2022 Patient Safety & Quality Summit

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Registration Information Register at www.gha.org/PSQS Member Rate - $325 SHIP-participating hospitals will receive $945 credit per person (up to two people) following their attendance. A late fee of $50 will apply at the close of business on Friday, Dec. 17. Refunds minus a $50 processing fee will be accepted through Friday, Dec. 31.

Hotel Information The Ritz-Carlton Reynolds, Lake Oconee 1 Lake Oconee Trail Greensboro, GA 30642 706-467-0600 Room Rates - $199/night Once you register for the conference, a confirmation number and a link to book your room will be emailed to you. Reservations must be made by Friday, Dec. 17. We expect rooms to sell out fast, so we encourage you to register and book your room early. You will be responsible for the full payment of rooms upon booking. Refunds for rooms will be given only until Friday, Dec. 17.

Your safety is our priority. We will adhere to all CDC guidelines regarding COVID-19, and masks will be available at the registration desk. Any additional guidelines and procedures will be communicated in advance.


Learning Objectives • • • • • • • • • • • • • •

Discuss similarities and differences in the ratings criteria of the organizations that analyze hospital performance and publish ratings. Characterize the importance of culture, process, and measurement in achieving high reliability. Discuss how a statewide surgical quality improvement collaborative could be used in Georgia to partner with surgeons to improve surgical outcomes. Describe how multiple statewide entities can work together toward a common goal. Review the role benchmarked performance reports at the surgeon and hospital level can play in statewide quality improvement Describe the application of a clinical care delivery spectrum. Explain the importance of a clinical care delivery spectrum in decreasing avoidable transfers. Discuss implementing a clinical care delivery spectrum. Recognize the forces driving CMS value-based care initiatives. Quantify the financial impact of value-based payment programs. Identify quality priorities for future success. Describe how the Invisible Architecture™ is more important than the visible architecture of bricks, chrome, and glass. Explain how presenting your organization’s cultural blueprint to the world can create a competitive advantage, especially for recruitment and retention. Discuss the importance of transitioning from a culture of accountability to a culture of ownership and how to reinforce the three non-negotiable elements of such a culture: emotionally positive, self-empowered, and fully engaged.


Continuing Education Credits In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and Georgia Hospital Association Research and Education Foundation (GHAREF). AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team. Credit Designation for Nursing AXIS Medical Education designates this continuing nursing education activity for 6.5 contact hours. Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity. Quality Professionals This program has been approved by the National Association for Healthcare Quality for a maximum of 6.5 CPHQ continuing education credits for this event. AXIS Contact Information For information about the accreditation of this program, please contact AXIS at info@axismeded.org. Disclosure of Conflicts of Interest AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity. AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity. The faculty reported the following relevant financial relationships or relationships they have with ineligible companies of any amount during the past 24 months: Name of Faculty/Presenter

Reported Financial Relationship

Alan Kent, DHA, FACHE

Nothing to disclose

Caprice Greenberg, MD, MPH, FACS

Nothing to disclose

Jeanette May, PhD, MPH

Nothing to disclose

Louise Bryde, MHA, BSN, RN

Nothing to disclose

Kim Rask, MD, PhD

Nothing to disclose

Joe Tye

Nothing to disclose


The following directors, planners, managers and reviewers reported no financial relationships they have with any ineligible company of any amount during the past 24 months: Name of Directors, Planners, Managers and Reviewers Kathy McGowan, MPH Andy Cobb Katelyn Quartuccio, PharmD, BCPS Holly M. Hampe, DSc., RN, MHA, MRM, CPHQ Dee Morgillo, MEd., MT(ASCP), CHCP Disclaimer Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Requirements for credit: • Attend/participate in the educational activity and review all course materials. • Complete the CE Attestation/Evaluation form online by February 5, 2022 by 11:59 pm ET. Instructions will be provided. If you do not complete the online evaluation by this date, you will not be able to get CE credit for this event. • Upon successful completion of the online form, your statement of completion will be presented to you to print.


Schedule at a Glance Tuesday, Jan. 4 8-8:30 a.m.

Registration and Continental Breakfast

8:30-9 a.m.

Welcome Back! Opening Remarks Earl Rogers, President and CEO Rhett Partin, SVP of Clinical Services & Public Health Kathy McGowan, Vice President of Quality & Patient Safety Georgia Hospital Association

9-10 a.m.

5 Stars: The Unpredictable Journey to Ratings and High Reliability Alan Kent, DHA, FACHE, Managing Principal Caldwell Butler & Associates

10-10:30 a.m.

Break

10:30-11:30 a.m.

Improving Outcomes with a Statewide Surgical Quality Improvement Collaborative Caprice C. Greenberg, MD, MPH, FACS, Professor of Surgery, Moretz/Mansberger Distinguished Chair of Surgery Medical College of Georgia at Augusta University Jeanette C. May, PhD, MPH, Associate Director School of Medicine and Public Health, University of Wisconsin

11:30 a.m.-1:30 p.m.

Awards Luncheon LifeLink Awards for Organ Donation Presented by Kim Kottemann Josh Nahum Award Presented by Armando Nahum GHA Patient Safety & Quality Awards Presented by GHA Chair Don Avery and Earl Rogers

1:30-1:55 p.m.

Break

1:55-2:55 p.m.

Developing a Clinical Care Delivery Spectrum Louise Bryde, Principal Stroudwater Associates

2:55-3:15 p.m.

Break

3:15-4:30 p.m.

GHA First Place Patient Safety & Quality Award Winners Panel Moderated by Kathy McGowan


Wednesday, Jan. 5 7:30-8:15 a.m.

Breakfast

8:15-9:15 a.m.

Quality-Based Medicare Reimbursement: An Overview of CMS Quality Payment Programs Kimberly Rask, MD, PhD, Chief Data Officer Alliant Health Group

9:15-9:30 a.m.

Break

9:30 a.m.-noon

Designing Your Invisible ArchitectureTM for the Post-Pandemic World Joe Tye Values Coach


Session Descriptions 5 Stars: The Unpredictable Journey to Ratings and High Reliability Alan Kent, DHA, FACHE, Managing Principal Caldwell Butler & Associates

While the daily commitment to quality patient care is always of paramount importance to hospital leaders and clinicians, hospital ratings garner headlines and can become the goal. The multitude of ratings agencies and organizations, some more important than others, use different and sometimes conflicting criteria and formulae to determine rankings. Learn the story of one hospital’s experiences and how commitment to process, measurement and a culture of accountability impact outcomes in the journey to high reliability. Speaker Bio Dr. Alan Kent is the Managing Principal with Caldwell Butler & Associates, an innovative performance and margin improvement consulting firm. He most recently served as President & CEO of Memorial Health Meadows, formerly Meadows Regional Medical Center, a position he held for over 20 years. Alan has over 40 years of leadership experience in hospital executive and consulting roles which have included hospital turnaround operations, significant on time/under budget construction projects, operational improvement and revenue growth. He has presided over a three-time IBM Watson Top 100 Hospital that also received A’s from the Leapfrog Group and a CMS 5-star ranking. He is passionate about helping managers at all levels, from front line supervisors to executives, develop organizational leadership skills. He also strives to build effective relationships with physicians and senior leaders. Board certified as a Fellow in the American College of Healthcare Executives, Alan is a faculty member of ACHE, an adjunct faculty member in the Jiann-Ping Hsu College of Public Health at Georgia Southern University and a frequent lecturer at Georgia State University and the Medical University of South Carolina. He holds the degrees of Bachelor of Science in health systems from the Georgia Institute of Technology, Master of Health Administration from Georgia State University and Doctor of Health Administration from the Medical University of South Carolina.


Improving Outcomes with a Statewide Surgical Quality Improvement Collaborative Caprice Greenberg, MD, MPH, FACS Professor of Surgery, Moretz/Mansberger Distinguished Chair of Surgery Medical College of Georgia at Augusta University Jeanette May, PhD, MPH Associate Director School of Medicine and Public Health, University of Wisconsin

Hear how one state is improving quality of care by using an innovative statewide quality improvement collaborative. From this case study, learn how the Surgical Collaborative of Wisconsin developed an infrastructure, a data platform, and a corresponding mechanism to support surgeons through the dissemination of evidence-based guidelines and best practices. Speaker Bios Caprice C. Greenberg MD MPH, is a surgical oncologist treating breast cancer and health services researcher with a multi-disciplinary, multi-institutional research program. She has been funded by multiple federal agencies, including the National Institutes of Health (NIH), the Agency for Health Care Research and Quality, and the Patient-Centered Outcomes Research Institute. She has founded several organizations to ensure research impacts practice, including the Surgical Collaborative of Wisconsin and the Academy for Surgical Coaching. Dr. Greenberg has served in multiple national leadership roles, including as recorder and president of the Association for Academic Surgery and President of the Surgical Outcomes Club. Dr. Jeanette May is part of the School of Medicine and Public Health at the University of Wisconsin, where she is the associate director for the Surgical Collaborative of Wisconsin. Prior to her appointment with the University, Dr. May was the lead researcher and disparities expert for the Centers for Medicare and Medicaid National Impact Assessment Quality Measurement report. Dr. May was also a principal investigator for several Robert Wood Johnson Foundation Culture of Health Grants and has been a part of many large NIH collaborative grants in the areas of population health, rural health, and cancer.


Awards Luncheon Josh Nahum Award presented by Armando Nahum LifeLink Awards for Organ Donation presented by Kim Kottemann GHA Patient Safety & Quality Awards presented by GHA Chair Don Avery and Earl Rogers The GHA Patient Safety and Quality Awards luncheon is a hallmark of the Patient Safety and Quality Summit, where GHA has the opportunity to recognize hospitals that have demonstrated significant patient safety and quality improvement through projects of their choosing. Hospitals nominate these projects for an award in one of six categories: Critical Access Hospitals, Hospitals with Less Than 100 Beds, Hospitals with 100–299 Beds, Hospitals with Greater Than 300 Beds, Specialty Hospitals, and Josh Nahum Award for Achievement in Infection Prevention and Control. Additionally, hospitals that win an award this year and have won three or more Patient Safety and Quality Awards within the previous five years will receive the distinguished Circle of Excellence Award. The GHA Patient Safety and Quality Awards are presented by the current GHA chair and GHA’s president and CEO. LifeLink of Georgia will also present two hospitals with the Barbara and John Ware Donate Life Award. This award honors hospital partners who are committed to saving and enhancing lives through organ and tissue donation. Hospitals are nominated based on their demonstration of support of organ and tissue donation, including activities that the hospital participated in to increase the opportunity for organ and tissue donations.


Developing a Clinical Care Delivery Spectrum Louise Bryde Principal Stroudwater Associates

Rural hospitals struggle to increase inpatient, observation, and swing bed admissions, but few hospitals go through a formal process of identifying the types of patients who can be cared for at the hospital instead of transferring them. Developing a clinical care delivery spectrum can help hospitals decrease both variability in admissions and potentially avoidable transfers. It can also provide a consistent message as to the patient population that can be cared for at your hospital. This presentation will describe what a clinical care delivery spectrum is, why it is important, and why completing this process is beneficial. Speaker Bio Louise Bryde joined Stroudwater in 2013 and brings to the firm more than 35 years of experience in healthcare management and clinical operations. She has a proven record of accomplishments in developing and executing initiatives to enhance access and improve quality and value of healthcare delivery. At Stroudwater, she focuses on population health, strategic planning, clinical quality and operational improvement, and models of care, including Patient-Centered Medical Home (PCMH) and Team-Based Care initiatives. In addition, she leads the Six Building Blocks Opioid Management Program service offering, an evidence-based quality improvement roadmap to help primary care practices implement consistent, guideline-driven care for their chronic pain patients on long-term opioid therapy. Before joining Stroudwater, Bryde formed Louise Bryde & Associates, LLC, a healthcare consulting firm specializing in care integration/models of care delivery and CAHPS/Star Rating evaluation and improvement initiatives. Previously, Bryde served as Senior Clinical Director for United Health Group (UHG) - Ovations, Atlanta, Georgia, where she held the National Clinical Lead role for Ovations Medicare Community Programs, as well as prior Regional and Georgia Market Health Services Director positions with a multi-state Medicare Advantage Special-Needs Plan.

GHA’s First Place Patient Safety and Quality Award Winners Panel Moderated by Kathy McGowan The panel will feature hospital quality representatives who will discuss their journey to success, as well as the implementation of evidence-based processes and best practices in reducing the risk of adverse outcomes and improving patient safety and quality.


Quality-Based Medicare Reimbursement: An Overview of CMS Quality Payment Programs Kimberly Rask, MD, PhD, Chief Data Officer Alliant Health Group

This session will provide an overview of the many quality payment programs that impact hospital reimbursement. Understanding their commonalities and CMS’s vision for the future of hospital payments can help executive leaders position their organizations for success. Speaker Bio Kimberly J. Rask, MD, PhD, is chief data officer at Alliant Health Group, providing analytic support to Medicare, Medicaid, ESRD and private health care program partners. Since 2008, she has provided clinical and analytic direction at Alliant for economic evaluations, patient safety initiatives, quality data reporting and community-based interventions. A primary care physician and health economist, she was previously on faculty at Emory University, where her research and teaching focused on quality and outcomes measurement with a particular focus on rural and underserved populations. She currently serves on national expert panels that review the evidence base for interventions to reduce cardiovascular disease for the CDC and is co-chair of the Rural Health Advisory Group of the National Quality Forum. A magna cum laude graduate of Bryn Mawr College, she attended the University Of Pennsylvania School Of Medicine. After completing her residency in internal medicine, she was a Robert Wood Johnson Clinical Scholar and completed the health economics PhD program at the Wharton School along with a fellowship in general internal medicine at the Hospital of the University of Pennsylvania.


Designing Your Invisible Architecture™ for the Post-Pandemic World Joe Tye, Head Coach Values Coach

The pandemic has challenged our hospitals’ values, stressed our cultures, and seriously affected worker attitudes. These are the three elements in the Values Coach construction metaphor for Invisible Architecture (what we call “the blueprint behind the blueprint”), where the foundation is core values, the superstructure is organizational culture, and the interior finish is workplace attitude. In this breakout workshop, we will cover strategies to revisit and, in some cases, remodel the Invisible Architecture of our organizations. Speaker Bio Joe Tye is head coach of Values Coach. He works with hospitals and other health care organizations to help them build a more positive culture of ownership by engaging staff at every level in a commitment to shared values and expectations. Joe earned a master’s degree in hospital administration from the University of Iowa and an MBA from the Stanford Graduate School of Business, where he was class co-president. He is the author or coauthor of 12 books, including “The Florence Prescription” and “Building a Culture of Ownership in Healthcare,” which was named the American Journal of Nursing (AJN) Book of the Year. He created The Twelve Core Action Values, a course on values-based life and leadership skills that has been called “graduate school for the seven habits.” Prior to founding Values Coach in 1994, Joe was chief operating officer for a large community teaching hospital. On the volunteer front, he was founding president of the Association of Air Medical Services and a leading activist fighting against unethical tobacco industry marketing practices. Joe and his wife Sally have two adult children. They live on a small farmstead in Iowa and their second home is a tent in the Grand Canyon.


Limited Table Sponsorships Available! $2,000

Six-foot, draped table in prominent location for the entire conference (one-and-a-half days) • • • • •

Estimated ratio of 200 participants to three sponsors 70+ hospitals represented Senior-level hospital leadership represented, including VPs, directors, and CEOs Participant names and contact information provided Sponsorship includes one free registration and three meals at the hotel.

Interested sponsors must be pre-approved. Please make inquiry or request to: Rhett Partin, Senior Vice President of Clinical Services and Public Health rpartin@gha.org 229-237-3334


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