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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.


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Lessons Learned from the NPSF Patient Safety Congress

Posted By Administration, Thursday, May 14, 2015
Updated: Thursday, May 14, 2015

Leadership, Culture, and the Power of Patients Made a Strong Showing at the 2015 NPSF Congress.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

The National Patient Safety Foundation hosted the 17th Annual NPSF Patient Safety Congress last month in Austin, and it was wonderful to see so many health professionals gathered in one place to learn and share best practices about patient safety. We are so grateful to our enthusiastic attendees, our committed faculty and planning committee, our exhibitors, and of course, the supporting organizations that helped make the Congress such a success. It was particularly exciting to meet so many members of the NPSF membership programs, the American Society of Professionals in Patient Safety and the NPSF Stand Up for Patient Safety program, and get to hear from them in person.


One of the lessons I took from the meeting is how much the discussions about culture and leadership resonated with attendees. We weren’t mired in theory—our speakers focused on practical ways to help change culture—which, of course, requires strong leadership commitment. During our opening keynote session, Dr. Gary Kaplan, chief executive officer and chairman of Virginia Mason Health System, said that leaders—be they CEOs or unit managers—should aim to be “idea coaches.” They need to support their staff in working on ideas, encourage root cause thinking, be straightforward with feedback, and ask questions to spark creativity and critical thinking. As he noted, this kind of behavior can be a stretch for some who think that they, as the leader, need to solve all the problems.


Dr. Gerald Hickson, senior vice president for quality, safety, and risk prevention and assistant vice chancellor for health affairs at Vanderbilt University Medical Center, talked about the people, processes, and technology that are necessary to bring about culture change. Disrespect and disruptive behavior, even when rare, can be very damaging to an organization, and Vanderbilt uses a detailed and well-defined process for addressing such behavior when it occurs. Their tools and approach have shown real results, with improvements in hand hygiene compliance, improved adherence with clinical protocols, and reduced malpractice claims and expenses.


The bookend to this discussion was our closing keynote, by Dr. Allan Frankel, chief medical officer, Safe and Reliable Healthcare, and author of The Essential Guide for Patient Safety Officers. Dr. Frankel gave examples of organizations that are generative in their approach to patient safety—meaning safety and improvement are hardwired into their operations. He pointed out that professionalism, behavioral norms, psychological safety, and culture are measurable. “Cultures catapult from mediocrity into excellence when all the components come together,” he said.


Another top takeaway came from three speakers who began their work in patient safety as patients or family members of patients. Through their powerful stories, Kim Blanton, Chrissie Blackburn, and Beth Daley Ullem showed the many ways that health care organizations can better partner with patients. Their journeys from places of loss and fear to positions of influence show that some organizations are making real progress in patient engagement, and I know a lot of our attendees took these lessons to heart. (Read more about this topic on the P.S. blog.)


Last but not least, I came away from the meeting with a renewed appreciation for the value of networking. Many attendees told me how much they gain from talking face-to-face with others—be they peers in similar organizations or industry representatives discussing new and innovative tools. Some attendees made new friends and professional connections, while others caught up with colleagues they met at past NPSF Congresses. The strength of our connections and commitment to making health care safer truly brought this year’s Congress theme, United in Safety, to life.


Visit for more news about the annual meeting. If you attended the 2015 Congress, we’d love to hear your comments, either via the survey we sent, or comment below.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute. 

Tags:  culture  leadership  networking  NPSF Congress  patients 

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