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19th Annual NPSF Patient Safety Congress Day 2 Recap
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19th Annual NPSF Patient Safety Congress




New Guide Released - Leading a Culture of Safety
One of the most critical roles of healthcare leaders is to ensure the safety of patients and the workforce. Over the past year, the American College of Healthcare Executives and the NPSF Lucian Leape Institute worked together and partnered with a number of progressive healthcare organizations and renowned experts in leadership, safety, and culture to identify strategies and tactics known to contribute to a culture of safety. The result of this work is a practical, tactical resource for healthcare leaders to use in their organizations’ culture transformation.

The project was led by Charles D. Stokes, FACHE, executive vice president and chief operating officer, Memorial Hermann Health System, and current ACHE Chair, and Gary S. Kaplan, MD, FACMPE, chair and chief executive officer, Virginia Mason Health System, and chair of the LLI. They, along with Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement, and President of the LLI, discussed the work during a breakout session at the NPSF Congress.

Learn more or download Leading a Culture of Safety: A Blueprint for Success.



  Original members of the
NPSF Lucian Leape Institute

Opening Keynote
In welcoming attendees, Dr. Gandhi gave special thanks to the founders of NPSF and to board members past and present. She introduced a short video of memories of the past 20 years. View the video here or click on the photo.

Derek Feeley, CEO of IHI, called the merger "a merger of mission, a merger of purpose," and invited attendees to help the combined organization begin a national and international conversation about where patient safety needs to go.

Donald M. Berwick, MD, MPP, FRCP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, and former Administrator of the Centers for Medicare & Medicaid Services gave the opening keynote address. Dr. Berwick's talk looked at the evolution of patient safety over the past 20 years, calling it "an enormous PDSA cycle." He noted challenges and missteps along the way, including the separation of safety from quality. "Fragmentation is the enemy," he said. "We don't have the resources to waste on tribalism."


Breakout Snapshots:

Session 101 A Comprehensive Framework for Patient Safety, Reliability and Clinical Excellence

Carol Haraden, PhD, Senior Vice President, Institute for Healthcare Improvement, presented a framework that details the components that must be present in order to have safer care everywhere. Read more here.


Session 301 – Implementing Root Cause Analysis and Action - What we've learned on our journey

Jessica Behrhorst and Richard D. Guthrie, Jr., MD, CPE, Ochsner Health System describe a journey though the implementation of the new Root Cause Analysis and Action model. Read a blog post about their work.





Awards Conferred for Extraordinary Nurses and for Excellence in Patient Engagement
Carlos A. Urrea, MD, MPH, Vice President, Medical Affairs, Hill-Rom, presented the 2017 NPSF DAISY Award for Extraordinary Nurses. Peggy Kattenberg, BSN, RN, CMSRN, of Penrose —St. Francis Health Services in Colorado, received the individual award. The 2017 team award went to Team Kalynn at the Medical Intensive Care Unit at Ronald Reagan UCLA Medical Center, part of UCLA Health. Read more about the honorees.


University of Rochester Medical Center’s UR Voice Team and Holland Bloorview Kids Rehabilitation Hospital’s Client and Family Centered Care Simulation Development Team were named the winners of the fourth annual Sherman Award for Excellence in Patient Engagement. The awards were presented by Mark O’Leary, President of Taylor Communications, parent organization of the blog. Read more.





Congrats to Today's Raffle Winners!

 Congratulations to today's raffle winners:

  • Kirsten Windos and Donna Clayton each won a 2018 NPSF Congress registration.
  • Jennifer Topscher and Jeannie Haggan each won a FitBit.
  • Donna Shaw won a one-year membership to the American Society of Professionals in Patient Safety (ASPPS).

Join us on Friday in the Simulation & Learning Center and get your chance to win. The final drawing takes place at Booth 401 at 1:00 PM.


Visit the Congress Website

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