The National Patient Safety Foundation is proud to partner with the American Hospital Association in sponsoring the AHA-NPSF Comprehensive Patient Safety Leadership Fellowship. This year-long program provides essential training in patient safety, quality, and performance improvement.

The fellowship consists of four in-person learning sessions, periodic teleconferences, webinars, various self and organizational assessments, and individual coaching.

This curriculum is based on the 2009 paper Transforming Healthcare: A Safety Imperative from the Lucien Leape Institute at NPSF. It prepares health care leaders to guide patient safety improvement initiatives and drive transformational change within their organizations.

The fellowship framework includes a focus on foundational elements of patient safety, such as leadership roles, culture and communication, and incorporates them into four pillars of patient safety:

• Care coordination
• Patient centeredness
• Organizational culture
• Transparency and learning organization

Fellows complete an action learning project to bring real change within their organizations and demonstrate their ability to apply the concepts learned. This rigorous approach ensures that Fellows can translate knowledge and best practices learned into action within their own organizations.

Applications for the 2013-2014 are being accepted through March 15, 2013. Please visit the fellowship website for more information.

The AHA and the National Patient Safety Foundation are sponsors of this program.

Partners include: The Health Education & Research Trust, Health Forum, the American Society for Healthcare Risk Management, the American Organization of Nurse Executives and the Society of Hospital Medicine.

Cancer services cover a wide range of activities, from health promotion and screenings to diagnosis, surgery, medical or radiotherapy, palliative care, and disease management. Likewise, the safety risks and opportunities for error are broad and far-reaching in consequence, and include adverse drug interactions, patient misidentification and cross-contamination of laboratory specimens. The risk of error grows with the introduction of new therapies and the advance of personalized medicine.

In written comments to his colleagues prior to the meeting, Rep. Barber said, “As Congress continues to address health issues, a concise overview of some of the key issues, challenges, and solutions related to cancer and patient safety should help guide the institution’s analysis, debate, and action.”

Patricia McGaffigan, RN, MS, interim president of NPSF, represented the Foundation’s commitment to supporting health systems in their efforts to improve safety in cancer care. She also recounted personal experience with the health care system that served to illustrate some of the very issues under discussion.

Joining Ms. McGaffigan on the expert panel were Mara Aspinall, president and CEO, Ventana Medical Systems, Inc., and global head, Roche Tissue Diagnostics; Maurie Markman, MD, senior vice president of clinical affairs and national director of medical oncology, Cancer Treatment Centers of America; and Eric Walk, MD, FCAP, senior vice president, medical and scientific affairs, Ventana Medical Systems.

Ms. McGaffigan also answered questions informally after the session. View the video below.

Part I

Part II

The report defines what integration should look like in the health system of the 21^st century, highlights ongoing barriers to better coordinated care, and outlines opportunities for improvement.

“One of the greatest challenges in the effort to provide higher quality, affordable health care is finding ways to integrate the wide array of services that patients with serious illnesses need. For too long, patients have been left to their own devices to make sense out of advice and directions from multiple providers in multiple locations. It doesn’t work. The system has to do that for them,” said Lucian L. Leape, MD, chair of the Institute and a widely renowned leader in patient safety. “Our hope is that this report will spark serious attention to this critical problem.”

One of the problems is that there is little agreement about what care integration really means. Order from Chaos looks at definitions, critical components, and two distinct levels of care integration: the process of care and the activities that make up the processes. The report summarizes the chief barriers to care, and points to six areas where progress is needed:

Shared Understanding: Making the link between care integration and patient safety common knowledge among all stakeholders.

Patient Engagement: Involving patients as active participants in care; as reviewers of their care and care processes; and in the design of care processes.

Measures: Creating ways to quantify the links between care integration, clinical outcomes, and financial impact.

Evaluation: Allowing for robust assessment of whether effective integration is actually taking place.

Education and Training: Creating curricula, not only for medical schools, but also for hospital boards and leadership teams, that focus on the issues of patient safety and care integration.

National Spread: Advancing research and technology to support care integration throughout the country.

David M. Lawrence, MD, the retired chairman and chief executive officer of Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals, served as chair of the Leape Institute Roundtable on Care Integration. A founding member of the Leape Institute, Dr. Lawrence led the effort to produce the current report.

“We are grateful to our roundtable experts who contributed to this report,” said Diane C. Pinakiewicz, MBA, CPPS, president of the Lucian Leape Institute and president of the National Patient Safety Foundation. “On the heels of this work, we are continuing collaborative efforts to promote discussion and innovation around this important topic.”

This report is the second in a planned series of reports on issues that the Lucian Leape Institute has identified as top priorities in ongoing efforts to improve patient safety. The first, Unmet Needs: Teaching Physicians to Provide Safe Patient Care, was published in 2010. Subsequent Institute initiatives will address restoration of joy and meaning in professional work and ensuring the safety of the health care workforce; promotion of active consumer engagement in patient care; and provision of fully transparent care.

Besides Dr. Leape and Ms. Pinakiewicz, current members of the Lucian Leape Institute include Carolyn M. Clancy, MD, director, Agency for Healthcare Research and Quality; Janet Corrigan, PhD, MBA, former president, National Quality Forum; Susan Edgman-Levitan, PA, executive director, John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital; Gary S. Kaplan, MD, FACMPE, Chairman and CEO, Virginia Mason Medical Center; Julianne M. Morath, RN, MS, Chief Quality and Patient Safety Officer, Vanderbilt Medical Center; Dennis S. O’Leary, MD, President Emeritus, The Joint Commission; Paul O’Neill, Former Chairman and Chief Executive Officer, Alcoa, and 72nd Secretary of the US Treasury; and Robert M. Wachter, MD, associate chair, Department of Medicine, University of California at San Francisco.

The Leape Institute is especially grateful to Roundtable members Richard M.J. Bohmer, MD, MBA, Harvard Business School, and Sara Singer, PhD, of the Harvard School of Public Health, Harvard Medical School, and the Mongan Institute of Health Policy at Massachusetts General Hospital, who worked closely with Dr. Lawrence in drafting the report.

The full report is available online at www.npsf.org/lli. A webinar is being planned for early December, with Dr. Lawrence and Dr. Leape discussing the content of this report.

The Lucian Leape Institute at the National Patient Safety Foundation gratefully acknowledges Hospira for its generous support of the LLI Expert Roundtable on Care Integration.

About the Lucian Leape Institute

The Lucian Leape Institute at NPSF, established in 2007, is charged with defining strategic paths and calls to action for the field of patient safety, offering vision and context for the many efforts under way within health care, and providing the leverage necessary for system-level change. Its members comprise national thought leaders with a common interest in patient safety whose expertise and influence are brought to bear as the Institute calls for the innovation necessary to expedite the work and create significant, sustainable improvements in culture, process, and outcomes critical to safer health care.

About National Patient Safety Foundation

The National Patient Safety Foundation (NPSF) has been pursuing one mission since its founding in 1997–to improve the safety of care provided to patients. As a central voice for patient safety, NPSF is committed to a collaborative, multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the work of the National Patient Safety Foundation, please visit: www.npsf.org.

Contact:
Patricia McTiernan
617-391-9922
pmctiernan@npsf.org

“September 1st marked the nine-year anniversary of a two-month commitment I made in 2003 to assume executive leadership of NPSF,” said Ms. Pinakiewicz, referring to her intended short stay leading the organization. “NPSF has come a long way in the past nine years. I am very proud of the position we are now in and the talented staff we have in place, and I think it is time for me to turn the privilege of leading this organization over to someone new.”

Ms. Pinakiewicz has been instrumental in NPSF’s growth, including the design and launch of accredited continuing education and continuing medical education resources, the creation of the Certification Board for Professionals in Patient Safety, and the establishment of NPSF as a significant resource for patient safety expertise with a strong presence both nationally and overseas.

“Our Foundation has achieved many accomplishments with Ms. Pinakiewicz at the helm. We owe her a debt of gratitude for her leadership and stewardship of the National Patient Safety Foundation for the past nine years,” said Gerald B. Hickson, MD, Chairman, NPSF Board of Directors. “The Board supports Ms. Pinakiewicz’s decision to pursue a new endeavor, and we are confident that NPSF will continue building a noble legacy to make medicine kinder and safer.” Ms. Pinakiewicz will hold the honorary position of distinguished advisor to NPSF and will assist in ensuring continuity through the transition.

In anticipation of this decision, the Board has been actively involved in preparing a transition plan and is currently conducting a national search for a successor. “We believe that this transition will build on the foundation of NPSF’s commitment to improving the safety of patients while continuing as an integral resource for organizations and individuals in the health care industry,” noted Dr. Hickson.

About National Patient Safety Foundation

NPSF has been pursuing one mission since its founding in 1997—to improve the safety of care provided to patients. As a central voice for patient safety, NPSF is committed to a collaborative, multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the work of the National Patient Safety Foundation, please visit www.npsf.org.

Contact:
Patricia McTiernan
617-391-9922
pmctiernan@npsf.org

A new module in the TeamSTEPPS program offers tools and resources to create a customized training plan with the goal of building teamwork skills as they relate to patients with LEP. The materials include a readiness assessment survey, training materials and guides, exercises, patient outcome surveys, and more.

In conjunction with the new TeamSTEPPS module, AHRQ has published an online guide, Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals. This text was developed to help hospital leaders learn how to identify, report, monitor, and prevent medical errors among patients with LEP.

These tools were developed by the Disparities Solutions Center at the Mongan Institute for Health Policy, based at Massachusetts General Hospital in Boston, and Abt Associates, a health care consulting organization.

Now, the Agency for Healthcare Research and Quality is offering a free toolkit to help acute care and post-acute care facilities evaluate and improve their current medication reconciliation process. The toolkit, Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation, can help facilities reduce patient harm due to adverse drug events or medication errors.

This toolkit is based on the Medications at Transitions and Clinical Handoffs (MATCH) Web site. It provides a framework to capture complete, accurate medication information through electronic health records (EHRs) and enables the development of a medication reconciliation process or the redesign an existing process.

For more information, visit the website, or contact AHRQ via e-mail AHRQpubs@ahrq.hhs.gov or by phone at 1-800-358-9295.

The National Patient Safety Foundation’s Research Grants Program seeks to stimulate new, innovative projects directed toward enhancing patient safety in the United States. The program’s objective is to promote studies leading to the prevention of human errors, system errors, patient injuries and the consequences of such adverse events in the health care setting. In this first stage of a two-stage application process, Letters of Intent (LOIs) are solicited for research and development that is broadly related to identifying the causes of preventable injuries and errors and/or developing prevention strategies and methods to implement them. Based on these LOIs, a limited number of applicants will be invited to submit a full proposal.

In order to be eligible for consideration, LOIs must be delivered to NPSF no later than November 6, 2012. The number of grants to be awarded will depend on the nature and quality of applications received and the total funds available. A multidisciplinary team of experts will evaluate the LOIs. Investigators will be notified of the status of their LOIs no later than January 15, 2013.

In the second stage of the process, a limited number of applicants will be invited to submit a full proposal. Full proposals will be due on February 27, 2013. Finalists will be notified of acceptance or rejection for a grant award no later than April 15, 2013.

Please download the full request for LOIs for complete instructions and eligibility requirements or visit the Research Grants Program page.

For more information:
Call: 617.391.9900
E-mail: research@npsf.org

A recent article in Focus on Patient Safety highlights the work of the Centers for Education and Research on Therapeutics (CERTs), a network of research centers established in 1999 by the United States federal government to add to the evidence base on the safety and effectiveness of therapeutics—a broad category that includes drugs, medical devices, and biological products, such as vaccines. The article specifically focuses on recent CERTs research on the use of computerized information systems in health care settings.

Read or download the article.

A recent post on a health care job website looked at patient safety as a career path for experienced nurses. The article quoted one patient safety specialist as noting that, “The unique element of this role is the relationship across disciplines.”

That’s a key point: That while many experienced nurses transition to patient safety manager or director roles, patient safety touches every area of health care. While a nursing background is certainly helpful, health professionals from other disciplines may also move into a role with a primary focus on patient safety.

The article noted that certification is now available for patient safety professionals.

What’s been your path to patient safety? Tell us via the comment box below or write to us at info@npsf.org.

Read the summary story online.