Foundation Program Sites

Attending a Webinar

Have lunch with the Coalition! All webinars are from noon to 1pm PST and open to anyone interested. Webinars are free to those on staff at any of our member organizations, and available at a small fee to non-members.  Provider approved by the California Board of Registered Nursing, Provider Number CEP16359 for 1.2 contact hours. If you are interested in learning more about upcoming webinars or are interested in hosting a webinar please contact Steve Levy –

The Shared Decision Making Series





November 14, 2019 | Shared Decision Making 103: Elevating  Shared Decision Making to Uphold Health Equity
Description: Whether your organization has adopted or is in the process of adopting Shared Decision Making techniques, there are important elements to consider to ensure that your adoption of these practices is empowering to patients of all backgrounds. Rashmi Sharma, covered methods of elevating your organizational and individual SDM practices through a lens of health literacy, equity, and cultural competency by understanding and addressing language barriers, cognitive biases, and known disparities that can affect a patient’s comprehension and awareness of their treatment options, hinder their involvement and empowerment in their own care, and decrease the positivity of their care experiences and outcomes.

 October 30, 2019| Shared Decision Making 102: Adopting Shared Decision Making
Description: Now that you have gained a better understanding of how to define Shared Decision Making and its benefits in concept, it’s time to explore how to go about getting boots on the ground and putting these techniques into practice. Angie Sparks and Randal Moseley covered tips, best practices and firsthand advice for adopting SDM, “transcending the checklist” to more fully integrate SDM into practice as a care philosophy, real world examples of its adoption, and means of overcoming barriers, using the findings of the Bree Collaborative’s Shared Decision Making workgroup and others.

September 25, 2019 | Shared Decision Making 101: Understanding Shared Decision Making
Description: Shared decision making is a key component of patient-centered care but can be misunderstood or rushed-through.
What exactly is shared decision making, why is this so important to improving patient’s experiences and involvement in their care, and how can providers use shared decision making in clinical care? Ginny Weir and Emily Transue shared an overview of the Bree Collaborative’s recommendations for Shared Decision Making as developed by a workgroup of subject matter experts. The speakers discussed when shared decision making is appropriate, benefits to patients and to providers, and how to champion shared decision making within your own organization.

August 26, 2019 | Building Bridges Between Acute and Long-Term Care
Description: The transition from the hospital to another in-patient setting is fraught with potential gaps in performance.
Lisa Evans and Chistine (Chris) Lafrenz; two experienced post-acute partners who are passionate about building the bridges between acute and post-acute/long-term care. Much work has been done across Washington State to improve these bridges and patient safety. At the national level, reducing avoidable rehospitalizations has drawn much attention and the quality improvement work in this arena is robust. In Washington State, almost one out of five patients transferred to a lower level of care return to the hospital within 30 days. The only way to improve this outcome is through building strong partnerships that center on process improvement, consistent evaluation of the process, and strong two-way communication. During this webinar, Lisa Evans and Chris LaFrenz  reviewed the current landscape as it relates to expectations for the transitions of care, best practices of workflows between the acute and post-acute/long-term care setting as well as suggestions on how to measure success.

The Diagnostic Improvement Series

January 23, 2019 |The Technology | The Impact of Health Informatics on Diagnosis
Description:This kickoff presentation for the four-part Diagnostic Improvement Series set the stage with a brief epidemiology of the problem of Dx error and featured a discussion on the impact of health informatics on diagnosis. The presentation was hosted by Dr. Mark L. Graber, the Founder and President Emeritus of the Society to Improve Diagnosis in Medicine (SIDM). The electronic health record is clearly front and center in considering the impact of health IT on diagnosis; the presentation highlighted both the many ways the EHR facilitates and improves the diagnostic process, and a few of the frightening new problems that have emerged, including clinician burnout and the copy-paste nightmare. Health IT has also enabled entirely new opportunities to improve diagnosis, including telehealth, the use of ‘trigger tools’ to monitor diagnostic safety and quality, and the new decision-support tools that are available today to assist with everyday diagnosis. On the horizon are artificial intelligence applications that can diagnose novel conditions just from your voice or a photo of your face.

February 21, 2019 | The Research | Improving Diagnosis through Research into the Physician’s Mind and the Patient’s Experience
Description: Dr. Meyer, a cognitive psychologist, discussed theories and research data about the vulnerabilities that exist in clinician cognition as well as potential ways to combat those vulnerabilities to achieve more accurate, timely diagnoses for patients. Dr. Giardina is a social scientist and patient safety researcher at Michael E DeBakey and assistant professor at Baylor College of Medicine. She discussed the value of engaging patients in diagnostic error reporting as well as her recent work analyzing patient- and family-reported error narratives to identify factors that contribute to diagnostic error.

March 20, 2019 | The Patients | Improving Diagnosis Through Patient and Family Engagement
Description: This presentation introduced the National Academy of Medicine’s (NAM) definition of diagnostic error and the diagnostic process framework as well as the role of patients and family members as co-producers of improved diagnosis. The presenter, Sue Sheridan, Director of Patient Engagement at SIDM, mapped two diagnostic error case studies onto the NAM diagnostic framework identifying breakdowns in the patient’s diagnostic journey that led to patient harm as well as opportunities for patient and family engagement. The presenter shared recent patient focus group results and current tools, methods, and strategies that are currently being used by healthcare systems, clinicians and practices to engage patients and family members in improving diagnostic safety and quality

April 24, 2019 | The Providers | Team-Based Approaches to the Diagnostic Process
Description:A panel comprised of Sheryl Kalbach, Social Worker and Patient and Family Experience Specialist at Seattle Children’s Hospital; Kay Rawlings, a parent of an SC patient; and SC neonatologist and pediatrics professor Craig Jackson brought their experiences together to share advice on improving diagnosis and the patient experience through relationship building, transparency, and collaborative care — much of it through improving the “soft skills” involved in diagnosis, error disclosure, follow-up, and support. This talk illuminated how a provider’s approach to communication and collaboration colors the experience of the patient and family and included a parent’s valuable first-hand take on such an experience and her advice for improving it.

The Care for the Colleague Series

November 29th, 2018 |Care for the Caregiver: How Compassion Mitigates Burnout. Wrapping up our Care for the Colleague series, we turn to the crucial topic of burnout, and how to address, reduce, and prevent it with provider-focused compassion. In this lunchtime webinar, Michael J. Goldberg from Seattle Children’s Hospital and the Schwartz Center for Compassionate Healthcare (developer of the popular Schwartz Rounds) covered the harm burnout poses to both providers and patients; why medicine has lagged behind other industries in understanding this harmful phenomenon; how neuroscience can serve to help us understand and respond to burnout; and how to create a useful anti-burnout framework with compassion at its center. The framework recognizes that the experience of the care provider drives the experience of the patient and family. Its design is to provide compassion and collaboration at three levels: the individual caregiver, their teams, and organizational leadership. This webinar is appropriate for patient and quality officers and executives, nurses, physicians, front-line clinicians, and anyone concerned with reducing and preventing burnout and increasing compassion in the medical workplace.

October 25th, 2018 | Providing Safe Spaces for Providers That Promote Connection, Empathy, and Wellbeing. In discussing care for the colleague, the question of how to build compassion for your providers into the system is a crucial one for healthcare organizations to address. Balint groups are a well-established format for discussion of cases that are challenging for providers, from complex patient interactions to unexpected events, with a goal of helping participants transform uncertainty, confusion, and difficulty in the patient-provider relationship into a more therapeutic alliance. Providers can derive benefit from these safe spaces that allow them to process comfortably with other providers and compare notes, while benefits to the patient can flow downstream in the form of improved care and outcomes — in fact, Balint groups were first formed in London in the 1950s by psychoanalysts Michael and Enid Balint who coined the term “patient-centered medicine.” Led by Dr. Robbie Sherman, Medical Director for the Patient Experience and

Physician Development at the Polyclinic, this presentation will inform the audience about the structure of Balint groups, how they help to foster well-being, prevent burnout, and offer positive effects to patients, and how participants can go about joining or forming a Balint group if they are interested. This webinar is appropriate for physicians, nurses, front-line clinicians, safety and quality officers and executives, patient advocates, and anyone with concern for the importance of building compassion into both sides of the patient-provider relationship. WEBINAR LINK: The recording from this webinar can be found here. SLIDES LINK: The slides from this webinar can be found here.

September 27th, 2018 | Care for the Colleague: Bringing Encouragement and Support in Difficult Events. Learn about designing, implementing, and monitoring a successful Care for the Colleague program! Presented by Kit Hoffman with first-hand experience of setting up such a program at Confluence Health, this webinar offers listeners a chance to learn about designing automatic, non-punitive support that reduces psychological, physical, and professional distress for healthcare professionals and equips them to deliver safe, compassionate care. Kit will share the unique approach they’ve brought to this effort in designing Confluence’s BESIDE program, incorporating a mental health professional into the process, and go over research identifying key elements of Care for the Colleague programs with practical steps for implementation and evaluation. Finally, you will learn brief skills to help you respond to a healthcare professional who has had an adverse or stressful patient event. This webinar is appropriate for front-line clinicians, patient safety and quality professionals, mental health professionals, healthcare leadership, and anyone else interested in learning about implementing care for the colleague in the workplace.

November 16th, 2017 | Expanding Understanding of Communication & Resolution through CRP Certification with Dr. Tom Gallagher, Mike Farrell, Marcia Rhodes, and Dr. Timothy Dellit. Communication and Resolution Programs (CRPs) are the emerging best practice for addressing patient harm when it happens and preventing it in the future. Following a successful CRP Leadership Retreat in September, we want to provide healthcare leaders some guidance on where to go next to learn more about becoming involved in CRP efforts. In particular this webinar will highlight CRP Certification, a unique activity being piloted here in Washington that allows both providers and healthcare organizations an opportunity for focused feedback on their use of a CRP after an episode of care. This webinar is appropriate for front-line clinicians, hospital administrators, and anyone involved or interested in reshaping responses to patient harm while also making strides to prevent it.



The Bias & Inequities Series

October 4th, 2017 | How Clinician Bias May Contribute to Health Inequities with Nancy Fisher of CMS. How can unintentional clinician bias manifest into patient harm? What about more overt bias? Dr. Nancy Fisher, known affectionately by many as Doc Nancy, has spent much of her career trying to address harmful bias and the health inequities it causes. In her philosophy, medicine is not just a science, but an art, an interpersonal relationship, and a communication process, much of which is non-verbal. Without these elements, poor quality of care ensues – in itself a health inequity. In this webinar, Dr. Nancy Fisher will explore these ideas in sharing how bias, by putting an inaccurate focus on a patient’s identity, actually results in making care less patient-centered. More importantly, she will explore how bias can be identified and addressed on the pathway to fixing this often hidden, yet extremely critical issue. This webinar is appropriate for front-line clinicians, patient safety and quality administrators, and anyone involved or interested in making strides in solving biases and inequities in the healthcare system.

SLIDE LINK: The slides from this webinar can be found here.

September 21st, 2017 | Reducing Disparities in Diabetes Care: From Data to Doing with Lisa Packard of Qualis Health. It’s no secret that for those in historically underserved populations, daily management of health conditions poses unique challenges. In this webinar, we looked at these challenges through the lens of health equity and social determinants of health with a focus on diabetes, a hugely prevalent disease that is widely known to disproportionately affect underserved populations. Presenter Lisa Packard, who has spent years focused on health inequities and diabetes, shared how diabetes patients can take charge of their health through community-based workshops teaching positive self-management techniques. She also went over how healthcare professionals can help support these individuals, foster the linkages between communities and clinics/health systems, and find or implement these kinds of trainings – particularly the evidence-backed Diabetes Self-Management Program (DSMP) workshops. Lisa also reviewed the evidence behind the Diabetes Prevention Program (DPP) and quality improvement opportunities that can be identified using Medicare claims data. This webinar was appropriate for front-line clinicians, patient safety and quality improvement professionals, and anyone involved or interested in making strides in health disparities and/or diabetes work.


June 28th, 2017 | Addressing Bias, Language Barriers, and Inequities in Healthcare with Cheri Wilson of IHI. Have you ever wondered why sometimes our thoughts don’t match our actions? In this interactive webinar, participants learned more about implicit bias and how it affects our everyday lives in everything from healthcare and beyond, to areas of criminal justice, employment, housing, and media. Most importantly, participants were equipped with tips and debiasing techniques for mitigating implicit bias as a strategy for reducing disparities in health and healthcare and for promoting health equity. This webinar was appropriate for front-line clinicians, patient safety and quality improvement professionals, and anyone involved or interested in making strides in health equity work.


The Workplace Safety Series


March 29th, 2017 | Applying the 6 Elements of Safety Risk Assessment to Healthcare Redesign with David Frum of Salus Architecture and Mary McHugh of the Northwest Kidney Centers. According to researchers with the Agency for Healthcare Research and Quality, there is a growing evidence-base that “designing for safety and quality can improve patient outcomes and safety, promote healing, increase patient satisfaction, and reduce costs.” David Frum and Mary McHugh joined us to share lessons about this important element of safety culture that is too often overlooked. The webinar focused on defining the Center for Health Design’s 6 elements of Safety Risk Assessment – Infection Control, Patient Handling, Medication Safety, Falls, Behavioral Health, and Security – and illustrated how they can be applied to the design of medical environments. In particular, having worked closely on a project redesigning an outpatient setting at the Northwest Kidney Centers, the speakers provided real-world examples of how these elements have been applied to a dialysis clinic, though the concepts were applicable to other medical settings as well. This webinar was appropriate for hospital and clinic administrators, nursing leaders, facility design professionals, employee health professionals, quality improvement professionals, infection prevention professionals, pharmacists, safety officers, and anyone involved in a healthcare setting who was interested in getting an in-depth look at Safety Risk Assessment, healthcare redesign, and human factors engineering with compelling first-person examples.

SLIDE LINK: The slides from this webinar can be found here

February 22nd, 2017 | “We’re All in This Together”: Team Strategies for Workplace Violence Prevention with Dr. Nan Yragui of the Washington State Department of Labor and Industries. According to the Bureau of Labor Statistics, workers in healthcare and social assistance settings are 5 times more likely to be victims of nonfatal violent acts than the average worker in any other occupation, with ER nurses being at the highest risk and prevalence unfortunately on the rise. In light of these facts, this important webinar shared proven, high-performing strategies for healthcare teams to employ in preventing workplace violence and promoting a culture of safety for both patients and staff. Dr. Yragui, who has spent years dedicated to studying workplace aggression, introduced lessons learned from a qualitative study conducted by herself and her SHARP research team, findings from nursing staff focus groups and supervisor interviews, team support strategies for safety, and how patient safety is linked to staff safety through these prevention strategies. This webinar was appropriate for nurses, front-line clinicians, physicians, hospital administrators, and anyone involved in a healthcare setting who would like to arm themselves with valuable knowledge for enhancing safety culture in the workplace.

August 3, 2016: “Communication Resolution Programs: From the Patient Perspective.” In the concluding webinar of this series, patient safety advocate and leader Carole Hemmelgarn, presents a look at CRP’s from the patient perspective. This webinar will address the needs of patients and families after harm has transpired.  It will identify the four most common elements patients/families want to know after medical errors, and why.  After harm occurs care providers, patients and families suffer emotional distress.  Carole will discuss the similarities of pain and suffering that happens among these individuals.  Finally, the presentation will discuss how to engage patients and families in your organization after they have been harmed.

July 20, 2016: “Communication Resolution Programs: Focus on Implementation.” In part 2 of the WPSC’s webinar series on Communication Resolution Programs, Dr. Tim McDonald, Medical Director of Quality and Safety at the Sidra Medical and Research Center, presents a look at CRP’s in action. This presentation focuses on organizational implementation of a CRP system of event response.

June 22, 2016: “Communication Resolution Programs: Making Care Safer Through Transparency & Accountability.” Communication and Resolution Programs (CRPs) make care safer by fostering a culture of accountability, improvement, and transparency. When an adverse event takes place, research shows that most patients and their families want an honest explanation of what happened, an apology, and to understand how similar events will be prevented. These events are traumatic for both the families of patients and health care teams involved in the care. Rather than hide adverse events, CRPs promote candid, empathetic communication and timely resolution for patients and caregivers, coupled with learning to prevent recurrences.

April 13, 2016: “Organizational Commitment to Improving Surgical Outcomes: One Institution’s Journey.” Madigan Army Medical Center adopted the evidence-based practices developed by the Strong for Surgery public health campaign that engages patients (active duty, family members, retirees, and all beneficiaries) and their surgeons in a preoperative nutrition program to improve overall health and the likelihood of positive surgical outcomes. The nutrition screening checklist is just one tool in the resource bundle that identifies surgical candidates at high-risk for postoperative complications using evidence surrounding body mass index, weight loss, appetite, swallowing ability, and albumin levels. Through interactions with community partners Madigan has learned that the populations who may benefit the most from the intervention include colorectal, gastrointestinal oncology, vascular, ENT, bariatric and abdominoplasty patients. Madigan’s interdisciplinary approach to perioperative nutrition support is designed to restore health following major surgery by incorporating an evidence-based, safe, proactive, and collaborative intervention with demonstrated benefit in modulating the immune response to surgical trauma. This presentation will describe the Madigan Army Medical Center Strong for Surgery experience with suggestions to promote adoption of strategies to optimize nutrition status preoperatively and promote healing postoperatively. There will be a discussion of institutional resources needed for successful implementation and sustainment.

March 9, 2016: “Is Patient Safety the New Tort Reform? The Impact of Transparency on Patients, Families, Staff & Culture?” Martin Hatlie, JD, CEO, Project Patient Care, will explore what was learned in two case studies about communication with patients or family members after an adverse event . This session will focus on real experiences of patients, family members and healthcare providers who found ways to compassionately communicate and successfully partner in the aftermath of patient safety events.  

February 10, 2016: “Engaging Your Patients: Create a Culture of Service Excellence.” Edward Leigh, founder and Director of the Center for Healthcare Communication, shared what to say to patients – and what NEVER to say to patients! In this high-content and energizing webinar, participants learned powerful strategies to dramatically enhance both patient engagement and patient safety. Topics for discussion included: establishing immediate rapport, powerful interviewing / educating tools, and sensitively handling patients experiencing intense emotions. The easy-to-implement guidelines not only reduce patient stress; they reduce your stress too.  Click here to see the slides from this presentation.

January 20, 2016: “The Washington Patient Safety Coalition – A Year in Review and Glace Ahead.” The Coalition’s Program Director, Kelly Veit presented a review of WPSC’s current activities and major achievements. We shared the results of our bi-annual strategic planning session, and outline the new organizational goals that will guide our activities over the course of the next 3 years. Click here to see the slides from this presentation.

The Addiction Treatment Series

October 26th, 2016 | Part two of the Addiction Treatment series: Washington State’s Opioid Response Plan & What You Can Do to Help.” This unique webinar featured co-presenters with direct involvement in Washington State’s response to the opioid epidemic: Dr. Kathy Lofy of the Washington State Department of Health and Ginny Weir of the Dr. Robert Bree Collaborative. Especially relevant following the recent opioid crisis compact signed by Governor Inslee, this three-part presentation shared 1) the epidemiology of the problem, with attention to population health inequities, 2) current work underway in Washington State to align prescribing practices with evidence-based guidelines, and 3) concrete ways healthcare professionals could help implement the goals of these initiatives from within their networks. This was a highly educational webinar appropriate for clinicians, prescribers, policy makers, hospital administrators, and anyone with a shared interest in contributing to opioid epidemic solutions in Washington State.

September 28th | Part one of the Addiction Treatment Series: “Current Tools in Behavioral Health and Addiction Care for Rural Healthcare and Beyond.” With so much in progress in the increasingly critical topic of addiction treatment and its integration with mental/behavioral health, it can be difficult for healthcare professionals to keep up with what kind of resources are available and how to utilize them. In this kick-off to our series, Dr. Ries of the UW Medical School familiarized listeners with current tools and resources available here in Washington State aimed at effectively caring for mental/behavioral health populations, addressing warning signs of addiction, employing intervention tools, and utilizing best practices for referral to treatment. These included expanded telehealth tools and the new UW PACC (Psychiatry and Addictions Case Consultation) program, designed to expand the behavioral health and addictions care capacity of healthcare professionals especially in remote, underserved areas. The webinar was appropriate for primary care providers, mental health or addictions providers, psychiatrists, and rural healthcare professionals.

December 9, 2015: “RCAs: Challenges, Successes and a Roadmap Forward.” Presenters Joanie Ching and Gena Tadych of Swedish will share their challenges, successes and roadmap forward with building a scalable model of response analysis, including the Root Cause Analysis (RCA) tool, in a complex, multi-campus healthcare system. The primary areas of focus will be on prioritization, closing action Items, systematizing learnings, and building on both Just Culture Principles and our Culture of Safety.

November 18, 2015: “Bringing the Patient Experience to RCA with Patient Advisors”.  Speakers from PeaceHealth shared the experience of introducing Patient Advisers onto Root Cause Analysis teams in an acute care hospital, including the selection process, the job description, the training provider, and the feedback and lessons learned along the way.Click here for slides .

October 14, 2015: Jan Brauer RN, BSN, MA. Family Birth Center nurse and  TeamSTEPPS Master Trainer presented Creating Change in a Critical Access Hospital: A “Before” and “After” Look at Applying Team STEPPS Tools. Jan Brauer of Hood River Providence will conclude the series by highlighting how Team STEPPS created measurable change within a Critical Access hospital in Oregon. The presentation will provide a “before and after” glimpse at the organization, and focus on applying these tools within inpatient settings.

September 9, 2015: “TeamSTEPPS: Application of Communication Tools to Reduce Care Barriers in an Outpatient Setting.” Presented by Dr. Joseph Montella,  MS, CPE. Associate Professor Department of Obstetrics and Gynecology – Jefferson Medical College. Building upon the information presented in the August webinar, this session discussed how applying TeamSTEPPS principles can create a shared mental model for error reduction and can provide a powerful tool to improve access and timeliness of care by improving communication among personnel in the outpatient primary care setting. The results of two outpatient performance improvement projects (with metrics) were presented. Webinar participants gained the ability to associate each principle with a particular barrier to care and to think of TeamSTEPPS principles not only as face-to-face communication tools, but also as tools to improve written and electronic communication.

August 12, 2015: “TeamSTEPPS:  A Proven, Practical Approach to Address Human Factors in Improving Patient Safety.” Presented by Jan Brauer RN, BSN, MA. Family Birth Center nurse and  TeamSTEPPS Master Trainer. This first of the three part Team STEPPS series was introductory, and geared towards an audience with minimal back ground knowledge of this topic.  The August webinar gave an overview of AHRQ’s TeamSTEPPS.  It covered a description of the “what” and “why” of this teachable tool.  TeamSTEPPS can help you achieve your patient safety goals by equipping each member of your staff with communication tools.

June, 10, 2015: “Medication Reconciliation in Transitions of Care.” Jeff West, RN, MPH, of Qualis Health engaged participants in critical reflection on the medication reconciliation process using the  MARQUIS Medication Reconciliation Implementation Toolkit as a guide. Qualis Health, the Quality Innovation Organization for Idaho and Washington, works to improve care for Medicare beneficiaries, families, and caregivers across the region. Click here for slides , Click here for handouts.

April 15, 2015: “Involving Patients and Families to Drive Improvement.” Patient and family centered care has made it to center stage in discussions of quality and safety. Organizations think they understand what their patients and families want and what they experience through satisfaction survey instruments, but do they really? And measurement doesn’t equal involvement. Attendees were introduced to how Virginia Mason Medical Center is using a set of experience-based design methods and a patient-family partner program to embed the voice of their customers in redesigning patient experiences across the continuum of care. Presented by Ann Hagensen, RN, Project Manager, Patient Relations and Service, and Jennifer Phillips, Innovation Director, Kaizen Promotion Office, Virginia Mason Medical Center.

February, 11, 2015: “Medication Lists Across the Continuum: What are the best ways to collect patients’ medication lists?” The process for obtaining patient medication lists for hospital admission was reviewed in detail, including the resources MultiCare uses when the home medications are unknown to the patient. Pharmacist interventions and communication with providers were discussed, as well as providers’ responsibilities at admission and at discharge medication reconciliation. Presented by Tasheba West PharmD, BCPS, MS, Clinical Pharmacist, Department of Pharmacy Services, MultiCare Health System. Click here for slides.

December 10, 2014: Root Cause Analysis and Just Culture.  Presented by David Allison and Dr. Andrea Halliday, PeaceHealth Oregon West Network. Click here for slides.

November 19, 2014: More Than a Meeting: Maximizing the effectiveness of your Root Cause Analysis process. Presented by Leanne Park, RN, JD, Director of Risk Management, Providence Health Care. She presented a brief overview of best practices in place locally and nationally with an emphasis on practical application; outlined several success stories, and shared tools and discussed technology available to support event review and action item follow up. Click here for slides.

October 8, 2014: Using Root Cause Analysis in the post-acute setting. Lisa Evans, Senior Administrator at ManorCare, presented methods and examples of RCAs in long-term and post-acute settings. The webinar  included recommendations for sharing lessons learned with partner hospitals to prevent avoidable rehospitalizations. Click here for slides.

August 20: Lessons learned in TeamSTEPPS sustainment. Presented by Bill Hurley, MD, CMO at Summit Pacific Medical Center, and Co-Director of the UW National TeamSTEPPS training program. What to do and not do in the development and evolution of healthcare teamwork in organizations. Dr. Hurley drew upon his experience with TeamSTEPPS in military, community hospital, and academic center settings. Click here for slides. Click here for slides.

August 13: TeamSTEPPS Implementation: what works? Presented by Laura Maynard, Director of Collaborative Learning, North Carolina Center for Hospital Quality and Patient Safety, North Carolina Hospital Association. After attending this webinar, participants were be able to (1) discuss the importance of assessment, strategy and planning in TeamSTEPPS™ implementation; (2) describe an effective coaching model for sustaining use of TeamSTEPPS™ tools; and (3) understand resources available and strategies for integrating TeamSTEPPS™ into ongoing safety and quality improvement. Click here for slides.

June 18: Rachel Digmann, PharmD, BCPS, Clinical Pharmacy Specialist at Telligen (Iowa QIO), described the current process to evaluate medication reconciliation and medication management across care settings and its relationship to patient outcomes. Early work on this project identified the need for a multidimensional, community-based interdisciplinary team to evaluate the current structure of medication reconciliation and to evaluate sustainable options for improvement. This program will highlight preliminary outcomes from the first phase of the project and will present recommendations on other hospitals and communities might consider establishing a similar project or program in their community.

March 12: Judith Hibbard, DrPh, University of Oregon. Patient Activation: what is it, how is it measured, what have we learned, and how is it related to outcomes? This webinar was sponsored by the Washington State Nurses Association. Click here for slides.

February 12: Thomas Gallagher, MD (University of Washington) and Olga Owens, JD (Patient and Family Advisory Council, HealthPact) presented an overview of current state of the art around communication and resolution programs nationally and in Washington State, with insight and perspective from a patient/consumer advisor.

December 11: Keeping Patient Centered during the Design, Build and Birth of a New Medical Center: Renee Jensen (Chief Executive Officer) and Brenda West (Chief Nursing Officer) of Summit Pacific Medical Center described the process of transforming 50-year-old Mark Reed Hospital into a state of the art, patient-centered medical center in Elma. Click here to download slides.

November 13: Patient Glycemic Control & Reducing Occurrence of Surgical Site Infection, presented by Rebecca Davis, Madigan Army Medical Center

October 23: Improve Patient, Visitor and Staff Safety through Key Components of Therapeutic Communication with Behavioral Challenged Individuals. Presented by Martin Reinsel, MA, LMHC, clinical educator and therapist at Navos, Seattle, WA. Click here to download slides.

September 19: Patient Safety – Building a Culture of Respect and Accountability. Presented by Renae N. Battié, MN, RN, CNOR Dennis DeLeon, MD. Click here to download slides.

August 14: Health Literacy – Practical Advice for Improving Patient Understanding. Presented by Gail A. Nielsen, BSHCA, FAHRA, RTR (recently retired as the Director of Learning and Innovation, Iowa Health System). Click here to download slides: Part 1 Part 2 Part 3

July 7: Improving care transitions and reducing readmissions. Presented by Sharon Eloranta, MD, Medical Director, Quality and Safety Initiatives, Qualis Health. Click here to download slides.

May: Learn how senior leadership (Boards, trustees, C-suite) can facilitate and advance safety priorities. Led by Tom VanDawark of Orca Partners, LLC Click here to download slides.

April: Five Skills for Managing Risk in a Just Culture: How today’s leaders and managers can manage risk, develop a true learning organization, and embrace practices that treat employees with justice, accountability, and empathy. Presented by Paul LeSage, Outcome Engenuity. Click here to download slides.

March: Motivational interviewing and patient activation. Presented by Val Overton, Fairview Medical Group.

February: One size does not fit all: patient safety considerations for ethnic minorities. Presented by Alan Harney, Tulalip Tribes Health Clinic. Click here to download slides.

December: Medication Reconciliation in Ambulatory Care, presented by Barbara Hyland-Hill, RN, MN, NEA-BC and Meg Kilcup, PharmD.

November: Using Lean tools in a critical access hospital and clinic setting, presented by Renee Smith.

October: Hospital Based Transitions, presented by Jeffery Liles, MD FHM, Providence Health Care, Spokane, “Ease My Way.”

September: Human Factors Engineering, presented by Leanne Morrison, RN, MN.

July:Engaging physicians in patient safety, presented by Rayburn Lewis, MD, Swedish Medical Center.

June: A collaborative, systems-level approach to eliminating healthcare-acquired MRS, CLABSI, and other infections, presented by the University of Washington Medical Center.

April: “Human Factors: what is it (or what are they?) and what does it mean for patient safety?” presented by Jason Fouts, Principal Human Factors Engineer (Mobia Group). Suggested Readings from the Short Course on Human Factors Engineering and Patient Safety from The Center for Quality and Productive Improvement at the University of Wisconsin, Madison.

March: “Multi-dose Medication Dispensing for Discharge – relabeling multi-dose medications to avoid inadvertent discontinuation,” presented by Darin Smith, PharmD, BCPS, FASHP, (Norman Regional Health System, Norman, Oklahoma) and Susan Boyer, MS, BS Pharm, (WA State Board of Pharmacy).

February: “Generational differences in the healthcare work force and their effects on patient safety” presented by Karen McNamara RN, BSN, M.Ed. Click here to watch the video (generational differences attached).

December: “Chronic Opioid Therapy: Safer Patient Management in the Ambulatory Setting”, presented by Paul Fletcher, MD, Assistant Medical Director of Primary Care and Occupational Medicine, Group Health Permanente.

Barbara Hyland-Hill, Director of Nursing Operations at Group Health Cooperative, also provided this Health Affairs article on “Group Health’s Initiative To Avert Opioid Misuse And Overdose Among Patients With Chronic Noncancer Pain”

November: “Nuts and bolts of disclosure: practical aspects of doing disclosure in your facility”, presented by Michael G. Lloyd, Home health/Hospice Compliance, patient safety and risk manager, Providence Senior and Community Services

Nuts and bolts of disclosure
Handout version_Nuts and bolts of disclosure

September: “Implementing the Comprehensive Unit-Based Safety Program (CUSP),” presented by Janine Wiggins, Harrison Medical Center.

Related resources:
VA National Center for Patient Safety
Institute for Healthcare Improvement

July: Melissa Edmister, RN, BSN (Providence St. Peter Medical Center) discussed “Assessing and improving a culture of safety, including the use of peer review and self-reflection.”

June: Denise Fowler, RN, BSN, MS, Chief Clinical Officer (Whitman Hospital & Medical Center, Colfax) presented on “Hospital-Community-Patient Partnerships to Improve Handoffs & Decrease Readmissions

April: Ross Ehrmantraut, RN, BA, CCRN, Patient Safety Officer, and Elizabeth McNamara, RN, MN, Clinical Operations Manager for Infection Control (Harborview Medical Center) presented on “Not Just Another Checklist: Using Technology to Implement Time-Out in the Non-OR Setting.”

March: Cynthia May, RN, MSN, Director of Nursing Practice, Quality & Operations/Chief Nurse (Harrison Medical Center, Bremerton) presented on “So wash your hands! – What’s the problem? ”

Harrison Medical Center has also made available the following resources for editing and use in your organization:

Hand Hygiene Surveillance Procedure
Unit Based Hand Hygiene Survey Instructions
Survey Form
Survey Form for Ambulatory Care Setting

February: Lynn Stapleton RN, MN, Clinical Nurse Educator (Providence Holy Family Hospital, Spokane) presented on “A Healthy Work Environment — What it is, how to build and sustain it, and its effect on patient safety.”–For more resources, see the AHRQ Patient Safety Primer on Disruptive Behavior on our Sites & Resources page…

November: Trent Kelly, JD (Washington State DOH Agency Coordinator for the Chronic Pain Management Rules Workgroup) and Chuck Cumiskey, RN, BSN, MBA (Nursing Practice Advisory, Washington State DOH Nursing Care Quality Assurance Commission) presented on “Facts and Fictions about ESHB 2876: Chronic non-cancer pain management.”Trent’s presentation / Chuck’s presentation / Pain Management – Draft Pattern Rules

October: Michael Lloyd, MBA, CPCU, ARM, CPHRM, Manager, Patient Safety, Risk & Compliance (Providence Health and Services) presented on To ID or Not To ID – Who is my patient and what am I doing to him?

September: Michael Haight, MD, MHA, Vice Pres., Medical Affairs (Sacred Heart Children’s Hospital, Spokane) presented on Culture of Safety – Can we get physicians engaged?.

August: Sheila Yates, Manager, Patient Safety and Diane Schultz, Medication Safety Manager (Group Health Cooperative, Seattle) spoke about creating a Patient Safety Culture in Ambulatory Care and Why Reporting Counts.

July: Dr. Hope Wechkin, Medical Director (Evergreen Hospice and Palliative Care) spoke about the safe and appropriate use of hospice and palliative care services.

June: Rebecca Davis (Harrison Medical Center), Lynnette Truxal, RN, MN (1.1 MB PDF) (Madigan Army Medical Center), and Rosemary Grant (University of Washington) presented an overview of their experiences in improving surgical site infections through use of national and local benchmarking data (i.e., NSQIP and SCOAP).

May: Carol Parry, Family Centered Care Specialist, and Rachel Trindle, Family Advisor (Seattle Children’s), presented on Engaging Patients and Families as Safety Partners.

April: Jeanette Harris, Infection Preventionist (Multicare Health System), presented on dealing with Multi-Drug Resistant Organisms – Prevention in Seven Steps.

March: Cindy Sayre, MN, ARNP (University of Washington Medical Center) discussed Fall Prevention — Challenge and Opportunity.

January: Norman Gregory (Providence Everett Medical Center) spoke about the Culture of Transparency and Dr. Dan O’Connell shared challenges and strategies for Disclosing Errors and Resolving Adverse Events and Outcomes, including supporting patients and providers.