2021 Root Cause Analysis (RCA) Innovation Virtual Summit

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Register Now
April 14, 2021
9:00 a.m. – 1:00 p.m., PST
11:00 a.m. –  3:00 p.m., CST
12:00 – 4:00 p.m., EST

This educational activity is jointly provided by AXIS Medical Education and California Hospital Association for Hospital Quality Institute in collaboration with Collaborative Healthcare Patient Safety Organization (CHPSO) and Alliance for Quality Improvement and Patient Safety (AQIPS)

Overview

Hospital Quality Institute (HQI), along with Collaborative Healthcare Patient Safety Organization (CHPSO) and Alliance for Quality Improvement and Patient Safety (AQIPS), will present a first of its kind virtual summit that will enlighten health care professionals on Root Cause Analysis (RCAs) best practices and the recent innovations using the National Peer Protections to improve the processes and the delivery of patient care throughout the health care continuum.  

This summit is comprised of a series of “pre-summit” webinars that set the stage for a half-day virtual event featuring expert keynote speakers, general sessions full of valuable information, and individual breakout sessions addressing RCAs in specific environments. The summit will explore how RCA and RCA2 can be more effective in developing solutions and spurring action to mitigate patient harm. 

This is an excellent educational resource for staff who currently conduct RCAs. 

Please join us as we move towards innovative thinking to improve the delivery of patient care for the communities we serve. 

This summit series is complimentary for members of HQI, CHPSO, and AQIPS (and their members). Register for one or all – it’s that easy.

Target Audience 

 Health care professionals working in Nursing, Risk Management, Compliance and Quality and Patient Safety, and for select sessions, Physicians employed or with medical staff privileges at hospitals, skilled nursing, or clinics.

Agenda

Pre-Summit Webinars

February 16 | 11:00 a.m. – 12:00 p.m., PST | Diagramming/Causal Analysis
Jerry Allen, Senior Advisor, The Just Culture Company

February 25 | 11:00 a.m. – 12:00 p.m., PST | Applying the RCA² Methodology for RCA Review and Feedback
Adam Novak, Director of Safety Initiatives, MHA Keystone Center

March 4 | 11:00 a.m. – 12:00 p.m., PST | RCA 101/RCA Triggers
Dr. Deb Bakerjian, Clinical Professor, Betty Irene Moore School of Nursing, UC Davis and Dr. Ulfat Shaikh, Director of Healthcare Quality and Professor of Pediatrics, University of California Davis School of Medicine

March 23 | 11:00 a.m. – 12:00 p.m., PST | Affective Biases in Medical Decision Making: What are They and What Should We Do About Them?
Linda M. Isbell, PhD, Feldman-Vorwerk Family Professor in Social Psychology and Head of Social Psychology Program, University of Massachusetts Amherst

Register for one or all webinars. 

2021 Root Cause Analysis (RCA) Innovation Virtual Summit 

April 14, 2021
9:00 a.m. – 1:00 p.m., PST
11:00 a.m. –  3:00 p.m., CST
12:00 – 4:00 p.m., EST

9:00 – 9:30 a.m. | Keynote Session – Healthcare Transformation: Leading with Safety
Tejal Gandhi, MD, MPH, CPPS, Chief Safety and Transformation Officer, Press Ganey
Join our keynote speaker as she sets the stage by defining harm in patient safety. She will then share insights on the importance of leading with a focus on safety for organizational transformations. In order to reach desired goals, she will provide attendees with rubric to assist in transformation, including examples of strategies and tactics.

9:30 – 10:30 a.m. | General Session — RCA2 Applied
Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM, Senior Director, Patient Safety, Institute for Healthcare Improvement
The Root Cause Analysis (RCA) process is a widely used risk management tool often reserved for sentinel events. However, investigations often are incomplete and do not lead to sustainable improvement. In this session, you will be introduced to the Root Cause Analysis and Action (RCA2) process. Grounded in the principals of high reliability and patient safety culture, this novel approach to the event review process emphasizes the engagement of interprofessional teams in order to build stronger, more sustainable actions.  

10:30 – 10:45 a.m. | Break

10:45 a.m. – 12:00 p.m. | Concurrent Breakout Sessions (choose one)

  1. Conducting RCAs in a Primary Care Setting
    Mary Parson-Snyder, Patient Safety Analyst/Consultant, ECRI
    This session will provide an understanding of how to apply concepts and techniques that will assist health care professionals and physician leaders in the primary care setting with the ability to conduct more effective RCAs and reduce system issues contributing to adverse events.
  2. Conducting RCAs in a Skilled Nursing Facilities/Assisted Living
    Victor Lane Rose, MBA, NHA, FCPP, CPASRM, Director, Aging Services, ECRI; and Jean Harpel, Operations Manager, Aging Services, ECRI
    This session will discuss the important role that effective RCAs play in driving an aging services provider organization’s performance improvement effort to help prevent harm, decrease risk, improve quality, and increase safety for all stakeholders. Session activities will help prepare attendees to conduct competent RCAs and develop purposeful action recommendations that result in meaningful change within the organization as part of its ongoing risk and QAPI systems. (Not accredited for CME.)
  3. Conducting RCAs in Community Pharmacy
    John Kessler, Founder and Chief Clinical Officer, SecondStory Health, LLC; and Tara Modisett, Executive Director, Alliance for Patient Medication Safety; Tasha Polster, Vice President, Pharmacy Quality, Compliance and Patient Safety; and Catherine Stimmel, Director, U.S. Pharmacy Quality Assurance and Patient Safety, Walgreens Boots Alliance
    The pharmacy breakout session will describe two models of the RCA2 process, conducted in both the retail pharmacy and community (independent) pharmacy environments. Each model will describe how the RCA2 process is conducted in a way that maximizes protections under the PSQIA and learnings from a Just Culture perspective. Speakers will also describe strategies that increase the effectiveness of RCA2s in the noninstitutional pharmacy environment and the role of the PSO in assuring that the RCA2 is thorough and credible. (Not accredited for CME.)
  4. Conducting RCAs in Rural and Critical Access Hospitals
    Carrie Pinasco, BS, CDM, BCQS, Senior Director, Quality, Safety & Health Policy, Midwest Alliance for Patient Safety PSO; and Gail Brondum, BS, LPN, Executive Director, Nebraska Coalition for Patient Safety
    This session will focus on establishing structures and processes in small, rural hospitals to support conducting effective RCAs. We will review challenges that are unique to conducting RCAs in these environments and how to overcome those potential barriers. Participants will learn the importance of establishing and implementing action plans as part of a thorough RCA.

12:00 – 12:15 p.m. | Break

12:15 – 1:00 p.m. | General Session — RCAs Under the PSQIA — Innovation and Legal Aspects
Peggy Binzer, JD, Executive Director, Alliance for Quality Improvement and Patient Safety; and Lisa Mead, RN, MS, CPHQ, CHPC, President, Crowne Healthcare Advisors
This session will highlight innovative RCAs and audit programs conducted under the PSQIA protections. Participants will learn how to use the PSQIA to improve the RCA process and share learnings with colleagues and throughout the health care continuum.

1:00 – 1:30 p.m. | Closing Session
Carmela Coyle, President & CEO, California Hospital Association
Session description coming soon. (Not accredited for CME.)

Register for one or all events by clicking the registration tab.

Pre-Summit Webinar Series

Please note the four Pre-Summit Webinars are SOLD OUT – Recordings will be available approximately two weeks after each live event.

Webinar 1: RCA Causal Diagramming​

Date: February 16, 2021
Time: 11:00 a.m. – 12:00 p.m., PST
1:00 – 2:00 p.m., CST
2:00 – 3:00 p.m., EST

Target Audience — Health care professionals working in Nursing, Risk Management, Compliance and Quality and Patient Safety, and Physicians employed or with medical staff privileges at hospitals or clinics.

This educational activity is jointly provided by AXIS Medical Education and California Hospital Association for Hospital Quality Institute.

Overview

RCA Causal Diagramming​
Root cause analysis (RCA) is a widely used tool in risk management practices. It is necessary when trying to figure out what went wrong, and how to prevent it from happening again. Cause-and-effect tools are an important component of effective RCA’s. Jerry Allen will explain RCA cause-and-effect representations along with providing examples.

Topics:

  • Causal diagramming theory
  • Methods of causal diagramming construction
  • Causal relationships depicted through causal diagramming
  • Two examples of causal diagramming use
Faculty

Jerry Allen, MS is a Senior Advisor at The Just Culture Company, working with organizations from a wide variety of industries to achieve better outcomes through the application of the Workplace Accountability, Root Cause Analysis, and Highly Reliable Outcomes models. He has taught numerous training and certification courses to leaders looking to implement Just Culture accountability and learning systems in their organizations. He has three decades of experience in the high-consequence world of commercial transportation, earning two international awards for his work in aviation safety and human factors.

Jerry has guided multiple Just Culture implementations across high-risk industries both as a member of two organization’s leadership teams and as a Just Culture Company Senior Advisor.

In his industrial aviation work, he oversaw the strategic management, assurance, and continuous improvement of the Bristow Group’s Safety Management System (SMS). His work included creating and implementing new group-wide Just Culture policies and Event Review Group (ERG) processes, including providing ERG support to regional leaders following training, and tele-coaching leaders to ensure new processes and tools were used consistently across the Group.

Jerry holds a Bachelor of Science from The College of the Ozarks, where he studied Aviation Science, as well as a Master of Science in Safety from the University of Central Missouri, with a concentration in System Safety. His research interests include risk theory, risk management and human factors.

Registration

Special Accommodations or Questions: If you require special accommodations pursuant to the Americans with Disabilities Act, or have other questions, please call (916) 552-7637.

This summit series is complimentary for members* of HQI, CHPSO, and AQIPS (and their members). Register for one or all – it’s that easy. 
*If you are a nonmember you may register for a fee of $1000.

Continuing Education

Full participation in the webinar is a prerequisite for receiving professional continuing education (CE) credit. Registrant must complete post-event survey, attest to participation and, when required, provide a professional license number.

Compliance The Compliance Certification Board (CCB)® has approved this event for up to 1.2 CCB CEUs. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.

Health Care Executives CHA is authorized to award 1 hour of pre-approved ACHE Qualified Education credit for this program toward advancement, or recertification, in the American College of Healthcare Executives. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

Nursing — Provider approved by the California Board of Registered Nursing, Provider CEP 16793, for 1.2 contact hours.

Quality — This program has been approved by the National Association for Healthcare Quality for a maximum of 1 CPHQ continuing education credits for this event.

Risk Managers — This meeting has been approved for a total of 1.0 contact hours of Continuing Education Credit toward fulfillment of the requirements of ASHRM designations of FASHRM (Fellow) and DFASHRM (Distinguished Fellow) and towards CPHRM renewal.

Accredited Continuing Medical Education (CME)

    Accreditation Statement — In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and California Hospital Association for Hospital Quality Institute.  AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    Credit Designation for Physicians — AXIS Medical Education designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    AXIS Contact Information — For information about the accreditation of this program please contact AXIS at or info@axismeded.org.

    Learning Objectives — 

    1. Describe a methodology for cause-and-effect representations
    2. Distinguish between direct cause, probabilistic cause and conditional information within the process of developing cause-and-effect representations
    3. Demonstrate the methodology through an example event
    4. Define the role of physicians and physician leaders in the root cause analysis (RAC) process and communication

    Disclosure of Conflicts of Interest — AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is t producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity

    AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by  staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

    The faculty, Jerry Allen, MS reports no relevant financial relationships or relationships he has with ineligible companies of any amount during the past 24 months:

    The directors, planners, managers and reviewers reported the following financial relationships they have with any ineligible company of any amount during the past 24 months:

    Name of Planner/Manager

    Reported Financial Relationship

    Liz Mekjavich

    Nothing to disclose

    Peggy Binzer

    Nothing to disclose

    Ronald Viggiani, MD

    Nothing to disclose

    Dee Morgillo, MEd., MT(ASCP), CHCP

    Nothing to disclose

    Disclaimer  — Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management.

    Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

    Requirements for credit —  

    • Attend/participate in the educational activity and review all course materials. 
    • Complete the CE Attestation/Evaluation form online by 11:59 pm ET on March 16, 2021. Instructions will be provided. If you do not complete the online evaluation by this date, you will not be able to get CME credit for this event.
    • Upon successful completion of the online form, your statement of completion will be presented to you to print.

    Webinar 2: Applying the RCA² Methodology for RCA Review and Feedback​

    Date: February 25, 2021
    Time: 11:00 a.m. – 12:00 p.m., PST
    1:00 – 2:00 p.m., CST
    2:00 – 3:00 p.m., EST

    Overview

    Applying the RCA² Methodology for RCA Review and Feedback​
    The MHA Keystone Center is a federally-recognized Patient Safety Organization (PSO), and is a component of the Michigan Health & Hospital Association. The MHA Keystone Center PSO works to adopt a strong cultural stance on patient safety by emphasizing the importance of improvement at the organizational and unit levels. Mr. Novak will describe resources and training methods used by this organization to analyze RCAs and effectively communication crucial findings to its members.

    Faculty

    Adam Novak is currently serving as director of safety initiatives at the MHA Keystone Center. He manages all aspects of the MHA Keystone Center Patient Safety Organization (PSO), and oversees the development and deployment of patient safety culture-improvement efforts across all departmental projects under the umbrella of high reliability. Adam currently serves as an editorial review board member for two peer reviewed journals: Patient Safety and Journal of Healthcare Risk Management.

    Registration

    This summit series is complimentary for members* of HQI, CHPSO, and AQIPS (and their members). Register for one or all – it’s that easy. 
    *If you are a nonmember you may register for a fee of $1000.

    Special Accommodations or Questions: If you require special accommodations pursuant to the Americans with Disabilities Act, or have other questions, please call (916) 552-7637.

    Continuing Education

    Full participation in the webinar is a prerequisite for receiving professional continuing education (CE) credit. Registrant must complete post-event survey, attest to participation and, when required, provide a professional license number.

    Compliance The Compliance Certification Board (CCB)® has approved this event for up to 1.2 CCB CEUs. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.

    Health Care Executives CHA is authorized to award 1 hour of pre-approved ACHE Qualified Education credit for this program toward advancement, or recertification, in the American College of Healthcare Executives. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

    Nursing — Provider approved by the California Board of Registered Nursing, Provider CEP 16793, for 1.2 contact hours.

    Quality — This program has been approved by the National Association for Healthcare Quality for a maximum of 1 CPHQ continuing education credits for this event.

    Risk Managers — This meeting has been approved for a total of 1.0 contact hours of Continuing Education Credit toward fulfillment of the requirements of ASHRM designations of FASHRM (Fellow) and DFASHRM (Distinguished Fellow) and towards CPHRM renewal.

    Webinar 3: RCA 101: Making it Work for the Team

    Date: March 4, 2021
    Time: 11:00 a.m. – 12:00 p.m., PST
    1:00 – 2:00 p.m., CST
    2:00 – 3:00 p.m., EST

    Target Audience — Health care professionals working in Nursing, Risk Management, Compliance and Quality and Patient Safety, and Physicians employed or with medical staff privileges at hospitals or clinics.

    This educational activity is jointly provided by AXIS Medical Education and California Hospital Association for Hospital Quality Institute.

    Overview

    RCA 101: Making it Work for the Team​
    Errors or patient harm can be devastating for a health care team, particularly if there are poor patient outcomes. Understanding the cause of the error is essential so that the problem can be prevented in the future. Root cause analysis is one of the most important tools to determine the cause of errors. Attend this webinar and learn about the root cause analysis process and how it can be used to protect your patients’ safety and your health care professionals’ peace-of-mind.

    Faculty

    Deb Bakerjian, PhD, APRN, FAAN, FAANP, FGSA  is a clinical professor at the Betty Irene Moore School of Nursing at UC Davis. Her education and research interests focus on patient safety, quality improvement, interprofessional team-based care, and geriatrics. She is the Director for two HRSA funded programs that focus on interprofessional education and collaborative practice in primary care. She is also the Director of the first primary care NP Residency program at UC Davis.

    Ulfat Shaikh, MD, MPH, MS, FAAP is the Director of Healthcare Quality and Professor of Pediatrics at the University of California Davis School of Medicine where she focuses on improving health care delivery systems and outcomes. Dr. Shaikh does this by designing, implementing, and evaluating health systems improvement methods across a broad range of health care settings.

    Registration

    This summit series is complimentary for members* of HQI, CHPSO, and AQIPS (and their members). Register for one or all – it’s that easy. 
    *If you are a nonmember you may register for a fee of $1000.

    Special Accommodations or Questions: If you require special accommodations pursuant to the Americans with Disabilities Act, or have other questions, please call (916) 552-7637.

    Continuing Education

    Full participation in the webinar is a prerequisite for receiving professional continuing education (CE) credit. Registrant must complete post-event survey, attest to participation and, when required, provide a professional license number.

    Compliance The Compliance Certification Board (CCB)® has approved this event for up to 1.2 CCB CEUs. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.

    Health Care Executives CHA is authorized to award 1 hour of pre-approved ACHE Qualified Education credit for this program toward advancement, or recertification, in the American College of Healthcare Executives. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

    Nursing — Provider approved by the California Board of Registered Nursing, Provider CEP 16793, for 1.2 contact hours.

    Quality — This program has been approved by the National Association for Healthcare Quality for a maximum of 1 CPHQ continuing education credits for this event.

    Risk Managers — This meeting has been approved for a total of 1.0 contact hours of Continuing Education Credit toward fulfillment of the requirements of ASHRM designations of FASHRM (Fellow) and DFASHRM (Distinguished Fellow) and towards CPHRM renewal.

    Accredited Continuing Medical Education (CME) 

      Accreditation Statement — In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and California Hospital Association for Hospital Quality Institute.  AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

      Credit Designation for Physicians — AXIS Medical Education designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

      AXIS Contact Information — For information about the accreditation of this program please contact AXIS at or info@axismeded.org.

      Learning Objectives —    

      • Summarize the physician and other team members role in contributing to the root cause analysis process
      • Utilize a cause-and-effect chart in root cause analysis for physicians and other team members to identify causes of patient safety problems
      • Explain the 5 Why’s of root cause analysis and how physicians and other team members can use this tool to identify causes of patient safety problems
      • Discuss the physician’s and other team member’s role in validating root causes

      Disclosure of Conflicts of Interest — AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is t producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity

      AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by  staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

      The faculty, Deb Bakerjian, PhD, APRN, FAAN, FAANP, FGSA and Ulfat Shaikh, MD, MPH, MS, FAAP report no relevant financial relationships or relationships they have with ineligible companies of any amount during the past 24 months.

      The directors, planners, managers and reviewers reported the following financial relationships they have with any ineligible company of any amount during the past 24 months:

      Name of Planner/Manager

      Reported Financial Relationship

      Liz Mekjavich

      Nothing to disclose

      Peggy Binzer

      Nothing to disclose

      Ronald Viggiani, MD

      Nothing to disclose

      Dee Morgillo, MEd., MT(ASCP), CHCP

      Nothing to disclose

      Disclaimer  — Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management.

      Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

      Requirements for credit  

      • Attend/participate in the educational activity and review all course materials. 
      • Complete the CE Attestation/Evaluation form online by 11:59 pm ET on April 4, 2021. Instructions will be provided. If you do not complete the online evaluation by this date, you will not be able to get CME credit for this event.
      • Upon successful completion of the online form, your statement of completion will be presented to you to print.

      Webinar 4: Affective Biases in Medical Decision Making: What are They and What Should We Do About Them?​

      March 23, 2021
      11:00 a.m. – 12:00 p.m., PST
      1:00 p.m. – 2:00 p.m., CST
      2:00 p.m. – 3:00 p.m., EST

      Target Audience — Health care professionals working in Nursing, Risk Management, Compliance and Quality and Patient Safety, and Physicians employed or with medical staff privileges at hospitals or clinics.

      This educational activity is jointly provided by AXIS Medical Education and California Hospital Association for Hospital Quality Institute.

      Overview

      Affective Biases in Medical Decision Making: What are They and What Should We Do About Them?​
      Human cognition is imperfect and can be unknowingly derailed by many seemingly innocuous factors, including how we feel. A voluminous body of research in psychology demonstrates that our thoughts, judgments and behaviors can be powerfully influenced by affect. Although these influences may be adaptive in many circumstances, they can contribute to some notable biases in human thought and behavior. In this interactive webinar, we will review what affective bias is, different sources of bias (e.g., patients, providers, system factors), and different types of bias (e.g., those associated with race, ethnicity, mental illness, gender). We will then examine how these biases can influence medical decision making and behavior, and contribute to adverse events.  Building on this foundation, we will explore how a consideration of affective biases can be incorporated into root cause analyses and investigated as a contributory factor in medical error.  Finally, bias mitigation strategies will be discussed. ​

      Faculty

      Linda M. Isbell, PhD, is the Feldman-Vorwerk Family Professor in Social Psychology (2020-2025) at the University of Massachusetts Amherst and serves as the Head of the Social Psychology Program. Dr. Isbell is an expert in social cognitive and affective science. Her current research investigates how physicians’ and nurses’ emotions contribute to medical errors when treating emotionally-evocative patients and those with mental illnesses in the emergency department. This work, which is supported by a grant from the Agency for Healthcare Research and Quality (AHRQ), is laying the foundation for interventions to mitigate risk and improve patient safety.

      Registration

      This summit series is complimentary for members* of HQI, CHPSO, and AQIPS (and their members). Register for one or all – it’s that easy. 
      *If you are a nonmember you may register for a fee of $1000.

      Special Accommodations or Questions: If you require special accommodations pursuant to the Americans with Disabilities Act, or have other questions, please call (916) 552-7637.

      Continuing Education

      Full participation in the webinar is a prerequisite for receiving professional continuing education (CE) credit. Registrant must complete post-event survey, attest to participation and, when required, provide a professional license number.

      Compliance The Compliance Certification Board (CCB)® has approved this event for up to 1.2 CCB CEUs. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.

      Health Care Executives CHA is authorized to award 1 hour of pre-approved ACHE Qualified Education credit for this program toward advancement, or recertification, in the American College of Healthcare Executives. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

      Nursing — Provider approved by the California Board of Registered Nursing, Provider CEP 16793, for 1.2 contact hours.

      Quality — This program has been approved by the National Association for Healthcare Quality for a maximum of 1 CPHQ continuing education credits for this event.

      Risk Managers — This meeting has been approved for a total of 1.0 contact hours of Continuing Education Credit toward fulfillment of the requirements of ASHRM designations of FASHRM (Fellow) and DFASHRM (Distinguished Fellow) and towards CPHRM renewal.

      Accredited Continuing Medical Education (CME) 

        Accreditation Statement — In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and California Hospital Association for Hospital Quality Institute.  AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

        Credit Designation for Physicians — AXIS Medical Education designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

        AXIS Contact Information — For information about the accreditation of this program please contact AXIS at or info@axismeded.org.

        Learning Objectives — 

        • Identify affective bias, different types of affective bias, and sources of bias.
        • Describe how affect can influence medical decision making and contribute to medical error.
        • Explore ways in which bias may be investigated and incorporated into a root cause analysis as a contributory factor in an adverse event.
        • Investigate mitigation strategies that may reduce effects of biases on medical decision making and reduce adverse events.

        Disclosure of Conflicts of Interest — AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is t producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity

        AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by  staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

        The faculty, Linda M. Isbell, PhD, reports no relevant financial relationships or relationships she has with ineligible companies of any amount during the past 24 months.

        The directors, planners, managers and reviewers reported the following financial relationships they have with any ineligible company of any amount during the past 24 months:

        Name of Planner/Manager

        Reported Financial Relationship

        Liz Mekjavich

        Nothing to disclose

        Peggy Binzer

        Nothing to disclose

        Ronald Viggiani, MD

        Nothing to disclose

        Dee Morgillo, MEd., MT(ASCP), CHCP

        Nothing to disclose

        Disclaimer  — Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management.

        Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

        Requirements for credit   

        • Attend/participate in the educational activity and review all course materials. 
        • Complete the CE Attestation/Evaluation form online by 11:59 pm ET on April 23, 2021. Instructions will be provided. If you do not complete the online evaluation by this date, you will not be able to get CME credit for this event.
        • Upon successful completion of the online form, your statement of completion will be presented to you to print.

        Objectives

        Objectives for the Summit include:

        • Identify key components to conducting a thorough, credible, effective root cause analysis.
        • Increase knowledge of how health care professionals are improving the RCA process using the National Peer Protections. 
        • Recognize the importance of using RCAas a consistent approach to organizational learning and improvement in all health care settings.
        • Encourage the inclusion of potential bias in RCA related to factors such as Race, Ethnicity, SES/Homelessness/Behavioral Health.
        • Discover how health care professionals are conducting root cause analyses in settings of care which do not ordinarily conduct such analysis under the National Peer Protections.
        • Increase knowledge of how PSOs are implementing peer-to-peer RCA assessments and sharing lessons learned with their member organizations.

        Faculty

        Carmela Coyle, President & CEO, CAHHS-CHA
        Carmela Coyle began her tenure as President & 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, 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.

        Prior to 2008, Coyle spent 20 years in senior policy positions with the American Hospital Association (AHA), including 11 years as the senior vice president of policy, where she served as a national media spokesperson and led AHA’s policy development and strategy planning activities. Earlier in her career, she worked for the Congressional Budget Office in Washington, D.C., advising members of Congress and their staff on the economic and budgetary implications of legislative policy.

        Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM, Senior Director, Patient Safety, Institute for Healthcare Improvement (IHI)
        Prior to joining IHI, Jessica Behrhorst served as the Assistant Vice President of Quality and Patient Safety at Ochsner Health System where she oversaw various projects involving patient safety, performance improvement, regulatory readiness, ambulatory nursing, and quality outcomes. In her time there she also led the system-wide implementation of Root Cause Analysis and Action (RCA2). She has presented her work on RCA2 and Improving the Culture of Safety at various regional and national meetings and has also worked on research projects involving reduction in sepsis mortality and access to health care for underserved populations.

        Peggy Binzer, JD, Executive Director, Alliance for Quality Improvement and Patient Safety (AQIPS)
        Peggy Binzer serves as the Executive Director of the Alliance for Quality Improvement and Patient Safety (AQIPS), the nation’s leading professional association for PSOs and their healthcare provider members. AQUIPS leads efforts to measurably improve patient safety and the quality of patient care by fostering the ability of providers to implement a culture of safety and high reliability.  Peggy 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, she has assisted hospitals, specialty physician associations, health systems and management organizations in becoming patient safety organizations (PSOs). In addition, she has provided health systems, pharmacy chains, and other providers with legal guidance to improve the quality of patient care and implement the PSQIA’s protections through the establishment and maintenance of a Patient Safety Evaluation System (PSES).

        Gail Brondum, BS, LPN, Executive Director, Nebraska Coalition for Patient Safety
        Gail Brondum joined the Nebraska Coalition for Patient Safety (NCPS) as the Executive Director in 2017. In this role, she works to support health care providers across the region in their patient safety and quality improvement efforts. Previously, Brondum was the Director of Clinical Quality Improvement at Blue Cross and Blue Shield of Nebraska. In this role, she developed and implemented clinical quality improvement strategies for the health plan with a goal of improving member health outcomes. Brondum also has served as Operations Director, Quality Management Services, at Alegent Bergan Mercy Medical Center in Omaha, Nebraska, where she had oversight of quality improvement, patient safety, infection prevention, accreditation, environment of care, care management, and social work. Prior to that, as Quality/Risk Management Director at Pender Community Hospital in Pender, Nebraska, she had responsibility for quality, risk management, patient safety, regulatory compliance, medical staff functions, employee health, and facility safety.

        Tejal Gandhi, MD, MPH, CPPS, Chief Safety and Transformation Officer, Press Ganey
        Dr. Gandhi is responsible for advancing the Zero Harm movement, improving patient and workforce safety, and developing innovative health care transformation strategies. In addition, Dr. Gandhi is leading the Press Ganey Equity Partnership to advance equity in health care.

        Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI) where she led IHI programs focusing on improving patient and workforce safety. Prior to this, Dr. Gandhi was President and Chief Executive Officer of the National Patient Safety Foundation (NPSF) from 2013 until 2017, when NPSF merged with IHI. She has also served as President of the Lucian Leape Institute, a think tank founded by NPSF that now operates within the IHI Safety portfolio, and she was a board member of the Certification Board for Professionals in Patient Safety which administers the Certified Professional in Patient Safety credential.

        Jean Harpel MSN, RN, GCNS, Operations Manager, Aging Services, ECRI
        Jean Harpel is a geriatric clinical nurse specialist and a risk management analyst. Ms. Harpel is presently the Operations Manager of the Aging Services team at ECRI Institute where she provides environment-of-care safety and security and quality and risk management consultation to aging services/post-acute care providers. She educates leadership and staff on how to implement Risk Management systems within their communities. As part of the ECRI Institute consultation services she reviews incident reports from aging services member providers and works with the organizations to help reduce future risk and harm to their residents as well as helping achieve focus on developing a culture of safety and accountability. She has developed institutional- based learning programs utilizing electronic media, traditional lecture, just-in-time activities and bedside initiatives that have focused on safe and efficient care delivery. She has written, implemented and reviewed policies and procedures for continuing care retirement communities and home care providers.

        John Kessler, BS Pharm, PharmD, Founder and Chief Clinical Officer, SecondStory Health, LLC
        John M. Kessler, BS Pharm, PharmD, is the founder and Chief Clinical Officer of SecondStory Health, LLC. He has more than 40 years of experience in safe medication systems design, adverse drug event reporting and errors analysis. He has a combined experience of 30 years in serving as a member on both academic Institutional Review Boards and Independent Review Boards, with 11 years serving in the Chair role overseeing human protections in clinical research.  He has chaired the United States Pharmacopoeia’s advisory panel on medication errors, and he has served as an ex-officio member of the National Coordinating Council for Medication Error Reporting and Prevention. He has consulted with health care organizations and regulatory authorities in the United States, South Africa, Brazil, and the Middle East on medication safety.

        Lisa Mead, RN, MS, CPHQ, CHPC, President, Crowne Healthcare Advisors
        Lisa started her career as a nurse in 1984. She has been a long-time health care provider and business executive who helps individuals and companies develop, execute and succeed in manifesting change. Lisa focused on quality and leadership development as key business strategies in every leadership position from supervisor to C-level executive.

        Over her 30-year career, Lisa used quality tools to realize successful business results and ensured that all levels within her organizations were challenged to develop their leadership skills. Each organization achieved outstanding results with a focus on quality and development as key drivers for successful business outcomes that exceeded organization expectations.

        Tara Modisett, Executive Director, Alliance for Patient Medication Safety (APMS) Patient Safety Organization
        Tara Modisett serves as the Executive Director of the Alliance for Patient Medication Safety (APMS) Patient Safety Organization. Ms. Modisett has trained pharmacy staff in medication patient safety for over 10 years. The mission of APMS is to foster a culture of quality within the profession of pharmacy that promotes a continuous systems analysis to develop best practices that will reduce medication errors, improve medication use and enhance patient care.

        Mary Parsons-Snyder, MBA, Patient Safety Analyst/Consultant, ECRIMary Parsons-Snyder joined ECRI in January 2017 as a Patient Safety Analyst/Consultant. Ms. Parsons-Snyder has nearly 40 years’ experience in Critical Care, Emergency Department, Ambulatory Care, Nursing Administration, Patient Safety, Risk Management and Quality at an acute care facility with multiple campuses in Philadelphia. In addition, she was Operations Manager at one of the last remaining Nursing Diploma Programs in Philadelphia. She is trained in Lean Six Sigma.

        Carrie Pinasco, BS, CDM, BCQS, Senior Director, Quality, Safety & Health Policy, Midwest Alliance for Patient Safety PSO
        Carrie Pinasco is the Director for the Midwest Alliance for Patient Safety (MAPS) in Naperville, Illinois. Ms. Pinasco’s health care career includes 12 years of extensive experience supporting clinical benchmarking projects, patient safety data collection and Patient Safety Organization (PSO) program development. She completed the Team STEPPS Fundamentals program developed by Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality. Additional training included Six Sigma and Kaizen Continuous Process Improvement workshops. After a career in patient safety at UHC (now Vizient, Inc.), Carrie joined MAPS to provide marketing, strategic planning, data management and educational support to the PSO program. Ms. Pinasco spearheads the coordination of all member engagement including onboarding, data collection, training, member collaboration, advisory council activities and website education. In addition, she oversees MAPS’ collaboration efforts with other PSOs, marketing and new business development.

        Tasha Polster, BS,  Vice President, Pharmacy Quality, Compliance and Patient Safety
        Tasha Polster is the Vice President of Pharmacy Quality, Compliance and Patient Safety for Walgreens. Her responsibilities include overseeing the Pharmacovigilance group and Walgreens Patient Safety Organization, Third Party Operations, Immunizations, Pharmacy Compliance as well as implementing strategic initiatives. In addition, Ms. Polster supervises the eRx, Automation and Pharmaceutical Integrity group, which was created to take on the difficult task of establishing guidelines for the proper dispensing of controlled substances. She is actively involved in transforming community pharmacy to play a greater role in combatting the misuse of narcotics, rolling out Walgreens drug take back and naloxone programs.

        Victor Lane Rose, MBA, NHA, FCPP, CPASRM, Director, Aging Services, ECRI
        Victor Rose has worked in the healthcare and non-profit sector for more than 25 years, serving in various executive and leadership roles. Currently, he serves as ECRI’s Director of Aging Services, coordinating business development and consulting in safety, risk management, and quality improvement to providers nationwide and across the aging services care continuum.

        Mr. Rose has taught management at DeSales University, served on LeadingAge’s PA Public Policy Committee, and authored numerous healthcare management and aging services articles and white papers. Topics include state survey preparedness, budgeting, risk management, building design, staffing and scheduling, legal discovery and QAPI, scope of service, and most recently post incident investigations, post incident notifications and another on emergency preparedness in relations to outbreak and pandemic response.

        Additional professional activities include serving as the Board President for the Eastern Pennsylvania Geriatrics Society (EPGS), Column Editor for Annals of Long-Term Care (ALTC) “ECRI Strategies” column, and on the ALTC editorial board.

        Catherine Stimmel, PharmD, Director, U.S. Pharmacy Quality Assurance and Patient Safety, Walgreens Boots Alliance
        Catherine Stimmel is the Director of Pharmacy Quality Assurance and Patient Safety. Her responsibilities include oversight of quality accreditation, clinical decision support, REMS, patient safety technology development, and leading the retail and community-based specialty divisions of the Patient Safety Research Foundation, Inc. Ms. Stimmel earned her PharmD from Butler University School of Pharmacy and Health Sciences.

        Summit CE

        Continuing Education

        Full participation in the webinar is a prerequisite for receiving professional continuing education (CE) credit. Registrant must complete post-event survey, attest to participation and, when required, provide a professional license number.

        Compliance The Compliance Certification Board (CCB)® has approved this event for up to 4.8 CCB CEUs. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.

        Health Care Executives CHA is authorized to award 4.0 hours of pre-approved ACHE Qualified Education credit for this program toward advancement, or recertification, in the American College of Healthcare Executives. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

        Nursing — Provider approved by the California Board of Registered Nursing, Provider CEP 16793, for 4.8 contact hours.

        Quality — This activity will be submitted to the National Association of Healthcare Quality for CPHQ CE hours.

        Risk Managers — This meeting has been approved for a total of 4.0 contact hours of Continuing Education Credit toward fulfillment of the requirements of ASHRM designations of FASHRM (Fellow) and DFASHRM (Distinguished Fellow) and towards CPHRM renewal.

        Accredited Continuing Medical Education (CME) 

          Accreditation Statement — In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and California Hospital Association for Hospital Quality Institute.  AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

          Credit Designation for Physicians — AXIS Medical Education designates this live activity for a maximum of 3.5 AMA PRA Category 1 Credit(s)™.

          Physicians should claim only the credit commensurate with the extent of their participation in the activity.

          AXIS Contact Information — For information about the accreditation of this program please contact AXIS at or info@axismeded.org.

          Learning Objectives — 

          1. Explain the physician role in leading patient safety transformation within healthcare organizations. 
          2. Identify methodologies and techniques that lead to more effective and efficient RCAs and increase engagement of health care professionals and clinicians on the Root Cause Analysis process within the organization.
          3. Investigate common errors that health care professionals and physicians may encounter while conducting RCA in the primary care setting.
          4. Examine the unique challenges physicians may encounter while conducting RCA in rural and critical access hospitals and the processes to overcome these barriers.
          5. Discuss national peer protections afforded to physicians that allows for open discussion amongst peers about the quality of patient care, what can go wrong and best practices for when things go wrong.

          Disclosure of Conflicts of Interest — AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is t producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity

          AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by  staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

          The faculty reported the following financial relationships they have with any ineligible company of any amount during the past 24 months:

          Name of Faculty

          Reported Financial Relationship

          Tejal Gandhi, MD, MPH, CPPS

          Nothing to disclose

          Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM

          Nothing to disclose

          Mary Parson-Snyder

          Nothing to disclose

          Carrie Pinasco, BS, CDM, BCQS

          Nothing to disclose

          Gail Brondum, BS, LPN

          Nothing to disclose

          Peggy Binzer, JD

          Nothing to disclose

          Lisa Mead, RN, MS, CPHQ, CHPC

          Nothing to disclose

          The directors, planners, managers and reviewers reported the following financial relationships they have with any ineligible company of any amount during the past 24 months:

          Name of Planner/Manager

          Reported Financial Relationship

          Liz Mekjavich

          Nothing to disclose

          Peggy Binzer, JD

          Nothing to disclose

          Ronald Viggiani, MD

          Nothing to disclose

          Dee Morgillo, MEd., MT(ASCP), CHCP

          Nothing to disclose

          Disclaimer  — Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management.

          Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

          Requirements for credit   

          • Attend/participate in the educational activity and review all course materials. 
          • Complete the CE Attestation/Evaluation form online by 11:59 pm ET on May 14, 2021. Instructions will be provided. If you do not complete the online evaluation by this date, you will not be able to get CME credit for this event.
          • Upon successful completion of the online form, your statement of completion will be presented to you to print.

          Registration

          This summit series is complimentary for members* of HQI, CHPSO, and AQIPS (and their members). Register for one or all – it’s that easy.

          *If you are a nonmember and would like to register there is a $1000 registration fee.

          CLICK HERE to register.

          Please note the four Pre-Summit Webinars are SOLD OUT – Recordings will be available approximately two weeks after each live event. 

          Space is still available for the Root Cause Analysis (RCA) Innovation Virtual Summit.

          Special Accommodations or Questions: If you require special accommodations pursuant to the Americans with Disabilities Act, or have other questions, please call (916) 552-7637.