Executive Fellowship in Patient Safety

First On- Campus Session Curriculum (draft)
Date:               6/21/06 – 6/24/06 (Wednesday-Saturday).
Location:  College of William and Mary School of Law, South Henry Street, Williamsburg, Virginia
Hotel: Governor’s Inn, 506 North Henry Street (757.229.1000). Fellows are not required to stay at the Governor’s Inn (discounted rate). Fellows can make hotel reservations individually at another facility.
Directions:     From Interstate 64 take exit 238 onto Route 143 east. Follow Route 143 to the second traffic light and bear right onto Route 132. Continue on Route 132 Approximately 1.8 miles, the Governor’s Inn is at the top of the hill on the right.
Dress Code:  For all events, the dress code is casual. 

Wednesday, June 21, 2006
Note: Walking is an option—the session location is about 10-12 blocks from the Governor’s Inn. Bike rental is also available at the Woodlands.

Thursday, June 22, 2006

Friday, June 23, 2006

The Art and Science of  Medication Safety
Hedy Cohen, RN, BSN
Vice President, Institute for Safe Medication Practice (ISMP)

“Development and Implementation of a Statewide Risk Prevention and Management System”
Thom Smith, RN, MA
Director, Virginia Operations for WVMI, Inc. , Richmond, Virginia 

Saturday, June 24, 2006

Executive Fellowship in Patient Safety Proposed On-Line Curriculum
Class of 2007 (draft) 

Session 1 - Fundamentals of Patient Safety: (July 9 - 22, 2006, 2 weeks)

Faculty: Dr. Carl Armstrong, Senior Medical Advisor, American Hospital Association, Virginia Hospital and Health Association)  

• Human Error Theory, IOM reports

• Patient Safety, JCAHO, National Activity, State Activities

• Future of Patient Safety

Session 2 – Environmental Impact on Patient Safety Progress in the US:  (July 23 – August 12, 2006, 3 weeks)

Faculty: Dr. Kelly Devers, Associate Professor, Department of Health Administration, VCU

• Projects from For-profit hospital

• Not-For Profit Hospitals

• Internal facility restraints

• External, regulatory constraints

 Session 3 - Human Factors Engineering & Use of Technology) (August 13 – September 2, 2006, 3 weeks)

 Faculty:  Dr. Ben-Tzion Karsh, Associate Professor, University of Wisconsin

• Human Factors Engineering & Ergonomics

• Human Factors Systems Analysis    

• Human Factors on Micro & Macro Level

• Application of Human Factors Engineering to Patient Safety Initiatives

• Human Factors Engineering:  Why a part of Patient Safety

• Application of Human Factors Engineering to Patient Safety Initiatives

Session 4 – Medication Safety:  (September 10 – October 14, 2006, 5 weeks) 

Faculty: Institute of Safe Medication Practices (ISMP)

•  Understand where medication errors occur in the medication use system and the role technology may play in error prevention.

•  Perform a “safety” test on your pharmacy and/or computerized prescriber order entry system.

• Discuss the impact of organization culture and advance preparation on implementing new technology in an organization.

• Discuss the impact of organizational culture on medication safety

• Discuss the characteristics of a non-punitive culture of safety

• Describe the value of applying medication safety strategies to high alert medications, high-risk patients, and error prone processes.

• Identify methods of improving medication safety through the use of high-leverage strategies including principles of standardization, redundancy,  independent double checks, forcing functions and simplification

• Determine the related system breakdowns that result in medication errors

 Session 5 - Developing an Error Reporting System: October 15 – 28, 2006 2 weeks)

Faculty: Angela M. Ebel, MSN. Performance Improvement Specialist at Children's Hospital of the King's Daughters in Norfolk Virginia and a graduate of the Executive Fellowship in Patient Safety.

• Voluntary vs. Mandatory Reporting Systems

• Paper vs. Web-based Systems

• Eliminating Blame

• Creating Follow-up Techniques

• Developing Physician Buy-in

• Critique of Models Available

• Information Technology and Reporting Systems

Section 6 – The Impact of Medical Malpractice Laws on Patient Safety: October 29 – November 18, 2006 3 weeks)

Faculty: Professor Karen Swisher, Professor, School of Health Administration, Virginia Commonwealth University

• Legal perspectives of telling patients/families about medical error

• Liability of disclosure and discovery of documents

• Patient safety and negligent credentialing

• Tort reform to enhance patient safety processes

• Applicable state and federal laws pertaining to patient safety

• Working with legal counsel to enhance risk management and patient safety at the same time

University closed for Thanksgiving Holiday November 19 -25, 2006

Session 7 - Developing a Comprehensive, Proprietary Patient Safety and Risk Prevention Program (Overview of Project Development & Implementation), Methodology: (November 26 – December 23, 2006 4 weeks)

Faculty: Dr. Debrah Mobley, Director, Performance Improvement, VCU Health Systems

Dale Harvey, MS, RN Performance Improvement Coordinator, VCU Health Systems

• Organization & Design, Methodologies, Indicators & Gauges

• Designs of Patient Safety Research

• Organizational Queries and Project Proposals                     

• Project Design Structure

• Project Support

• Root Cause Analysis

• 6 Sigma

• Failure Mode Effect Analysis

Off: University Closed December 23, 2006 – January 2, 2007

Session 8 - Organizational Culture Change:  Creating a Culture of Patient Safety:  (January 2 – 27, 2007 4 weeks) 

• Organization Change Theory

• Learning Culture        

• Proactive vs. Reactive Responses to Medical Errors           

• Creating Systems that Defy Error

• Developing Your Organization's Philosophy

• Organizational Structure and Tools to Facilitate a Culture of Patient Safety

Faculty: Dr. Jean Grube, Director for Patient Safety Interventions, Wisconsin Medical Injury Reporting System (WMIR)

Session 9 – The Impact of Leadership on Successful Patient Safety Initiatives:  (January 28, - February 24, 2007, 4 weeks) 

Faculty:  Professor Kenneth White, Ph.D, FACHE, Professor & Director of Graduate Programs in Health Administration at VCU

• Elements of leadership styles

• How to create vision

• Examples of leadership in the health care industry

Session 10 – Developing a Credentialing System to Promote Quality in Clinical Care (February 25 – March 17, 2007 3 weeks)

Faculty:  TBA

• Developing a System-Level solution for problem doctors

• New techniques in credentialing to promote patient safety

• Identifying and fixing performance problems

• Expanding assessment programs

• Measuring performance

• Developing remediation programs

• Working with professional boards and associations

• Understanding and reassessing peer review initiatives

• State and federal laws impacting on credentialing process

Off March 18 – 24, 2007

Session 11 - Changing Patterns of Communication within the Healthcare Team:  (March 25 – April 14, 2007, 3 weeks)

Faculty:  Lt. Col.  Beth Kohsin, Retired United States Air Force

• Nature of Teams

• Medical Team Management as an Element of Patient Safety

• uman Factors as Barriers to Effective Teamwork

• Ideas for Teambuilding and Integrating Medical Team Management

• Tools in Daily Practice

• Medical Team Management Tools

Session 12 – The Use of Evidence Based Guidelines for Patient Safety:  (April 15 – May 5, 2007, 3 weeks)

Faculty:  Dr. Jacquie Byer, Professor, University of Central Florida

• www.Guidelines.gov

• How Guidelines are used in Other Facilities

•  Implementing Guidelines

• Use of Guidelines in Credentialing

Session 13 – Re-engineering with Technology for Quality and Productivity:  (May 6 – May 19, 2007, 3 weeks)

Faculty:  Dr. Ramesh Shukla, Professor, Virginia Commonwealth University)

• Trends in Efficiency and Productivity in Healthcare Institutions

• Factors Affecting Performance:  Structure vs. People vs. Systems

• Strategic View of Technology as an Enabler

• Re-engineering Clinical Enterprise with Technology for Quality & Productivity

May 23 – 26, 2007, 2007:  VIPCS Conference, Project Presentations, and Graduation Ceremonies:  Richmond, Virginia (on the campus of Virginia Commonwealth University) Visit www.vipcs.org for information regarding Virginian’s for Improving Patient Care & Safety Conference.  Certain Fellows will be selected to present their projects; all others will attend (conference fee waived for fellows attending)

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in the Nation.