Pioneering Innovative Healthcare Quality and Patient Safety #257004

Upon completion of this course, participants will be able to:

• Articulate the Vision for a High-Reliability Organization (HRO): Apply the principles of HRO (preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise) to a healthcare setting.

• Master Advanced Quality Improvement (QI) Methodologies: Utilize sophisticated QI tools and frameworks beyond basic PDSA, including Lean Six Sigma, Model for Improvement, and Complexity Science.

• Lead a Robust Safety Culture: Implement and sustain a Just Culture that balances system-based learning with individual accountability, encouraging error reporting without fear of blame.

• Apply Human Factors and Systems Engineering: Analyze and redesign processes, environments, and technologies to minimize cognitive load and prevent human error.

• Leverage Data and Technology for Predictive Safety: Use data analytics, AI, and digital health tools to identify risks proactively, predict adverse events, and measure the true cost of harm.

• Design and Lead Innovative Patient Safety Initiatives: Develop, pilot, and scale a strategic safety innovation project within their own organization.

This course is critical for clinical and administrative leaders who are responsible for driving the quality and safety agenda within their organizations.

• Chief Quality Officers, Chief Medical Officers, and Chief Nursing Officers

• Patient Safety Officers, Risk Managers, and Quality Directors

• Clinical Department Chairs and Service Line Leaders

• Directors of Nursing and Nurse Managers with QI responsibilities

• Physician and Nurse Quality Champions

• Healthcare Administrators and Operations Leaders

• Infection Preventionists and Medication Safety Pharmacists

• Professionals in government or accreditation bodies focused on healthcare quality

• Pre-assessment
• Live group instruction
• Use of real-world examples, case studies and exercises
• Interactive participation and discussion
• Power point presentation, LCD and flip chart
• Group activities and tests
• Each participant receives a binder containing a copy of the presentation
• slides and handouts
• Post-assessment

Day 1: Foundations of a Pioneering Safety Culture

• Morning:

  • Module 1: The Evolution of Patient Safety: From “To Err is Human” to High-Reliability Organizing. The business and moral case for zero harm.

  • Module 2: The Five Principles of High-Reliability Organizations (HROs): Deep dive into each principle with healthcare-specific case studies.

• Afternoon:

  • Module 3: Cultivating a Just Culture: Differentiating human error, at-risk behavior, and reckless conduct. Implementing a fair and just accountability model.

  • Workshop: Culture Assessment: Participants evaluate their organization’s current safety culture using validated tools and concepts.

  • Day 1 Recap: Building the cultural bedrock for safety.

Day 2: Advanced Methodologies for Quality Improvement

• Morning:

  • Module 4: The Model for Improvement & SMART Aim Statements: Crafting precise, measurable, and time-bound aims for QI projects.

  • Module 5: Mastering Measurement for Improvement: Selecting outcome, process, and balancing measures. Creating run charts and control charts to interpret data.

• Afternoon:

  • Module 6: Lean Six Sigma in Healthcare: Applying DMAIC (Define, Measure, Analyze, Improve, Control) and tools like value stream mapping to reduce waste and variation in clinical processes.

  • Workshop: Mapping a Defect: Teams use a current safety issue (e.g., medication errors, HAPIs) to create a detailed process map and identify failure points.

  • Day 2 Recap: Moving from problem-solving to system-design.

Day 3: Human Factors, Systems Thinking, and Design

• Morning:

  • Module 7: Introduction to Human Factors Engineering: Understanding why humans make errors and how to design systems that are error-proof (Poka-Yoke).

  • Module 8: Cognitive Load and Situational Awareness: Strategies to reduce mental strain on clinicians and improve decision-making in high-stress environments.

• Afternoon:

  • Module 9: Proactive Risk Assessment: Conducting Failure Mode and Effects Analysis (FMEA) on a high-risk process before an event occurs.

  • Simulation: Redesigning a Process: Teams use human factors principles to redesign a common, error-prone procedure (e.g., patient handoff, code cart setup).

  • Day 3 Recap: Designing systems for inherently safer care.

Day 4: Technology, Data, and Transparency

• Morning:

  • Module 10: The Digital Frontier in Patient Safety: Leveraging EHR data analytics, AI for predictive risk scoring, and telehealth to enhance safety.

  • Module 11: Openness and Communication: Implementing rigorous communication tools (SBAR, CUS) and transparent reporting systems for near-misses and adverse events.

• Afternoon:

  • Module 12: Root Cause Analysis (RCA) 2.0: Moving beyond traditional RCA to a more robust, systems-focused analysis that leads to sustainable actions.

  • Workshop: Conducting a Mock RCA: Teams work through a complex patient safety case to identify latent systems failures.

  • Day 4 Recap: Using data and dialogue to drive learning.

Day 5: Integration, Leadership, and Sustaining Change

• Morning:

  • Module 13: Leading Change and Overcoming Resistance: Strategies for engaging senior leadership, physicians, and frontline staff in the safety mission.

  • Module 14: The Economics of Safety: Calculating the cost of harm (direct and indirect) to build a compelling financial argument for safety investments.

• Afternoon:

  • Capstone Activity: The Safety Innovation Project Plan: Participants develop a detailed proposal for a pioneering safety initiative in their organization, including:

    • Aim Statement

    • Stakeholder Analysis

    • Measurement Strategy

    • Communication Plan

    • Sustainability Model

  • Final Presentations & “Shark Tank” Feedback Session: Participants pitch their projects to a panel of peers and instructors for constructive critique.

  • Course Conclusion: Commitment to action, final review, and awarding of certificates.