in your organization.
3. Explore – through examples provided in this workshop – implementation of frameworks in healthcare systems using blueprints specific to their organizations. Experience specific tools like bystander interventions; implicit bias training; Quality, Equity and Safety Rounds; learning groups.

Harm, as a result of both individual and systemic errors, is commonplace in today’s delivery of oral health care. Although these harms are usually less severe than in medicine, there is still considerable potential for reduced quality of life for patients. This session for anyone with an interest in improving the quality and safety of oral health care delivery will present approaches for dental adverse event (DAE) reporting and dental quality metrics (DQM) development. The morning session will incorporate a series of short talks discussing cutting-edge dental patient safety efforts ranging from sedation safety to safety culture. With quality improvement (QI) as the focus for the afternoon, we will introduce the Dental Quality Learning Consortium and explore DQMs developed for sealants, caries risk assessments, caries treatment, and periodontal disease. Additional short talks will canvas the use of technology to drive QI, the intersection between cost and QI, and how a large practice successfully strives for high quality.

After this presentation you will be able to:

1. Discuss cutting-edge research and strategies for improving quality and patient safety in the dental care setting.
2. Explain the concept of pain as a neglected dental adverse event.
3. Describe existing dental quality measures and their real-world implementation within the dental care setting.

Learn to lead innovation workshops to support a culture of creative inquiry using materials that fit into one small box. Pairing Silicon Valley design thinking with rapid cycle innovation, use improvisational games and patient-centric empathy-gathering excursions to develop innovative solutions to health care problems. Attendees will leave with lesson plans and exercises to facilitate their own low-cost workshops. This session will be taught by a former improvisational theater instructor who helps frontline staff solve everyday problems.

After this presentation you will be able to:

1. Describe components of rapid cycle innovation workshops to tackle ‘wicked’ health care delivery problems with empathy.
2. Identify the essential materials to create a low-cost innovation lab-in-a box.
3. Explain how to practice improvisational design-thinking exercises at your organization for rapid cycle innovation workshops.

The rate at which improvement spreads relies at least in part on the people who are implementing the change in practice. IHI's Psychology of Change Framework helps leaders at all levels focus on the people advancing improvement efforts: the way that we think and feel, what motivates us, and how we behave when we encounter change. This session engages participants in developing pragmatic ideas to apply to their improvement context in response to people’s resistance and other adaptive challenges. It features U.S. and global examples of Psychology of Change methods, including their use in implementing the checklist for surgical patient care at McLeod Regional Health Center in Florence, South Carolina, resulting in its adoption in 100 percent of surgical cases, a decrease in surgical mortality by 33 percent, an annual economic return of more than US$4 million in surgical team productivity, improved safety culture measures, increased job satisfaction, decreased burnout, and a surgical perioperative care model focused on the medical and social needs of patients and their families. Participants will practice Psychology of Change methods together and apply to their improvement work. Everyone is encouraged to come with a willingness to play, build new relationships, reflect on the experience of change, share ideas and resources, and have fun!

After this presentation you will be able to:

1. Attendees will explore IHI’s Psychology of Change Framework and examples of its highest-leverage tools and methods
2. Attendees will practice using the tools and methods with one another
3. Attendees will apply tools and methods to their current work during or after the session

All health care disciplines are struggling with burnout, substance abuse, depression, dropping out, and suicide. Addressing the harmful effects of second victimization through peer support and expedited linkage to mental health resources can change the culture of medicine and promote longer and healthier careers. This session’s presenters were successful in launching the Helping Healers Heal (H3) second victim program in the two largest safety net systems in the United States. Participants of this interactive session will walk away with the background, expertise, and skillset to provide second victim peer support to their colleagues. They will also understand the structure of a second victim peer support program and be able to build similar programs at their home institutions.

After this presentation you will be able to:

1. Describe how to develop peer support champions who can provide emotional and psychological support to second victims in their home institutions.
2. Prepare to develop second victim champions who have the knowledge and expertise to start second victim programs at their home institutions.
3. Develop empathy and emotional intelligence.

Burnout negatively impacts both providers and patients. Joy in work is the most impactful leading indicator (within our control) of patient experience, outcomes, and costs. Joy in work, the opposite of burnout, is camaraderie, passion, fulfillment, psychological safety, and engagement, interwoven with loyalty to each other and the mission. It connects people to purpose and creates a high-functioning organization. We will present evidence for effectiveness with examples from clinical settings in North America and Europe.

After this presentation you will be able to:

1. Identify the patient, staff, and organizational benefits of joy in work.
2. Explain how to implement six key system changes that increase positivity or reduce negativity to cultivate joy in work.
3. Demonstrate application of quality improvement methods to enhance joy in work.

While today’s “Organizations as Usual” suffer from blind spots, commonly accepted levels of delays and mistakes, firmly entrenched silos, and losses from internal competition, they possess the ability to manage many resources as a single system, guided by leaders inspired by Dr. Deming. Whether you are a long-time Deming enthusiast or new to the community, this session is designed to reveal opportunities for improvement to health care organizations yearning to join others in becoming “unusual.”

After this presentation you will be able to:

1. Identify opportunities for moving from the "Old Economics" of managing actions (parts, tasks, and milestones) to the "New Economics" of managing interactions.
2. Compare the two modes of thinking which operate in our blind spots.
3. Describe the competitive advantage of understanding the differences between Compliance Excellence and Contextual Excellence.

Sustaining organizational performance and quality improvement depends on leaders measuring, coaching, and developing team capability. From the board to the front line, each function has responsibilities, interconnected activities, and skills that must become habit, i.e., “Teamwork at a Grand Scale.” In this interactive course, we explore new thinking supported by case studies. Participants will take away strategies to implement a management system and develop leadership competencies to deliver results, sustain improvement, and create a learning organization.

After this presentation you will be able to:

1. Identify the skills needed by each level to sustain the work, improve the work, develop people, and shape culture.
2. Identify insights from real-world case studies and shared organizational efforts.
3. Describe frameworks and models that can be used to build organizational structure and development plans to achieve sustainable improvement and performance.

Virginia Mason Health System achieves outstanding results by applying the Virginia Mason Production System as its management system. Lean methods and tools are applied comprehensively, beyond discrete improvement projects. This hardwires improvement into all aspects of organizational life through training all team members, ensuring one common improvement approach and language while fostering alignment from the board room to the frontlines of care. This is a radical departure from the common use of lean or other improvement methods to redesign processes on a project basis. The management system applies the same approaches to the way this organization is led and managed. This session describes what a comprehensive management system looks like in practice, how it operates and, most important, why these methods engage both hearts and minds, essential for engagement, implementation and sustained results. It shines a light on the change management principles underpinning lean execution to explain how what looks like a mechanistic approach is built on respect for people principles and deeply humanistic. This session is designed for senior leaders; Quality Improvement professionals; operations and clinical leaders. Examples from Virginia Mason’s experience will illustrate how to apply improvement methods to create a comprehensive management system. Participants will gain an understanding of why creating a lean management system can generate engagement and empowerment of leaders and frontline team members along with an appreciation for how to move beyond point improvements to a more comprehensive, over-arching approach to leading and managing a complex organization.

After this presentation you will be able to:

1. Describe the key components of a comprehensive management system.
2. Articulate the human change management principles that underpin the technical tools of lean and how together the tools and skilled adaptive leadership can embed improvement as a way of life
3. Determine how quality improvement approaches your organization uses can be expanded and applied to how the organization is led and managed

This highly interactive session will discuss what it takes to establish a culture of continuous improvement in a large, complex organization. We will learn together how to create a coherent management system that focuses on quality and about the types of behaviors that encourage a culture where people feel empowered to improve the system in which they work. We will encourage people to reflect on their current habits and behaviors and identify strengths to build on, as well as places to test out new behaviors. The session will build on the learning at East London NHS Foundation Trust, which has attempted to embed a culture of continuous improvement for the past six years. It will include tips and ideas around how to engage the Board, how to engage staff, how to involve patients more deeply, as well as how to design an infrastructure for improvement and develop improvement skills at scale.

After this presentation you will be able to:

1. Identify the high-leverage leadership behaviors that can support a transition to a continuous improvement culture.
2. Create a personal plan related to leadership behaviors that support a culture of continuous improvement.
3. Create a step-by-step plan to create an improvement system within your organization.

This session will teach participants the tools of value management, as developed by the Institute for Healthcare Improvement in partnership with NHS Scotland. These tools allow point-of-care leaders (especially charge nurses, nurse managers) to lead teams in improving quality while reducing costs continuously. Application of these tools has revealed their potential to reduce cost per patient by 12-15%. In addition to introduction to the methodology, participants will hear case studies in three national contexts: the Scottish NHS, Hamad Medical Corporation in Qatar, and Northwell Health based in New York City.

After this presentation you will be able to:

1. Learn practical tools to improve value at the point-of-care, with a focus on linking measurement to continuous improvement.
2. Understand strategies to engage front-line staff, physicians, and senior leaders.
3. Learn how to introduce these tools incrementally and how to structure spread of the methodology across teams.

Addressing vexing issues of patient flow in hospitals is essential to ensure safe, high quality, patient-centered care. Failure to provide the “right care, in the right place, at the right time” puts patients at risk for sub-optimal care. Poorly managed hospital flow also adds to the already taxing burden on clinicians and staff and diverts their attention from clinical care. Improving hospital-wide patient flow is critical for increasing value -- for patients, clinicians and health care systems. This full-day workshop will feature IHI’s framework for achieving hospital-wide patient flow. This framework guides hospital and health system leaders and quality improvement teams through an in-depth examination of: 1) a system view of patient flow, 2) theories for improvement, 3) simple rules to guide learning and improvement; and 4) high-leverage strategies and interventions to improve hospital-wide patient flow. Three case studies will describe implementation of initiatives that have led to measurable and sustainable solutions for achieving hospital-wide patient flow.

After this presentation you will be able to:

1. 1. Describe the IHI framework for system optimization to improve hospital-wide patient flow
2. 2. Utilize an approach for “sense-making” regarding the multiple strategies for improving hospital operations and patient flow throughout the hospital
3. 3. Analyze organizational capability, change concepts and successful interventions for creating a sustainable system for system-wide hospital flow, so that patients receive the right care, in the right place, at the right time

As Improvement Science is being applied through a Collaborative model to achieve population-level outcomes, now in multiple sectors and across sectors, there are common adaptive challenges emerging across the work. Without existing roadmaps for navigating these challenges, there is a growing need and opportunity for leaders working in this space to learn from each other and collaborate to discover improved ways of supporting this work. To address these population-level outcomes there is increasing pressure to develop frameworks which can be adapted for use to address a wide range of complex problems. This dynamic session will use case studies from the fields of health care, homelessness, education and work across the non-profit sector to teach methods, tools and frameworks ranging from high-level theory of change frameworks to tools developed to cut through complexity and address adaptive challenges. Session participants should plan to walk away with tools and frameworks that they can readily apply to their work, new connections to peers doing similar types of scaled improvement work, as well as ideas co-produced with other participants on how to address common and emerging challenges.

After this presentation you will be able to:

1. Understand and apply tools and frameworks presented to achieve breakthrough results in participants’ unique context
2. Identify emerging challenges in multi-stakeholder improvement initiatives and leverage peer to peer engagement to generate change ideas to address these challenges

In this interactive workshop, healthcare systems transforming population health, participants will assess where they are on the journey and gain knowledge, tools, and insights to support their efforts and accelerate their progress. We will explore key levers from working within patient populations to implementing a total health anchor institution strategy, with a focus on building equity and measuring well-being across these key levers. Existing frameworks, well-being measurement strategies, bright spots from the field, and sharing between participants will foster practical ideas for getting started.

After this presentation you will be able to:

1. Assess where you are on the journey to population health and identify key levers and opportunities to improve health, well-being, and equity of your patients and communities
2. Identify how to measure well-being and make the case for measuring well-being in health systems and communities
3. Gather ideas and draw on the expertise of other participants and case examples to define short, medium, and long-term actions to take to your organization

This session will explore Root Cause Analyses and Actions (RCA2) through the lens of an organization that has implemented the process within their own system. Expanding on RCA, RCA2 is used to drive improvement when reviewing events that cause or may cause serious harm, and in developing and implementing sustainable and measurable actions that prevent future harm to both patients and staff. This session is intended for anyone who may lead or participate in event analysis and will focus on application of the recommendations and tools presented in RCA2 framework. Participants will walk away with a clear understanding of the Root Cause Analyses and Actions process and practical tools to improve their organizations RCAs.

After this presentation you will be able to:

1. Identify the current state of root cause analysis (RCA), and why improvements are essential
2. Describe the methodology and processes associated with RCA2
3. List approaches for implementing a successful RCA2 process

Transforming a complex organization’s culture requires a strategic approach. This session will detail our safety journey as Children’s National embarked on a cultural transformation to eliminate preventable harm. The journey began in 2007 and focused on developing ownership for safety among direct care staff, local management, and executive leadership.Between 2014 and 2017, the number of safety event report totals doubled to more than 10,000 submitted annually. Safety culture measurement tools demonstrated positive perceptions of safety improved by 10 percent. Most significantly, the hospital’s serious safety event rate decreased by 93 percent. This reduction constitutes the lowest rate in the hospital’s history and improvement beyond many industry benchmarks.

After this presentation you will be able to:

1. Identify interventions to develop a strong culture of safety across all levels of an organization.
2. Describe the role of direct care staff, local management, and executive leadership in cultural transformation.

Advance care planning (ACP) plays important roles in clinic, inpatient, and community settings. Roles include improved length of stay, reduced mortality index, improved patient satisfaction, and increased completion of advance directives (AD). To improve these outcome and related process measures, stigmas associated with ACP need to be reduced. This session will review programs to address stigmas that have resulted in more than 2000 patient conversations related to ACP and statistically significant improvements related to AD documentation, interdisciplinary team meetings, palliative care referrals, end-of-life views, and likelihood for completing an AD.

After this presentation you will be able to:

1. Identify the settings in which Advance Care Planning requires reduction in stigmas and improvement.
2. Describe interventions to improve process measures related to advance care planning, such as advance directive documentation, interdisciplinary team meetings, palliative care referrals, and views on end-of-life issues.
3. Describe interventions to improve mortality index and reduce advance care planning stigmas.

The idea behind Words Matter™ is that the success of a concept can turn on a word. Words Matter™ is a well-tested process that was developed to create, test, and zero in on the right words to influence behavior. It’s been used with great success by leading companies such as Procter & Gamble to change minds and habits — but, until now, it has seldom been applied in health care. It’s time to change that. During this interactive workshop, participants will explore examples and case studies from within and outside of health care to learn about the impact of language and choose words that matter by measuring them against three key criteria.

After this presentation you will be able to:

1. Explain how to convince others in your organization why ‘words matter’ and how ‘getting the words right’ matters.
2. Identify areas in your organization where making changes in language can have an impact on the quality of care and patient outcomes.
3. Explain the process necessary to develop the language most likely to have significant impact on changing behavior.

Many health care team members suffer negative emotional consequences after experiences such as adverse events, colleagues’ illnesses, or patient aggression. Our peer support program promotes workforce wellness by supporting clinicians during times of heightened pressure and vulnerability. The program was one of the first to rely on trained clinician colleagues rather than mental health professionals. Participants will practice reaching out to a colleague, validating concerns, and reflecting on emotions together using principles of a just culture.

After this presentation you will be able to:

1. Identify the effects of adverse events on clinicians.
2. Describe approaches to providing effective peer support to colleagues.
3. Identify steps in building an institutional peer support program.

Shared Decision Making is a two-way relational process of helping people to reflect on and express their preferences based on their unique circumstances, expectations, beliefs, and values. Achieving effective Shared Decision Making in everyday clinical practice can be extremely challenging ? but it is an essential component of person-centered care. This highly interactive and practical session aims to bring the theory of Shared Decision Making to life by exploring the context, tools, and challenges involved in its everyday implementation. Participants will learn and use practical tools, rooted in real world clinical encounters, to build measurable confidence and skill.

After this presentation you will be able to:

1. Develop confidence in moving from awareness to daily use of Shared Decision Making in personal practice.
2. Describe different practical tools available to assist in achieving effective Shared Decision Making.
3. Explain how to overcome the challenges and barriers to implementing Shared Decision Making.

Understanding what matters to older adults is key to best aligning the health care they receive in wellness, sickness, and end of life. Work with a focus on “What Matters” has evolved at IHI over the past several years in two different streams: the Age-Friendly initiative and Conversation Ready work. Age-Friendly work focuses on improving care for older adults through the 4Ms Framework: What Matters, Medication, Mentation, and Mobility. Conversation Ready work focuses on making sure patients’ end-of-life care wishes are received, recorded, and respected, including by understanding who they want to serve as their proxies. These two streams of work have been tested in many health care systems, and there are toolkits to share for translating the learning into action. Baystate Health system provides an example of an interdisciplinary team that has used the toolkits to improve care for older adults with great success.

After this presentation you will be able to:

1. Explain why understanding "What Matters" is a key to providing the best health care to older adults.
2. Describe key resources available for improving care and outcomes for older adults across the health care spectrum.
3. Delineate critical aspects of the Age-Friendly and Conversation Ready initiatives.
4. Identify a starting point and develop an action plan to improve care for older adults in your health care setting.

Swedish Medical Group is a not-for-profit healthcare system in the greater Seattle area. Primary Care Behavioral Health (BH) has been increasingly integrated into our primary care clinics starting in Q4 of 2014. At present, a BH provider is integrated into 15 of the 28 primary care and pediatric clinics. BH providers are considered members of the primary care team, and see patients for brief interventions related to health behaviors throughout episodes of care. However, no program evaluation looking at the impact of this integration has been explored to date. The current study was designed to better understand the population accessing BH in the Swedish health system, as well as impact on utilization patterns. As systems try to move from fee for service towards more value based care, clarity around the overall financial impact of integration is necessary. Study questions include a description of the health care utilization patterns of patients who have had interactions with BH in their primary clinic. A program evaluation question of whether engagement with a BH provider in primary care reduces avoidable ED visits will be explored. We will also explore whether there is a difference in shifting utilization based on the frequency of visits with BH. This presentation will include methodology, lessons learned, and goal of improved understanding of healthcare utilization (i.e. avoidable ED visits/ hospitalizations) for support of further integration efforts.

After this presentation you will be able to:

1. Describe the impact of integrating BH providers into primary care on healthcare utilization
2. Identify ways that BH has been integrated and supports appropriate healthcare utilization

Facing the challenge of working across health and care to prevent poor health outcomes? Do you recognise that this needs to start in early childhood, through support for families and communities? This session is the opportunity to learn from 3 strategic partners of IHI; Cincinnati Children’s Hospital, Region Jönköping County, and the Scottish Government, who have matured their quality improvement work from acute healthcare delivery to a focused approach on integrating health and care efforts with the aim of impacting on health outcomes for the population. The partners will share their priorities and approaches, challenging the current norms of healthcare delivery and exploring frameworks and methods to support practice. They will discuss ways to transform how health, social care, education and non-profit services partner with families to address health equity and population health needs, ensuring 'just-in-time' support. Participants will hear case studies from each of the 3 systems exploring the methods applied. They will have opportunity to explore new and developing approaches in the innovation space, as we expose what makes the biggest difference to upstream preventative work in health. Join this learning lab to explore the work of the partners and contribute to a great conversation about emerging work, predicted to impact on outcomes of the population for generations to come.

After this presentation you will be able to:

1. Understand how systems are exploring new ways of working to support upstream preventative care and tackle health inequities
2. Explore frameworks designed to address population health outcomes, old and new
3. Develop knowledge of approaches which will support progress towards improving health outcomes in your own system

Five years ago, Hartford HealthCare aimed to advance safety across its system by adopting a model of high reliability to decrease the incidence of patient harm. With leaders on board, the organization has woven high reliability into its operational model and data structures, including tracking harm and serious safety events through dashboards and more than 40 clinical counsels. As a result, Hartford HealthCare has sustained a 70 percent reduction in Serious Safety Events for nearly two years. Presenters will share the best practices to begin and sustain a high-reliability journey, including barriers and how to overcome them. They will discuss how to spread the principles of a high-reliability organization across the continuum of care.

After this presentation you will be able to:

1. Identify and learn to implement the principles of a high-reliability organization.
2. Specify strategies for engaging leadership in performance improvement initiatives related to safety and quality improvement.
3. Explain how to spread successful harm reduction initiatives across an integrated health system.

Each day, hundreds of healthcare workers are injured on the job. In 2017, over 224,000 US hospital employees suffered work-related injuries and illnesses – over twice the rate for private industry as a whole. Employee injuries impact the health and well-being of our staff, come at a high cost to hospitals and health systems, and affect patient safety. We can and must do better. Armed with data, stories, and a commitment to improve, 19 health care organizations joined together over the last year to meaningfully and measurably address workforce safety within their organizations. By sharing data, promising practices, and challenges, the group has helped advance their individual and collective workforce safety related efforts by making workforce injury reduction a strategic goal and ensuring senior leadership reviews workforce safety data as close to real time as possible and developing robust injury review and reporting process and chartering multi-professional teams to improve workforce safety. This session is ideal for executive leaders. Quality and safety experts, clinical providers and occupational safety experts. The session will be a combination of sharing best practices from leading organizations, describing multi-organization learning networks and engaging audience in sharing best practices. The session is intended to give participants specific actionable steps to help their organization accelerate improvements in workforce safety. Specific measurable outcomes including nationally standard metrics established by the Occupational Safety and Health Administration (OSHA).

After this presentation you will be able to:

1. Attendees will learn key components of an effective workforce safety program for a healthcare organization
2. Attendees will understand the critical role workforce safety plays for accomplishing all strategic goals including patient safety
3. Attendees will be exposed to specific improvements for adoption including data, event review and executive engagement

Diagnostic errors take a toll on patients, families, and providers. We developed an educational video to help providers understand how diagnostic errors occur and avoid errors through improved decision-making, collaboration with patients and teammates, and systems that support timely, accurate, and effectively communicated diagnoses. Knowledge checks monitor performance and viewers’ feedback is gathered for continuous improvement. Other complementary initiatives include guides to enhance patient-clinician partnering, online practice of diagnostic skills, and clinical reasoning support systems.

After this presentation you will be able to:

1. Describe a method to create and build awareness of diagnostic errors.
2. List strategies to gain leadership and institutional support to address diagnostic errors.
3. Explain how a culture of learning, systems support, and psychological safety builds diagnostic excellence.

Understanding and using a few key quality improvement tools will increase the effectiveness of your improvement efforts. Join three pioneers in quality improvement in health care to build your skills in seven basic tools of quality – flowcharts, run charts, driver diagrams, Pareto charts, histograms, cause-and-effect diagrams, and scatter diagrams – tools that you can apply as soon as you return home.

After this presentation you will be able to:

1. Summarize seven basic quality improvement tools.
2. Identify opportunities to apply these tools in your work.

Whether you are looking to implement a new or already existing improvement, this session will advance your capability to take improvements to full scale across your organization or system. Learn how to use a sequence of activities, including strategies to enhance adoption of the improvements and the infrastructure needed to support them, as a guide to achieving your scale-up goals.

After this presentation you will be able to:

1. Identify the key steps in designing successful scale-up efforts.
2. Apply methods for building will, developing ideas, and supporting system-wide implementation.
3. Assess readiness for starting and/or enhancing scale-up activities.

“All improvement requires change, but not all change is improvement.” What is a change? What are the fundamental principles of improvement? How can we use these principles to have a lasting impact on the health of those we care for? In this two-part workshop, learn from two pioneers in the quality improvement movement about the history and practice of the science of improvement in health and health care and how to use the Model for Improvement to improve the care you provide every day. You'll leave inspired and filled with practical knowledge that you can use immediately in all of your improvement work.

After this presentation you will be able to:

1. Identify the fundamental principles of improvement.
2. Identify opportunities to apply the principles of improvement in your work using the Model for Improvement.

To help older adults avoid the hazards of hospitalization, Hospital at Home (HaH) was developed. In HaH, acute hospital-level care is provided at home by an interdisciplinary team including MDs, NPs, RNs and SWs. We estimate a potential 611,000 Medicare patients can be enrolled yearly in HaH nationally. A recent Center for Medicare & Medicaid Innovation Demonstration showed that patients cared for in HaH experience 50% fewer readmissions and ED visits and provide higher HCAHPS ratings. Description and Audience: Interest in HaH has exploded recently due to increasing penetration of Medicare managed care, the development and spread of accountable care organizations (ACOs) and a shift in focus among some health systems towards value-based care, population health and community-based care. This session is designed for those health systems who have an interest in learning more about HaH or who are contemplating starting a program. HaH could be an important option for those interested in being an Age Friendly Health System. Through a combination of didactic learning and interactive discussion, participants will increase their knowledge of this care model as well as exploring their organization’s readiness to adopt this model. Examples / Applications: Mount Sinai’s Health System 5-year experience with HaH will be described in depth to bring the HaH model to life. Value to session participants: In addition to the description of HaH and the Mount Sinai experience, session participants will be given the opportunity to explore issues related to HaH implementation in their own health systems.

After this presentation you will be able to:

1. Describe the rationale and advantages of the Hospital at Home model of care.
2. Identify the key core components of the Hospital at Home model of care.
3. Determine the organization readiness to consider adoption of HaH

Up to 25% of older adults who are hospitalized have delirium and an additional 30% will develop delirium while they are in the hospital. The cost to the older adults and family caregivers is profound -- increased morbidity and persistent functional decline. The cost to health systems, communities and payers is also significant -- increased nursing time per patient, higher per day hospital costs, increased length of hospital stay, higher rates of nursing home placement and increased mortality Yet, it is estimated that 30 – 40% of delirium is preventable. An Age-Friendly Health System in one in which four evidence-based elements of care are practiced with older adults – the 4Ms of What Matters, Medication, Mentation and Mobility – that together can increase prevention, recognition and treatment of delirium. Putting the 4Ms into practice, and the case for doing so, has the potential to improve the cost, quality and experience of care. The University of California San Francisco (UCSF) put the 4Ms into practice to improve quality and experience. They calculated the return on investment for doing so and built a case for spread of the 4Ms across the health system. Come learn about the UCSF journey. And learn how to champion the reliable adoption of the 4Ms in your health system, access to a return on investment calculator to build the business case for improved care of older adults in your health system.

After this presentation you will be able to:

1. Learn how to champion the reliable adoption of the 4Ms in your health system
2. Understand common barriers to preventing and identifying delirium and approaches to overcome them
3. 3. Be able to initiate development of a business case for adoption of the 4Ms

Does your practice know how many trans clients it serves? What are your clients’ preferred pronouns, and where does that information live in the chart? How do you query care quality items that depend on knowing a client’s sexual orientation? As health care providers strive to become more culturally competent in serving the LGBTQ+ community, they may face challenges in assessing and closing gaps in care. Quality Improvement staff, Health IT professionals, and administrators will benefit from this discussion of strategies in identifying and monitoring quality measures and reaching out to LGBTQ+ clients in a culturally competent and safe way.

After this presentation you will be able to:

1. Describe strategies to improve health outcomes for members of the queer community by improving the QI community's ability to monitor care quality for LGBTQ+ clients.
2. Explain the need to implement LGBTQ+ culturally competent methods of data collection, monitoring of quality measures, and client outreach.
3. Discuss LGBTQ+ -specific considerations in health care quality improvement.

Disrespect and abuse of women during childbirth is a widespread problem that is particularly severe in marginalized populations. In this session for caregivers, administrators, and community advocates, a young mother will share her personal experience and her vision of quality care, and presenters will describe a curriculum in empathic communication that improved care in Ethiopia. We will provide a practical approach to improving care and reducing disparities through trainings in empathic communication.

After this presentation you will be able to:

1. Describe the scale of disparities in care provision and care outcomes for mothers and newborns across the globe.
2. List theoretical approaches to decreasing disparities in marginalized populations.
3. Identify practical approaches and available tools for increasing empathy as a strategy to decrease disparities in care and outcomes.

Attempts to address inequity in the health care system have been rapidly gaining momentum. But though much effort has been expended in the process, the philosophical origins of this work are infrequently considered. In this session, we will explore the roots of health equity; the historical precedent of paternalism that has shaped current relational inequity; and the postures and practices of patient and family engagement, effective communication, and shared decision-making that address the relational equity as experienced in a national oral health collaborative and through organizational adoption of the Bridges Out of Poverty© program.

After this presentation you will be able to:

1. Reimagine the assumption of equality as the vital root structure supporting the growth of equity.
2. Explore the rooted relational postures of effective communication and engagement as they relate to equity.
3. Experience the radical relational skills that help cultivate health equity, letting true equality bloom.

In 2001, the Institute of Medicine put forth six domains of health care quality. This includes “equitable” as the sixth pillar, defined as, “care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.” Yet, there persist systematic and widespread differences in health outcomes by race, gender, language, and other factors. This session will feature the experience of two Institute for Healthcare Improvement (IHI) Pursuing Equity collaborators who have used the IHI five-component equity framework to improve health equity in their organizations: 1) Make equity a strategic priority 2) Build infrastructure to support health equity 3) Address the multiple determinants of health 4) Eliminate racism and other forms for oppression 5) Partner with the community to improve health equity. HealthPartners will share key reflections on developing an actionable framework for health equity, including equipping teams with the knowledge and resources needed to provide appropriate care and service; engaging communities to learn how to best support them; and, improving care through data-driven quality improvement. Brigham Health will share a proposal to re-conceptualize health care events pertaining to unconscious bias, racism, sexism, or other forms of discrimination, as patient safety events, as they almost always have direct or indirect impacts on the quality and safety of care delivery. Case examples will highlight a new process - built around high reliability or “Just Culture” principles – that systematically integrates health equity into root cause analyses in patient safety/experience and quality.

After this presentation you will be able to:

1. Identify strategies for developing and operationalizing the five-component equity framework
2. Describe new strategies for integrating health equity into high reliability culture and principles

Researchers estimate that 2.5 million patients annually are impacted by pressure injuries, the majority of which may be preventable. For health care leaders, having confirmed, accurate, actionable pressure injury incidence data is critical for mitigating risk and decreasing the probability for developing and evolving pressure injury in the hospitalized patient. In this session, attendees will explore tactics for developing an improvement science implementation, including workflow redesign and two informatics solutions, to improve pressure injury analytics.

After this presentation you will be able to:

1. Describe acute care setting workflow changes that may result in confirmed and actionable hospital-acquired pressure injury data.
2. Identify technology solutions that may result in actionable (real-time) hospital-acquired pressure injury analytics.

The very different contexts in which health care teams work and their varying abilities to implement change can pose real challenges for spreading improvement interventions and replicating their outcomes effectively at scale. Drawing on the analytical framework set out in the recent Health Foundation report "The Spread Challenge," this session will explore approaches for spreading improvement interventions and supporting their successful adoption. We will look at various strategies for codifying interventions, such as theory-of-change models and capability-based models, that can help adopters translate the interventions into their own context. These issues will then be illustrated through an in-depth case study of a sophisticated approach to spreading improvement capability: The Flow Coaching Academy, a program that supports teams across the United Kingdom to improve patient flow.

After this presentation you will be able to:

1. Identify different strategies for describing improvement interventions in order to spread them effectively.
2. Develop an understanding of the implementation challenges that teams often face when adopting new ideas and how they can be supported to overcome them.
3. Learn important considerations for the design and leadership of programs to spread improvement interventions.

Patients expect health care teams to learn what works quickly and implement effective practices reliably. Additionally, administrators expect interprofessional, frontline teams to drive continuous improvement. A learning healthcare system, as envisioned by the Institute of Medicine, integrates innovation into the care experience. Numerous, laudable examples are emerging that vary in real-world application of these concepts. In this session, health care leaders will illustrate how these systems combine quality improvement and implementation science to accelerate learning.

After this presentation you will be able to:

1. Compare and improvement, delivery system, implementation, and learning health system science.
2. Develop a checklist for application of core concepts and methods for improvement.
3. Identify key organizational and structural attributes of a functioning learning health system.

Quality improvement (QI) approaches celebrate and encourage failure for the rich learning opportunity it provides. However, in reality, people desire positive results and workplace culture often makes us fear failure. This session will present an honest account of setting up quality improvement (QI) programs in large mental health and acute settings in England and Wales. Throughout the session, we'll endeavour to share our own personal and joint successes and failures, the roller coaster journey they represent, and the resources you need to survive and grow when the possibility of failure is likely. We hope to embolden conversations that hold failure as a core component of continuous improvement.

After this presentation you will be able to:

1. Explain how to identify failure early on and what to do next.
2. Describe how to implement key tenets of improvement to progress your QI program regardless of current context.
3. Be prepared to work creatively with the messiness of change and manage the psychology of failure in QI.

By identifying and monitoring the key elements of quality standards in a patient’s care journey, patients can be well-prepared for the next phase of their recovery. This presentation will demonstrate how the implementation of clinical pathways supported efforts to integrate quality-related practices while improving efficiencies for inpatient units at a specialized mental health institution. A hospital-wide target was established to measure the percent of non-forensic and forensic patients whose discharge length-of-stay (LOS) met the overall clinical pathway target. Strong patient flow processes such as a cohesive bed-management system, discharge activities, and standardized assessment tools were implemented to provide individualized care planning focused on efficiency, improving quality, and identifying an expected LOS for most patients. In 2018/19, there was a 15 percent improvement in the LOS target. Additionally, the impact of this work has demonstrated a 12 percent improvement in the number of admissions for the facility from 2016/17 to 2018/19.

After this presentation you will be able to:

1. Explain how the engagement of point-of-care and physician leaders in the development of clinical pathways can improve the quality of care for patients and patient flow in a specialized mental health care setting.
2. Describe how reducing process variation improves patient outcomes by sequencing activities and ensuring the right disciplines are engaged at the right time.
3. Specify tools and practices that are important considerations for implementing clinical pathways in inpatient mental health settings.

The members of the Facility Management and Security Leadership Team of the Bellin Healthcare System knew they needed to reframe their understanding of “Why we do our work.” They felt their contributions to quality outcomes had to be top of mind. They began working with Rosie and David Bartel, who are patient safety advocates. The Bartels began meeting with Bellin staff and contractors to share more of their personal story. As the meetings continued, the reason for “Why we do our work?” became clearer. Staff soon realized that the patient story needed to frame all the work they were doing. This presentation will provide help reframing the question of “Why we do our work” for everyone in health care. Participants will learn how having an ongoing relationship with patients and their families will produce meaningful results. They will hear how a patient story can be used to motivate everyone in health care to perform at the highest level.

After this presentation you will be able to:

1. Identify patient stories that will produce a meaningful answer to the question “Why do we do our work?”
2. Describe how to develop meaningful relationships with patients and their families in all areas of “work” in health care systems.
3. Describe how to implement an ongoing relationship with patients and families that will motivate everyone in health care to perform at the highest level.

The current environment in healthcare leads to high turnover in clinicians and hospital staff and can significantly impact a patient’s experience and outcome. By shadowing patients and their care teams at every level, a true working experience can be identified; systematic change be hardwired into any organization. Using the knowledge gleaned from shadowing all experiential stakeholders, better care experiences can be co-designed, leading to improved staff satisfaction, higher levels of compassion, joy in experience and reduction in turnover. Learn to use shadowing to develop a culture of improvement and engage staff in the process of co-design. Use the goShadow app to actively shadow and create reports to determine your true current state and work towards the ideal. Discuss real world scenarios; learn how to inspire change and systematically improve both employee and patient experiences as well as co-create better outcomes from the ground up.

After this presentation you will be able to:

1. Describe how to eliminate stakeholder confusion and anxiety by breaking down barriers and giving a voice to the chronically underheard.
2. Identify ways to effectively determine the real current state of staff experience and share findings with staff in order to co-create an ideal state.
3. List approaches to inspire change and systematically improve both employee and patient experience.

The New York State Delivery System Reform provided a unique opportunity to support integrated care by building capacity for systems change through workforce development. We will share an overview of the Delivery System Reform and the results of a network-wide survey of providers and staff focused on teamwork, burnout, joy-in-work, and resiliency. Our analyses informed targeted organizational development programming, such as strategies that identify and develop staff willing to try new approaches into organizational change agents.

After this presentation you will be able to:

1. Describe how Delivery System Reform provided an opportunity to build integrated care and systems change through a data driven workforce development strategy.
2. Describe how survey data informed the development of strategies to decrease staff burnout, and improved teamwork, staff well-being, and joy in work across a diverse provider network including hospitals, primary care, Federally Qualified Health Centers, behavioral health care, substance use providers, skilled nursing facilities, and community-based organizations.
3. Identify ways to incorporate change principles and the IHI Framework for Improving Joy in Work to build staff agency.

Leaders at every level are confronted with specific issues, performance concerns, and pressure to fix them. You are expected to know how to act, but are you making the right decision? In this session, learn how improvement science can support leaders to discover if an issue is due to identifiable reasons or is the result of a process to improve, and what actions to take to support enhancing performance in each case.

After this presentation you will be able to:

1. Simulate the issues with static or color coded dashboards
2. Show the value of a vector of measures displayed for learning
3. Describe the risk of acting on data with our understanding what’s going on

Why do some improvement efforts end when a leader moves on? In this session we will explore how leaders fail to create systems that ensure the continuation of an improvement culture beyond their tenure. We will share evidenced-based approaches to building sustainable processes and avoiding common pitfalls. Focusing on a few important practices can lead to long term success for an organization, no matter who is doing the leading.

After this presentation you will be able to:

1. Explain why some continuous improvement cultures come to an end.
2. Describe how to build systems that reinforce and maintain the culture of continuous improvement.
3. Identify components of a plan for improvement that lasts beyond changes in leadership.

Developing a culture of quality, safety, equity, and joy in work requires sustaining psychological safety so that communication is open, honest, and collaborative. But psychological safety is quite vulnerable to the presence of power differentials — such as between leaders, both clinical and administrative, and the staff and providers who report to them. Neuroscience and psychological studies have shown that power differentials frequently evoke ways of communicating, even in skilled and well-meaning professionals, that can be inadvertently disruptive to shaping desired culture. Risks are especially high in environments of stress and complexity that are ubiquitous in health care. This workshop will be beneficial for participants whether or not they feel they have formal positional or professional authority. Participants will receive a set of articles and a tool with high-leverage principles as well as specific examples of actions that help to manage the risks of power. Four real-life work situations involving power differentials will be presented to demonstrate how to use the tool.

After this presentation you will be able to:

1. Identify why and how issues of power can so easily disrupt efforts to shape the culture toward one of quality, safety, equity, and joy in work.
2. Describe methods for managing the risks of power differentials that facilitate open, honest, and productive communication.
3. Explain how to implement decision-making approaches that maximize the chances for empowerment and alignment.

Invite only event

The Architecture of High Value Health Care national conference, co-directed by the High Value Practice Academic Alliance and the American Hospital Association, is a venue to share initiatives that improve quality, safety, experience and outcomes, while reducing total cost of care. This session will include innovative and practical projects from the 2019 conference to showcase exemplary value-improvement initiatives from different institutions. Anyone in health care interested in improving quality and affordability, including physicians, nurses, advanced practice providers, QI project managers, hospital leadership and trainees. The importance of prioritizing quality, safety, patient and patient outcomes will be emphasized. Participants will gain an understanding the pillars of value-improvement work, interventions used and the relative impact of these interventions on costs for patients, payers and medical centers.

After this presentation you will be able to:

1. 1. Understand the variety of value improvement work and areas for their own efforts to improve quality and safety while reducing total cost of care.
2. 2. Appreciate the different interventions and models that can improve the value of care providers deliver.
3. 3. Learn how to effectively design value improvement initiatives to prioritize quality, safety, patient experience and patient outcomes, and how to determine the impact of these initiatives on costs for patients, payers and medical centers

Healthcare systems are at a crossroads. In order to sustain a viable healthcare system, it is imperative to reduce costs and improve quality. In a recent Vizient study, 81% of health system participants identified clinical variation as a barrier, due to disparate data systems and incentives. Standardization, governance and culture were identified as opportunities across the entire continuum of care. Spectrum Health became a health system (comprised of 14 hospitals, a medical group and continuing care) more than 20 years ago, however the Quality, Safety and Experience departments remained separate. In 2018, Spectrum Health began systemness by aligning department structures and leadership in order to pivot to one standard of care. Alignment goals were developed to engage the system in improving these metrics. In addition, each service line set goals to improve specific measures to surpass the national median benchmark. These goals are monitored and cascaded through an operational deployment system that engages leaders in improvement and establishes accountability. A quality data model is in development to provide service lines and entities with leading and lagging metrics that are drillable to service line and provider levels. Operational and physician service line leaders are now taking accountability for clinical outcomes. A significant decrease in sepsis mortality has been achieved along with substantial progress in readmissions, likelihood to recommend and metrics performing at less than the national benchmark. The ultimate goal is to own the value equation for our consumers by lowering cost and improving quality and safety outcomes.

After this presentation you will be able to:

1. Engage health system leaders to move to value and implement one standard of care.
2. Develop the framework to enable the transition to value and one standard of care.
3. Implement measurement and communication tools that support improving value and one standard of care.

This session will provide you with strategies and initiatives to use in the post-acute setting to help lower readmissions; lower length of stay (LOS) in skilled nursing facilities (SNF); and greatly improve patient care, quality, and safety. Nurse practitioners (NPs) can play a large role in meeting your health system goals and ensuring that your outcomes are improved. Even if you are not ready to employ a nurse practitioner, we will discuss other initiatives that you can implement in your community. Examples include: developing criteria to set up preferred provider SNF networks, medication programs, nurse triage and case management/throughput solutions. This discussion will also include strategies to help you meet your health system Accountable Care Organization (ACO) and value-based contract goals to lower overall spend and cost for the patients you serve.

After this presentation you will be able to:

1. Describe strategies for an embedded NP model in SNFs and effective criteria to develop preferred provider SNF networks.
2. Identify quality metrics to track related to re-admissions with SNF network partnerships.
3. Learn ways to lower spend and LOS in the post-acute setting.

Human-centered design (HCD) is used to create products and services that match user’s needs. This session will provide an overview of basic principles of HCD. Participants will practice one tool in small groups: rapid prototyping with real patient-generated solutions. Then participants will demonstrate what they have learned by selecting where HCD tools fit in Lean, Total Quality Management, Six Sigma, and other frameworks. Both presenters are Kaiser Permanente trained instructors and facilitators in HCD.

After this presentation you will be able to:

1. Describe basic human-centered design principles, with an emphasis on rapid prototyping.
2. Practice rapid prototyping business solutions in a small group.
3. Identify where in improvement processes human centered design tools are most applicable.

With 1 in 5 individuals experiencing a mental health concern in any given year, timely access to high-quality behavioral health remains a persistent challenge. The integration of behavioral health has clearly emerged as a best practice, both for expanding access to care as well as improving quality; however, questions around implementation, scale, and sustainability remain. This session will describe the development of a population health framework for behavioral health in a large integrated health system serving diverse populations. Augmenting traditional acute care and ambulatory services, this emerging continuum of integrated services includes collaborative care treatment of mental health in primary care, “reverse integration” of physical health in mental health settings, comprehensive care management through the Health Home model, adult and pediatric behavioral health crisis centers, and telehealth consultation. Application of these services to specific populations will be examined through a series of case presentations, with emphasis on care pathways, data collection, and outcomes reporting.

After this presentation you will be able to:

1. Describe skills and strategies for increasing access and quality of care for a wide range of behavioral and mental health issues among diverse patient populations.
2. Understand the role of collaborative case-based supervision and consultation in clinical settings for leveraging scarce specialty psychiatric resources and improving integration of behavioral health services.
3. Recognize the need for a variety of developmental and age-based strategies across the continuum of integrated behavioral health care.

Hospital Galveston (HG), a maximum-security correctional hospital within the University of Texas Medical Branch (UTMB), provides medical care to 78 percent of the offenders' population in Texas. This vulnerable patient population comes with a variety of conditions that can prolong the length of stay (LOS). Prolonged LOS correlates with a decrease in bed availability and can lead to a loss of resources and putting public safety at risk. Following the identification of an average LOS of 9.12 days, the hospital used methodologies to identify and implement improvements including Find-Organize-Clarify-Uncover-Select (FOCUS); Plan-Do-Study-Act (PDSA); and Standardize, Sustain, and Spread (SSS). After a year, the impact of interdisciplinary rounding, the use of a risk assessment tool, and the inclusion of the warden/security staff in patient care have contributed to a reduction of 1.43 days in LOS. As a result, more beds have become available, a decrease in medical expense has been noted, and improvements have been seen in the areas of public safety and patient outcomes.

After this presentation you will be able to:

1. Discuss the value of interdisciplinary rounding, a risk assessment tool, and warden inclusion in patient care.
2. Describe how quality improvement tools such as process flow charts, brainstorming, cause-and-effect diagrams, and the 8Ps Risk Assessment Tool can help to identify best practices in decreasing LOS.
3. Discuss the accountability of individual health care team members and correctional officers in patient care discussion to reduce the length of stay.

Opioid-related deaths have increased six-fold over the last two decades, with more than 130 people dying each day from an opioid-related overdose. Emergency Departments (EDs) are at the frontline of the opioid crisis and often the place of first presentation for patients at risk of or suffering from opioid use disorder (OUD). Given their open-door, 24/7 access to care, EDs are well-positioned to diversify practices to improve patient care. This session will highlight the innovative work being done at two U.S. health care organizations (an urban, safety net hospital and a large public health system), describing specific changes, results, challenges, and lessons learned. Participants will hear from an interprofessional panel about their comprehensive approaches to refine practices for screening, identification, harm reduction, treatment initiation, and linkage to care. Participants will also have an opportunity to interact with the presenters and each other to generate creative ideas for tests of change and identify how they can re-design a specific aspect of care for ED patients with OUD at their organizations.

After this presentation you will be able to:

1. Learn effective strategies to improve care for opioid use disorders in the ED
2. Understand the key roles of different team members in testing and implementing changes
3. Discuss and identify change ideas to test at your organization

Learn to develop, implement, and improve workflows while successfully screening for social needs (food, housing, transportation, and finances). This three-in-one session will discuss how three organizations screened and addressed social needs among pediatric primary care patients, adult ambulatory patients, and hospital employees. We will share troubleshooting strategies and successes, as well as tools for organizations at any stage of implementation. We will also delve into handling positive screens – developing staff roles, identifying available resources, and documenting cases.

After this presentation you will be able to:

1. Identify lessons learned and best practices for the implementation or optimization of social needs screening workflows.
2. Describe challenges and identify troubleshooting techniques to successfully screen for social needs.
3. Describe and develop an approach to addressing positive needs identified during screening.

Perinatal outcomes in the United States are suboptimal, with infant mortality rates greater than many other developed countries, and maternal mortality rates that are not decreasing as they are in other countries. State-based, perinatal quality collaboratives (PQCs) have shown that the application of collaborative, improvement science methods can lead to better perinatal health outcomes. These state or multi-state networks are made up of multidisciplinary teams working to improve measurable outcomes for maternal and infant health by advancing evidence-informed clinical practices and processes using quality improvement (QI). Using this collaborative model, the Louisiana Perinatal Quality Collaborative (LaPQC) supports 35 hospitals to apply continuous quality improvement, aiming to reduce Louisiana’s severe maternal morbidity rate and racial health disparity. The LaPQC team centers and prioritizes equity by leveraging the power of patient stories, data stratification, and other techniques to encourage more thoughtful and consistent approaches to data quality and the identification of key processes that impact care as they relate specifically to disparities. Through this approach the LaPQC team works to build not only QI capacity, but a culture of equity-focused improvement. This session will highlight the essential elements of the PQC model of population-based QI, discuss key strategies that support successful statewide perinatal QI initiatives, and present examples from the Louisiana PQC, which is implementing this model to improve maternal health and reduce racial and ethnicity disparities in the state.

After this presentation you will be able to:

1. Apply quality improvement principles for improving statewide perinatal health
2. Identify the essential elements of a fully functional Perinatal Quality Collaborative, including participation of key partners and stakeholders
3. Describe why health equity is an essential driver in ensuring high-quality perinatal outcomes
4. Identify and integrate responsive techniques for supporting hospitals to accelerate improvement related to the reduction of disparities, such as facility team collaboration and on-the-ground coaching

Five years ago, Hartford HealthCare aimed to advance safety across its system by adopting a model of high reliability to decrease the incidence of patient harm. With leaders on board, the organization has woven high reliability into its operational model and data structures, including tracking harm and serious safety events through dashboards and more than 40 clinical counsels. As a result, Hartford HealthCare has sustained a 70 percent reduction in Serious Safety Events for nearly two years. Presenters will share the best practices to begin and sustain a high-reliability journey, including barriers and how to overcome them. They will discuss how to spread the principles of a high-reliability organization across the continuum of care.

After this presentation you will be able to:

1. Identify and learn to implement the principles of a high-reliability organization.
2. Specify strategies for engaging leadership in performance improvement initiatives related to safety and quality improvement.
3. Explain how to spread successful harm reduction initiatives across an integrated health system.

Each day, hundreds of healthcare workers are injured on the job. In 2017, over 224,000 US hospital employees suffered work-related injuries and illnesses – over twice the rate for private industry as a whole. Employee injuries impact the health and well-being of our staff, come at a high cost to hospitals and health systems, and affect patient safety. We can and must do better. Armed with data, stories, and a commitment to improve, 19 health care organizations joined together over the last year to meaningfully and measurably address workforce safety within their organizations. By sharing data, promising practices, and challenges, the group has helped advance their individual and collective workforce safety related efforts by making workforce injury reduction a strategic goal and ensuring senior leadership reviews workforce safety data as close to real time as possible and developing robust injury review and reporting process and chartering multi-professional teams to improve workforce safety. This session is ideal for executive leaders. Quality and safety experts, clinical providers and occupational safety experts. The session will be a combination of sharing best practices from leading organizations, describing multi-organization learning networks and engaging audience in sharing best practices. The session is intended to give participants specific actionable steps to help their organization accelerate improvements in workforce safety. Specific measurable outcomes including nationally standard metrics established by the Occupational Safety and Health Administration (OSHA).

After this presentation you will be able to:

1. Attendees will learn key components of an effective workforce safety program for a healthcare organization
2. Attendees will understand the critical role workforce safety plays for accomplishing all strategic goals including patient safety
3. Attendees will be exposed to specific improvements for adoption including data, event review and executive engagement

Diagnostic errors take a toll on patients, families, and providers. We developed an educational video to help providers understand how diagnostic errors occur and avoid errors through improved decision-making, collaboration with patients and teammates, and systems that support timely, accurate, and effectively communicated diagnoses. Knowledge checks monitor performance and viewers’ feedback is gathered for continuous improvement. Other complementary initiatives include guides to enhance patient-clinician partnering, online practice of diagnostic skills, and clinical reasoning support systems.

After this presentation you will be able to:

1. Describe a method to create and build awareness of diagnostic errors.
2. List strategies to gain leadership and institutional support to address diagnostic errors.
3. Explain how a culture of learning, systems support, and psychological safety builds diagnostic excellence.

Understanding and using a few key quality improvement tools will increase the effectiveness of your improvement efforts. Join three pioneers in quality improvement in health care to build your skills in seven basic tools of quality – flowcharts, run charts, driver diagrams, Pareto charts, histograms, cause-and-effect diagrams, and scatter diagrams – tools that you can apply as soon as you return home.

After this presentation you will be able to:

1. Summarize seven basic quality improvement tools.
2. Identify opportunities to apply these tools in your work.

Whether you are looking to implement a new or already existing improvement, this session will advance your capability to take improvements to full scale across your organization or system. Learn how to use a sequence of activities, including strategies to enhance adoption of the improvements and the infrastructure needed to support them, as a guide to achieving your scale-up goals.

After this presentation you will be able to:

1. Identify the key steps in designing successful scale-up efforts.
2. Apply methods for building will, developing ideas, and supporting system-wide implementation.
3. Assess readiness for starting and/or enhancing scale-up activities.

To help older adults avoid the hazards of hospitalization, Hospital at Home (HaH) was developed. In HaH, acute hospital-level care is provided at home by an interdisciplinary team including MDs, NPs, RNs and SWs. We estimate a potential 611,000 Medicare patients can be enrolled yearly in HaH nationally. A recent Center for Medicare & Medicaid Innovation Demonstration showed that patients cared for in HaH experience 50% fewer readmissions and ED visits and provide higher HCAHPS ratings. Description and Audience: Interest in HaH has exploded recently due to increasing penetration of Medicare managed care, the development and spread of accountable care organizations (ACOs) and a shift in focus among some health systems towards value-based care, population health and community-based care. This session is designed for those health systems who have an interest in learning more about HaH or who are contemplating starting a program. HaH could be an important option for those interested in being an Age Friendly Health System. Through a combination of didactic learning and interactive discussion, participants will increase their knowledge of this care model as well as exploring their organization’s readiness to adopt this model. Examples / Applications: Mount Sinai’s Health System 5-year experience with HaH will be described in depth to bring the HaH model to life. Value to session participants: In addition to the description of HaH and the Mount Sinai experience, session participants will be given the opportunity to explore issues related to HaH implementation in their own health systems.

After this presentation you will be able to:

1. Describe the rationale and advantages of the Hospital at Home model of care.
2. Identify the key core components of the Hospital at Home model of care.
3. Determine the organization readiness to consider adoption of HaH

Up to 25% of older adults who are hospitalized have delirium and an additional 30% will develop delirium while they are in the hospital. The cost to the older adults and family caregivers is profound -- increased morbidity and persistent functional decline. The cost to health systems, communities and payers is also significant -- increased nursing time per patient, higher per day hospital costs, increased length of hospital stay, higher rates of nursing home placement and increased mortality Yet, it is estimated that 30 – 40% of delirium is preventable. An Age-Friendly Health System in one in which four evidence-based elements of care are practiced with older adults – the 4Ms of What Matters, Medication, Mentation and Mobility – that together can increase prevention, recognition and treatment of delirium. Putting the 4Ms into practice, and the case for doing so, has the potential to improve the cost, quality and experience of care. The University of California San Francisco (UCSF) put the 4Ms into practice to improve quality and experience. They calculated the return on investment for doing so and built a case for spread of the 4Ms across the health system. Come learn about the UCSF journey. And learn how to champion the reliable adoption of the 4Ms in your health system, access to a return on investment calculator to build the business case for improved care of older adults in your health system.

After this presentation you will be able to:

1. Learn how to champion the reliable adoption of the 4Ms in your health system
2. Understand common barriers to preventing and identifying delirium and approaches to overcome them
3. 3. Be able to initiate development of a business case for adoption of the 4Ms

Does your practice know how many trans clients it serves? What are your clients’ preferred pronouns, and where does that information live in the chart? How do you query care quality items that depend on knowing a client’s sexual orientation? As health care providers strive to become more culturally competent in serving the LGBTQ+ community, they may face challenges in assessing and closing gaps in care. Quality Improvement staff, Health IT professionals, and administrators will benefit from this discussion of strategies in identifying and monitoring quality measures and reaching out to LGBTQ+ clients in a culturally competent and safe way.

After this presentation you will be able to:

1. Describe strategies to improve health outcomes for members of the queer community by improving the QI community's ability to monitor care quality for LGBTQ+ clients.
2. Explain the need to implement LGBTQ+ culturally competent methods of data collection, monitoring of quality measures, and client outreach.
3. Discuss LGBTQ+ -specific considerations in health care quality improvement.

Disrespect and abuse of women during childbirth is a widespread problem that is particularly severe in marginalized populations. In this session for caregivers, administrators, and community advocates, a young mother will share her personal experience and her vision of quality care, and presenters will describe a curriculum in empathic communication that improved care in Ethiopia. We will provide a practical approach to improving care and reducing disparities through trainings in empathic communication.

After this presentation you will be able to:

1. Describe the scale of disparities in care provision and care outcomes for mothers and newborns across the globe.
2. List theoretical approaches to decreasing disparities in marginalized populations.
3. Identify practical approaches and available tools for increasing empathy as a strategy to decrease disparities in care and outcomes.

Attempts to address inequity in the health care system have been rapidly gaining momentum. But though much effort has been expended in the process, the philosophical origins of this work are infrequently considered. In this session, we will explore the roots of health equity; the historical precedent of paternalism that has shaped current relational inequity; and the postures and practices of patient and family engagement, effective communication, and shared decision-making that address the relational equity as experienced in a national oral health collaborative and through organizational adoption of the Bridges Out of Poverty© program.

After this presentation you will be able to:

1. Reimagine the assumption of equality as the vital root structure supporting the growth of equity.
2. Explore the rooted relational postures of effective communication and engagement as they relate to equity.
3. Experience the radical relational skills that help cultivate health equity, letting true equality bloom.

In 2001, the Institute of Medicine put forth six domains of health care quality. This includes “equitable” as the sixth pillar, defined as, “care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.” Yet, there persist systematic and widespread differences in health outcomes by race, gender, language, and other factors. This session will feature the experience of two Institute for Healthcare Improvement (IHI) Pursuing Equity collaborators who have used the IHI five-component equity framework to improve health equity in their organizations: 1) Make equity a strategic priority 2) Build infrastructure to support health equity 3) Address the multiple determinants of health 4) Eliminate racism and other forms for oppression 5) Partner with the community to improve health equity. HealthPartners will share key reflections on developing an actionable framework for health equity, including equipping teams with the knowledge and resources needed to provide appropriate care and service; engaging communities to learn how to best support them; and, improving care through data-driven quality improvement. Brigham Health will share a proposal to re-conceptualize health care events pertaining to unconscious bias, racism, sexism, or other forms of discrimination, as patient safety events, as they almost always have direct or indirect impacts on the quality and safety of care delivery. Case examples will highlight a new process - built around high reliability or “Just Culture” principles – that systematically integrates health equity into root cause analyses in patient safety/experience and quality.

After this presentation you will be able to:

1. Identify strategies for developing and operationalizing the five-component equity framework
2. Describe new strategies for integrating health equity into high reliability culture and principles

Researchers estimate that 2.5 million patients annually are impacted by pressure injuries, the majority of which may be preventable. For health care leaders, having confirmed, accurate, actionable pressure injury incidence data is critical for mitigating risk and decreasing the probability for developing and evolving pressure injury in the hospitalized patient. In this session, attendees will explore tactics for developing an improvement science implementation, including workflow redesign and two informatics solutions, to improve pressure injury analytics.

After this presentation you will be able to:

1. Describe acute care setting workflow changes that may result in confirmed and actionable hospital-acquired pressure injury data.
2. Identify technology solutions that may result in actionable (real-time) hospital-acquired pressure injury analytics.

The very different contexts in which health care teams work and their varying abilities to implement change can pose real challenges for spreading improvement interventions and replicating their outcomes effectively at scale. Drawing on the analytical framework set out in the recent Health Foundation report "The Spread Challenge," this session will explore approaches for spreading improvement interventions and supporting their successful adoption. We will look at various strategies for codifying interventions, such as theory-of-change models and capability-based models, that can help adopters translate the interventions into their own context. These issues will then be illustrated through an in-depth case study of a sophisticated approach to spreading improvement capability: The Flow Coaching Academy, a program that supports teams across the United Kingdom to improve patient flow.

After this presentation you will be able to:

1. Identify different strategies for describing improvement interventions in order to spread them effectively.
2. Develop an understanding of the implementation challenges that teams often face when adopting new ideas and how they can be supported to overcome them.
3. Learn important considerations for the design and leadership of programs to spread improvement interventions.

Patients expect health care teams to learn what works quickly and implement effective practices reliably. Additionally, administrators expect interprofessional, frontline teams to drive continuous improvement. A learning healthcare system, as envisioned by the Institute of Medicine, integrates innovation into the care experience. Numerous, laudable examples are emerging that vary in real-world application of these concepts. In this session, health care leaders will illustrate how these systems combine quality improvement and implementation science to accelerate learning.

After this presentation you will be able to:

1. Compare and improvement, delivery system, implementation, and learning health system science.
2. Develop a checklist for application of core concepts and methods for improvement.
3. Identify key organizational and structural attributes of a functioning learning health system.

Quality improvement (QI) approaches celebrate and encourage failure for the rich learning opportunity it provides. However, in reality, people desire positive results and workplace culture often makes us fear failure. This session will present an honest account of setting up quality improvement (QI) programs in large mental health and acute settings in England and Wales. Throughout the session, we'll endeavour to share our own personal and joint successes and failures, the roller coaster journey they represent, and the resources you need to survive and grow when the possibility of failure is likely. We hope to embolden conversations that hold failure as a core component of continuous improvement.

After this presentation you will be able to:

1. Explain how to identify failure early on and what to do next.
2. Describe how to implement key tenets of improvement to progress your QI program regardless of current context.
3. Be prepared to work creatively with the messiness of change and manage the psychology of failure in QI.

By identifying and monitoring the key elements of quality standards in a patient’s care journey, patients can be well-prepared for the next phase of their recovery. This presentation will demonstrate how the implementation of clinical pathways supported efforts to integrate quality-related practices while improving efficiencies for inpatient units at a specialized mental health institution. A hospital-wide target was established to measure the percent of non-forensic and forensic patients whose discharge length-of-stay (LOS) met the overall clinical pathway target. Strong patient flow processes such as a cohesive bed-management system, discharge activities, and standardized assessment tools were implemented to provide individualized care planning focused on efficiency, improving quality, and identifying an expected LOS for most patients. In 2018/19, there was a 15 percent improvement in the LOS target. Additionally, the impact of this work has demonstrated a 12 percent improvement in the number of admissions for the facility from 2016/17 to 2018/19.

After this presentation you will be able to:

1. Explain how the engagement of point-of-care and physician leaders in the development of clinical pathways can improve the quality of care for patients and patient flow in a specialized mental health care setting.
2. Describe how reducing process variation improves patient outcomes by sequencing activities and ensuring the right disciplines are engaged at the right time.
3. Specify tools and practices that are important considerations for implementing clinical pathways in inpatient mental health settings.

The members of the Facility Management and Security Leadership Team of the Bellin Healthcare System knew they needed to reframe their understanding of “Why we do our work.” They felt their contributions to quality outcomes had to be top of mind. They began working with Rosie and David Bartel, who are patient safety advocates. The Bartels began meeting with Bellin staff and contractors to share more of their personal story. As the meetings continued, the reason for “Why we do our work?” became clearer. Staff soon realized that the patient story needed to frame all the work they were doing. This presentation will provide help reframing the question of “Why we do our work” for everyone in health care. Participants will learn how having an ongoing relationship with patients and their families will produce meaningful results. They will hear how a patient story can be used to motivate everyone in health care to perform at the highest level.

After this presentation you will be able to:

1. Identify patient stories that will produce a meaningful answer to the question “Why do we do our work?”
2. Describe how to develop meaningful relationships with patients and their families in all areas of “work” in health care systems.
3. Describe how to implement an ongoing relationship with patients and families that will motivate everyone in health care to perform at the highest level.

The current environment in healthcare leads to high turnover in clinicians and hospital staff and can significantly impact a patient’s experience and outcome. By shadowing patients and their care teams at every level, a true working experience can be identified; systematic change be hardwired into any organization. Using the knowledge gleaned from shadowing all experiential stakeholders, better care experiences can be co-designed, leading to improved staff satisfaction, higher levels of compassion, joy in experience and reduction in turnover. Learn to use shadowing to develop a culture of improvement and engage staff in the process of co-design. Use the goShadow app to actively shadow and create reports to determine your true current state and work towards the ideal. Discuss real world scenarios; learn how to inspire change and systematically improve both employee and patient experiences as well as co-create better outcomes from the ground up.

After this presentation you will be able to:

1. Describe how to eliminate stakeholder confusion and anxiety by breaking down barriers and giving a voice to the chronically underheard.
2. Identify ways to effectively determine the real current state of staff experience and share findings with staff in order to co-create an ideal state.
3. List approaches to inspire change and systematically improve both employee and patient experience.

The New York State Delivery System Reform provided a unique opportunity to support integrated care by building capacity for systems change through workforce development. We will share an overview of the Delivery System Reform and the results of a network-wide survey of providers and staff focused on teamwork, burnout, joy-in-work, and resiliency. Our analyses informed targeted organizational development programming, such as strategies that identify and develop staff willing to try new approaches into organizational change agents.

After this presentation you will be able to:

1. Describe how Delivery System Reform provided an opportunity to build integrated care and systems change through a data driven workforce development strategy.
2. Describe how survey data informed the development of strategies to decrease staff burnout, and improved teamwork, staff well-being, and joy in work across a diverse provider network including hospitals, primary care, Federally Qualified Health Centers, behavioral health care, substance use providers, skilled nursing facilities, and community-based organizations.
3. Identify ways to incorporate change principles and the IHI Framework for Improving Joy in Work to build staff agency.

Leaders at every level are confronted with specific issues, performance concerns, and pressure to fix them. You are expected to know how to act, but are you making the right decision? In this session, learn how improvement science can support leaders to discover if an issue is due to identifiable reasons or is the result of a process to improve, and what actions to take to support enhancing performance in each case.

After this presentation you will be able to:

1. Simulate the issues with static or color coded dashboards
2. Show the value of a vector of measures displayed for learning
3. Describe the risk of acting on data with our understanding what’s going on

Why do some improvement efforts end when a leader moves on? In this session we will explore how leaders fail to create systems that ensure the continuation of an improvement culture beyond their tenure. We will share evidenced-based approaches to building sustainable processes and avoiding common pitfalls. Focusing on a few important practices can lead to long term success for an organization, no matter who is doing the leading.

After this presentation you will be able to:

1. Explain why some continuous improvement cultures come to an end.
2. Describe how to build systems that reinforce and maintain the culture of continuous improvement.
3. Identify components of a plan for improvement that lasts beyond changes in leadership.

Developing a culture of quality, safety, equity, and joy in work requires sustaining psychological safety so that communication is open, honest, and collaborative. But psychological safety is quite vulnerable to the presence of power differentials — such as between leaders, both clinical and administrative, and the staff and providers who report to them. Neuroscience and psychological studies have shown that power differentials frequently evoke ways of communicating, even in skilled and well-meaning professionals, that can be inadvertently disruptive to shaping desired culture. Risks are especially high in environments of stress and complexity that are ubiquitous in health care. This workshop will be beneficial for participants whether or not they feel they have formal positional or professional authority. Participants will receive a set of articles and a tool with high-leverage principles as well as specific examples of actions that help to manage the risks of power. Four real-life work situations involving power differentials will be presented to demonstrate how to use the tool.

After this presentation you will be able to:

1. Identify why and how issues of power can so easily disrupt efforts to shape the culture toward one of quality, safety, equity, and joy in work.
2. Describe methods for managing the risks of power differentials that facilitate open, honest, and productive communication.
3. Explain how to implement decision-making approaches that maximize the chances for empowerment and alignment.

The Architecture of High Value Health Care national conference, co-directed by the High Value Practice Academic Alliance and the American Hospital Association, is a venue to share initiatives that improve quality, safety, experience and outcomes, while reducing total cost of care. This session will include innovative and practical projects from the 2019 conference to showcase exemplary value-improvement initiatives from different institutions. Anyone in health care interested in improving quality and affordability, including physicians, nurses, advanced practice providers, QI project managers, hospital leadership and trainees. The importance of prioritizing quality, safety, patient and patient outcomes will be emphasized. Participants will gain an understanding the pillars of value-improvement work, interventions used and the relative impact of these interventions on costs for patients, payers and medical centers.

After this presentation you will be able to:

1. 1. Understand the variety of value improvement work and areas for their own efforts to improve quality and safety while reducing total cost of care.
2. 2. Appreciate the different interventions and models that can improve the value of care providers deliver.
3. 3. Learn how to effectively design value improvement initiatives to prioritize quality, safety, patient experience and patient outcomes, and how to determine the impact of these initiatives on costs for patients, payers and medical centers

Healthcare systems are at a crossroads. In order to sustain a viable healthcare system, it is imperative to reduce costs and improve quality. In a recent Vizient study, 81% of health system participants identified clinical variation as a barrier, due to disparate data systems and incentives. Standardization, governance and culture were identified as opportunities across the entire continuum of care. Spectrum Health became a health system (comprised of 14 hospitals, a medical group and continuing care) more than 20 years ago, however the Quality, Safety and Experience departments remained separate. In 2018, Spectrum Health began systemness by aligning department structures and leadership in order to pivot to one standard of care. Alignment goals were developed to engage the system in improving these metrics. In addition, each service line set goals to improve specific measures to surpass the national median benchmark. These goals are monitored and cascaded through an operational deployment system that engages leaders in improvement and establishes accountability. A quality data model is in development to provide service lines and entities with leading and lagging metrics that are drillable to service line and provider levels. Operational and physician service line leaders are now taking accountability for clinical outcomes. A significant decrease in sepsis mortality has been achieved along with substantial progress in readmissions, likelihood to recommend and metrics performing at less than the national benchmark. The ultimate goal is to own the value equation for our consumers by lowering cost and improving quality and safety outcomes.

After this presentation you will be able to:

1. Engage health system leaders to move to value and implement one standard of care.
2. Develop the framework to enable the transition to value and one standard of care.
3. Implement measurement and communication tools that support improving value and one standard of care.

This session will provide you with strategies and initiatives to use in the post-acute setting to help lower readmissions; lower length of stay (LOS) in skilled nursing facilities (SNF); and greatly improve patient care, quality, and safety. Nurse practitioners (NPs) can play a large role in meeting your health system goals and ensuring that your outcomes are improved. Even if you are not ready to employ a nurse practitioner, we will discuss other initiatives that you can implement in your community. Examples include: developing criteria to set up preferred provider SNF networks, medication programs, nurse triage and case management/throughput solutions. This discussion will also include strategies to help you meet your health system Accountable Care Organization (ACO) and value-based contract goals to lower overall spend and cost for the patients you serve.

After this presentation you will be able to:

1. Describe strategies for an embedded NP model in SNFs and effective criteria to develop preferred provider SNF networks.
2. Identify quality metrics to track related to re-admissions with SNF network partnerships.
3. Learn ways to lower spend and LOS in the post-acute setting.

Human-centered design (HCD) is used to create products and services that match user’s needs. This session will provide an overview of basic principles of HCD. Participants will practice one tool in small groups: rapid prototyping with real patient-generated solutions. Then participants will demonstrate what they have learned by selecting where HCD tools fit in Lean, Total Quality Management, Six Sigma, and other frameworks. Both presenters are Kaiser Permanente trained instructors and facilitators in HCD.

After this presentation you will be able to:

1. Describe basic human-centered design principles, with an emphasis on rapid prototyping.
2. Practice rapid prototyping business solutions in a small group.
3. Identify where in improvement processes human centered design tools are most applicable.

With 1 in 5 individuals experiencing a mental health concern in any given year, timely access to high-quality behavioral health remains a persistent challenge. The integration of behavioral health has clearly emerged as a best practice, both for expanding access to care as well as improving quality; however, questions around implementation, scale, and sustainability remain. This session will describe the development of a population health framework for behavioral health in a large integrated health system serving diverse populations. Augmenting traditional acute care and ambulatory services, this emerging continuum of integrated services includes collaborative care treatment of mental health in primary care, “reverse integration” of physical health in mental health settings, comprehensive care management through the Health Home model, adult and pediatric behavioral health crisis centers, and telehealth consultation. Application of these services to specific populations will be examined through a series of case presentations, with emphasis on care pathways, data collection, and outcomes reporting.

After this presentation you will be able to:

1. Describe skills and strategies for increasing access and quality of care for a wide range of behavioral and mental health issues among diverse patient populations.
2. Understand the role of collaborative case-based supervision and consultation in clinical settings for leveraging scarce specialty psychiatric resources and improving integration of behavioral health services.
3. Recognize the need for a variety of developmental and age-based strategies across the continuum of integrated behavioral health care.

Hospital Galveston (HG), a maximum-security correctional hospital within the University of Texas Medical Branch (UTMB), provides medical care to 78 percent of the offenders' population in Texas. This vulnerable patient population comes with a variety of conditions that can prolong the length of stay (LOS). Prolonged LOS correlates with a decrease in bed availability and can lead to a loss of resources and putting public safety at risk. Following the identification of an average LOS of 9.12 days, the hospital used methodologies to identify and implement improvements including Find-Organize-Clarify-Uncover-Select (FOCUS); Plan-Do-Study-Act (PDSA); and Standardize, Sustain, and Spread (SSS). After a year, the impact of interdisciplinary rounding, the use of a risk assessment tool, and the inclusion of the warden/security staff in patient care have contributed to a reduction of 1.43 days in LOS. As a result, more beds have become available, a decrease in medical expense has been noted, and improvements have been seen in the areas of public safety and patient outcomes.

After this presentation you will be able to:

1. Discuss the value of interdisciplinary rounding, a risk assessment tool, and warden inclusion in patient care.
2. Describe how quality improvement tools such as process flow charts, brainstorming, cause-and-effect diagrams, and the 8Ps Risk Assessment Tool can help to identify best practices in decreasing LOS.
3. Discuss the accountability of individual health care team members and correctional officers in patient care discussion to reduce the length of stay.

Opioid-related deaths have increased six-fold over the last two decades, with more than 130 people dying each day from an opioid-related overdose. Emergency Departments (EDs) are at the frontline of the opioid crisis and often the place of first presentation for patients at risk of or suffering from opioid use disorder (OUD). Given their open-door, 24/7 access to care, EDs are well-positioned to diversify practices to improve patient care. This session will highlight the innovative work being done at two U.S. health care organizations (an urban, safety net hospital and a large public health system), describing specific changes, results, challenges, and lessons learned. Participants will hear from an interprofessional panel about their comprehensive approaches to refine practices for screening, identification, harm reduction, treatment initiation, and linkage to care. Participants will also have an opportunity to interact with the presenters and each other to generate creative ideas for tests of change and identify how they can re-design a specific aspect of care for ED patients with OUD at their organizations.

After this presentation you will be able to:

1. Learn effective strategies to improve care for opioid use disorders in the ED
2. Understand the key roles of different team members in testing and implementing changes
3. Discuss and identify change ideas to test at your organization

Learn to develop, implement, and improve workflows while successfully screening for social needs (food, housing, transportation, and finances). This three-in-one session will discuss how three organizations screened and addressed social needs among pediatric primary care patients, adult ambulatory patients, and hospital employees. We will share troubleshooting strategies and successes, as well as tools for organizations at any stage of implementation. We will also delve into handling positive screens – developing staff roles, identifying available resources, and documenting cases.

After this presentation you will be able to:

1. Identify lessons learned and best practices for the implementation or optimization of social needs screening workflows.
2. Describe challenges and identify troubleshooting techniques to successfully screen for social needs.
3. Describe and develop an approach to addressing positive needs identified during screening.

Perinatal outcomes in the United States are suboptimal, with infant mortality rates greater than many other developed countries, and maternal mortality rates that are not decreasing as they are in other countries. State-based, perinatal quality collaboratives (PQCs) have shown that the application of collaborative, improvement science methods can lead to better perinatal health outcomes. These state or multi-state networks are made up of multidisciplinary teams working to improve measurable outcomes for maternal and infant health by advancing evidence-informed clinical practices and processes using quality improvement (QI). Using this collaborative model, the Louisiana Perinatal Quality Collaborative (LaPQC) supports 35 hospitals to apply continuous quality improvement, aiming to reduce Louisiana’s severe maternal morbidity rate and racial health disparity. The LaPQC team centers and prioritizes equity by leveraging the power of patient stories, data stratification, and other techniques to encourage more thoughtful and consistent approaches to data quality and the identification of key processes that impact care as they relate specifically to disparities. Through this approach the LaPQC team works to build not only QI capacity, but a culture of equity-focused improvement. This session will highlight the essential elements of the PQC model of population-based QI, discuss key strategies that support successful statewide perinatal QI initiatives, and present examples from the Louisiana PQC, which is implementing this model to improve maternal health and reduce racial and ethnicity disparities in the state.

After this presentation you will be able to:

1. Apply quality improvement principles for improving statewide perinatal health
2. Identify the essential elements of a fully functional Perinatal Quality Collaborative, including participation of key partners and stakeholders
3. Describe why health equity is an essential driver in ensuring high-quality perinatal outcomes
4. Identify and integrate responsive techniques for supporting hospitals to accelerate improvement related to the reduction of disparities, such as facility team collaboration and on-the-ground coaching

During health system consolidation, risks to patients arise when clinicians practice in new settings or with new patient populations without sufficient planning. We developed the System Expansion Toolkit to support clinical planning prior to affiliation. It provides guidance on addressing potential safety risks, including differences in infrastructure, responsibilities, and culture, as well as a checklist for establishing council to manage identified risks. Attendees from any discipline will learn about prospective planning and post-merger risk reduction.

After this presentation you will be able to:

1. Recognize the ways in which health system expansion can lead to patient harm.
2. Describe two approaches to mitigate the risk of patient harm from system expansion.
3. Examine two newly recognized areas of patient safety risk from system expansion.

Just Culture is not a buzzword; it is a paradigm shift. Leaders in High Reliability Organizations use a just approach, creating an environment where staff freely voice concerns. Through the power of stories, we will apply Just Culture to real cases in today’s health care environment. This session benefits executives and safety leaders searching for an innovative, successful approach to cultural change and anyone who wants a deeper understanding of Just Culture. We will share our roadmap and lessons learned through implementation at a large, multicenter medical system. Our novel framework has successfully trained >1,300 diverse leaders; 98 percent of them find it useful for their daily work.

After this presentation you will be able to:

1. Explain why a Just Culture is an essential precursor to High Reliability.
2. Identify key steps in sustaining cultural change.
3. Integrate lessons from our model into an implementation strategy for your organization.

Nationally, increasingly complex care and procedures are moving to an ambulatory setting. With these changes, it becomes increasingly important to move from the old model of hospital-based quality programs to system-wide infrastructure to ensure high quality care. We will discuss our experience developing and integrating a system-wide ambulatory quality, safety, and risk infrastructure, including identifying and mitigating major ambulatory quality and safety hazards, improving outcomes, increasing quality metric scores, and strengthening safety initiative coordination.

After this presentation you will be able to:

1. Identify the benefits of developing and implementing a system-wide infrastructure for ambulatory quality, safety, and risk.
2. List potential quality and safety hazards in the ambulatory environment and successful initiatives to improve outcomes.

This session describes management practices adopted by top-performing health care organizations designed to sustain and improve highly reliable, safe, and efficient care. Our study of 10 leading acute care organizations yielded a ‘Management System Architecture’ focused on specific integrated responsibilities for managers at all levels. Key drivers of high-performance management include daily standard work; formal accountability; frequent, data-grounded communication; problem-solving methodology; protocols for escalating problems, and positive trust relationships among managers and staff.

After this presentation you will be able to:

1. Distinguish between management for quality control and quality improvement.
2. Describe standard high-performance management practices at three levels of management, with a focus on the point of care.
3. Describe recommended approaches to introducing a high-performance management system.

Participants of this session can expect to deepen their understanding of measurement for improvement, the types of measures, how to collect data, and how to analyze data over time. In all improvement efforts, it’s necessary to measure whether the changes being tested are leading to improvement. Identifying and developing a family of measures is useful in understanding the system from multiple perspectives. In addition, measurement takes place at different levels, from the outcome level down to the level of individual Plan-Do-Study-Act (PDSA) cycles. A Measurement Tree is a tool that can help highlight the logical links between measures in our system, and collecting and looking at data over time in the form of a run chart is useful to inform teams whether changes are leading to improvement.

After this presentation you will be able to:

1. Understand the three faces of performance measurement.
2. Describe the difference between Outcome, Process, Balancing, and PDSA measures and their relationship to one another.
3. Explain how to collect and analyze data over time when pursuing improvement of a system.

It is estimated that 8.8% of people over the age 65 will develop dementia. With 10,000 people turning 65 every day, the impact on families, communities and the health system is profound. Health care costs of someone with dementia each year is calculated to be $33,329 more than someone without dementia. Those costs are borne by families, tax payers, communities and health systems. Effective integration of work on Alzheimer’s and dementia is accelerating in the U.K. and the U.S. For example, the Focus on Dementia improvement programme has been testing models of care coordination in Scotland. In the United States, similar models of care have been developed and tested, including the UCLA Alzheimer’s and Dementia Care Program, the Aging Brain Care Program at Eskenazi Health and others. This workshop will engage interdisciplinary teams from the U.K. and U.S. and audience members in a discussion of models of care for people with dementia in the US and UK and the results across the Triple Aim. The discussion will address how people can make improvements at the individual, care team and organization/health system level. The discussion will be grounded in how we ask and act on What Matters to the older adult with dementia and their family caregivers.

After this presentation you will be able to:

1. Articulate how the 4Ms Framework of an Age-Friendly Health System applies evidence-based care across the 4Ms (What Matters, Medication, Mentation and Mobility) and its application to care of people with dementia
2. Describe the specific challenges for people with dementia in the acute hospital setting and learn practical tools/ approaches to help hospitals become dementia friendly
3. Identify improvements that care teams and organizations can make to improve care of people with dementia
4. Understand how to ask, and put into practice, What Matters to people with dementia

Wait times are a feature of emergency departments (EDs) across the Greater Toronto Area, where Trillium Health Partners (THP) serves more than 270,000 patients in its EDs every year. A report by the Institute for Clinical Evaluative Sciences identified that some transfers from long-term care facilities (LTCs) to the ED were potentially avoidable, especially because elderly residents who are transferred to the ED can incur adverse effects such as altered level of consciousness, exposure to hospital-acquired infections, and loss of muscle mass. To reduce the number of ED visits from LTCs and ensure patients received the attention they needed as their conditions changed, an interdisciplinary team met with stakeholders across THP ED and Silverthorn LTC to identify primary root causes for patient transfers. Interventions were initiated from August 2017 to March 2018, and corresponded with a 50 percent reduction in the number of ED visits from Silverthorn LTC to THP.

After this presentation you will be able to:

1. Develop strategies to engage long-term care facilities, including their management, staff, patients, and patient caregiver populations.
2. Describe how to implement telemedicine networks between long-term care facilities and hospitals that may lead to a reduction in total transfers.
3. Identify how some common yet powerful quality improvement tools can help guide decision-making and project direction.

Identifying disparities requires stratifying quality data by race, ethnicity, language, and other social determinants of health. This session will discuss strategies for developing a disparities dashboard to support population health efforts of health plans, hospitals, and health centers. Ten years ago, Massachusetts General Hospital created its first disparities dashboard, which has evolved into the Annual Report on Equity in Healthcare Quality. Participants will learn core components, key pitfalls, and ways to interpret data for action.

After this presentation you will be able to:

1. Identify core components of a disparities dashboard.
2. Develop strategies to move from data to action.

Many organizations are working to improve staff diversity, inclusion, and equity. To do this effectively, organizations should develop a staff representative of the communities where they work and improve their systems and processes so all employees may thrive. The Institute for Healthcare Improvement (IHI) and the University of Arkansas for Medical Sciences (UAMS) are two organizations advancing equity for their staff. IHI’s Internal Equity Improvement Team will share what they’ve learned in the last seven years about the promises and limitations of incorporating QI methods into equity work – sharing their updated driver diagram, describing their evaluation methods, and offering suggestions for starting and sustaining work that is fundamental for psychological safety and joy in work. As part of the IHI Leadership Alliance, UAMS enacted The Call to Action – which articulates the role of health care change agents as advocates, organizational leaders, and community partners to accelerate health equity – to ensure that 1,000 more staff earned a local living wage and also developed recruitment and retention strategies for their graduate medical education programs and clinical faculty. Join us to accelerate your own organizational efforts by learning how UAMS conducted baseline assessments to set contextually relevant aims and sought to build will amongst key stakeholders, improve the hiring pipeline, and develop sustainable career pathways. From advocating for more equitable policies to diversifying hiring at all levels of the organization to ensuring that each employee is making a living age, these leaders are connecting, learning, and improving together to ensure that the Triple Aim is not only an aspiration for some but achievable for all.

After this presentation you will be able to:

1. Identify the responsibility organizations have to advance equity for their workforce
2. Recognize the systems, processes, and cultures that limit employees’ ability to thrive
3. Distinguish between diversity, inclusion, and equity and identify how your organization might advance your equity journey

With the goal of becoming a leader in improving patient outcomes and achieving zero harm by 2026, Piedmont Healthcare (PHC) has designed a successful methodology for the development of clinical best practices and standard work through the delivery of ‘Promise Packages.’ This tool is used by frontline staff, management, and leadership alike as a one-stop-shop providing a comprehensive set of resources, including performance-tracking tools, across an 11-hospital health care system. Participants will learn that the use of a tool such as the Promise Package, in conjunction with staff accountability and engagement, generates a collaborative environment where clinical staff, management, and quality improvement work together to improve patient outcomes. The rapid success of the Package was a breakthrough in standardizing improvement efforts and best practices at PHC, and this model exemplifies the possibility of creating a culture of safety and achieving zero harm in health systems across the country.

After this presentation you will be able to:

1. Describe components required for successful standard work development, implementation, and sustainability.
2. Identify appropriate performance tracking tools through clear process and outcome metric goals that allow for the impartial evaluation of interventions.
3. Explain the importance of multidisciplinary teams to process and quality improvement work.

Management of data acquisition and conversion into quantifiable goals and process improvement work is a significant requirement for hospitals today. Memorial Health System utilizes a value stream management approach that allows senior leadership, frontline managers, value stream owners (embedded Lean Six Sigma Black Belts), patient safety coordinators, data scientists, and patient experience liaisons to identify and define key performance indicators that enhance the identification of process improvement work critical to the organization. Such work is then led by the appropriate specialty embedded within the value stream, which has realized more than $53 million in cost savings or revenue enhancements. Attendees at this session will walk through an experiential exercise around the development and definition of the value stream structure (based upon the Donabedian Model) and the processes that surround the structure. Specific processes and tools will be distributed, providing a roadmap for implementation of the value stream structure within the attendee’s home organization.

After this presentation you will be able to:

1. Describe value stream structure and the potential impact on quality and operations improvement.
2. Identify value stream-based methodology components for potential implementation at your organization.
3. Utilize handouts to develop performance indicators for major service lines within your organization.

Have you ever been overwhelmed with dashboards and data, yet lacked the information needed to manage your organization? In this session, participants will learn how physicians, nurses, IT professionals, managers, and leaders at Mount Sinai St. Luke’s in New York City used Lean methodology to harness data from the electronic medical record and designed a new generation command center, the James Jones Daily Management and Incident Command Center (DMC), to transparently display real-time information. The DMC consists of 10 digital real-time dashboards that drive daily operations, foster collaborative decision-making, pilot the use of predictive analytics, and allow sharing of information and resources among hospitals in the Mount Sinai Health System. It is the hub of the Mount Sinai St. Luke’s interdisciplinary safety huddle and the home base for emergency management response teams. Participants in this workshop will be given templates of our dashboards and will view a video of the command center, hopefully inspiring participants to create similar models in their own organizations.

After this presentation you will be able to:

1. Articulate how and why to integrate real-time data with daily management and emergency management strategies.
2. Describe the process by which a multidisciplinary team can build a command center to foster transparency and integrate workflows.
3. Identify multiple examples of how to use a command center to improve flow, safety, and emergency management and share specific examples of how predictive analytics are being piloted for real-time daily management.

A Home-Based Primary Care Practice had a waiting list of eligible patients, and the team recognized a need to optimize processes to expand the program. In addition to expanding the patient census, the team envisioned increasing employee engagement and empowering staff to drive change. Multiple improvement strategies were implemented to meet all goals and can serve as an example applicable to any patient care practice. This session will provide insight into how improvement tools can be used in combination to maximize buy-in and benefit. The example walks through phases of work that included qualitative interviews, root cause analysis, value/non-value-add analysis, swim lane diagrams, brainstorming, a priority payoff matrix, and tracking ownership and timelines for completion.

After this presentation you will be able to:

1. Identify the value of process improvement tools to structuring a large redesign.
2. Describe the synergy created when using multiple improvement tools.
3. Describe how to implement a coordinated approach to process redesign using multiple improvement tools.

Improved patient flow increases the safety and quality of care. Across the state of Victoria, Australia, significant access and patient flow issues have been experienced in the face of rising demand. A partnership between Victorian government agencies and health care providers sought to improve timeliness of access to emergency care through a systemic focus on patient flow. In this session, participants will learn from Safer Care Victoria’s experience implementing patient flow partnerships over a three-year period, which resulted in 50,000 more patients achieving timely access to emergency care. It will discuss appropriate lower-level process metrics, capability development for improvement, how to get the most out of partner services, building will, sustaining change, and continuous improvement.

After this presentation you will be able to:

1. Identify the key components and design principles of a state-wide patient flow partnership.
2. Explain how to diagnose and address common challenges of the partnership model.
3. Evaluate how Safer Care Victoria’s approach can be tailored for future partnerships.

In Radboudumc, one of the biggest academic hospitals in the Netherlands, we had 25 units that were each responsible for their own bed planning. Every day, some units had a shortage of beds, and some units had beds available. In the units with a shortage of beds, doctors and nurses spent a lot of time trying to fix the problems as they occurred. There was no overview of bed usage and availability, and there was no coordination between the different units. This led to delays, off-service patients, and regular last-minute cancellation of treatments. In June 2018, Radboudumc implemented IHI's Real-Time Demand and Capacity Management (RTDC), an administrative system that matches the supply of beds to the demand for beds across the hospital. To implement this system, we used IHI's reliability design principles such as segmentation, standard work, small tests of change, and rapid data collection.

After this presentation you will be able to:

1. Recognize the power of RTDC to improve flow in your hospital.
2. Learn how to apply reliability design principles to successfully implement RTDC or tackle other improvement projects.

Why do some innovations spread faster than others? At Ariadne Labs we create scalable solutions to improve health care delivery. We have identified challenges for spreading innovation, including understanding organizational readiness for change, such as leadership commitment, capabilities, teamwork, and culture. We built a context-assessment tool to improve the likelihood of successful implementation of health innovations. Implementation and research teams need a context-assessment tool to better identify where and when to implement, as well as to inform design and support of their implementation efforts to reach more facilities and providers effectively and efficiently.

After this presentation you will be able to:

1. Describe the root causes of barriers to scaling health system innovation.
2. Identify ways that health systems can successfully implement innovations.
3. Explain how Ariadne Lab’s Context Assessment Tool can serve as a resource to help successful implementation.

A key issue that prevents clinicians from achieving joy in work and delivering harm-free care is excessive workload. Scotland has recognized this and addressed the issue head on, through legislating for health and care staffing. The legislation ensures suitably qualified staff in such numbers to provide high-quality care and improve health, well-being, and safety of the people they serve. It is not about ratios: It is about using a set of tools and methodologies to identify the needs of service users and define the associated workload and skill set required to meet those needs. In the session, we will use case studies and research to describe the impact excessive workload has on staff and service users; discuss the legislative approach; demonstrate tools and methodologies, including use of quality measures; describe monitoring and governance; and demonstrate linkage to Scotland’s approach to quality and safety. Participants will gain understanding of the approach and knowledge of tools and methodologies that may be applied in their setting.

After this presentation you will be able to:

1. Describe the impact of excessive workload on the health, well-being, and safety of the clinical workforce and the association between excessive workload and harm to patients.
2. Implement key components of workload tools and methodologies to better assess workload and plan required staffing and skill mix to reduce harm.
3. Explain the impact of legislative solutions to achieve improvement in quality, safety, and well-being for staff and service users.

How can an organization engage senior leaders and board members in safety and quality? Over the past several years, our board has visited care delivery sites, with rewards for both leadership and frontline staff. Themes included high reliability, patient experience, and community benefit, with visits to inpatient units, outpatient satellites, the emergency department, and more. New dynamics have inspired staff, changed the conversation at board meetings, and increased our Culture of Safety score.

After this presentation you will be able to:

1. List components of a plan for board and non-clinical engagement in safety and quality.
2. Identify the relationships between safety and quality and the role of the board.
3. Describe a safety matrix that supports escalation of events (e.g., patient, employee/staff, and enterprise) to senior management and the board.

Students and residents across health professions are building a movement across campuses, communities, and clinical settings to tackle pressing challenges. To achieve systems change, organizations can prioritize efforts to engage rising leaders and build their quality improvement skills. Based on key learnings from more than a decade of leadership of large-scale mobilization efforts, the IHI Open School and select network leaders will share a roadmap for building community and sustained engagement in quality improvement.

After this presentation you will be able to:

1. Identify and measure important elements for building community and quality improvement capability in the next generation of health care leaders.
2. Describe strategies to implement core elements of quality improvement and community organizing frameworks to build intrinsic motivation, engage key stakeholders, build momentum for change, and produce meaningful results.
3. Explain approaches to co-designing work with students and residents across health professions to implement both small and large-scale community and action-oriented improvement efforts.

How do organizations move toward population-based care for the entire spectrum of patients within their practices when reimbursement models often run counter to population-based efforts? This session will provide a real-world example of how Brigham Health Primary Care negotiates that complexity, while making the journey from individual-based reactive care to team-based proactive care. This session will describe Brigham’s efforts to create programs to support closure of gaps in care, high-risk care management, implementation of the IMPACT model for behavioral health, social determinants of health screening and management, and practice redesign in support of team-based care. While your world may differ from Brigham’s dramatically, these programs and initiatives can be scaled and scoped to meet your local context.

After this presentation you will be able to:

1. Explain practice contexts and their impact on clinical practice models.
2. Explain general principles of population management.
3. Apply operational elements of specific population management programs or practice capabilities for use at home.

How do you build a quality improvement model that honors all stakeholders and all needs? How do you incorporate cultural transformation and Lean thinking? Payer needs? Provider needs? Patient outcomes? Revenue? Employee experience? Regulatory requirements? The perfect textbook answer is: Quality structures baseed on the IHI Triple Aim are emerging drivers of reimbursement, with deep impact particularly for primary care practices engaged in successfully moving with their payer partners away from fee-for-service models and increasingly toward value-based ACO and shared savings payment structures. The reality is: We make mistakes. (But we learn from them, which is truly wonderful. More on that later!) Our experience shows the key to success is aligning quality measures across payer contracts and within a balanced scorecard construct, allowing for a maximal return on resource investments.

After this presentation you will be able to:

1. Participants will understand the role and value of a balanced scorecard methodology in promoting clinical quality and financial success within a primary care delivery system.
2. Participants will be able to articulate 3 strategies for successful implementation of an integrated quality/payment improvement model.

With shifting reimbursement paradigms, health care organizations must redesign care, but clinicians may not have the necessary financial information or skills. In developing home-based acute care options with Accountable Care Organizations (ACOs), we created tools to use current reimbursement structures and identify gaps in payment and impact on patients’ out-of-pocket expenses. These tools assisted ACOs in reaching clinically and financially optimal outcomes, including hospital and emergency department utilization, cost of redesigned care, safety, and satisfaction.

After this presentation you will be able to:

1. Identify strategies for mapping the cost and reimbursement for redesigned home-based care pathways.
2. Identify the interactions between care that is reimbursable, care that requires out-of-pocket costs to patients, and payment gaps.
3. Describe ways to change the paradigm regarding frontline healthcare clinicians understanding of cost and reimbursement to achieve high quality lower cost care models.

With the increased emphasis on value-based care and bundled payments, there is an expanding role of transitional care services and outpatient care navigation for patients who were recently hospitalized. These services help improve care and reduce the rate of readmission, but inevitably some patients still wind up back in the emergency department (ED). Often the ED provider is unaware of available outpatient services that would allow for the safe discharge of a patient who might otherwise be readmitted. We have developed a readmission collaborative to improve ED communication in order to increase the rate of ED discharge. The improvement has been successfully implemented across 10 hospitals with an increase in the rate of ED discharge for patients with transitional care management after index hospitalization.

After this presentation you will be able to:

1. Describe how to develop a standardized communication approach for patients in the ED with outpatient care navigation services.
2. Explain how to create educational material for ED providers regarding outpatient care navigation services and support.
3. Prepare to collaborate with inpatient provider teams to create a pathway for ED patients with recent hospitalizations.

Conversations about rising health care costs increasingly focus on the burden on patients and families. If, as Dr. Paul Batalden’s said, “Every system is perfectly designed to get the results that it gets,” how can we change the outcome? Several opportunities exist for health care organizations to effect change both at the system level and through advocacy at the policy level. Learn how organizations can address major drivers of financial toxicity among patients and employees.

After this presentation you will be able to:

1. Identify the primary drivers of financial toxicity experienced by patients in your system, including your own employees.
2. Learn how one system created a “win” for the system and for patients by reducing the financial burden borne by patients.
3. Describe components of an action plan to test within your organization.

Accountable Care Organizations can be quite complex, and not all are achieving the desired reductions in cost while improving quality and the personal experience of care. At Southcentral Foundation (SCF), an Alaska Native customer-owned and managed system that runs the two-time Baldrige award-winning Nuka System of Care, the answer has been a highly capable primary care system that brings almost everything to the individual and family through integration and co-location. SCF has made a huge investment in people and system capability, leading to dramatically reduced total cost through less lab, radiology, pharmacy, specialist, and hospital use This session will show how SCF’s entire system has become a true ‘learning organization’ with insatiable curiosity and innovation aligned with the deeply embedded corporate culture built from a customer-driven design.

After this presentation you will be able to:

1. Describe the ways in which SCF uses integrated care teams, with primary care as the hub, to provide care for customer-owners.
2. Develop methods for building integrated systems based on SCF’s system of integrated care.
3. Identify the benefits of SCF’s integrated, primary care-centric system, including improved health outcomes and increased customer satisfaction.

One component of persistent inequity in access for minority populations is the lack of palliative care teams in many safety net hospitals. The IHI Test of Respect (TOR) tool measures care that respects a person’s values and goals. In a safety net hospital in an area with a racially segregated, largely African American population, a retrospective review of deaths of patients from the area found higher average TOR scores among patients who had seen a palliative care team member.

After this presentation you will be able to:

1. Describe how to implement the Test of Respect tool as a quality metric to reflect equitable care that respects values and goals of all persons that are end of life.
2. List strategies to create equitable access to care in the seriously ill by establishing palliative care teams in safety net hospitals.

How can we be more person-centered in our work? How will we measure success? This interactive session, co-led by people with lived experience and practitioners from the SCALE Initiative of 100 Million Healthier Lives, will provide a framework and practical toolkit for a variety of health and health care settings. Using an equity lens and real-world examples, this session will help participants examine their organizations’ efforts and offer opportunities to try methods to engage community members, improve outcomes, and reduce inequities.

After this presentation you will be able to:

1. Examine where your organization/health care system is along the continuum of co-design and co-implementation.
2. Practice applying the Community of Solutions Framework and an equity lens to identify areas for improvement in working with people with lived experience.
3. Describe how to apply new skills that create space for co-design with stakeholders at all levels (including individuals with lived experience) to programs, processes, and systems.

Coordinating behavioral and physical health care for families with children ages 0–5 has been a challenge for those who live Pueblo, Colorado, one of the state’s most impoverished neighborhoods. Parents are dealing with multiple entities who, in the past, had little reason to harmonize efforts for individual families or the broader community. Launch Together has been improving the coordination of behavioral and physical care for young families by bringing together primary care, behavioral health organizations, home visiting groups, child care and educational agencies, public health, and child advocacy organizations to create seamless referral loops that improve outcomes for Pueblo’s most needy children. In this session, Launch Together team members will describe how tools such as IHI’s Psychology of Change white paper and the Model for Improvement have helped them create successful momentum in improving the lives of Pueblo’s neediest families and how other communities can combine IHI tools to make changes to take a “two-generation” approach to improving community well-being.

After this presentation you will be able to:

1. Describe an example of the use of IHI’s Psychology of Change for communities and organizations to emulate.
2. Discuss how health equity can be pursued beyond the typical walls of the health care ecosystem.
3. Describe methods to improve the social and emotional well-being of children ages 0-5 using quality improvement tools and a cross-sector approach.

There is growing interest in health and well-being, a holistic, person-centered outcome of the Triple Aim. This session will provide you with tools and guidance for measurement for both patients and communities. In addition to health, well-being is prominently featured in several national measurement frameworks; however, there is lack of clarity about what well-being is and few practical and accessible tools to measure it. In this session we will share a conceptual measurement framework, the adult and youth well-being assessments that were developed for the 100 Million Healthier Lives (100MLives) initiative, and results from HealthPartners’ population health and well-being measurement initiative. We will share our experience using some of these instruments to date, and the new understanding we have of the health burdens, behaviors and well-being of certain populations. We will share the 100MLives "Measure What Matters" and HealthPartners Summary Measures of Health and Well-being platforms that you can use to implement, report and share well-being assessments, including guidelines for sampling and measuring health and well-being, as well as a platform for implementing, reporting and sharing results. This session will be of value to your organization and your communities as you develop summary measures of population health and well-being.

After this presentation you will be able to:

1. Implement valid methods to describe and quantify the health and well-being of populations cared for by your health care organization
2. Incorporate well-being measures and instruments into your strategic planning efforts
3. Access a platform to implement, report and share your population health and well-being results

School districts and other educational institutions are realizing that they cannot meet all the needs of every student alone. In order for every child to reach their fullest potential, educational institutions have begun to rely on the support of cross-sector partners. In doing so, they are able to accelerate their progress towards improving outcomes for kids. StriveTogether, a collective impact organization that specializes in cross-sector work in over 60 communities across the US, is working to solve complex problems and transform the educational system to produce more equitable outcomes for children, cradle to career. To move outcomes for children these cross-sector teams have shared goals, commitment to data for learning and improving, and use rapid cycle improvement methods to accelerate their work. This session will highlight StriveTogether’s collaborative improvement methodology that combines essential continuous improvement tools with change management and design thinking techniques. Attendees will learn how StriveTogether has utilized IHI’s breakthrough series to execute impact and improvement networks and other continuous improvement practices that has resulted in improvement in prenatal to age three development, third grade reading proficiency and high school graduation rates.Learn about the critical role healthcare professionals and organizations have in collective impact work including the story of Cincinnati Public Schools who worked collaboratively to increase reading proficiency with Cincinnati Children’s Hospital.

After this presentation you will be able to:

1. Participants will describe the benefits of collective impact and the collaborative improvement methodology.
2. Participants will examine the role healthcare and other cross sector partners play in advancing educational outcomes and discuss how this relates to their local community.
3. Participants will identify how a lens of equity is embedded and applied by practitioners and compare to their work.

High quality maternity care is guided by the best available research and implemented using improvement science principles. Quality improvement bundles provide a structured way of improving processes of care and health outcomes. This session describes the outcomes and lessons learned using QI bundles from a U.S. maternity quality collaborative aimed at reducing the rate of primary cesareans in low risk women and a Nationwide QI Collaborative aimed at reducing the rate of severe perineal trauma in Australian women.

After this presentation you will be able to:

1. Describe the design and effective use of QI bundles in two large-scale maternity quality Collaboratives
2. Become familiar with the core leadership skills to initiate and lead a QI improvement project
3. Recognize the qualities of effective teams, best practices for team formation and management

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This session will discuss our study that assesses the frequency and types of harm in a representative sample of Massachusetts institutions today, covering both inpatients and outpatients. We will share an approach that institutions can use operationally to assess the frequency of harm in an ongoing way, which leverages new harm detection approaches and electronic health records. We will share case examples from our experience developing the framework and tools, as well as advances in methods of assessing harm since the Harvard Medical Practice Study (HMPS) transformed medicine’s view of patient safety 30 years ago. We will review the use of consensus panels and electronic surveys to compare different methods of safety measurement, the development of an electronic data collection tool for chart review, and the use of an application for real-time adverse event surveillance with electronic health record data.

After this presentation you will be able to:

1. Describe a framework to identify and prioritize the triggers and measures of patient harm that are most relevant to your institution in real time.
2. Compare and contrast contemporary methods for real-time adverse event surveillance.

For clinicians and quality leaders, we provide a framework for deprescribing diabetes medications in older patients. This framework includes patient case studies and a toolkit for potentially difficult deprescribing conversations. We will share 1-year clinical outcomes of our program, which was associated with a potential survival benefit and a reduction in hypoglycemia while maintaining glucose control. In this session, we will discuss our journey to creating a dedicated deprescribing service with pharmacists and physicians.

After this presentation you will be able to:

1. Identify two challenges in deprescribing and methods to overcome those challenges.
2. List deprescribing opportunities which you will seek to recognize in your practice.
3. Describe behavioral science approaches to having a deprescribing-related conversation with a provider or patient.

Scotland is a small country, with 55,000 births per year, so 274 stillbirths in one year — which was the case in 2012 — was a lot in this context. In response, the Chief medical Officer for Scottish Government gave the Maternity and Children's Quality improvement Collaborative (MCQIC) this aim: Reduce stillbirth by 15 percent by 2015. Using approaches that will be discussed in this session, such as building improvement capacity in the system and focusing on a few to impact many, MCQIC contributed to a 23 percent reduction in stillbirth from 2014, surpassing the goal. Data is submitted to the MCQIC team via run charts where it is aggregated and analyzed. Boards are supported to understand their own data.

After this presentation you will be able to:

1. Identify methods to successfully lead large-scale improvement.
2. Describe clinical improvements related to fetal movement that can reduce stillbirth rate.
3. Describe common challenges of leading large-scale improvements.

There are proven interventions used to reduce medication-related harm and a growing body of knowledge that supports the application of these changes to produce desired outcomes. However, there are also system-level bottlenecks that prevent the ‘copy and paste’ approach to implementing interventions from one setting to another. IHI’s Africa Hospital Patient Safety Initiative has approached this problem by leveraging several layers of stakeholder engagement and strategically selected interventions to adapt proven frameworks in three countries: Ethiopia, Ghana, and South Africa. Teams were developed at all levels of the system to support implementation, and technology was tested to facilitate real-time coaching and feedback. Additionally, dosing models were tested in each country to identify effective and efficient capability building interventions.

After this presentation you will be able to:

1. Describe how context must be considered when designing improvement efforts in different parts of the world.
2. List the steps to building a meaningful set of measures to track change and improvement.
3. Describe the critical factors to building a culture of improvement in the context of rural settings.

Physical and verbal violence toward health care workers has no place in the healing environment of the hospital; yet, according to the Occupational Safety and Health Administration (OSHA), approximately 75 percent of nearly 25,000 workplace assaults reported annually occur in health care and social service settings. Participants in this session will learn how to build a comprehensive program to decrease workplace violence, applying strategies that will protect their workforce and the community and developing a safety roadmap to enact best practices and innovations. Participants will explore the Connecticut hospitals’ Safer Hospitals Initiative, which keeps health care organizations safer by stopping violence before it begins. The initiative has identified strategies to create a culture of safety that highlight the principles of high reliability and represent a multifaceted approach for successfully combating violence at all levels of an organization.

After this presentation you will be able to:

1. Describe innovative strategies designed to decrease the incidence of violence in health care by utilizing high reliability principles and practices.
2. Identify specific workplace violence strategies that will protect your workforce and the communities they serve both at the macro- and micro-system level.
3. Develop a Safety Implementation Roadmap to bring best practices and innovations to combat incidences of violence to your organization and beyond.

The need for rapid and sustainable change in health care is urgent. IHI's Breakthrough Series (BTS) Collaboratives provide a powerful tool for spreading improvements when established design principles are used and common pitfalls are avoided. This interactive session covers topic selection, change packages and measurement systems, engaging teams, and running robust learning sessions and action periods. We will use examples of Collaboratives from around the world on a variety of topics. This session shares didactic information about the BTS methodology along with interactive exercises.

After this presentation you will be able to:

1. Apply established design principles for successful BTS Collaboratives.
2. Diagnose and address common challenges in using the BTS method.

Patients on the same medication do not all receive the same dose. Why, then, should we expect that the same dose of the science of improvement will be appropriate for all individuals within an organization? This session's presenters will explain IHI’s dosing approach and how it can be used to build capacity and capability for improvement. Dosing strategies will be offered, and case studies will be used to demonstrate how the dosing approach can be applied successfully in organizations of different types and sizes.

After this presentation you will be able to:

1. Describe the IHI dosing strategy and related implementation.
2. Provide examples and case studies of how the dosing approach has been successfully applied in organizations of different types and sizes.
3. Explain how the dosing approach can be applied to your organization.

The rate at which improvement spreads relies at least in part on the people who are implementing the change in practice. IHI's Psychology of Change Framework helps leaders at all levels focus on the people advancing improvement efforts: the way that we think and feel, what motivates us, and how we behave when we encounter change. This session features U.S. and global examples and engages participants in developing pragmatic ideas to apply to their improvement context in response to people’s resistance and other adaptive challenges.

After this presentation you will be able to:

1. Attendees will be introduced to three key mindsets for working with people’s resistance to change
2. Attendees will explore IHI’s psychology of change framework and examples of its highest-leverage tools and methods
3. Attendees will be able to identify at least one tool or method that can be applied to their current work during or after the session

The United States population of people over 65 years is expected to double by 2030 to over 74 million. Is your health system asking older adult patients What Matters? Are you using an evidence-based framework to organize the complex care many older adults need? Older adults present as patients to our hospitals and ambulatory care practices every day and very often a geriatrician is not available to guide their care. The Age-Friendly Health System (AFHS) initiative, founded by The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA), developed an evidence-based framework to organize the care. The 4Ms Framework of Age-Friendly Health Systems is based on the evidence-based pillars of What Matters, Medication, Mentation and Mobility. The 4Ms provide a foundation, upon which to build excellence in the care of older adults. In this session, you will learn lessons from inpatient hospital and ambulatory care teams putting the 4Ms into practice. The CVS MinuteClinic planning journey will lead participants through the planning phases of this large-scale improvement initiative. They will share tools, including workflows, Quality Improvement Tools and EHR changes and their implementation map, to inspire you to begin implementing the 4Ms Framework of an Age Friendly Health System in your practice setting. Maine Health will share the Data Reporting and Key Performance Indicators used to identify barriers, track milestones, and ensure sustainability of the model in various settings. The destination of success will include a preliminary plan that participants can take back to start their journey of achieving Age-Friendly Health Systems.

After this presentation you will be able to:

1. Identify the components of 4Ms Framework of Age-Friendly Health Systems
2. Learn to utilize data to identify 4Ms strengths and gaps
3. Be able to identify at least two improvement strategies for creating successful workflows aimed at implementation of the 4Ms
4. Begin development of an implementation plan for Age-Friendly Health Systems

Health disparities and their root causes are the most glaring, unresolved problem in American health care. Navicent Health and Atrium Health, two large health systems, have each been recognized for their health equity work, Navicent as a 2018 American Hospital Association Equity of Care award winner and Atrium as an Honoree. In this session, they will share examples of the various processes implemented to identify disparities, prioritize what to address, develop interventions, and measure impact for target populations. Each health system engaged multi-disciplinary internal partners to develop data dashboards, and, more importantly, each health system engaged multi-sector partners in the community to address the root causes of disparities. The importance of leadership support and alignment to system-level strategy to develop the infrastructure and process to support the work will be discussed.

After this presentation you will be able to:

1. Identify health outcome disparities by various patient populations.
2. Explain the impact of the social determinants of health that drive adverse outcomes.
3. Describe how to implement and evaluate a comprehensive Equity of Care program.

Using an interactive panel format, this session will showcase two recent projects focused on building health equity in clinical and community settings. One, led by a team at Massachusetts General Hospital, aimed to address racial and language disparities in patients’ experiences of the transition from hospital to the community. The other, co-led by Kaiser Permanente and the American Heart Association, sought to address disparities in blood pressure control among African Americans in a nationally supported, locally-led effort, with pilots in San Diego and Atlanta. Panelists will discuss (1) the value of authentic stakeholder engagement and trust building, (2) the role of data in prompting collective action and assessing ongoing progress toward goals, and (3) the importance of intervening at multiple levels simultaneously, from small, simple interventions to large system changes. The discussion will illustrate that reducing and ultimately eliminate health inequities will require collaborating with diverse stakeholders and recognizing the iterative, incremental nature of progress. Importantly, critical process achievements – such as development of trusting relationships among collaborators – can be difficult to measure and quantify. The case studies and conversation, revealing key strategies and lessons learned, will highlight how a shared commitment to health for all inspire and spark organizational and community capability building.

After this presentation you will be able to:

1. Understand the importance of trust building as a foundation for building health equity in diverse clinical and community settings
2. Appreciate the value and challenges of collecting and using quantitative and qualitative data to build consensus and informed decision making
3. Learn how a spectrum of intervention strategies can be applied in real-world contexts to support health equity improvement

It can take weeks or months to plan a QI project; doesn’t it make sense to spend time developing a plan to communicate with important stakeholders to help ensure its success? Just as any viable QI initiative should have a measurement strategy, teams should have a communications strategy to mobilize the will to change, convey the ideas and evidence needed to accelerate improvement, and support the execution and spread of effective interventions. Drawing upon more than a decade of experience, session presenters will share a QI communications framework designed for use by even non-communications professionals from any health care discipline. Using case examples from multiple countries, they will provide tips, describe how to prevent common pitfalls, and help participants get started on developing their own communications plan.

After this presentation you will be able to:

1. Provide at least three examples of how to use the QI communications framework to accelerate quality improvement.
2. Describe why just as every QI initiative should have a measurement strategy, it should also have a communications strategy.
3. Develop the start of a plan to use communications to advance quality improvement work, including a small test of change.

Going beyond a local system to create a dispersed learning network allows for a wider pool of people and ideas. This requires a virtual knowledge commons or Learning Exchange to support sharing across distance and time. Quality team members, patients, family, physicians, and researchers will discuss challenges and successes. Attendees will learn user-centered design principles for developing a Learning Exchange, the importance of continuous evolution, and the benefits of a shared platform.

After this presentation you will be able to:

1. Describe three key requirements to building a geographically dispersed learning network.
2. Identify three benefits to a virtual knowledge exchange and common data structure to accelerate innovation and adoption to improve care.
3. Apply principles of community and user centered design to an iterative, co-creation process for designing a knowledge exchange.

Virtual collaboration fuels large scale improvements, enabling us to involve more people, engage patients and families in a less daunting way, involve colleagues without taking them from their jobs, increase diversity, and make better decisions. We will share case studies from our virtual collaboration work with thousands of frontline staff and patients across the English National Health Service, through which we built shared purpose, accelerated outcomes, slashed travel costs and environmental impact, and improved care.

After this presentation you will be able to:

1. Describe familiarity with the core principles of virtual collaboration and understand how it can be combined with other approaches for faster, better outcomes.
2. Identify how diverse groups in the virtual space can take ownership for generating ideas, solve problems, agree direction and plan actions.
3. Develop a sense of how virtual collaboration methods could be applied in your own setting.

A growing awareness of preventable maternal harm stems in part from striking racial inequalities in outcomes in the United States. High-volume delivery centers in Washington, DC and Detroit have partnered with community organizations and individuals. They codesigned services which build trust and improve outcomes. This work is based on critical quality improvement principles: that those most affected by the delivery system possess a wealth of change ideas, and that communities possess key assets for improvement.

After this presentation you will be able to:

1. Describe current inequitable maternal health care experiences within delivery systems.
2. Identify principles of humble and respectful co-design within health care systems and community stakeholders.
3. Examine the method and application of gathering and testing ideas that the Washington, DC and Detroit communities are applying in their journeys.

Communicating ideas and making decisions both require effective visual displays. Analytic challenges for improvement include identifying trends, patterns, or relationships in data and analyzing sources of variation. We will present graphical methods for different types of improvement studies with an emphasis on time series methods that afford a whole-system view, including underutilized Shewhart control charts. Using practical examples, we will highlight key principles for quality improvement teams and challenge participants to critique and design graphics.

After this presentation you will be able to:

1. Identify appropriate charts and other data visualization tools given various improvement objectives, study designs, and available data sources.
2. Recognize basic principles of graphical excellence in a quality improvement context and best practices to communicate data with compelling clarity and efficiency.
3. Describe insights about Shewhart control charts as a fundamental method for analyzing data and communicating information in quality improvement studies.

Reducing opioid use is a complex problem that requires tailored solutions. Traditional quality improvement methods facilitate context-specific changes. Implementation science provides tools to increase uptake. We used a new framework, the Model for Improvement and Implementation (MFII), which systematically integrates both approaches. Through the MFII, we implement an intervention to reduce surgical prescribing of opioids. This framework to identify barriers and strengthen support for implementation is applicable to other complex issues.

After this presentation you will be able to:

1. Describe the interface between improvement science and implementation science.
2. Explain how to apply the Model for Improvement and Implementation to daily practice.
3. Identify crucial factors addressed in the implementation of a complex intervention to reduce opioid prescribing.

Health care leaders know that for their organizations to successfully adapt to the rapidly changing payment and service landscape, they need a motivated, engaged, and productive workforce — a workforce that finds joy in work. Fostering joy in work is about creating systems that promote staff engagement, satisfaction, and resilience. This should be a shared responsibility of caregivers, leaders, and organizations. To that end, IHI faculty will be sharing tested models for co-producing joy with staff through the IHI Framework for Improving Joy in Work and examples of leadership models and improvement methodologies known to nurture joy in work.

After this presentation you will be able to:

1. Describe key leadership behaviors that raise staff engagement and restore joy.
2. Identify key system changes to improve joy in work.
3. Take away at least one distributed leadership model you can use to co-create joy in your workplace.

A culture characterized by respectful behavior is essential to remarkable patient and team member experiences and quality care. This session describes how an organization can foster respect, equity, and inclusion through a comprehensive program including listening sessions and learning events. Focuses include the role of leadership and the impact of “second-hand” respect on observers. Health care leaders, clinicians, board members, and educators will benefit from stories, case examples, tools, and methods to measure results.

After this presentation you will be able to:

1. Describe how an organization can develop an integrated program to build a culture which fosters respect.
2. Identify the impact of “second hand” respect or disrespect on others who witness and experience it.
3. List ways to measure changes in an organization’s culture of respect.

This fun-filled session will use case studies to describe learning from three healthcare systems focused on improving the experience of all staff groups and enhancing joy in work at scale; utilizing quality improvement science and the IHI’s joy in work framework. With demand on our health and care systems increasing and new resources remaining scarce, there is growing evidence of burnout amongst healthcare providers. This session will show you how it is possible to enable staff to feel a sense of autonomy and control over the system in which they work; to own the efforts to improve their daily experience of work through the use of systematic quality improvement techniques; and to use the rigor of improvement science to test and measure in the pursuit of improved joy in work. You will leave this session with practical examples and inspiring stories from three different healthcare systems across the globe, providing you with ideas, tools and motivation to get you started on your own joy in work journey.

After this presentation you will be able to:

1. Understand and explore the underpinning components of joy in work at individual, team and system level
2. Appreciate how three healthcare systems across the globe are focused on finding and creating joy in work
3. Describe practical next steps in using the science of improvement to find and create joy in work in their own system

Quality continues to grow as a strategic priority for health care organizations, and the role of Chief Quality Officer is emerging to lead it. What does it takes to lead quality at a system level. Join the faculty of the IHI CQO Professional Development Program to learn five strategies for meeting the ongoing challenge of leading quality across a system.

After this presentation you will be able to:

1. Define the evolving role of chief quality officers
2. Describe five strategies for leading quality across the system

With a growing emphasis on quality, a more integrated approach to quality management is needed. Twenty years ago, Cincinnati Children’s Hospital Medical Center (CCHMC) set out to become the leader in improving child health. The organization has progressed through developing improvement capability, high reliability, microsystem leadership, distributed expertise, partnership with the community to address disparities, and now a culture of empowerment. This session will share lessons from CCHMC and the IHI Quality Management System Framework.

After this presentation you will be able to:

1. Describe the Quality Strategy and Quality Management System frameworks.
2. Describe the quality transformation journey of a leading healthcare organization and how it relates to your work.
3. Identify ways to apply the CCHMC journey and frameworks to your own efforts to lead and manage quality.

Leading and managing a health care delivery organization is often like drinking from a fire hose. Leaders need new skills and ways to focus their efforts to deliver results. Providence St. Joseph Health is committed to developing leadership systems to shape culture and deliver Triple Aim results for populations. We will explore strategies to develop leadership capability as well as how the IHI High-Impact Leadership Behaviors have been used across a complex integrated delivery system.

After this presentation you will be able to:

1. Describe the organizational development strategy deployed at Providence St. Joseph Health to develop clinical and administrative leadership competencies.
2. Describe how the IHI High-Impact Leadership Behaviors are translated and deployed in daily work within the Providence St. Joseph Health delivery system.
3. Identify the challenges of building leadership capability across a system and lessons learned.

This session will engage participants in a robust dialog around key drivers identified by the IHI Alliance for “Reducing BIG Waste” — both those achievable in the shorter-term where you work and practice, as well as through longer-ranging solutions to address this “gnarly opportunity” across the US healthcare system. The IHI Leadership Alliance is a dynamic collaboration of leaders from 44 diverse health care organizations united by a common mission — to work with one another and in partnership with our patients, workforces, and communities to foster “Care better than we've ever seen, health better than we've ever known, at a cost we can all afford...for every person, every time”. Over the past two years, members have been collaborating to answer the question: If health care systems, providers, and payers could collectively “write a check” back to the American people and return the money, where could substantial savings come from and how much could be saved, redirected or returned? The team will share this new Driver Diagram, review the compilation of a “checkbook” now totaling over $1 trillion annually of waste reduction opportunities, and present a call to action to local organizations, partnerships and advocacy efforts for health care reform and redesign needs. This session will offer attendees insights from leaders from two participating Alliance organizations, and the opportunity to learn from their local and shared IHI Alliance experiences in creating a common language, working across shared platforms, and achieving substantial cost savings while improving quality through strategic alignment and partnerships.

After this presentation you will be able to:

1. Demonstrate local health system adoption of key strategies to reduce non-value-added waste.
2. Develop strategies for forming successful collaborative partnerships for action in local, state, and national communities to address more complex waste opportunities.
3. Provide a provocative call to action for advocacy for health care reforms and redesign needs to address regulatory, legislative, and other systemic barriers to returning the money.

This session describes actionable tools and approaches that Accountable Care Organizations (ACOs) have developed for implementing care delivery improvements in a value-based payment environment. It will highlight: The Care Coordination Toolkit, the first in a series of publicly-available ACO Toolkits from the Centers for Medicare & Medicaid Services (CMS) that describes strategies to improve collaboration across care settings; seven case studies delving into ACOs’ experiences developing and implementing successful initiatives to improve care delivery; and presentations and discussions from ACO-affiliated participants that engaged in more than 50 in-person meetings across the country to consider innovative solutions to pressing challenges.

After this presentation you will be able to:

1. Develop strategies to improve health care outcomes and patient experience within a value-based payment environment.
2. Harness Medicare ACOs’ experiences and tools to improve the quality and value of care delivery.
3. Identify next steps to engage key stakeholders in your organization to increase care coordination and collaboration.

Cambridge Health Alliance (CHA) is a vibrant, innovative health system providing essential services to more than 140,000 patients north of Boston. When the Psychiatry Department identified barriers to care (including long wait times, extensive waitlists managed through cumbersome processes, decentralized scheduling, and low slot utilization — all resulting in poor patient care), the team embarked on a 2-year Lean framework effort to streamline the referral, triage, and scheduling processes for improved access. This session will reveal how improvement methods and qualitative and quantitative analyses were implemented at an organizational level to achieve transparency, buy-in, and sustainability for a patient-centered model for equitable care across CHA. Participants will gain a comprehensive understanding of how to use Lean and improvement methodologies in resource-limited settings to assess system failures and identify opportunities to improve operations to meet population health management objectives for system-wide transformation.

After this presentation you will be able to:

1. Assess system failures and gaps that impact timely, reliable, and appropriate access to care.
2. Identify opportunities for improvement in transitions of care, referral management, network development, and population management.
3. Learn from the successes and challenges of implementing system-wide transformation initiatives for population health.

Coproduction theory argues healthcare is not a product delivered to patients, but a service co-generated by the health care system and the people engaged in care. We have modified a value creation framework to develop a coproduction model for health care. The International Coproduction of Health Network launched a Community of Practice (CoP) of stakeholders to optimize the model and research a new assessment approach. We will share CoP case studies and conduct assessment simulations.

After this presentation you will be able to:

1. Define coproduction of health care service and differentiate coproduction assumptions from those of traditional health care delivery models.
2. Describe the core components of the International Coproduction of Health Network (ICoHN) prototype value model and discuss this as an example of a coproduction value creation model for health care operations.
3. Identify value-creating coproduction activities using the new prototype value creation model in different contexts based on case studies derived from ongoing development work in the ICoHN coproduction value creation CoP.

The Clinical Redesign (CRD) method an innovative framework built on the Model for Improvement to drive value-focused improvement in evidence-based care delivery through rapid-cycle (90 day) projects at any size hospital or health system. CRD has evolved from a small team to a system-wide improvement engine; since April 2015, we have completed over 220 projects. Examples include reducing opioid prescriptions, removing wasteful inpatient laboratory testing, and incorporating real-time data in patient-centered clinical operations.

After this presentation you will be able to:

1. Identify the essential elements and structure needed to improve operational pain points within 90 days and sustain success long term.
2. Identify matrix relationships within their organizations and develop plans to leverage collaboration to promote change.

Patients who frequently utilize the emergency department (ED) are among the most resource-intensive patients to manage – and the most vulnerable. Our work focuses on multi-visit patients (MVPs), a more patient-centered term than “super-utilizers.” Multidisciplinary efforts to address medical and non-medical needs through an individualized care coordination plan reduced total ED visits, ED admissions, and 30-day readmissions. Our approach for MVPs has implications for hospital capacity while improving care for a population often left behind.

After this presentation you will be able to:

1. Explain the process for creating a care coordination plan for a patient.
2. Describe the importance of understanding each patient’s needs and acting upon them in order to impact utilization.
3. Identify innovative ways to keep patients out of the ED and the hospital.

In order to improve quality and to deliver value along with volume,a systems approach is required to create an exceptional experience for patients. By seeing the entire episode of care through the patient’s eyes and identifying the people and places that they encounter through their journey, a Hospital Within a Hospital (HWH) and Focused Care Centers (FCC) can be built. Focused Care Centers (FCC) allow for the development of high-performance clinical teams that deliver care for a specific disease. The aggregation of many FCC into a HWH ensures the coordination of inpatient and outpatient pathways to ensure optimal outcomes and experience for patients and staff alike. FCC enable innovations that result in value driven changes but also permits providers the ability to easily “scale up”. The combination of FCC and the Patient Centered Value System (PCVS) brings together all of the people and processes in one place, allowing the focus to be the experience and not just the clinical services. This maximizes the efficient utilization of health care resources to benefit patients. Hear outpatient, inpatient, surgical and diagnostic testing-based examples from the UPMC Bone and Joint Center of how to create, maintain and spread a standardized care model without sacrificing quality or cost.

After this presentation you will be able to:

1. Describe the stepwise process to build a focused care center.
2. Identify ways to engage stakeholders and encourage buy-in to pursue a one stop shop for patient care.
3. Explain how to map the patient experience to build in essential components for patient and staff experience.

Caregivers are at risk for stress, anxiety, social isolation, and declines in physical and mental health. Telehealth provides a unique opportunity to meet their needs. Using multi-phase human-centered design (HCD), we gathered perspectives of caregivers, patients, clinicians, and administrators and co-created solutions. We designed a telehealth ecosystem to better connect caregivers, patients, and the care team. We will share HCD principles and our roadmap for integrating telehealth into inpatient and post-hospitalization care delivery.

After this presentation you will be able to:

1. Describe caregiver needs and opportunities for the aging population and understand how to address these through application of a human-centered design (HCD) approach.
2. Develop an understanding of how to leverage human-centered design methods and mindsets to improve care delivery and access a step-by-step approach to applying co-design and human-centered design in your organization
3. Identify potential facilitators and barriers to implementing human-centered design in your organizational settings with a roadmap for integrating human-centered design in your project areas

Communication, Apology, and Resolution Programs (CRPs) are comprehensive, principled, and systematic programs to prevent and respond to adverse events. An effectively implemented CRP can improve patient respect, promote learning, and build support for providers who have been involved with a medical error. A critical next step for the CRP field is to identify a core set of CRP metrics and complementary implementation and improvement strategies that can help institutions adopt and optimize CRPs. A national project funded by three patient advocates has developed a multi-step process to develop, refine, and implement these CRP metrics. The leaders of this project will share the rationale for undertaking this CRP initiative, share the metrics to augment the spread of CRPs, present a CRP Implementation and Improvement guide, and discuss intended use of these tools.

After this presentation you will be able to:

1. Describe the root causes and consequences of inconsistent implementation of CRPs and the role that metrics and an Implementation and Improvement Guide could play in addressing this problem.
2. List the key metrics related to CRP structure, process, and outcomes recently developed by a national panel of experts.
3. Explore how health systems can improve the implementation of a CRP using CRP metrics and the implementation guide.

There is a major public health crisis across North America resulting in an unprecedented rise in deaths due to opioid overdoses. Improving access to treatments and support through interconnected services and programs is much more effective than simply telling people to prescribe less. In this session, you will hear two case examples of how primary care is working to address this critical challenge. We will begin with the BC Patient Safety & Quality Council’s recent journey of mapping current treatment options and support for people with substance use concerns in primary care settings, in which both health care provider and peer (patient) perspectives were explored. We will then hear from South Central Foundation, an Alaska Native customer-owned health care system that has employed a whole fabric of programs and services to meet this complicated challenge.

After this presentation you will be able to:

1. Explain the value of integrating patient and health care provider experiences in real time journey mapping sessions.
2. Describe how a well-coordinated range of services supported by a highly capable range of improvement staff, workforce training, and support infrastructure can address opioid addiction.
3. Discuss how the same approach can be mobilized to tackle other complex health equity problems.

This session will describe the impact of adopting the Triple Aim as a framework for organizational strategy from the perspective of two health care systems. It will describe the tangible steps that organizations can take in adopting the Triple Aim as well as the challenges this may present. We will bring experience from Bellin Health and East London NHS Foundation Trust, both of which have aligned their organizational strategy to the Triple Aim framework. This session will be helpful for senior leaders who are keen to consider how to start impacting the health of the populations they serve, beyond just delivering high-quality health care, and creating a coherent narrative and alignment through large, complex organizations. We will help you develop a plan with ideas on how to co-create a simple organizational strategy; how to adapt your measurement system toward the Triple Aim; and how to engage staff, communities, and partners in helping deploy the strategy.

After this presentation you will be able to:

1. Understand the Triple Aim framework and how it might apply as a framework for organizational strategy.
2. Identify initial steps to move toward adopting a strategy that aligns with the Triple Aim, including ways to engage physicians, staff, and patients in the journey.
3. Describe potential challenges and opportunities that would arise through adopting the Triple Aim and share ideas that might be helpful.

The majority of avoidable adverse events are due to teamwork and communication failures between clinicians and the people they are caring for. In obstetrics, these errors are occurring in the context of high maternal mortality rates, overuse of cesarean births, and birth trauma related to lack of adequate voice in childbirth. We have designed a process innovation, called Team Birth, that aims to improve both safety and dignity in care by improving psychological safety and reliability during team communication. The person-centered team during labor includes the birthing person and her support system, nurses, and midwives and/or obstetricians. Each member of the team has access to different pertinent information regarding events in childbirth. In this workshop, we will review a simple process that enables every member of the team to consider relevant information at the same time, with a shared mental model of how to proceed with the information when important labor management decisions are required. Based on four years of research, design, and testing, our Delivery Decisions Team at Ariadne will present findings and a set of tools to promote behaviors that enable high-performing teams in childbirth.

After this presentation you will be able to:

1. Discuss strategies and structures to enable high-performing teams to be person-centered.
2. Recognize opportunities to incorporate the person’s lived experience in their care.
3. Identify how context impacts the implementation of structures for teamwork and communication.

This session will discuss our study that assesses the frequency and types of harm in a representative sample of Massachusetts institutions today, covering both inpatients and outpatients. We will share an approach that institutions can use operationally to assess the frequency of harm in an ongoing way, which leverages new harm detection approaches and electronic health records. We will share case examples from our experience developing the framework and tools, as well as advances in methods of assessing harm since the Harvard Medical Practice Study (HMPS) transformed medicine’s view of patient safety 30 years ago. We will review the use of consensus panels and electronic surveys to compare different methods of safety measurement, the development of an electronic data collection tool for chart review, and the use of an application for real-time adverse event surveillance with electronic health record data.

After this presentation you will be able to:

1. Describe a framework to identify and prioritize the triggers and measures of patient harm that are most relevant to your institution in real time.
2. Compare and contrast contemporary methods for real-time adverse event surveillance.

For clinicians and quality leaders, we provide a framework for deprescribing diabetes medications in older patients. This framework includes patient case studies and a toolkit for potentially difficult deprescribing conversations. We will share 1-year clinical outcomes of our program, which was associated with a potential survival benefit and a reduction in hypoglycemia while maintaining glucose control. In this session, we will discuss our journey to creating a dedicated deprescribing service with pharmacists and physicians.

After this presentation you will be able to:

1. Identify two challenges in deprescribing and methods to overcome those challenges.
2. List deprescribing opportunities which you will seek to recognize in your practice.
3. Describe behavioral science approaches to having a deprescribing-related conversation with a provider or patient.

Scotland is a small country, with 55,000 births per year, so 274 stillbirths in one year — which was the case in 2012 — was a lot in this context. In response, the Chief medical Officer for Scottish Government gave the Maternity and Children's Quality improvement Collaborative (MCQIC) this aim: Reduce stillbirth by 15 percent by 2015. Using approaches that will be discussed in this session, such as building improvement capacity in the system and focusing on a few to impact many, MCQIC contributed to a 23 percent reduction in stillbirth from 2014, surpassing the goal. Data is submitted to the MCQIC team via run charts where it is aggregated and analyzed. Boards are supported to understand their own data.

After this presentation you will be able to:

1. Identify methods to successfully lead large-scale improvement.
2. Describe clinical improvements related to fetal movement that can reduce stillbirth rate.
3. Describe common challenges of leading large-scale improvements.

There are proven interventions used to reduce medication-related harm and a growing body of knowledge that supports the application of these changes to produce desired outcomes. However, there are also system-level bottlenecks that prevent the ‘copy and paste’ approach to implementing interventions from one setting to another. IHI’s Africa Hospital Patient Safety Initiative has approached this problem by leveraging several layers of stakeholder engagement and strategically selected interventions to adapt proven frameworks in three countries: Ethiopia, Ghana, and South Africa. Teams were developed at all levels of the system to support implementation, and technology was tested to facilitate real-time coaching and feedback. Additionally, dosing models were tested in each country to identify effective and efficient capability building interventions.

After this presentation you will be able to:

1. Describe how context must be considered when designing improvement efforts in different parts of the world.
2. List the steps to building a meaningful set of measures to track change and improvement.
3. Describe the critical factors to building a culture of improvement in the context of rural settings.

Physical and verbal violence toward health care workers has no place in the healing environment of the hospital; yet, according to the Occupational Safety and Health Administration (OSHA), approximately 75 percent of nearly 25,000 workplace assaults reported annually occur in health care and social service settings. Participants in this session will learn how to build a comprehensive program to decrease workplace violence, applying strategies that will protect their workforce and the community and developing a safety roadmap to enact best practices and innovations. Participants will explore the Connecticut hospitals’ Safer Hospitals Initiative, which keeps health care organizations safer by stopping violence before it begins. The initiative has identified strategies to create a culture of safety that highlight the principles of high reliability and represent a multifaceted approach for successfully combating violence at all levels of an organization.

After this presentation you will be able to:

1. Describe innovative strategies designed to decrease the incidence of violence in health care by utilizing high reliability principles and practices.
2. Identify specific workplace violence strategies that will protect your workforce and the communities they serve both at the macro- and micro-system level.
3. Develop a Safety Implementation Roadmap to bring best practices and innovations to combat incidences of violence to your organization and beyond.

The need for rapid and sustainable change in health care is urgent. IHI's Breakthrough Series (BTS) Collaboratives provide a powerful tool for spreading improvements when established design principles are used and common pitfalls are avoided. This interactive session covers topic selection, change packages and measurement systems, engaging teams, and running robust learning sessions and action periods. We will use examples of Collaboratives from around the world on a variety of topics. This session shares didactic information about the BTS methodology along with interactive exercises.

After this presentation you will be able to:

1. Apply established design principles for successful BTS Collaboratives.
2. Diagnose and address common challenges in using the BTS method.

Patients on the same medication do not all receive the same dose. Why, then, should we expect that the same dose of the science of improvement will be appropriate for all individuals within an organization? This session's presenters will explain IHI’s dosing approach and how it can be used to build capacity and capability for improvement. Dosing strategies will be offered, and case studies will be used to demonstrate how the dosing approach can be applied successfully in organizations of different types and sizes.

After this presentation you will be able to:

1. Describe the IHI dosing strategy and related implementation.
2. Provide examples and case studies of how the dosing approach has been successfully applied in organizations of different types and sizes.
3. Explain how the dosing approach can be applied to your organization.

The rate at which improvement spreads relies at least in part on the people who are implementing the change in practice. IHI's Psychology of Change Framework helps leaders at all levels focus on the people advancing improvement efforts: the way that we think and feel, what motivates us, and how we behave when we encounter change. This session features U.S. and global examples and engages participants in developing pragmatic ideas to apply to their improvement context in response to people’s resistance and other adaptive challenges.

After this presentation you will be able to:

1. Attendees will be introduced to three key mindsets for working with people’s resistance to change
2. Attendees will explore IHI’s psychology of change framework and examples of its highest-leverage tools and methods
3. Attendees will be able to identify at least one tool or method that can be applied to their current work during or after the session

The United States population of people over 65 years is expected to double by 2030 to over 74 million. Is your health system asking older adult patients What Matters? Are you using an evidence-based framework to organize the complex care many older adults need? Older adults present as patients to our hospitals and ambulatory care practices every day and very often a geriatrician is not available to guide their care. The Age-Friendly Health System (AFHS) initiative, founded by The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA), developed an evidence-based framework to organize the care. The 4Ms Framework of Age-Friendly Health Systems is based on the evidence-based pillars of What Matters, Medication, Mentation and Mobility. The 4Ms provide a foundation, upon which to build excellence in the care of older adults. In this session, you will learn lessons from inpatient hospital and ambulatory care teams putting the 4Ms into practice. The CVS MinuteClinic planning journey will lead participants through the planning phases of this large-scale improvement initiative. They will share tools, including workflows, Quality Improvement Tools and EHR changes and their implementation map, to inspire you to begin implementing the 4Ms Framework of an Age Friendly Health System in your practice setting. Maine Health will share the Data Reporting and Key Performance Indicators used to identify barriers, track milestones, and ensure sustainability of the model in various settings. The destination of success will include a preliminary plan that participants can take back to start their journey of achieving Age-Friendly Health Systems.

After this presentation you will be able to:

1. Identify the components of 4Ms Framework of Age-Friendly Health Systems
2. Learn to utilize data to identify 4Ms strengths and gaps
3. Be able to identify at least two improvement strategies for creating successful workflows aimed at implementation of the 4Ms
4. Begin development of an implementation plan for Age-Friendly Health Systems

Health disparities and their root causes are the most glaring, unresolved problem in American health care. Navicent Health and Atrium Health, two large health systems, have each been recognized for their health equity work, Navicent as a 2018 American Hospital Association Equity of Care award winner and Atrium as an Honoree. In this session, they will share examples of the various processes implemented to identify disparities, prioritize what to address, develop interventions, and measure impact for target populations. Each health system engaged multi-disciplinary internal partners to develop data dashboards, and, more importantly, each health system engaged multi-sector partners in the community to address the root causes of disparities. The importance of leadership support and alignment to system-level strategy to develop the infrastructure and process to support the work will be discussed.

After this presentation you will be able to:

1. Identify health outcome disparities by various patient populations.
2. Explain the impact of the social determinants of health that drive adverse outcomes.
3. Describe how to implement and evaluate a comprehensive Equity of Care program.

Using an interactive panel format, this session will showcase two recent projects focused on building health equity in clinical and community settings. One, led by a team at Massachusetts General Hospital, aimed to address racial and language disparities in patients’ experiences of the transition from hospital to the community. The other, co-led by Kaiser Permanente and the American Heart Association, sought to address disparities in blood pressure control among African Americans in a nationally supported, locally-led effort, with pilots in San Diego and Atlanta. Panelists will discuss (1) the value of authentic stakeholder engagement and trust building, (2) the role of data in prompting collective action and assessing ongoing progress toward goals, and (3) the importance of intervening at multiple levels simultaneously, from small, simple interventions to large system changes. The discussion will illustrate that reducing and ultimately eliminate health inequities will require collaborating with diverse stakeholders and recognizing the iterative, incremental nature of progress. Importantly, critical process achievements – such as development of trusting relationships among collaborators – can be difficult to measure and quantify. The case studies and conversation, revealing key strategies and lessons learned, will highlight how a shared commitment to health for all inspire and spark organizational and community capability building.

After this presentation you will be able to:

1. Understand the importance of trust building as a foundation for building health equity in diverse clinical and community settings
2. Appreciate the value and challenges of collecting and using quantitative and qualitative data to build consensus and informed decision making
3. Learn how a spectrum of intervention strategies can be applied in real-world contexts to support health equity improvement

It can take weeks or months to plan a QI project; doesn’t it make sense to spend time developing a plan to communicate with important stakeholders to help ensure its success? Just as any viable QI initiative should have a measurement strategy, teams should have a communications strategy to mobilize the will to change, convey the ideas and evidence needed to accelerate improvement, and support the execution and spread of effective interventions. Drawing upon more than a decade of experience, session presenters will share a QI communications framework designed for use by even non-communications professionals from any health care discipline. Using case examples from multiple countries, they will provide tips, describe how to prevent common pitfalls, and help participants get started on developing their own communications plan.

After this presentation you will be able to:

1. Provide at least three examples of how to use the QI communications framework to accelerate quality improvement.
2. Describe why just as every QI initiative should have a measurement strategy, it should also have a communications strategy.
3. Develop the start of a plan to use communications to advance quality improvement work, including a small test of change.

Going beyond a local system to create a dispersed learning network allows for a wider pool of people and ideas. This requires a virtual knowledge commons or Learning Exchange to support sharing across distance and time. Quality team members, patients, family, physicians, and researchers will discuss challenges and successes. Attendees will learn user-centered design principles for developing a Learning Exchange, the importance of continuous evolution, and the benefits of a shared platform.

After this presentation you will be able to:

1. Describe three key requirements to building a geographically dispersed learning network.
2. Identify three benefits to a virtual knowledge exchange and common data structure to accelerate innovation and adoption to improve care.
3. Apply principles of community and user centered design to an iterative, co-creation process for designing a knowledge exchange.

Virtual collaboration fuels large scale improvements, enabling us to involve more people, engage patients and families in a less daunting way, involve colleagues without taking them from their jobs, increase diversity, and make better decisions. We will share case studies from our virtual collaboration work with thousands of frontline staff and patients across the English National Health Service, through which we built shared purpose, accelerated outcomes, slashed travel costs and environmental impact, and improved care.

After this presentation you will be able to:

1. Describe familiarity with the core principles of virtual collaboration and understand how it can be combined with other approaches for faster, better outcomes.
2. Identify how diverse groups in the virtual space can take ownership for generating ideas, solve problems, agree direction and plan actions.
3. Develop a sense of how virtual collaboration methods could be applied in your own setting.

A growing awareness of preventable maternal harm stems in part from striking racial inequalities in outcomes in the United States. High-volume delivery centers in Washington, DC and Detroit have partnered with community organizations and individuals. They codesigned services which build trust and improve outcomes. This work is based on critical quality improvement principles: that those most affected by the delivery system possess a wealth of change ideas, and that communities possess key assets for improvement.

After this presentation you will be able to:

1. Describe current inequitable maternal health care experiences within delivery systems.
2. Identify principles of humble and respectful co-design within health care systems and community stakeholders.
3. Examine the method and application of gathering and testing ideas that the Washington, DC and Detroit communities are applying in their journeys.

Communicating ideas and making decisions both require effective visual displays. Analytic challenges for improvement include identifying trends, patterns, or relationships in data and analyzing sources of variation. We will present graphical methods for different types of improvement studies with an emphasis on time series methods that afford a whole-system view, including underutilized Shewhart control charts. Using practical examples, we will highlight key principles for quality improvement teams and challenge participants to critique and design graphics.

After this presentation you will be able to:

1. Identify appropriate charts and other data visualization tools given various improvement objectives, study designs, and available data sources.
2. Recognize basic principles of graphical excellence in a quality improvement context and best practices to communicate data with compelling clarity and efficiency.
3. Describe insights about Shewhart control charts as a fundamental method for analyzing data and communicating information in quality improvement studies.

Reducing opioid use is a complex problem that requires tailored solutions. Traditional quality improvement methods facilitate context-specific changes. Implementation science provides tools to increase uptake. We used a new framework, the Model for Improvement and Implementation (MFII), which systematically integrates both approaches. Through the MFII, we implement an intervention to reduce surgical prescribing of opioids. This framework to identify barriers and strengthen support for implementation is applicable to other complex issues.

After this presentation you will be able to:

1. Describe the interface between improvement science and implementation science.
2. Explain how to apply the Model for Improvement and Implementation to daily practice.
3. Identify crucial factors addressed in the implementation of a complex intervention to reduce opioid prescribing.

Health care leaders know that for their organizations to successfully adapt to the rapidly changing payment and service landscape, they need a motivated, engaged, and productive workforce — a workforce that finds joy in work. Fostering joy in work is about creating systems that promote staff engagement, satisfaction, and resilience. This should be a shared responsibility of caregivers, leaders, and organizations. To that end, IHI faculty will be sharing tested models for co-producing joy with staff through the IHI Framework for Improving Joy in Work and examples of leadership models and improvement methodologies known to nurture joy in work.

After this presentation you will be able to:

1. Describe key leadership behaviors that raise staff engagement and restore joy.
2. Identify key system changes to improve joy in work.
3. Take away at least one distributed leadership model you can use to co-create joy in your workplace.

A culture characterized by respectful behavior is essential to remarkable patient and team member experiences and quality care. This session describes how an organization can foster respect, equity, and inclusion through a comprehensive program including listening sessions and learning events. Focuses include the role of leadership and the impact of “second-hand” respect on observers. Health care leaders, clinicians, board members, and educators will benefit from stories, case examples, tools, and methods to measure results.

After this presentation you will be able to:

1. Describe how an organization can develop an integrated program to build a culture which fosters respect.
2. Identify the impact of “second hand” respect or disrespect on others who witness and experience it.
3. List ways to measure changes in an organization’s culture of respect.

This fun-filled session will use case studies to describe learning from three healthcare systems focused on improving the experience of all staff groups and enhancing joy in work at scale; utilizing quality improvement science and the IHI’s joy in work framework. With demand on our health and care systems increasing and new resources remaining scarce, there is growing evidence of burnout amongst healthcare providers. This session will show you how it is possible to enable staff to feel a sense of autonomy and control over the system in which they work; to own the efforts to improve their daily experience of work through the use of systematic quality improvement techniques; and to use the rigor of improvement science to test and measure in the pursuit of improved joy in work. You will leave this session with practical examples and inspiring stories from three different healthcare systems across the globe, providing you with ideas, tools and motivation to get you started on your own joy in work journey.

After this presentation you will be able to:

1. Understand and explore the underpinning components of joy in work at individual, team and system level
2. Appreciate how three healthcare systems across the globe are focused on finding and creating joy in work
3. Describe practical next steps in using the science of improvement to find and create joy in work in their own system

Quality continues to grow as a strategic priority for health care organizations, and the role of Chief Quality Officer is emerging to lead it. What does it takes to lead quality at a system level. Join the faculty of the IHI CQO Professional Development Program to learn five strategies for meeting the ongoing challenge of leading quality across a system.

After this presentation you will be able to:

1. Define the evolving role of chief quality officers
2. Describe five strategies for leading quality across the system

With a growing emphasis on quality, a more integrated approach to quality management is needed. Twenty years ago, Cincinnati Children’s Hospital Medical Center (CCHMC) set out to become the leader in improving child health. The organization has progressed through developing improvement capability, high reliability, microsystem leadership, distributed expertise, partnership with the community to address disparities, and now a culture of empowerment. This session will share lessons from CCHMC and the IHI Quality Management System Framework.

After this presentation you will be able to:

1. Describe the Quality Strategy and Quality Management System frameworks.
2. Describe the quality transformation journey of a leading healthcare organization and how it relates to your work.
3. Identify ways to apply the CCHMC journey and frameworks to your own efforts to lead and manage quality.

Leading and managing a health care delivery organization is often like drinking from a fire hose. Leaders need new skills and ways to focus their efforts to deliver results. Providence St. Joseph Health is committed to developing leadership systems to shape culture and deliver Triple Aim results for populations. We will explore strategies to develop leadership capability as well as how the IHI High-Impact Leadership Behaviors have been used across a complex integrated delivery system.

After this presentation you will be able to:

1. Describe the organizational development strategy deployed at Providence St. Joseph Health to develop clinical and administrative leadership competencies.
2. Describe how the IHI High-Impact Leadership Behaviors are translated and deployed in daily work within the Providence St. Joseph Health delivery system.
3. Identify the challenges of building leadership capability across a system and lessons learned.

This session will engage participants in a robust dialog around key drivers identified by the IHI Alliance for “Reducing BIG Waste” — both those achievable in the shorter-term where you work and practice, as well as through longer-ranging solutions to address this “gnarly opportunity” across the US healthcare system. The IHI Leadership Alliance is a dynamic collaboration of leaders from 44 diverse health care organizations united by a common mission — to work with one another and in partnership with our patients, workforces, and communities to foster “Care better than we've ever seen, health better than we've ever known, at a cost we can all afford...for every person, every time”. Over the past two years, members have been collaborating to answer the question: If health care systems, providers, and payers could collectively “write a check” back to the American people and return the money, where could substantial savings come from and how much could be saved, redirected or returned? The team will share this new Driver Diagram, review the compilation of a “checkbook” now totaling over $1 trillion annually of waste reduction opportunities, and present a call to action to local organizations, partnerships and advocacy efforts for health care reform and redesign needs. This session will offer attendees insights from leaders from two participating Alliance organizations, and the opportunity to learn from their local and shared IHI Alliance experiences in creating a common language, working across shared platforms, and achieving substantial cost savings while improving quality through strategic alignment and partnerships.

After this presentation you will be able to:

1. Demonstrate local health system adoption of key strategies to reduce non-value-added waste.
2. Develop strategies for forming successful collaborative partnerships for action in local, state, and national communities to address more complex waste opportunities.
3. Provide a provocative call to action for advocacy for health care reforms and redesign needs to address regulatory, legislative, and other systemic barriers to returning the money.

This session describes actionable tools and approaches that Accountable Care Organizations (ACOs) have developed for implementing care delivery improvements in a value-based payment environment. It will highlight: The Care Coordination Toolkit, the first in a series of publicly-available ACO Toolkits from the Centers for Medicare & Medicaid Services (CMS) that describes strategies to improve collaboration across care settings; seven case studies delving into ACOs’ experiences developing and implementing successful initiatives to improve care delivery; and presentations and discussions from ACO-affiliated participants that engaged in more than 50 in-person meetings across the country to consider innovative solutions to pressing challenges.

After this presentation you will be able to:

1. Develop strategies to improve health care outcomes and patient experience within a value-based payment environment.
2. Harness Medicare ACOs’ experiences and tools to improve the quality and value of care delivery.
3. Identify next steps to engage key stakeholders in your organization to increase care coordination and collaboration.

Cambridge Health Alliance (CHA) is a vibrant, innovative health system providing essential services to more than 140,000 patients north of Boston. When the Psychiatry Department identified barriers to care (including long wait times, extensive waitlists managed through cumbersome processes, decentralized scheduling, and low slot utilization — all resulting in poor patient care), the team embarked on a 2-year Lean framework effort to streamline the referral, triage, and scheduling processes for improved access. This session will reveal how improvement methods and qualitative and quantitative analyses were implemented at an organizational level to achieve transparency, buy-in, and sustainability for a patient-centered model for equitable care across CHA. Participants will gain a comprehensive understanding of how to use Lean and improvement methodologies in resource-limited settings to assess system failures and identify opportunities to improve operations to meet population health management objectives for system-wide transformation.

After this presentation you will be able to:

1. Assess system failures and gaps that impact timely, reliable, and appropriate access to care.
2. Identify opportunities for improvement in transitions of care, referral management, network development, and population management.
3. Learn from the successes and challenges of implementing system-wide transformation initiatives for population health.

Coproduction theory argues healthcare is not a product delivered to patients, but a service co-generated by the health care system and the people engaged in care. We have modified a value creation framework to develop a coproduction model for health care. The International Coproduction of Health Network launched a Community of Practice (CoP) of stakeholders to optimize the model and research a new assessment approach. We will share CoP case studies and conduct assessment simulations.

After this presentation you will be able to:

1. Define coproduction of health care service and differentiate coproduction assumptions from those of traditional health care delivery models.
2. Describe the core components of the International Coproduction of Health Network (ICoHN) prototype value model and discuss this as an example of a coproduction value creation model for health care operations.
3. Identify value-creating coproduction activities using the new prototype value creation model in different contexts based on case studies derived from ongoing development work in the ICoHN coproduction value creation CoP.

The Clinical Redesign (CRD) method an innovative framework built on the Model for Improvement to drive value-focused improvement in evidence-based care delivery through rapid-cycle (90 day) projects at any size hospital or health system. CRD has evolved from a small team to a system-wide improvement engine; since April 2015, we have completed over 220 projects. Examples include reducing opioid prescriptions, removing wasteful inpatient laboratory testing, and incorporating real-time data in patient-centered clinical operations.

After this presentation you will be able to:

1. Identify the essential elements and structure needed to improve operational pain points within 90 days and sustain success long term.
2. Identify matrix relationships within their organizations and develop plans to leverage collaboration to promote change.

Patients who frequently utilize the emergency department (ED) are among the most resource-intensive patients to manage – and the most vulnerable. Our work focuses on multi-visit patients (MVPs), a more patient-centered term than “super-utilizers.” Multidisciplinary efforts to address medical and non-medical needs through an individualized care coordination plan reduced total ED visits, ED admissions, and 30-day readmissions. Our approach for MVPs has implications for hospital capacity while improving care for a population often left behind.

After this presentation you will be able to:

1. Explain the process for creating a care coordination plan for a patient.
2. Describe the importance of understanding each patient’s needs and acting upon them in order to impact utilization.
3. Identify innovative ways to keep patients out of the ED and the hospital.

In order to improve quality and to deliver value along with volume,a systems approach is required to create an exceptional experience for patients. By seeing the entire episode of care through the patient’s eyes and identifying the people and places that they encounter through their journey, a Hospital Within a Hospital (HWH) and Focused Care Centers (FCC) can be built. Focused Care Centers (FCC) allow for the development of high-performance clinical teams that deliver care for a specific disease. The aggregation of many FCC into a HWH ensures the coordination of inpatient and outpatient pathways to ensure optimal outcomes and experience for patients and staff alike. FCC enable innovations that result in value driven changes but also permits providers the ability to easily “scale up”. The combination of FCC and the Patient Centered Value System (PCVS) brings together all of the people and processes in one place, allowing the focus to be the experience and not just the clinical services. This maximizes the efficient utilization of health care resources to benefit patients. Hear outpatient, inpatient, surgical and diagnostic testing-based examples from the UPMC Bone and Joint Center of how to create, maintain and spread a standardized care model without sacrificing quality or cost.

After this presentation you will be able to:

1. Describe the stepwise process to build a focused care center.
2. Identify ways to engage stakeholders and encourage buy-in to pursue a one stop shop for patient care.
3. Explain how to map the patient experience to build in essential components for patient and staff experience.

Caregivers are at risk for stress, anxiety, social isolation, and declines in physical and mental health. Telehealth provides a unique opportunity to meet their needs. Using multi-phase human-centered design (HCD), we gathered perspectives of caregivers, patients, clinicians, and administrators and co-created solutions. We designed a telehealth ecosystem to better connect caregivers, patients, and the care team. We will share HCD principles and our roadmap for integrating telehealth into inpatient and post-hospitalization care delivery.

After this presentation you will be able to:

1. Describe caregiver needs and opportunities for the aging population and understand how to address these through application of a human-centered design (HCD) approach.
2. Develop an understanding of how to leverage human-centered design methods and mindsets to improve care delivery and access a step-by-step approach to applying co-design and human-centered design in your organization
3. Identify potential facilitators and barriers to implementing human-centered design in your organizational settings with a roadmap for integrating human-centered design in your project areas

Communication, Apology, and Resolution Programs (CRPs) are comprehensive, principled, and systematic programs to prevent and respond to adverse events. An effectively implemented CRP can improve patient respect, promote learning, and build support for providers who have been involved with a medical error. A critical next step for the CRP field is to identify a core set of CRP metrics and complementary implementation and improvement strategies that can help institutions adopt and optimize CRPs. A national project funded by three patient advocates has developed a multi-step process to develop, refine, and implement these CRP metrics. The leaders of this project will share the rationale for undertaking this CRP initiative, share the metrics to augment the spread of CRPs, present a CRP Implementation and Improvement guide, and discuss intended use of these tools.

After this presentation you will be able to:

1. Describe the root causes and consequences of inconsistent implementation of CRPs and the role that metrics and an Implementation and Improvement Guide could play in addressing this problem.
2. List the key metrics related to CRP structure, process, and outcomes recently developed by a national panel of experts.
3. Explore how health systems can improve the implementation of a CRP using CRP metrics and the implementation guide.

There is a major public health crisis across North America resulting in an unprecedented rise in deaths due to opioid overdoses. Improving access to treatments and support through interconnected services and programs is much more effective than simply telling people to prescribe less. In this session, you will hear two case examples of how primary care is working to address this critical challenge. We will begin with the BC Patient Safety & Quality Council’s recent journey of mapping current treatment options and support for people with substance use concerns in primary care settings, in which both health care provider and peer (patient) perspectives were explored. We will then hear from South Central Foundation, an Alaska Native customer-owned health care system that has employed a whole fabric of programs and services to meet this complicated challenge.

After this presentation you will be able to:

1. Explain the value of integrating patient and health care provider experiences in real time journey mapping sessions.
2. Describe how a well-coordinated range of services supported by a highly capable range of improvement staff, workforce training, and support infrastructure can address opioid addiction.
3. Discuss how the same approach can be mobilized to tackle other complex health equity problems.

This session will describe the impact of adopting the Triple Aim as a framework for organizational strategy from the perspective of two health care systems. It will describe the tangible steps that organizations can take in adopting the Triple Aim as well as the challenges this may present. We will bring experience from Bellin Health and East London NHS Foundation Trust, both of which have aligned their organizational strategy to the Triple Aim framework. This session will be helpful for senior leaders who are keen to consider how to start impacting the health of the populations they serve, beyond just delivering high-quality health care, and creating a coherent narrative and alignment through large, complex organizations. We will help you develop a plan with ideas on how to co-create a simple organizational strategy; how to adapt your measurement system toward the Triple Aim; and how to engage staff, communities, and partners in helping deploy the strategy.

After this presentation you will be able to:

1. Understand the Triple Aim framework and how it might apply as a framework for organizational strategy.
2. Identify initial steps to move toward adopting a strategy that aligns with the Triple Aim, including ways to engage physicians, staff, and patients in the journey.
3. Describe potential challenges and opportunities that would arise through adopting the Triple Aim and share ideas that might be helpful.

The majority of avoidable adverse events are due to teamwork and communication failures between clinicians and the people they are caring for. In obstetrics, these errors are occurring in the context of high maternal mortality rates, overuse of cesarean births, and birth trauma related to lack of adequate voice in childbirth. We have designed a process innovation, called Team Birth, that aims to improve both safety and dignity in care by improving psychological safety and reliability during team communication. The person-centered team during labor includes the birthing person and her support system, nurses, and midwives and/or obstetricians. Each member of the team has access to different pertinent information regarding events in childbirth. In this workshop, we will review a simple process that enables every member of the team to consider relevant information at the same time, with a shared mental model of how to proceed with the information when important labor management decisions are required. Based on four years of research, design, and testing, our Delivery Decisions Team at Ariadne will present findings and a set of tools to promote behaviors that enable high-performing teams in childbirth.

After this presentation you will be able to:

1. Discuss strategies and structures to enable high-performing teams to be person-centered.
2. Recognize opportunities to incorporate the person’s lived experience in their care.
3. Identify how context impacts the implementation of structures for teamwork and communication.

Sharing learning, spreading ideas, and teaching are all vital aspects of the process of continuous quality improvement. One of the favored mediums for sharing learning is via the delivery of presentations, keynotes, and workshops to various audiences. But do we really know the best way to help our audiences understand the messages we are trying to share with them? This session will give you an introduction to an “audience-centered” approach to designing your communications – an approach that has been successfully used with a variety of speakers in all spheres, to design conference keynotes, lectures, workshops, teaching sessions, poster presentations, sales pitches, and after dinner speeches. This session would be ideal for anyone who needs to write presentations at any level, whether that’s at conferences, workshops or internal talks.

After this presentation you will be able to:

1. List the core principles behind presentation design to design engaging presentations for different learning situations and audiences.
2. Explain how to design “audience-centered” messages to help audiences to understand, learn, and remember.
3. Describe how to effectively use stories and visual aids to ensure presentations are memorable for their audiences.