Keith P. Chastain, MSQA, CMBB, CQE Senior Performance Improvement Project Manager BayCare Health System, Clearwater, Florida
Keith is an ASQ Certified Master Black Belt, ASQ Certified Quality Engineer and Lean Facilitator with 21 years of experience driving process improvement efforts across health care, manufacturing and customer service/technical support contact center environments. He is currently serving as a Senior Performance Improvement Project Manager at BayCare Health System in Clearwater, FL and holds a Master’s Degree in Quality Assurance from Southern Polytechnic State University and a Bachelor’s degree in Nuclear Engineering from the University of Florida. Keith has led numerous cross-functional teams on improvement projects and has coached, mentored and trained Six Sigma Black Belts, Green Belts, Executive Belts and Lean Facilitators.
Michelle is a Six Sigma Master Black Belt in the Healthcare Quality industry for over 25 years. She received her BS in Business Administration and Accounting at Florida Metropolitan University.
Michelle has worked both in the hospital setting as well as in the insurance side of healthcare. A Certified CPHQ and Lean Six Sigma Practitioner. Michelle currently works for BayCare Health Systems in the Performance Improvement Department leading projects that span the entire healthcare system.
Conference Day One, Thursday, April 27, 2023
8:15 AM Patient Fall Interprofessional Case Discussions Through a Just Culture Lens
Patient Case discussions associated with falls broken down to protocol, competencies, and interprofessional teamwork with an application of a just culture lens for gaps in care and or documentation.
Cassandra Vonnes, DNP GNP-BC APRN GS-C AOCNP CPHQ FAHA Geriatric Oncology Moffitt Cancer Center, Tampa, Florida
Dr. Vonnes attended the University of South Florida for her BS, MS, and DNP. Her 28-year NP experiences include acute care and outpatient services of internal medicine and cardiovascular medicine and was inducted as a Fellow of the American Heart Association for her contributions. She has taught clinical and didactic at the USF College of Nursing. She sits on the national Nurse Leadership Board for AARP and was recently appointed to the State of Florida Elder Affairs.
Under Dr. Vonnes leadership Moffitt Cancer Center was the first hospital in Florida to be recognized by the IHI as Committed to Care Excellence for the Older Adult. She is the host of the podcast of the national Gerontological Advanced Practice Nurses Association, GAPNA CHAT, highlighting clinical and policy issues related to the care of older adults. Dr. Vonnes has published and presented both nationally and internationally on Fall and Injury prevention, delirium, and geriatric assessment.
9:15 AM Promoting Change through Engagement of the Clinical Staff
A short conversation on how to engage clinical staff, administration, and physicians in performance improvement activities in a positive manner by including all stakeholders, selecting the appropriate champion for the initiative, and coaching effectively throughout the process.
Francetta Allen, MD, CPHQ, CPPS National Senior Director of Quality Envision Healthcare, Riverview, Florida
Fran holds a Bachelor of Science and Doctor of Medicine both from Universidad de CETC and has also attended Florida A&M University. Fran is a Certified Professional in Health Care Quality (CPHQ), Certified Professional in Patient Safety (CPPS), and is Six Sigma/Lean trained.
She has worked clinically in the Dominican Republic but was drawn to Regulatory Compliance, Quality and Performance Improvement. She has worked in private primary clinical practice areas as well as the hospital setting in both academic and community hospitals. She has held the role of AVP and VP of Regulatory Compliance and Quality at both University of Miami Hospital and Largo Medical Center. She recently served as AVP of Quality and Clinical Operations for HCA for the West Florida Division overseeing 15 hospitals, and currently has oversight of Quality at the National Level for Envision Healthcare. Fran has worked in the healthcare and regulatory compliance field for more than 20 years.
10:15 AM Promoting Change through Engagement of the Clinical Staff
The RCA2 process investigates adverse events to discover underlying system issues that contributed to the event. The RCA2 team is a multidisciplinary team responsible for conducting research, identifying root cause contributing factors, and identifying corrective actions. By combing the RCA2 methodology with modifying existing technologies, we were able to create a more efficient process for all involved. Creating a standardized template for documenting risk factors and contributing factors enabled the team to trend, track, and follow-up on corrective actions.
Kimberly Atrubin, MPH, CIC, CPHQ, FAPIC Director for Infection Prevention Tampa General Hospital, Tampa, Florida
Kim has been in the Tampa General Infection Prevention Department for more than 11 years. Prior to Infection Prevention, Kim worked at the Florida Department of Health in both Epidemiology and Environmental Health for nearly 5 years. In total, she has more than 16 years of experience in reviewing processes and providing recommendations for reducing infections.
She received her MPH in Epidemiology at the University of South Florida. She has been certified in Infection Prevention and Control since 2013 and certified in healthcare quality since 2017. She has reached Fellow status by the Association for Professionals in Infection Control and Epidemiology. She is actively involved as a member on national APIC’s Education Committee as well as her local APIC Chapter. In 2021, Kim and her team received the APIC Heroes Award for their response to the COVID-19 Pandemic.
Outside of work, Kim enjoys traveling and spending time with friends and family, including her two young boys.
Carmen Murphy, MSN, RN, CIC, FAPIC Manager for Infection Prevention Tampa General Hospital, Tampa, Florida
Carmen has been in the Tampa General Infection Prevention Department for more than 12 years. She has chaired the High-Level Disinfection Committee for 7 years, collaborating with multiple department leaders and team members to improve and centralize HLD practices in inpatient and ambulatory locations. Carmen practiced as a RN in critical care areas for 14 years prior to joining the IP department. She has brought insights on how to introduce or improve infection prevention practices in nursing processes to reduce HAIs and improve patient safety.
She received her MSN in Nursing Leadership and Management in 2019. She has been certified in Infection Prevention and Control since 2015 and reached Fellow status by the Association for Professionals in Infection Control and Epidemiology in 2022. She served her local chapter of APIC in 2020 as President-elect, 2021 as President, and 2022 as Immediate Past President.
Carmen also enjoys cats, crafting, thrifting, and spending time with her husband and 3 cats. She has recently enjoyed traveling to Colorado to spend time with her daughter, grandson, and 2 grand-cats.
11:30 AM Practical Data Collection for Healthcare
We need data, but it can be intimidating to get started. This presentation will support healthcare professionals in navigating the space related to gathering data for a stated need. General information on data collection will be covered. A significant portion of the presentation will cover data collection using a common electronic data collection tool, REDCap, that is widely available and used within the healthcare industry. Example projects made possible through use of REDCap will also be shown for context and awareness of both simple and advanced features available.
Michael Callahan Quality Improvement Advisor II Mayo Clinic, Jacksonville, Florida
Michael is married to the love of his life, Sarah, with whom he is helping to raise and homeschool four young children in Palm Coast, Florida. In his free time, he works as an improvement consultant and project lead for the Mayo Clinic out of Rochester, MN. After beginning his career in manufacturing, he transitioned into healthcare, the industry he has called home for the last 8 years. His experience is diverse after holding positions in research and clinical areas, inpatient and outpatient settings, and with pediatric and adult hospital systems. A lifelong learner, he has obtained degrees in bioengineering, chemical engineering, and operations research, education that has equipped him well for a career rich with problem-solving and creative thinking.
1:30 PM Designing Quality Healthcare Services
Deviceless remote patient monitoring. Accompanied telehealth. Hospital at Home. These are among the many new healthcare services currently rolling out in Florida to fulfill patient care needs that didn’t exist just a couple of years ago. The COVID pandemic advanced new healthcare service design in ways that few could have visualized. Building in quality is necessary to ensure that the many new services meet general standards of excellence desired by patient and healthcare practitioner alike. Using home paramedicine service design as an example, we’ll explore finding the problem, organizing a creative team, clarifying the problem, understanding the opportunity, and selecting an intervention.
Kenneth Peach, MBA, FACHE Health Council of East Central Florida Winter Park, Florida
Ken holds a Bachelor of Arts in Communication from Seton Hall University and a Master of Business Administration from Florida Institute of Technology. Ken earned his board certification in health care administration from the American College of Healthcare Executives. Following an early career in the broadcast business, Ken has spent 38 years in hospital, long-term care, health insurance, healthcare association, and health planning administration. Trained in quality improvement techniques by HCA, he has participated in and led QI initiatives in hospitals and nursing homes. In 2016, Ken wrote a series of grant proposals that funded the design of a unique home paramedicine service that is now expanding throughout Florida.
2:45 PM Achieving Organizational Excellence with a Modern Learning Ecosystem: Shift from “Order Taker” to “Performance Partner.”
When an organization has a true culture of service excellence, all of the quality, regulatory and compliance improvements follow. This includes not only adopting a culture of safety, but actually demonstrating one that promotes a learning environment for professional and organizational growth. It is when there is mutual respect and trust between stakeholders, individuals freely talk and embrace the focus towards service excellence. As the health care industry seeks to minimize risk and drive quality improvement through compliance and regulatory standards, organizations have a responsibility to make safety an organization’s top priority. This priority, the promotion of excellence can be demonstrated in clinical and operational actions and is often viewed as stakeholder’s level of commitment, compliance or conflict with organizational and industry standards.
This presentation will bring in evidence-based practices based on theory that connects organizational excellence to the role of establishing a learning environment grounded on a modern learning ecosystem, 70/20/10 to 100% performance model and hardwiring excellence. The modern learning ecosystem model addresses the implementation of adult learning principles, 70/20/10 to 100% performance emphasizes the importance of practical learning and job-related experiences when planning individual development in a professional sphere. Hardwiring excellence addresses a structured process based on five pillars (people, service, quality, finance, and growth) while utilizing nine principles (committing to excellence, measuring the important things, building a culture around service, creating and developing leaders, focus on employee satisfaction, building individual accountability, aligning behaviors with goals and values, communicating at all levels, and recognize and rewarding success) that direct all workforce member’s actions and an organization’s culture.
The delivery of healthcare has become more complex, but the makeup of the healthcare team has not changed. We are still human beings taking care of human beings. It is through the implementation of a philosophy (shared mental model) that utilizes internal and external standards, an organizational culture of service excellence can be brought to realization.
Doreen Herdman, has over ten years’ experience in a clinical role as a registered nurse (RN). She obtained a legal nurse consultant certificate and for seven plus years, was an in house nurse advisor in a plaintiff- medical malpractice law firm. Applying her clinical experience to the legal nurse consultant role, she continued to see the types of encounters patients and clinicians face in the healthcare industry. In 2012, she transitioned back to the healthcare industry as a compliance specialist. Doreen was licensed as a healthcare risk manager and is certified as a healthcare professional in quality (CPHQ), risk manager (CPHRM), patient safety (CPPS) and compliance (CHC). She also obtained a black belt in Lean Six Sigma (LSSBB) and is Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) master trained. After spending time in the health care quality and the compliance departments responsible for safety reporting, evidence based practices, and compliance audits, she has expanded her experience to include the human resources area. In June of 2022, she transitioned to the human resources department as the corporate clinical education manager at Shriner’s Children’s. Incorporating her clinical experience with the regulatory and healthcare standards, Doreen presently is responsible for developing system-wide structure and processes that promote a learning environment, and fosters the use of evidence-based practices. Having an understanding of the role of regulatory standards, the vision of high reliability and the expectation to deliver care in the current complex environment, Doreen brings multiple perspectives and expertise to various projects that helps move the quality of healthcare forward.
3:45 PM Skin Failure: An Underrecognized Condition
Are non-preventable pressure injuries truly due to pressure? We are familiar with heart failure, kidney failure, liver failure, etc. but what about skin failure? After all, skin is the largest organ in the body. With the rise in COVID patients, BayCare Health System saw a rise in pressure injuries. However, our wound care nurses noticed a unique trend with these injuries when all preventative measures were in place. With further research, collaboration, and information provided at the National Pressure Injury Advisory Panel Annual Conference, BayCare Health System embarked on a journey to understand the physiology of skin failure and to develop a process to identify and accurately document its presence. Through this effort, a definition, criteria, and process were adopted. Education was provided system wide across our fourteen acute care hospitals to all involved stakeholders, including wound care, nursing, providers, CDI, coding, and risk management. This has allowed for a proper diagnosis to be made, accurate documentation that reflects the patient’s true condition, and more reliable data when looking at pressure injury counts and opportunities.
Barbara Gillinder, BSN, RN, LHRM, CPHQ Quality Manager BayCare Health System, Clearwater, Florida
Barbara is the Quality Manager for Morton Plan North Bay Hospital in New Port Richey, Florida. Morton Plant North Bay is part of the BayCare Health System. She is responsible for the integrity and effectiveness of the quality assessment and performance improvement program. She provides leadership and guidance to hospital leaders, using data driven methodologies to address and resolve top opportunities for improvement. Prior to joining BayCare, Barbara served as a sanction specialist for a beneficiary and family centered care quality improvement organization. She was also a director of nursing for an ambulatory surgery center and has a background consisting of both emergency room and surgical services. Barbara is a nursing graduate of the University of North Carolina at Charlotte and received her license in healthcare risk management from the University of Florida. She has been awarded Who’s Who in American Nursing and is a member of several professional organizations including the National Association for Healthcare Quality and the Florida Society for Risk Management and Patient Safety. She enjoys spending time with her two young children and exploring new places.
Kristen Berlin Ph.D., MD, CHCQM-PHYADV, MBAc Physician Advisor BayCare Health System, Clearwater, Florida
Kirsten is a Physician Advisor for BayCare Health System. Prior to reinventing herself as a Utilization Management Physician, she practiced medicine as a Pediatric Hospitalist for 20 years at Johns Hopkins All Children’s Hospital and Saint Joseph’s Children’s Hospital in the Tampa Bay area. She currently works with system-based denials management and PA-led real-time observation management. She is the champion for skin failure across her hospital system, providing documentation guidance and education. She is the Pediatric Medical Director for Suncoast Hospice/Empath and the Medical Director for the Southwest Region of the Florida Department of Juvenile Justice. Dr. Berlin is currently pursuing her MBA in Healthcare Administration. When she is not working or studying, she is globetrotting with her teenagers and volunteering with rhinos at the Ol Pejeta Conservancy in Kenya. She is a self-declared “Peloton Addict” and cycling enthusiast who loves spending time with her schnauzer and her 3 free-hopping bunnies.
Conference Day Two, Friday, April 28, 2023
8:15 AM Evidence-Based Practice (EBP) Quality Initiative Pilot Project, Integration of the RN-Readiness for Hospital Discharge Scale (RN-RHDS) Questionnaire in the Inpatient Setting
Integration of the RN-Readiness for Hospital Discharge Scale (RN-RHDS) Questionnaire in the Inpatient Setting, in two neurology units. The project is a showcase of how EBP tools can be integrated to improve discharge process, improve readmissions, LOS and ED visits. 86 nurses participated and sample size of 264 patients evaluated for 9 months. Qualtrics was used for project documentation The project is an advancement of a DNP project which had 65 patients conducted for 3 months.
Emma B Kamau, DNP, MSN, RN-BC, BS Lecturer University of Miami, Miami, Florida
Dr. Kamau is a nurse educator with experience in diverse nursing specialties and has been an RN for 16 years including oncology, psychiatric, orthopedic and neurosurgery, and a board-certification in cardiovascular nursing. Dr. Kamau has been a nurse educator for 9 years and 3 years as a Lecturer. She holds a master’s in nursing education, a Doctor of Nursing practice with a focus on healthcare transformation from University of Miami School of Nursing and Health Studies. Dr. Kamau introduced the RN RHDS in the orthopedic unit as a DNP project. The DNP project improved patient discharge readiness for hip and knee orthopedic patients with significant reduction in readmission and LOS leading to a DNP manuscript publication in the Journal of Doctoral of Nursing Practice in 2021. In 2022, Dr, Kamau presented her DNP poster to the Florida Nurse Association research conference, Orlando, Florida and also to the 42nd Congress of National Association for Orthopedic Nurses (NAON) at Reno, Nevada where she received a 2nd position award. The evidence-based practice (EBP) quality initiative project, integration of the RN-Readiness for Hospital Discharge Scale (RN-RHDS) questionnaire in the inpatient neurology units for 9 months is an advancement of the DNP project to showcase and collect data for planning and eventual hospital-wide implementation. Dr. Kamau is the co-chair of the UHealth Nursing research and evidence-based practice council.
9:15 AM Data, Data Everywhere, but Where Does One Begin?
For years, we have been asking for data. Data paints the picture. Data proves the story. We now have varied, reports, systems, dashboards; but what do they tell us? We cannot possibly know where we need to go if we do not know where we have been & what has happened in the recent past. We are now data rich, but I believe we are insight poor. Where do we start to peel the onion? How to we begin the journey of a thousand miles? How to we eat this enormous elephant in front of us? All cliché’s, I know, AND each cliché holds the same answer…one layer, one step and one bite at a time. All collectively moving in the same directions, for the same reason with the same belief, that by keeping our staff, our providers7 especially our patients SAFE, we can provide an environment where to Err is Human, but we cause ZERO harm.
Deborah F. Raposo RN, BSN, CIDI, BC-NI, LNC, CPHIMS, CPPS, IN Performance Improvement Specialist 4 Tampa General Hospital- Transplant Institute, Tampa, Florida
Debbie holds a Bachelor of Science in Nursing from the Salve Regina University and is a Registered Nurse entering her 39th year in the profession of healing bodies and minds. Her passion for lifelong learning has allowed her to continue a journey through the 31 flavors of nursing. From the bedside, to leadership, to informatics and analysis, to legal aspects, to information systems to patient safety, and to performance Improvement. Throughout her career, she has always focused on the outcomes and experience of her patients and their families. Continually striving to meet their needs, and expectation, heal their bodies and minds, and to do no harm in the process. She has been practicing performance improvement well before there was a name for it. She can remember working in the kitchen of a nursing home as a young high school student trying to think of ways to entice her patients to want to eat their meals (even the pureed bowls of “brown mush” as she called it) by how they were presented, how they smelled and how they tasted. And now in her current position in transplant- her motto “We are human, to Err is Human but we must strive to create Zero Harm…One layer of the onion, one step of a thousand miles and one bite of an elephant at a time”.
10:30 AM An Initiative to Reduce Sepsis Mortality
Sepsis is a costly problem and recognition and resuscitation are challenging. Sepsis mortality increases by 7.6% every hour when antibiotics are delayed. Methodist Dallas Medical Center shares their 2020 2022 journey to improve antibiotic administration within the first 3 hours for sepsis patients across the system. The goal was a system compliance rate of 80% by June 30, 2022.
Linda Scribner, BA, CPHQ, HACP, LSSGB Director, Quality Services Methodist Dallas Medical Center, Dallas, Texas
Linda Scribner is Director of Quality Services at Methodist Dallas Medical Center. Her role includes quality, risk, infection prevention, guest services and in-house interpretation services along with program management of Comprehensive Stroke and Trauma Services. She earned her bachelor’s degree at the University of Florida in Gainesville. Prior to her current role, her professional experience includes acute care healthcare improvement and medical staff quality in community and teaching hospital settings. She has co-authored two articles published in the Journal of Healthcare Management and the Journal of Healthcare Quality.
Linda served in board leadership positions in both Florida and Texas healthcare quality associations. She also served on the NAHQ Board in several positions including President in 2010 and is most recently past chair of the Healthcare Quality Certification Commission (HQCC) for the CPHQ credential. Linda is currently on the DFW Hospital Council Patient Safety Committee, the DFWHC Patient Safety Summit planning committee and is a member on the Department of Texas State Health Services Healthcare Safety Advisory Committee.
Linda is a recipient of the Florida Association for Healthcare Quality Outstanding Quality Professional, the Texas Association for Healthcare Quality Donna Rossa Distinguished Service Award, and the National Association for Healthcare Quality Claire Glover Distinguished Member Award.
11:30 AM The role of emotional intelligence in healthcare: Why does it matter and how can we improve it?
This lecture provides an overview of emotional intelligence (EI). The defining characteristics and components for measurements will be discussed. The impact EI has on factors that affect healthcare quality and patient safety will be explored. Ways to improve EI will be taught, as to leave with strategies and tools to help the attendees and their patients and colleagues!
Sandy Weiss, DBA, MBA-HCM, RN, CPHQ, CPPS, CSM, PMP Adjunct Faculty University of South Florida, Muma College of Business, Tampa, Florida
Dr. Sandy Weiss is a Registered Nurse with a passion for all things healthcare! Dr. Weiss teaches a variety of management courses for the University of South Florida’s Muma College of Business at the undergraduate and graduate levels. She currently serves as the Vice President of Education for a medical device startup in addition to consulting in the healthcare quality arena. Most recently, she served as the Division Director of Quality for a large for-profit healthcare system, where she led clinical quality and regulatory compliance initiatives within the ambulatory care setting. She has robust experience across the healthcare continuum, from co-founding a companion care company, working on CMS contracts (CCSQ & CMMI), to leading in the acute care and inpatient rehabilitation settings.
She earned her Doctor of Business Administration and Master of Business Administration with a Concentration in Healthcare Management from Saint Leo University. Her dissertation focused on Registered Nurse emotional intelligence, turnover intention, and job performance. Her most recent publication, a collaboration with colleagues at USF and an HCA West Florida Division Pharmacist, explored the relationship between Pharmacist emotional intelligence, occupational stress, job performance, and psychological affective wellbeing. A publication on Pharmacist resilience and burnout is currently in the works!
Dr. Weiss is a Certified Professional in Healthcare Quality (CPHQ), a Certified Professional in Patient Safety (CPPS), Certified Scrum Master (CSM), and Project Management Professional (PMP). She also holds a graduate certificate in Innovation and Human Centered Design from The Johns Hopkins Carey Business School and is an AHRQ TeamSTEPPS Master Trainer.
1:30 PM Innovation Enhances Quality
This presentation will describe the organization’s Innovation Ecosystem, focus on human centered design, and how the various innovation projects support and enhance quality and improvement for patients and employees. Multiple examples of innovations in practice will demonstrate the value they provide in engaging staff to test new ideas and promote the organization to be future focused.
Susan V. White, PhD, RN, CPHQ, FNAHQ, NEA-BC Chief, Quality Management Orlando VA Healthcare System, Orlando, Florida
Dr. White’s areas include quality management, patient safety, risk management, survey readiness, infection control, utilization management/case management, performance measures, improvement/innovation and controlled substance inspections. She has an extensive career in administration, management, and clinical roles. She is a member of NAHQ,, AONL, FNA, and Sigma Theta Tau. She is a reviewer for the Journal for Health care Quality. She is an NAHQ Fellow; recipient of the FAHQ Quality Award, the NAHQ Claire Glover Quality Award, and FAHQ Author Award. She was co-editor of Patient Safety. Principles and Practices by Springer (2004) and completed the performance improvement section in HQ Solutions (2022).
Stephanie is an Innovation Specialist with the Orlando VA Health Care System. She has been with the Veterans Healthcare Administration for eight years. Having worked as a registered dietitian in acute care, long-term care, outpatient, community and research settings, Stephanie utilizes her diverse experience to help design human-centered innovative solutions to health care problems. In her current role, she works with innovators on a local, regional and national level by providing education, guidance and support to bring their creative ideas to life.
2:30 PM Incorporating Just Culture Concepts in Event Investigations/RCAs
Myka has more than 20 years of healthcare experience and has dedicated the last 14 years to healthcare risk management and patient safety. She has served as the lead risk management and patient safety executive for two large multifaceted healthcare systems.
Myka is a registered nurse and has a clinical background in emergency medicine and trauma services. She earned a master’s degree in healthcare administration and a Bachelor of Science degree in nursing from West Texas A&M University. She holds the designations of certified professional in healthcare risk management, certified professional in patient safety, and certified professional in healthcare quality. Myka also is a TeamSTEPPS® master trainer.
Myka has served on several committees and the Patient Safety Task Force for the American Society for Healthcare Risk Management and was recently named to serve as a faculty member for ASHRM. She serves a Board of directors for Florida Society for Healthcare Risk Management. She also is a member of the Florida Association for Healthcare Quality, Institute for Healthcare Improvement, the National Association for Healthcare Quality.
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