Patient Safety Evaluation System — 2023 Virtual Summit

8:00 – 8:15 a.m. | Welcome and Opening Comments
Peggy Binzer, AQIPS

8:15 – 9:30 a.m. | Keynote | Recommitting to the Zero Harm Goal as the Way to Emerge from the Pandemic
Mark Chassin, MD, FACP, MPP, MPH, President Emeritus, The Joint Commission, Partner, Relia Healthcare Advisors
As the pandemic diminishes in severity, how can health care organizations restart or re-energize these initiatives? Dr. Chassin will discuss the rationale for aiming for zero harm, describe how such efforts can greatly assist recovery from some of the pandemic’s worst effects on the health care workforce, and provide specific guidance on how to get back on the road to high reliability.  

9:30 – 10:45 a.m. | Press Ganey Safety Event Classification Patient Safety Measurement System Safe Table* (Not Recorded)
Kerry Butler, PharmD, MBA, Senior Manager Strategic Consulting, Press Ganey

*The PSES Summit includes two National Safe Tables. To participate in the Safe Tables, you are required to agree to a confidentiality agreement that can be found here. You will be asked to agree prior to joining the Safe Table session.

10:45 – 11:00 a.m. | Break

11:00 a.m. – 12 noon | Concurrent Breakout Sessions (Choose one)

1. Journey Towards Cooperative Quality & Safety Engagement with Emergency Medical Services Partners
   Susan Gilpatrick, Manager, Healthcare Risk Operations and Todd Pelletier, Director, Patient Transfer Center, Sutter Health
   Presenters will share and discuss their journey to increasing reliability and safety in the transfer and transportation of our patients through partnering with Emergency Medical Services providers through quality & safety review in protected forums.
   Learning objectives:

• Describe the system’s perceived patient safety risks in the Hospital/EMS relationship
• Understand key concepts critical to developing an agreement to ensure PSWP protection in separate organizations with a PSES
• Define key language to ensure PSWP protection in separate organizations with a PSES
• Discuss next steps and understand applicability in other health systems

2. Bringing Reliability to Causal Analysis: Using Human Factors Engineering
   Lee Erickson, Senior Vice President, Chief Quality Officer, Tufts Medicine
3. Hazards on the Road to High Reliability: Structuring Your PSES to Pave the way to Patient Safety
   Andrew Martin, MSN, RN, CPHRM, Patient Safety Analyst IV, and Jeraldine Stoltzfus, MBA-HA, RN, BA, ECRI

8:00 – 8:15 a.m. | Welcome and Comments
Robert Imhoff, President, Hospital Quality Institute

8:15 – 9:15 a.m. | Concurrent Breakout Sessions (Choose one)

1. Workplace Shortages
   Kelsay Irby, RN, St. Michael Medical Center; Sharon Hickman, MBA, CPHQ, CPPS, Vice President, Performance & Excellence Optimization, Prisma Health
2. NAPA Anesthesia Patient Safety Institute “Anesthesia Risk Alert Program”
   Julie Marhalik-Helms, BSN, RN, Vice President of Quality Improvement and Brett Lee, MD, MPH, FASA, Director of Clinical Excellence and Performance Improvement, North American Partners in Anesthesia
   In this presentation we will review how PSO safe table case reviews and data analysis were used to create this program, the innovative patient safety paradigms and methodologies behind its interventions, how the program was implemented across the nationwide practice and the impact of the program to reduce harm in the targeted high-risk population of patients. 
   Learning Objectives:

• Learn how a robust Patient Safety Evaluation System can be harnessed to create targeted interventions to reduce patient harm.
• Learn how innovative patient safety concepts such as “Safety II”, dual process decision-making, cognitive debiasing and blue team/red team methodology can be translated into practical interventions that save lives.
• Learn how a prescribed patient safety practice evolved to promote a culture of safety whose reach extends beyond the initial intended cohort of high-risk patients.

3. Event Reporting Analytics
   Scott Masten, PhD, Hospital Quality Institute
4. Designing a PSES for Centralized Programs
   Peggy Binzer, Executive Director, Alliance for Quality Improvement and Patient Safety; Lisa Mead, Consultant, RN, MS, CPHQ, Crowne Healthcare Advisors  
   Join us for a hands-on workshop on designing and diagramming the PSES for centralized patient safety activities/programs. We will be taking innovative programs and creating PSES Policies and Procedures and program diagrams that are legally defensible. Participants who attend this program will have the skills to design and diagram both a parent and corporate PSES as well as create innovative centralized patient safety activities.
   Learning ojectives:

• Peer, Systems and RCA Analysis across a provider entity or health system
• Credentialing for a health system
• Disclosures of PSWP throughout a provider entity or health system

9:20 – 10:20 a.m. | Concurrent Breakout Sessions (Choose one)

1. Interfacility Safe Tables and Toolkit
   Brett Powell, Director HCA Patient Safety Organization, HCA Healthcare
2. Envision Professional Analysis Program
   Tracy Chamblee, Senior Healthcare Executive and Bobbi Maisenbacher, BSN, RN, CPPS, Manager, The Envision Healthcare Center for Quality and Patient Safety 
3. Workplace Violence
   Jennifer Taylor, PhD, MPH, CPPS, Director of the Center for Firefighter Injury Research and Safety Trends, Drexel University Dornsife School of Public Health; Gary Wingrove, FACPE, CP-C, President, The Paramedic Foundation
4. What’s New in the PSES and Case Law
   Robin Nagele, Esq., Principal Health Care, Post & Schell

10:30 – 11:45 a.m. | Mitigating Medication Misadventures: A Joint Root Cause Analysis Safe Table* (Not recorded)
Ellen Martin, PhD, RN, CPHQ, CPPS, Director of Clinical Safety Research, A&M Rural Community Health Institute

*The PSES Summit includes two National Safe Tables. To participate in the Safe Tables, you are required to agree to a confidentiality agreement that can be found here. You will be asked to agree prior to joining the Safe Table session.

11:45 a.m. | Closing Comments
Carmela Coyle, President & CEO, California Hospital Association

Peggy Binzer, Esq. 
Executive Director 
Alliance for Quality Improvement and Patient Safety (AQIPS) 
Peggy Binzer serves as the Executive Director of the Alliance for Quality Improvement and Patient Safety (AQIPS), the nation’s leading professional association for PSOs and their healthcare provider members. AQIPS fosters their members’ ability to improve the quality of healthcare delivery through the use of the Patient Safety Act protections.  Ms. Binzer spearheaded the crafting and passage of the Patient Safety and Quality Improvement Act (PSQIA) while serving as senior health counsel for the U.S. Senate Health, Education, Labor and Pensions (HELP) Committee. Since that time she has been assisting PSOs and providers to improve the quality of patient care and implement the Patient Safety Act’s protections.

Kerry Butler, PharmD, MBA 
Senior Manager, Strategic Consulting 
Press Ganey 
Kerry Butler brings more than 20 years of relevant experience to his role as a Manager for Press Ganey HPI. Since joining the firm in 2013, his focus has been on making “Reliability a reality” by leveraging his deep experience in implementing, deploying, and integrating high reliability organizing principles in systems, hospitals and clinics throughout the country. 

Tracy Chamblee 
Senior Healthcare Executive 
Envision Healthcare Center for Quality and Patient Safety 

Mark Chassin, MD, FACP, MPP, MPH 
President Emeritus 
The Joint Commission   
Dr. Chassin is one of the world’s leading experts in health care quality, patient safety, and process improvement. Before stepping down at the end of 2021, he was President and CEO of The Joint Commission for 14 years, leading the world’s pre-eminent health care standard-setting and accrediting body. Under his leadership, The Joint Commission enjoyed unprecedented growth worldwide in the number of accredited health care organizations, documentation of the positive impacts of accreditation on health care quality, and financial performance. Dr. Chassin introduced the concepts of high reliability and zero harm to health care. He directed the creation of The Joint Commission of programs that disseminated strategies, tools, and training programs for health care organizations to speed their progress toward high reliability. 

Carmela Coyle 
President & CEO 
California Hospital Association 
Carmela Coyle began her tenure as president and CEO of the California Hospital Association, the statewide leader representing the interests of more than 400 hospitals and health systems in California, in October 2017. Previously, Ms. Coyle led the Maryland Hospital Association for nine years, where she played a leading role in reframing the hospital payment system in Maryland and moving to a value-based methodology. Maryland is now considered a national leader in health care policy and innovation. 

Lee Erickson, MD, LSSMBB 
Senior Vice President, Chief Quality Officer 
Tufts Medicine 

Susan Gilpatrick 
Manager, Healthcare Risk Operations 
Sutter Health 

Sharon Hickman, MBA, CPHQ, CPPS 
Vice President, Performance Excellence & Optimization 
Prisma Health 

Robert Imhoff 
President 
Hospital Quality Institute (HQI) 
Robert Imhoff, President of the Hospital Quality Institute, has held positions of responsibility within the health care, non-profit and higher education fields. These positions include: President and CEO of the Maryland Patient Safety Center, Vice President of Development and External Relations for Mt. Washington Pediatric Hospital and Director of Corporate and Foundation Relations for Coppin State University. Mr. Imhoff currently serves on the executive committee of the California Maternal Quality Care Collaborative, the Board of Cal Hospital Compare and Alliance for Quality Improvement and Patient Safety (AQIPS). 

Kelsay Irby, RN 
ER Nurse 
St. Michael Medical Center 

Brent Lee, MD, MPH, FASA 
Director, Clinical Excellence and Performance Improvement 
North American Partners in Anethesia 

Bobbi Maisenbacher, BSN, RN, CPPS 
Manager 
The Envision Healthcare Center for Quality and Patient Safety 

Julie Marhalik-Helms, BSN, RN 
Vice President, Quality Improvement 
North American Partners in Anesthesia 

Andrew Martin, MSN, RN, CPHRM 
Patient Safety Analyst IV, Consultant 
ECRI 

Ellen Martin, PhD, RN, CPHQ, CPPS 
Director, Clinical Safety Research 
A&M Rural Community Health Institute (ARCHI) 
Dr. Ellen Martin is the Director of Patient Safety at the A&M Rural and Community Health Institute Patient Safety Organization, a federally-listed PSO with the Agency for Healthcare Research and Quality. Prior to joining ARCHI, Dr. Martin was the Director of Practice at the Texas Nurses Association and Director of Clinical Practice and Regulatory Affairs at the Texas Association for Home Care and Hospice. Dr. Martin has extensive experience in hospitals, community mental health, home health and hospice and holds certifications in health care quality and patient safety. Dr. Martin is passionate about supporting clinical teams to improve patient outcomes as well as preventing harm for vulnerable and underserved populations.  

Scott Masten, PhD 
Vice President, Measurement Science & Performance Analytics 
Hospital Quality Institute (HQI)  
In his work for HQI, Dr. Masten focuses on improving health care data quality and reducing patient injury, including the development of both data intake and data analytics platforms. He does this by bringing over 20 years of applied research and data experience including teaching research methods and statistics courses at both the graduate and undergraduate levels. 

Lisa Mead, RN, MS, CPHQ 
Consultant 
Crowne Healthcare Advisors

Robin Nagele, Esq. 
Principal Health Care 
Post & Schell 
Robin Nagele is a Principal in the firm’s Health Care Practice Group. She has a national health care litigation and consulting practice, in which she represents proprietary and not-for-profit health care providers, multi-hospital systems, integrated delivery systems, academic/teaching medical centers, and ancillary service providers, along with their medical, executive and corporate leadership, in complex commercial, regulatory and antitrust matters. 

Todd Pelletier, MS, RN, EMT-P 
Director, Sutter Health Transfer Center 
Sutter Health 
Mr. Pelletier is the System Director of the Transfer Centers and Patient Transport Services for Sutter Health. As a clinician, he worked as a Pediatric ICU RN, Peds/Neo Transport RN and Flight Nurse/Paramedic. As leadership and growth opportunities presented, he became an educator, supervisor, and manager for both air medical/critical care transport teams. He currently serves as a Reserve Firefighter and EMS Coordinator for the American Canyon Fire Protection District. 

Brett Powell 
Director, HCA Patient Safety Organization 
HCA Healthcare

Jeraldine Stoltzfus, MBA-HA, RN, BA 
Manager, PSO & Safety Solutions 
ECRI 
Jeraldine Stoltzfus is a Patient Safety Analyst at ECRI, where her responsibilities under the Patient Safety Organization include risk cause analysis educational presentations, deep dive event analysis and trends, process improvement and liaison services for member organizations. She is experienced in Nursing, Care Management, Quality Improvement, Risk Management and Patient Safety. 

Jennifer Taylor, PhD, MPH, CPPS 
Director, Center for Firefighter Injury Research and Safety Trends 
Dornsife School of Public Health at Drexel University 

Gary Wingrove, FACPE, CP-C 
President 
The Paramedic Foundation (EMERG) 

Members: $99
Nonmembers: $250

For this summit, those who qualify for the $99 registration fee are current members of: HQI, CHPSO, AQIPS or a member of an AQIPS PSO member. 

For this summit, nonmembers who qualify for the $250 rate are PSO’s who are not current members

Safe Table Confidentiality Agreement
The PSES Summit includes two National Safe Tables. To participate in the Safe Tables, you are required to agree to a confidentiality agreement that can be found here. You will be asked to agree prior to joining the Safe Table session.

Cancellation Policy
Cancellations must be made in writing seven or more days prior to the scheduled event and emailed to education@calhospital.org.
Substitutions are encouraged. Cancellation and substitution notification may be emailed to education@calhospital.org. In the unlikely event that the program is cancelled, refunds will be issued to paid registrants within 30 days.

Special Accommodations or Questions: If you require special accommodations pursuant to the Americans with Disabilities Act, or have other questions, please call (916) 552-7637.