AHA-NPSF Comprehensive Patient Safety Leadership Fellowship
Interested in advancing your skills in in patient safety, quality and performance improvement? This fellowship program is essential training.
The fellowship is a transformative learning experience consisting of four in-person learning sessions, periodic teleconferences, webinars, various self and organizational assessments and individual coaching. During the year-long program, fellows complete an action learning project to bring real change within their organizations and demonstrate their ability to apply the concepts learned.
The AHA and the National Patient Safety Foundation are sponsors of this program. Partners include: The Health Research & Educational Trust, Health Forum, the American Society for Healthcare Risk Management, the American Organization of Nurse Executives and the Society of Hospital Medicine.
Objectives of the fellowship
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; and transparency and learning organization (see figure).
This curriculum is based on the 2009 paper Transforming Healthcare: A Safety Imperative from the Lucien Leape Institute of NPSF. It prepares health care leaders to guide patient safety improvement initiatives and drive transformational change within their organizations.
Value of the fellowship
The year-long program offers in-person meetings, group conferencing and individual coaching and mentoring.
- Action Learning Project— Fellows design and complete a major patient safety or quality improvement project at their organizations. Fellows are provided a mentor to guide and help advance the progress of their project.
- Learning Retreats—Four in-person meetings lasting two to three days. At each retreat, workshops, led by expert faculty, will teach fellows tools and concepts of patient safety. The first meeting is held in conjunction with the AHA-Health Forum Leadership Summit (July) and the final retreat coincides with the NPSF Patient Safety Congress (May). Fellows attend each conference as part of the retreat.
- Webinars/Webcasts-Six interactive webinars featuring a selected reading, group assignment and discussion and access to select webcasts hosted by NPSF.
- Virtual Learning Community—A secure and dedicated site for fellows and faculty to communicate and share resources and ideas.
What you will learn
Fellows will gain the skills, knowledge and leadership capabilities to:
- Develop, lead and champion patient safety improvement projects as part of larger delivery system transformation efforts
- Build allies and partners to bridge organizational silos
- Develop an organization-wide commitment to safety
- Measure progress and impact of improvements and interventions
Fellows will be taught to the following patient safety topics:
- External and internal environmental factors
- Methods and strategies for identifying and preventing harm
- Human cognitive limitations and human factors theories, principles, methods and tools
- National health care reform agenda's impact on safety
- Measurement tools and methods
- Reliability science and its use in patient safety improvement
- Impact of culture on patient safety
- Teamwork and communication strategies
- Just culture and adverse event investigation
- Leadership styles and its impact on patient safety improvement
- Effective facilitation, listening and meeting skills
- Key elements of care coordination models and programs
- Concepts and principles of patient- and family-centered care
- Evolution of transparency in health care
- Strategies to promote organizational learning
- The business case for quality and patient safety
- Principles and techniques for spreading improvement
- Leveraging advancements in technology to improve patient safety
- Employee engagement and safety
Who should apply
Motivated health care leaders working in patient safety, quality, performance improvement and risk management, including:
- Senior executives
- Medical directors
- Nurse executives and managers
- Patient safety officers
- Risk managers and consultants
- Infection preventionists
- Pharmacy leaders
- Performance improvement leaders
- Prior training and experience and/or interest in developing and implementing patient safety and quality improvement initiatives
- Vision, passion and capability to make care safer in health care organizations
- Insight, courage and evidence of a commitment to lifelong growth and development
- Capacity and willingness to learn in collaboration with other health care professionals through action, reflection, feedback and support
- Commitment (from the employing organization and individual) for the fellow's continuing employment and active engagement in the fellowship, as well as financial support for tuition and travel expenses
Action learning project
The action learning project is the foundation of the fellowship program.
Each fellow designs a project, tied directly to their own professional and personal priorities that will advance patient safety and quality improvement in their organization. Fellows are required to design projects to aid their organizations in transforming care.
The project goals, scope and outcomes are approved by the fellows' sponsoring organization to ensure project support and organizational commitment. Fellows must provide a final report to their organization.
Successful completion of the project is a critical component of the fellowship experience. Each fellow will be assigned a mentor and will receive additional coaching assistance from program faculty and fellowship alumni.
Organizations can send individuals or teams to participate in the fellowship. A team of leaders is an effective way to integrate and sustain the project in the organization. It is recommended that teams submit one action learning project proposal as part of the application process.
Vice President, Quality, Safety and Resource Management
Chief Risk Officer
University of Michigan Health System
John Combes, MD
President and Chief Operating Officer, Center for Healthcare Governance
Senior Vice President, AHA
Vice President of Consulting
iplqi (Institute for Process, Leadership and Quality Improvement)
Rollin "Terry" Fairbanks, MD
Director, National Center for Human Factors Engineering in Healthcare, MedStar Institute for Innovation
Associate Professor of Emergency Medicine, Georgetown University
FosterHicks & Associates
Tejal Gandhi, MD
National Patient Safety Foundation
Partner and Principal Collaborator
SG Collaborative Solutions, LLC
Gerald Hickson, MD
Director, Center for Patient and Professional Advocacy, Professor of Pediatrics
Vanderbilt University Medical Center
Maulik Joshi, DrPH
President and CEO, Health Research & Educational Trust
Senior Vice President, Research, AHA
Donald Kennerly, MD
Vice President of Patient Safety and Chief Patient Safety Officer
Baylor Health Care System
Andrew Knight, PhD
Washington University in St. Louis
Della Lin, MD
Staff Anesthesiologist, Executive Director of CME, The Queen's Medical Center
Senior Fellow in Patient Safety and Health Systems Engineering, Estes Park Institute
Pamela Thompson, RN
Chief Executive Officer
American Organization of Nurse Executives
Mark Williams, MD
Editor-in-Chief, Journal of Hospital Medicine
Past President, Society for Hospital Medicine
Senior Lecturer in Residence
Loyola University School of Law
April 1, 2014--Applications due
May 2014--Selected candidates notified
June 30, 2014--Tuition payment due/new class orientation
July 16-22, 2014--Learning Retreat: Foundational Elements and Reliability (held in conjunction with the Health Forum and the AHA Leadership Summit July 20-22 in San Diego)
October 20-21, 2014--Learning Retreat: Patient Centeredness and Care Coordination, Chicago
February 23-25, 2015--Learning Retreat: Organizational Culture, Transparency and Organizational Learning
April 27 –May 1, 2015--Learning Retreat: Action Learning (held in conjunction with the 2015 NPSF Patient Safety Congress)
- Secured Class Sites
Virginia Mason Hospital: Exploring Root Causes, Reducing Falls
Members of the 2012-2013 graduating class of Comprehensive Patient Safety Leadership Fellows applied process improvement tools and the coaching support of the fellowship program to significantly reduce patient falls associated with delirium. Jessica Dunn, MSN, RN, GCNS, CNL; Alison Pyle MN, RN, MPH and Karina Uldall, MD, MPH, of Virginia Mason Medical Center in Seattle designed and implemented a project that looked at root causes of fall risk and prevention of delirium. Up to 82 percent of inpatients are effected by delirium, which can contribute to falls, extended length of stay, permanent cognitive impairment and other undesired outcomes. Dunn, director of clinical care coordination and geriatrics, and Uldall, psychiatry, organized a multidisciplinary team, and Pyle, director of the neuroscience/urology/transplant unit, led efforts on her unit, working with nursing staff to implement strategies to recognize risk factors for delirium and to convene care teams to intervene when risk factors are present. Strategies used included huddles between charge nurses and clinical nurse leaders to identify patients at risk for delirium, cognitive assessment tools, and discussions among the care team regarding interventions. Within a 12-month period, the project achieved significant reductions in delirium-associated falls. In 2011, 66 percent of falls on the intervention units were associated with delirium, and this dropped to 33 percent of falls in 2012. The project team is planning to spread the intervention beyond the neuroscience/urology/transplant unit to other units in the future. The AHA-NPSF Comprehensive Patient Safety Leadership Fellowship is a year-long program that combines in-person learning sessions, virtual conferencing and individual coaching and mentoring to advance the work of fellows in improving patient safety in their organizations.
Comprehensive Patient Safety Leadership Fellowship project by Kate Kovich of Advocate Health Care
A member of the 2012–2013 graduating class of Comprehensive Patient Safety Leadership Fellows provided leadership in the design and implementation of a strategic plan for patient safety to move her organization toward breakthrough improvement. Kate Kovich, administrator of patient safety at Advocate Health Care, a multihospital health system in Chicago, along with Rishi Sikka, MD, vice president of clinical transformation, led efforts to design a plan comprised of actionable tactics organized under four key strategies:
1. Positioning patient safety as the foundation of care
2. Teaching leaders how to lead to safety
3. Enabling the front line to identify and resolve safety issues
4. Fully engaging patients and families in patient safety
The most significant outcome of the project to date has been the implementation of 15-minute daily safety briefings at all 17 Advocate sites of care. The briefings are held early in the day to create situational awareness of current issues that have the potential to impact the safety, quality or service of the care delivered each day. The AHA-NPSF Comprehensive Patient Safety Leadership Fellowship is a yearlong program that combines in-person learning sessions, virtual conferencing and individual coaching and mentoring to advance the work of fellows in improving patient safety in their organizations.