Registration, coffee, continental breakfast

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Welcome and introductions [James Benneyan, HSyE, and Vince Watts, VA NCPS]

Session 1

Preventing Surgical Stapler Adverse Events: A Simulation-Based Curriculum [Helen J.A. Fuller, VA NCPS]

The Human Factors Analysis and Classification System: An Alternative to Root Cause Analysis [Awatef Ergai, HSyE]

Virtual Patient Simulation: A Method to Validate a Theory of Medical Diagnosis [Daniel Nystrom, VA NCPS]

Networking break, posters, coffee

Mini-Plenary

Healthcare Systems Engineering as an Improvement Strategy [James Benneyan, HSyE]

Session 2

Reducing Central Line Infections in the Medical Intensive Car Unit [Dominic Breuer, Ali Hobbs, Nicole Reppucci, HSyE]

General Quality Improvement with Falls [Tiffany Kim, VA NCPS]

Modeling the Spread of Outpatient Infections [Cory Stasko, HSyE]

Lunch Plenary

The Elephant in the Room: A Culture of Disrespect [Lucian Leape, MD, Harvard School of Public Health]

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Session 3

Your Target May be Wrong [Theodore Dushane, VA NCPS]

Antibiotic Stewardship from a Tragedy of the Commons Perspective [Brendan Bettinger, HSyE]

Networking break, posters, coffee

Moderated Poster Reception

CMS HSyE Demonstration Project [James Benneyan, HSyE]

Simulation of ED OUs [Kendall Sanderson, Cory Stasko, HSyE]

Work Domain Analysis Applied to Medical Diagnosis [Daniel Nystrom, VA NCPS]

Provider Perspectives on Challenges to Patient Centered Care at the End of Life [Shani Bardach]

Regional HAI Surveillance via SPC [Salah Haridy, Nicholas Andrianas, HSyE]

Curing Outside Utilization [Hande Musdal, Parth Vadera, Onur Uzunlar, HSyE]

CLABSI Reduction [Dominic Breuer, Ali Hobbs, HSyE]

Other presenters [Helen Fuller, Ted Dushane, Hammon Adjei, Paul Desh, Allyson Duffy, Tisha Poserina, Roksolana Starodub, Shweta Shah]

Closing comments [James Benneyan, HSyE, Vince Watts, VA NCPS]

Adjorn