Patient Safety Evaluation System – 2022 Virtual Summit

May 24, 2022 | 8:00AM - May 25, 2022 | 2:45PM PT

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8:00 – 8:15 a.m. | Opening Comments
Robert Imhoff, MPP, President, Hospital Quality Institute andPeggy Binzer, JD, Executive Director, Alliance for Quality Improvement and Patient Safety

8:15 – 9:15 a.m. | The Joint Commission – Health Care Providers Working with Accrediting Bodies in the Patient Safety Evaluation System (PSES)
Suzanne B. Gavigan, MSN, CRNP, CPPS, Acting Director, Office of Quality and Patient Safety, Division of Healthcare Improvement, The Joint Commission, and Kathleen Pankau, JD, RN, Senior Assistant, General Counsel, The Joint Commission
This session focuses on how health care organizations accredited by the Joint Commission can collaborate with The Joint Commission to promote patient safety.  The Joint Commission, in connection with accreditation and certification, may ask to view Patient Safety Work Product (PSWP) within the Hospital’s Patient Safety Evaluation System (PSES), in order to inform the accreditation/certification process and to assist efforts to improve patient safety in health care organizations.  Under the Patient Safety Act, a hospital’s voluntary disclosure of PSWP to its accrediting body does not breach the confidentiality of PSWP (note the protections cannot be waived under the Patient Safety Act.) When hospitals agree to permit The Joint Commission to access and review PSWP, the PSWP remains confidential and privileged.  Presenters will also review the top ten reported Sentinel Events to The Joint Commission in 2021. 
Learning Objectives:

  • Describe the role The Joint Commission and the Office of Quality and Patient Safety play in the PSES.
  • Describe the top ten reported sentinel events to The Joint Commission 2021.
  • Summarize the Patient Safety Work Product (PSWP) Disclosures to Accrediting Organizations under 42 U.S.C.

9:15 – 9:30 a.m. | Break

9:30 – 10:30 a.m. | Breakout Sessions (Choose One)

  1. Solving the Puzzle … Identification of Patient Safety Work Product
    Shannon Davila, MSN, RN, CIC, CPHQ, FAPIC, Associate Director, Patient Safety Organization; Stephanie Uses, PharmD, MJ, JD, Patient Safety Analyst, ECRI and the Institute for Safe Medication Practices PSO
    Join ECRI and the Institute for Safe Medication Practices PSO for an interactive session to define and identify what activities, data, reports, and other materials meet the patient safety work product criteria. Learning Objectives:
    ·  Explain what is considered Patient Safety Work Product.
    ·  Define what types of activities, data, reports, and other materials are considered Patient Safety Activities by the PSQIA of 2005.
    ·  Describe the connections between the Patient Safety Evaluation System (PSES), the pathways for reporting, and Patient Safety Work Product (PSWP) to federal protections.
  2. How to Develop an Affiliated Provider Safe-table
    Joanne Locke, JD, RN Senior Patient Safety Program Director, CRICO Academic Medical Center
    The development of Affiliated Provider Safe Tables creates an important opportunity for PSO Providers within the same healthcare network to convene across institutions, utilizing the privilege protections of the Patient Safety and Quality Improvement Act. Managing an Affiliated Provider Safe Table process requires education to assist providers with the implementation of a compliant program that improves patient safety and avoids potential legal challenges.
    Learning Objectives:
    ·  Describe who meets the definition of an “Affiliated Provider.”
    ·  Develop a compliant Affiliated Provider Safe Table process using organizing principles.
    ·  Outline practice pointers for the creation of Affiliated Provider policies and procedures.
  3. Patient Safety Evaluation System (PSES) Design and Diagramming
    Peggy Binzer, JD, Executive Director, Alliance for Quality Improvement and Patient Safety
    Join us for a hands-on workshop on designing and diagramming PSES 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 innovative patient safety activities. The program will provide examples on:

    ·  Credentialing 
    ·  Joint Peer Review/Root Cause Analysis/Confidential M&M between a Hospital and Medical Group
    ·  Disciplinary Action and Professional Behavior (including Bias)

    Learning Objectives: 
    ·  Use the PSQIA protections to create innovative programs that will improve the quality of the delivery of patient care.
    ·  Design policies and procedures and flow diagrams for innovative programs.

10:30 – 10:40 a.m. | Break

10:40 – 11:40 a.m. | Causal Analysis Safe-table
Vivian Eusebio, RN, PHN, MBA, Patient Safety Clinical Advisor, CHPSO; David Marx, JD, CEO, The Just Culture Company, LLC; Mattie Milner, PhD Human Factors, Advisor, The Just Culture Company, LLC; Heather Sherman, MS, MPH, PhD, Patient Safety Strategist and Consultant, Patient Safety and Quality Improvement Specialists, LLC
Producing a quality investigation should include an understanding of not only the system design but also an understanding of the human decision-making process, which ultimately led to the undesired outcome. This session will introduce a novel method of understanding and modeling cognitive processing and decision making.  
Learning Objectives: 

  • Identify factors that influence system design and the decision-making process.  
  • Describe the human decision-making process and cognitive processing.
  • Identify areas of opportunity to prevent or reduce undesired outcomes. 
  • Apply the human decision-making process and the findings from a threshold investigation to determine the appropriate managerial/organizational response to mitigate  

11:40 – 11:45 a.m.| Closing Remarks

8:00 – 8:15 a.m. | Welcome

8:15 – 9:15 a.m. | Just Culture Safe-table
Vivian Eusebio, RN, PHN, MBA, Patient Safety Clinical Advisor, CHPSO; David Marx, JD, CEO, The Just Culture Company, LLC; Barbara Olson, MS, RN, CPPS, FISMP, Chief Clinical Officer & Executive Lead, The Just Culture Company, LLC; Heather Sherman, MS, MPH, PhD, Patient Safety Strategist and Consultant, Patient Safety and Quality Improvement Specialists, LLC
Using the scenarios discussed during the causal analysis safe-table session, we will apply the principles of “just culture” to evaluate the conduct of participants involved in those events.  
Learning Objectives:  

  • Describe the just culture model.  
  • Apply the just culture algorithm to the scenarios provided. 
  • Identify appropriate responses to employee behavior, using a just culture framework. 

9:15 – 10:15 a.m. | Breakout Sessions (Choose One)

  1. Securing Privilege Protection Through Your PSES
    Robin Nagele, Esq, Principal, and Elizabeth Hein, Esq, Principal, Post & Schell, PC
    This session will discuss the legal protections and framework for a Patient Safety Evaluation System (PSES) and explain how providers can document the PSES to maximize the Patient Safety and Quality Improvement Act privilege protection for patient safety work plan — using the statutory text, regulations, and preamble guidance to combat common misperceptions from attorneys and courts.
    Learning Objectives:
    ·  Design your PSES to gain maximum privilege protection.
    ·  Outline common mistakes made by attorneys and judges about the Patient Safety Work Product (PSWP) privilege, and how to protect against them. 
    ·  Define the federal Act’s patient safety goals.​
    ·  Describe how sharing PSWP within your health system and external partners can further safety objectives and preserve strict privilege protection.
  2. Tiered and Management Huddles in the PSES
    Lee Erickson, MD, LSSMBB, SVP and Chief Quality Officer, Tufts Medicine
    Is your organization struggling to keep patient safety front and center of everything you do, every day? Are your colleagues frustrated by working in silos, feeling like they keep solving the same problems over and over again? Join this session to learn how an integrated daily management system with data-driven tiered huddles can drive continuous improvement, unify patient safety and quality, and create a real-time, proactive patient safety evaluation system.
    Learning Objectives:
    ·  List the components of a comprehensive integrated daily management system.
    ·  Design a model for root cause analyses that unifies process improvement and patient safety.
    ·  Apply basic principles of good work design to make care processes safer. 
  3. Artificial Intelligence
    Pelu Tran, BS, CEO, Ferrum Health; Scott Masten, Ph.D., Vice President, Measurement Science and Data Analytics; Tim Rehwald, SQL Server & DBA Programmer, Hospital Quality Institute
    In this session, we will discuss the use of Artificial Intelligence (AI) algorithms in providing a population-level safety net for medical errors and gaps in care.  
    Learning Objectives:  
    ·  List the common categories of medical errors of omission leading to malpractice and patient harm.
    ·  Identify the types of medical errors that are conducive to identification and prevention by artificial intelligence algorithms.
    ·  Describe the provider workflows to incorporate the results of artificial intelligence quality tools into existing protected quality committee and peer review activities.
    ·  Summarize the metrics that should be measured and monitored to ensure AI quality systems that are deployed are delivering clinical value.
    ​·  Describe an ROI justification model for AI quality systems based on averted malpractice cases, downstream care, and outcome improvement.
    ​·  Identify challenges and next steps to address adverse events.

10:15 – 10:30 a.m. | Break

10:30 – 11:30 a.m. | Falls Safe-table
Dawn Venema, PT, Ph.D., Associate Professor, University of Nebraska Medical Center; Anne Skinner, RHIA, MS, Associate Professor, University of Nebraska Medical Center; Heather Sherman, MS, MPH, PhD, Patient Safety Strategist and Consultant, Patient Safety and Quality Improvement Specialists, LLC, Victoria Kennel, Ph.D., Assistant Professor, Industrial-Organizational Psychologist, Department of Allied Health Professions Education, Research, and Practice, College of Allied Health Professions
It’s no secret that health care requires interprofessional teams, especially for multifactorial problems such as falls. We can use these types of teams in fall risk reduction efforts to proactively create systems and practices to reduce fall risk. Interprofessional teams are also useful retrospectively after a patient fall occurs to facilitate sensemaking of fall events and implement practice changes at the bedside and across the system to prevent future falls. This session will describe how a ‘team of teams’ approach can facilitate documentation of and learning from patient falls. A case study example will be used to engage the audience in a discussion of opportunities to learn from falls at the bedside and system levels and how lessons learned can inform fall risk reduction practice changes across the system.
Learning Objectives:

  • Describe how a ‘team of teams’ approach supports fall risk reduction in acute care settings.
  • Discuss a process for learning from falls that occur among teams at the bedside and across the system in the context of a fall case study.
  • Describe patient and patient family perception related to different scenarios connected to falls in hospital settings.

11:30 – 11:45 a.m. | Closing Remarks
Carmela Coyle,President & CEO, California Hospital Association


Peggy Binzer, JD
Executive Director
Alliance for Quality Improvement and Patient Safety (AQIPS) 

Ms. Binzer serves as the Executive Director of AQIPS, the nation’s leading professional association for PSOs and their health care provider members. She 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. As a partner in several law firms, Ms. Binzer assisted hospital and specialty physician associations, health systems, and management organizations become patient safety organizations.

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

Shannon Davila, MSN, RN, CIC, CPHQ, FAPIC
Associate Director
ECRI and Institute for Safe Medication Practices Patient Safety Organization

With a clinical background in adult critical care nursing, Ms. Davila specializes in infection prevention and health care quality improvement. She has provided leadership throughout several state and national patient safety programs including the New Jersey Sepsis Learning Action Collaborative and CMS Hospital Improvement Innovation Network. Ms. Davila is certified in infection control, health care quality, as a TeamSTEPPS Master Trainer and High Reliability Coach.

Lee Kim Erickson, PhD
Chief Quality Officer
Tufts Medicine

Dr. Erickson is not only the Chief Quality Officer for Tufts Medicine, she is also a Lean Sigma Six Master Black Belt and has extensive expertise in quality and patient safety, process improvement methodologies, and healthcare transformation. She works with clinical and operational departments to optimize the delivery of patient care, with a focus on expanding and strengthening the performance improvement infrastructure for health systems.

Vivian Eusebio
Patient Safety Clinical Advisor
Collaborative Healthcare Patient Safety Organization (CHPSO)

In her current role, Ms. Eusebio is the perfect harmony of clinical and analytics, where translating clinical practice information and improving patient care intersect. She combines years of experience as an Emergency Room Nurse, Informaticist, and Clinical Business Intelligence Analyst.

Suzanne B. Gavigan, MSN, CRNP, CPPS
Acting Director
Office of Quality and Patient Safety, Division of Healthcare Improvement 
The Joint Commission

Suzanne Gavigan is the Acting Director in the Division of Healthcare Improvement at The Joint Commission. She provides leadership and oversight for a team of trained patient safety experts who, collectively, evaluated 18,000 safety events and 1,100 sentinel events in 2021. They engage with accredited organizations across all programs to identify risks, develop strong improvement actions, maintain safety, and support quality of care for accredited customers. She is a Certified Yellow Belt, trained in the foundational concepts of problem-solving, making improvements to better customer expectations and organizational objectives.

Elizabeth Hein
Post & Schell, P.C.

As a Principal in Post & Schell, Ms. Schell provides Health Care Practice Group legal services to the Firm’s health care clients in litigation, regulatory and compliance matters. Her litigation practice includes assisting the defense of regulatory matters, medical staff litigation and injunctive proceedings. Among other things, her health care consulting services include assisting health care clients in internal investigations to identify and reduce or resolve exposures under state and federal law.

Victoria Kennel, PhD
Assistant Professor and Industrial Organizational Psychologist
Department of Allied Health Professions Education, Research and Practice
University of Nebraska Medical Center

As an Assistant Professor and Industrial Organizational Psychologist, Dr. Kennel has supported fall risk reduction research and quality improvement efforts focusing on the organization, team, and human behavioral factors that contribute to the success of fall risk reduction.

Joanne Locke, RN, JD
Senior Patient Safety Program Director
Academic Medical Center Patient Safety Organization (AMC PSO)

Ms. Lockes’ work experience includes being a Registered Nurse, legal counsel for plaintiff and defense medical malpractice firms, and regulatory experience as Associate Board Counsel, Massachusetts Board of Registration in Medicine, Patient Safety Division. She served as Director of Clinical Compliance, Risk Management, and Physician Credentialing at Brigham and Women’s Faulkner Hospital for ten years. This experience provides a unique perspective that permits her to analyze potential compliance issues and legal challenges that may arise in association with the development and implementation of Affiliated Provider Safe Tables.

Robin Locke Nagele
Post & Schell, P.C.

Robin Locke 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.

David Marx
Just Culture

Formerly a Boeing aircraft design engineer, Mr. Marx won the International Federation of Airworthiness’s Whittle Safety Award for developing a human error investigation process used by airlines worldwide. In the health care sector, Mr. Marx continues to help health care institutions and regulatory agencies reduce the risk of iatrogenic patient harm.

Scott Masten, Ph.D.
Vice President, Measurement Science & Performance Analytics
Hospital Quality Institute (HQI)

In his work for HQI, Mr. 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.

Barbara Olson, MS, RN, CPPS, FISMP
Senior Advisor
The Just Culture Company

As a senior advisor, Ms. Olson supports healthcare clients in planning and sustaining Just Culture as a system of workplace justice. She currently serves on the Certification Board for Professionals in Patient Safety Executive Oversight Committee and has certification as a Professional in Patient Safety (CPPS) since 2012. She has been a TeamSTEPPS Master Trainer since 2012.

Kathleen Pankau, JD, RN
Senior Assistant General Counsel
The Joint Commission

Kathleen Pankau is a nurse-attorney in the legal department at The Joint Commission. In this role, Ms. Pankau provides legal counsel to numerous The Joint Commission departments, including Accreditation and Certification Operations, Standards Interpretation Group, Office of Quality and Patient Safety, and Business Development. She also leads The Joint Commission’s response to inquiries and subpoenas regarding confidential accreditation and related records.

Tim Rehwald
SQL Server & DBA Programmer
Hospital Quality Institute (HQI)

Tim has 34 years of in-depth experience in information technology across many knowledge domains. That expertise includes a focus on databases, system performance, virtualization, security, and programming. He has written dozens of management and monitoring tools and maintains 11 professional and technical certifications. Tim supports the CHPSO application/database pipeline and helps keep the larger Hospital Quality Institute (HQI) back-end infrastructure running properly.

Anne Skinner, RHIA, MS
Assistant Professor
College of Allied Health Professions, University of Nebraska Medical Center

Ms. Skinner’s research interests include improving health care quality and patient safety through the transformation of data into information into knowledge into wisdom. As a member of the CAPTURE Falls research team at UNMC, she has extensive experience in learning from data to improve hospital systems and promote better patient outcomes.

Stephanie Uses, PharmD, MJ, JD 
Patient Safety Analyst 
ECRI and the Institute for Safe Medication Practices Patient Safety Organization
Ms. Uses is a Patient Safety Analyst at ECRI where she is responsible for development of education programs related to the safe use of medications. Other duties include review and analysis of health care data, such as root-cause analyses and other event reports, while providing custom feedback on the data. Ms. Uses has spoken on numerous patient safety topics, including the safe use of opioids, anticoagulation management, and drug shortages.

Dawn Venema, PT, PhD 
Associate Professor 
Department of Health and Rehabilitation Sciences
College of Allied Health Professions, University of Nebraska Medical Center

Dr. Venema has clinical and research experience in geriatrics, specifically focused on maintaining mobility and reducing fall risk in older adults. She has been involved in research and quality improvement initiatives for fall risk reduction in hospital settings. This work, known as Collaboration and Proactive Teamwork Used to Reduce (CAPTURE) Falls, has been funded by the Agency for Healthcare Research and Quality and the Nebraska Department of Health and Human Services. Dr. Venema also provides instruction to Doctor of Physical Therapy students at UNMC in evidence-based practice, mobility, and balance assessment.

Safe-table Discussion Confidentiality Agreement

Welcome to the CHPSO/AQIPS Safe-Table discussion.

By participating in this Safe-table, I agree to perform Patient Safety Activities, such as reviewing, analyzing, and participating in deliberations about Patient Safety Work Product within the CHPSO Patient Safety Evaluation System as CHPSO temporary volunteer Workforce. My term of service as CHPSO PSO Workforce terminates at the end of this safe-table. I understand that this safe-table is conducted in a safety culture where the focus is on systems or gap analysis and not on individual provider performance. All Patient Safety Work Product is confidential and shall not be disclosed except to provide feedback for quality improvement purposes. I understand that I will be participating in confidential conversations about sensitive confidential data that are intended to improve the quality of care at my facility. If I am disclosing information from my facility, I have permission to disclose the data and have removed any PHI and identification of any specific healthcare provider.

I understand that Confidentiality training and other rules for participating in the Safe-table will be provided to me at the beginning of the meeting. I agree that the confidentiality protections of Patient Safety Work Product shall survive after the meeting is adjourned and I will not disclose any Patient Safety Work Product discussed at this meeting except for quality improvement purposes within the facility. As this meeting is occurring via teleconference, I understand that I am responsible for taking reasonable steps to ensure that no impermissible disclosures occur at the location that I am participating in the meeting.

I recognize that 21 C.F.R. Part 3 provides for penalties — that I can be personally responsible for — of up to $11,000 for each Disclosure of Patient Safety Work Product – other than to provide feedback to the facility for quality improvement purposes.

Prior to entering the safe-table discussion, you will be prompted to acknowledge your acceptance of this agreement.

We would like to thank our corporate sponsor, BETA Healthcare Group for their support of the 2022 Patient Safety Evaluation System Summit.

BETA Healthcare Group (BETA) is the largest professional liability insurer of hospitals on the West Coast and provides liability and workers’ compensation coverages to protect hospitals, healthcare facilities, physicians, and other healthcare workers. BETA’s financial strength, rate stability, quality service and breadth of coverage is unparalleled in the industry. 

Heather Gocke
VP, Risk Management and Safety
BETA Healthcare Group