Education

Learn more about a systems engineering, multidisciplinary, multi-specialty approach with onsite or web sessions

Diagnostic Case Reviews

Give us 100 Cases to Review and we will help you to identify Opportunities for Improvement

Coaching

We will coach you to be a system thinker that supports transparency for system learning

Jeanne Huddleston, MD Presenting How to Move Beyond Mortality Review and Create the Next Generation Safety Learning System

Philosophical Approach: Safety Learning System™

Call us today to join a session to discuss the impetus for the Safety Learning System™ and its multidisciplinary, multi-specialty review process approach. Hear Dr. Huddleston share lessons learned through its development and evolution.

Fundamentals: Safety Learning System™

  • A systems engineering approach to solving complex problems
  • Multidisciplinary, multispecialty collaboration
  • Runs under Chatham House Rule
  • Is a process of System and process of care review – NOT peer review (Not related to preventability or causality)
shutterstock_454447759 (1) (1)

Upcoming Webinars:

Morality Reviews: Great Learning from Our Early Journey

Thursday February 16, 2017 from 12:00 PM to 1:30 PM CST

Patty Atkins, RN, MS, CNS, CPPS is responsible for Quality, Patient Safety and Lean Six Sigma for Sharp HealthCare, the largest healthcare system in San Diego, CA. She will share the terrific learning her organization has gleaned from mortality reviews, having worked with Dr. Jeanne Huddleston from the Mayo Clinic who are the leaders in this field. Her insights are just what our surveys have told us from frontline safety leaders in our National Research Test Bed.

Dr. Huddleston's work at the Mayo Clinic has generated one of the strongest positive reactions we have ever had in our nearly 100 monthly sequential webinars. The breakthrough work that can have enormous impact on the patient safety of healthcare institutions.

Following the presentation, a reactor panel will discuss how the insights can be applied to frontline care.

Sponsored by: Texas Medical Institute of Technology (TMIT) High Performer Team SafetyLeaders

Register Now

Tenets of a Safety Learning System

1.Multidisciplinary reviews

  • Nurses have equal voice
  • Multiple perspectives on patient journey
  • Identification of “contributing factors” (HF nomenclature)

2.Practicing providers & Deference to expertise

  • Omissions provide bigger opportunities
  • Increases physician involvement

3.Multispecialty, multidisciplinary case discussions

4.Actionable Information and Influence

  • Case-based teaching with patient stories
  • Six Sigma structure and analytics
  • Leading “up” and influencing change

Why does the structure work?

  • Moves away from insular peer review
  • Promotes culture change
  • It’s NOT about adverse events
  • Identifying process of care and system failures
  • Identifying opportunities for improvement
  • Inspiring action through stories
  • Right size quality improvement initiatives

Online Webinar Recordings:

Learn from Mortality Review AND the Living: Next Generation Safety Learning System™

Patient safety events are increasingly recognized as the 3rd leading cause of death including the typical adverse events we count and measure in patient safety. These existing measurement systems do not identify actionable opportunities for improvement nor provide obvious direction for next steps. The information Dr. Huddleston will share will help us understand areas of critical importance that will compliment what we do in prevention of adverse events.

View Here Courtesy of Texas Medical Institute of Technology (TMIT) High Performer Team SafetyLeaders

Learn from Mortality Review AND the Living: Part 2 – A Deeper Dive

In response to the overwhelmingly positive evaluations of our webinar last month addressing Learning from Mortality Reviews, we have asked Dr. Jeanne Huddleston to take a deeper dive into what can be learned from mortality reviews and how participants can start a program and learn from others.

View Here Courtesy of Texas Medical Institute of Technology (TMIT) High Performer Team SafetyLeaders

Learning from Collaboration on Mortality Reviews: The Journey

Dr. Huddleston and her colleagues at the Mayo Clinic have undertaken breakthrough work that can have enormous impact on the patient safety of healthcare institutions. In our July and August webinars, she shared the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System, and will be our introduction speaker for our webinar this month.

Our audience was polled and asked if they wanted to hear from groups at the front line who have learned from the Mayo Clinic work and are actively studying and collaborating on mortality reviews. Hanan Foley, MSN, RN, CPHQ, the Director of Quality and Safety at MedStar Georgetown University Hospital, will share their experience on the journey.

View Here Courtesy of Texas Medical Institute of Technology (TMIT) High Performer Team SafetyLeaders

Saving Lives Putting Mortality Reviews to Work – It does pay off!

Dr. Jeanne Huddleston from the Mayo Clinic generated one of the strongest positive reactions we have ever had in our nearly 100 monthly sequential webinars for her work in mortality reviews. She will now show how such information can be used to save lives.

She and her colleagues at the Mayo Clinic have undertaken breakthrough work that can have enormous impact on the patient safety of healthcare institutions. She will share how the learnings on their journey to analyze the stories of all patient deaths are being converted into results.

The information Dr. Huddleston will share will help us understand areas of critical importance that will compliment what we do in prevention of adverse events. Following her presentation, a reactor panel will discuss how the insights can be applied to frontline care.

View Here Courtesy of Texas Medical Institute of Technology (TMIT) High Performer Team SafetyLeaders