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Member Spotlight: Susan Mellott

Posted By Joanna Carmona, Thursday, August 10, 2017
Updated: Tuesday, August 8, 2017

The American Society of Professionals in Patient Safety (ASPPS) is a membership program for professionals

and others interested in patient safety. This is part of a series of member profiles. 

by Joanna Carmona 

Susan Mellott

Susan Mellott is a member of ASPPS


Susan Mellott, PhD, RN, CPHQ, FNAHQ

Associate Professor, Texas Women’s University

Could you tell us about your experience teaching patient safety to nursing students at Texas Women’s University?

I’ve been at Texas Women’s University full time since 2012 and realized a couple of years ago that there wasn’t much patient safety being taught in the undergraduate curriculum. I knew that we needed to put something in, so I started doing a research study where we embedded didactic as well as clinical patient safety concepts into the curriculum, and we’ve just finished our first semester. Students get the general patient safety overview and also discuss medical errors, near-misses, just culture, human factors, etc. Then the clinical faculty will observe them in a clinical setting, looking for things that either the students don’t do right or things they see nurses not doing right to take back and discuss in relation to those same concepts.


I also performed a needs assessment and found out that some faculty may not be fully up to date about patient safety. Some need to update their knowledge, others need greater confidence in teaching what they know.


What it comes down to is that we are redoing the entire undergraduate curriculum and there will be threads of patient safety throughout.


"They may think, 'Okay, we just have to keep the patient safe,' but it is far more than that."

—Susan Mellott

What made you interested in patient safety?

That’s easy. I cannot separate, as Don Berwick said at the 2017 Patient Safety Congress, patient safety from quality. I’ve always been involved with patient safety, but I see now that I’m teaching more of a need to move the courses over to the patient safety side. Human factors just keeps pulling me more and more into that and if I could keep working with human factors and patient safety, I’d be in seventh heaven.

How do we move forward to promote a culture of safety?

First of all, there are people who don’t understand what a culture of safety is. They may think “Okay, we just keep the patient safe,” but it is far more than that. Learning that Just Culture is a process, not the individual that makes mistakes, and that everybody will make a mistake at some point in time is so important. We need to look at the processes and refine those so that we prevent mistakes from happening or, if something does happen, we put in a safeguard to prevent it from getting to the patient. That’s one big factor.


People also fail to understand how you move from a basic mistake over to intended behavior and that there are different degrees as you move over. The way I teach it is: You know what you are supposed to do and you do it. But then you talk on the phone while you are driving with the idea that surely an accident won’t happen to me so you are willing to take that little bit of a risk. All of us in health care know that people find shortcuts and ways to get around doing things and so when we do that, we move into the same category as talking on the phone while driving. 


This year we are celebrating the 20th anniversary of NPSF. What do you think that means for the field of patient safety?

When Total Quality Management came out, no one knew what that was, but people were trying to put it into shape to have a quality culture within their organizations. Then in 1999, To Err Is Human came out, and many in the health care community said “Let’s drop this quality thing and get this patient safety culture figured out.” Many places still do not have a patient safety culture and they don’t have a quality culture either. The two things together, as I said before, I don’t think can be separated. The problem is that it has not been ingrained into a lot of organizations because the leadership focuses on other priorities like the financials, etc. However, with this being the 20th anniversary and with NPSF joining with IHI, people are going to take notice. To have the merger take place on the 20th anniversary is like a new celebration. 



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Joanna Carmona is communications coordinator at the Institute for Healthcare Improvement/National Patient Safety Foundation. Contact her at


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Stand Up Stand Out: Baylor Scott & White

Posted By Joanna Carmona, Tuesday, June 27, 2017

Stand Up Stand Out is an occasional feature on the blog highlighting the work of organizations that belong
to the NPSF Stand Up for Patient Safety program. In this post, read about what one Texas health system 

is doing to improve palliative care. 


Baylor Scott & White Health, a not-for-profit health system based in Texas, is a founding member of the IHI/NPSF Stand Up for Patient Safety program and has recently partnered with Ariadne Labs to roll out their Serious Illness Conversation and Care Planning Program across their system. Robert L. Fine, MD, FACP, FAAHPM, Clinical Director, Office of Clinical Ethics and Palliative Care at Baylor Scott & White Health, spoke to us about the genesis of the palliative care movement and how the program has initially influenced patient safety across their health system. 


Why did Baylor Scott & White partner with Ariadne Labs to implement their

Serious Illness Conversation and Care Planning Program?

The easy answer is that they had a complete, scalable, evidence-based product ready to go to help improve communication between patients and providers.


The deeper story, however, is the collective cumulative experience that led to the development of palliative care in first place. One of the earliest studies to suggest such a need was the SUPPORT study, published in JAMA in 1995. This study involved 9,000 seriously ill patients with a six-month mortality rate of 50% admitted to five major teaching hospitals. These weren’t hospice appropriate patients—at least not on admission—these were people with a 50% chance of survival and, in fact, half did survive. However, for the 50% of patients who died, the study revealed glaring care deficiencies leading to significant confusion about goals of care (with much unwanted treatment provided) and significant suffering. The SUPPORT study thus revealed a special sort of patient safety concern and care deficit.


At the root of this care deficit was poor communication. Many of us focusing on end-of-life care via ethics or hospice consultation came to understand that hospice could not serve patients in common circumstances like those found in the SUPPORT study until very late in the patient’s journey, and ethics consultation could largely work on only the moral dimensions of care. Some other sort of service not necessarily tied to definite terminal illness or ethical uncertainty/discord was required.


The notion of palliative care as distinct from hospice was just starting to evolve at that time and the SUPPORT study lent great credence to the need. In fact, I attempted to start a small palliative care program at Baylor University Medical Center in 1995, but the program was terminated before we could serve our first patients. It would be several more years before we could get our palliative care service line established. Palliative care as a specialty is now growing rapidly, but we’ve all realized that we can’t train palliative care doctors, nurses, and other professionals fast enough to serve every seriously ill patient who might benefit. We must help non-palliative care professionals develop better primary palliative care skills, such as better communication skills.


So, how can we do that? The reality is that busy physicians aren’t going to take a multi-day training to do it and non-palliative care specialty training will never include the intense communication training that is so much of the focus of a palliative medicine fellowship. However, non-palliative care professionals can and will participate in shorter training with role-play exercises over a few hours accompanied by ongoing coaching. BSWH chose the program from Ariadne Labs because they had the evidence-based solution we were looking for.


What does the Serious Illness Conversation and Care Planning Program consist of?

There are three basic components:

  • Tools that provide a scripted checklist approach to guide the clinician who isn’t comfortable with having these types of serious conversations;
  • Education for health care professionals using the tools; and
  • Systems change to help identify appropriate patients and to build the tools into the EMR so that any practitioner can look at the chart and be both guided in the conversation and see what has been previously discussed by others following the same conversational script.

It has been demonstrated that patients and doctors like the tools, it helps make conversations more complete, and the data are retrievable. This is a pretty big systems change and Ariadne has never taken it to a system as big as ours—this will be the first.


How are you rolling the program out across your system?

Systems change and EMR implementation is critical. It would frankly be easier in a system that has one EMR, but at Baylor Scott & White we have two different major EMRs. Another challenge is our sheer size and geographic spread. We are also one of the larger nonprofit systems in the country, the largest in Texas, and we have thousands of physicians, advance practice nurses, and others to be trained.


At the same time that we have been building the necessary tools into our EMRs, we are also training our palliative care experts to train others in the use of the SICP tools and process. I’ve observed that just because a palliative care professional is an expert communicator with patients of families, that doesn’t guarantee they will be an expert trainer, so the notion of “train the trainer” is very important. Each trained facilitator can then train three learners in three hours. Of course, the trainer needs to be available going forward to provide ongoing coaching when needed. It is a bit daunting given our size, but we see it as a perpetual task that we are slowly and deliberately weaving into the fabric of our organization. It is a project in perpetuity and we want this program to be self-sustaining.


What has been the reaction among team members to the new program?

We don’t teach much about end of life in medical school, especially not the differences in communication between those with less serious illnesses versus more serious illnesses, and this training is benefiting both palliative care professionals and those who may not be as comfortable having these conversations. The palliative care professionals, even though already skilled in serious illness conversation, are very excited. Some have said that it has actually shortened their goals-of-care conversations because the script helps to focus the conversations. We are also starting to hear from some early adopter non-palliative care professionals we have trained saying that they don’t need the palliative care team as often to have these conversations. I think some palliative care professionals might see that as a threat, but at BSWH we don’t!


Out in the community of doctors, there are those who haven’t been trained but are excited to be trained ASAP. There are others who feel they don’t have time to learn this right now, but we are working on how to encourage everyone to take the time for trainings.

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How do you think this program will impact patient safety across your system?  

It has already. When it comes to the structural impact, you see it by being able to open up the EMR and having a link at the top of the patient banner directly to the SICP script and answers. All you have to do is click to see what answers the patients gave. This is the beginning of real cultural change.


It is so vitally important because a lot of programs from the mid to late 1990s on have emphasized preventing  bad death, meaning a patient who received unwanted treatment, was separated from their family at death, experienced emotional and spiritual distress, had poorly treated pain, and experienced many other treatment deficits as well. That is a patient safety problem. If death comes, we should ideally provide what I refer to as “safe passage.” For example, if someone says ‘When I die, I want to go to heaven without your machines’ then we ought to be able to know that and offer them a safe passage to heaven or whatever their wishes may be. We use the idea of safe passage frequently with patients and families facing mortality because it is an idea that people get.


We recently had a palliative care physician say to us, "I found all this information that I normally don’t have when I’m consulted. It was in the SICP section of the EMR.  When I was called in as a consultant, the information present allowed me to sit down with the patient and family and say 'Based on the information you gave to your oncologist, I can suggest we do the following…'" The information not only gets to the right person at the right time, but it also gets dispersed to the whole team. We see this program continuing to influence patient safety as time goes on and the amount of trainers and trainees grows.


Read other Stand Up Stand Out stories.


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How does your organization encourage conversations with patients who are experiencing serious illness? Comment on this post below.

Note: to post a comment you must be logged in. Register or log in.


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Tags:  Stand Up for Patient Safety 

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Member Spotlight: Sam Watson

Posted By Joanna Carmona, Wednesday, June 21, 2017
Updated: Wednesday, June 21, 2017

The American Society of Professionals in Patient Safety (ASPPS) is a membership program for professionals

and others interested in patient safety. This is part of a series of member profiles.

by Joanna Carmona


Sam Watson is a member of ASPPS

Sam R. Watson, MSA, CPPS

Senior Vice President, Patient Safety and Quality, Michigan Health & Hospital Association


What are some of the main challenges for Michigan hospitals and health systems?

With regard to challenges related to hospitals and health systems and implementing both patient safety and quality activities, there’s so much to do. The opportunities to improve quality and safety are never ending. There is a tremendous amount of reporting burden that draws time and energy that, quite frankly, diverts attention from the work of improvement.


Patients are sicker than they have ever been in hospitals, and that draws the main focus of everyone. If you think about where improvement should happen, it shouldn’t be in the quality department or the safety department; it should be at the bedside. If you are caring for very sick patients, it’s one more thing to try to work into your day.


Could you tell us about your experience on the National Patient Safety Foundation Board of Advisors and what you look forward to as you make the transition to the IHI Board?

"If you think about
where improvement should happen,

it should be at the bedside."
—Sam Watson

Having the opportunity to participate in the NPSF Board of Advisors was a tremendous experience. To be surrounded by people who are so patient safety oriented and talented was a very humbling experience for me. I learned so much by listening to conversations around the table. The insights that people brought and the perspectives they had, you don’t get unless you are in that sort of environment. Looking ahead to the opportunity to serve on the IHI Board, again, it’s a very humbling thought considering the history of that organization and what it has brought to the world of improvement. To take that and magnify the work of safety in the NPSF mission is a tremendous opportunity.


What made you interested in joining the patient safety field?

My path to the world of patient safety was not direct. I’m actually a laboratorian, and my background is in clinical lab science, which is one of the few areas of health care that has been highly reliable, especially the blood blank. Quality is in everything we do. Transitioning into the quality and safety realm within the hospital setting, I found that the opportunity to influence care is profound in that you can bring everyone together to work on the problems of quality and safety.


As with many of us, there’s also personal experience—having a loved one who was affected by diagnostic error and to see what that meant to our family—that creates an amount of passion that you can only get, I think, by experience.


What is something that most people don’t know about you? 

Outside of the joy in doing the work I do, I race mountain bikes. I enjoy the adrenaline rush of hurtling through the woods on a single track and have been racing for over 25 years. As of late I have focused more on epic races, which are 50 miles or more.


The merger of IHI and NPSF took place as NPSF marked its 20th anniversary. What are your thoughts on that anniversary and how the patient safety field has changed?

Celebrating 20 years of the work NPSF has been doing is 20 years young. This is a nascent field. If you think back to 1999 with the IOM report, and of course Dr. Leape’s work before that, NPSF has created a vibe around patient safety, without which we wouldn’t have been propelled as far as we have. With everyone at the table, including providers, patients, and the medical device manufacturer community, I think that 20 years has resulted in so much change that otherwise wouldn’t have been accomplished.


You were a co-chair of the Board subcommittee that developed Call to Action: Patient Safety Is a Public Health Crisis and Patient Safety Requires a Public Health Response. Could you tell us about that experience? 

We had a subgroup of the Board of Advisors that came together and generated the Call to Action that, ultimately, the NPSF Board of Advisors and Board of Directors supported. The concept of this Call to Action is to raise awareness around the deficits that we still have in supporting patient safety work. To look at it as a public health issue is really unique from the standpoint of understanding that it’s not a doctor problem or a hospital problem; it is as critical as safe drinking water. Unless we magnify this issue to that level, it won’t get the attention or the resources it deserves.


To learn more about the American Society of Professionals in Patient Safety, visit


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Joanna Carmona is communications coordinator at the National Patient Safety Foundation at Institute for Healthcare Improvement. Contact her at



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Implementing Root Cause Analysis and Actions: Lessons Learned from the Journey

Posted By Administration, Tuesday, May 16, 2017
Updated: Monday, May 15, 2017

In a breakout session at the upcoming NPSF Patient Safety Congress, members of the Ochsner Health System team detail their effort to implement RCA2.

by Joanna Carmona

As Jessica Behrhorst, system director of quality and patient safety at Ochsner Health System admits, Root Cause Analysis and Actions (RCA2) seemed like an intimidating process before they started implementation in their 13-hospital health care system with more than 1,000 employed physicians and a non-employed medical staff of over 2,000. However, after taking the time to learn about RCA2 and teach it to their team, the health care staff at Ochsner is a lot more open to talking about the process, which has now been added to their regular toolkit. But the question is: how did they get there?


At this year’s NPSF Patient Safety Congress, Ms. Behrhorst and Richard D. Guthrie, Jr., MD, CPE, chief quality officer at Ochsner Health System, will describe their journey through the implementation of the new Root Cause Analysis and Actions model and what they’ve learned in the process.


“When we started in 2015, we were very aware that we couldn’t do RCA2 in a vacuum—it had to be part of a larger cultural change,” said Ms. Behrhorst. “We could put the pieces into place, but if we didn’t have a culture of reporting or trust from our staff that we were going to do something with those reports, we knew we wouldn’t be successful.”


One of the first successes they saw was a significant increase in the number of RCAs being performed including some RCAs on good catches that they may not have done in the past. For example, the team at Ochsner had seen several events where surgical equipment was coming back with bioburden. The equipment never touched or harmed a patient and was sent to get reprocessed, but staff started reporting it, so they used the sterilization process for the RCA2. The team had found enough risk by using the risk-based prioritization matrix that they thought a change in the process was necessary, allowing them to effect change in an area where a patient could have been harmed. 

Jessica Behrhorst

Richard Guthrie,

chief quality officer,

Ochsner Health System

Jessica Behrhorst

system director

of quality and

patient safety,

Ochsner Health System

Many of the tools Ochsner uses for RCA2 have come directly from the 2015 NPSF report, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Ochsner Health System created three distinct presentations based on the report in order to get the health care team up to speed and on board with the complex processes: one was created for leaders in the RCA2 team, another is specifically for team member briefings, and one holds the electronic version of the tools from the RCA2 report. 

Not only has implementing RCA2 proven to be successful within their own system but it has also become a way to share events and experiences with other facilities. Every month, Ochsner hosts a system quality meeting that includes chief nursing officers from across the system, their vice president of medical affairs, and performance improvement and pharmacy leaders. In that meeting, participants started sharing RCA events and the findings from those RCAs. As a result, teams started learning a lot from the sharing, particularly in instances when they found out that other facilities had faced similar events and could share tools to help mitigate the problem. The lasting effect was helping systems recognize that they are not operating in silos.While some areas of health care may fall into the ultra-safe category, where the goal is to avoid risk altogether, other areas may be categorized by the need to manage or mitigate risk.

In the spirit of not operating in silos, Session 301 will share lessons learned from the two years they have implemented RCA2, so that others may learn from their challenges and successes. 

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Do you have any lessons learned to share from implementing RCA2 in your institution? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Joanna Carmona is communications coordinator at the National Patient Safety Foundation at Institute for Healthcare Improvement. Contact her at

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Tags:  2017 Patient Safety Congress  RCA 

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Creating Structure for Sharing Information and Knowledge in Ambulatory Care: Two Exemplars

Posted By Administration, Thursday, May 11, 2017
Updated: Thursday, May 11, 2017

Breakout sessions at the upcoming NPSF Patient Safety Congress discuss how critical information sharing is to safety improvement work.

by Lorri Zipperer, MA


Communication between individuals to leverage what is known in all types of care environments can be difficult. Whether at the organizational or team level, defined goals, processes and expectations help to shore up what information is shared, how it is delivered, and what is done with it.


Two sessions at the 2017 NPSF Patient Safety Congress in Orlando will provide insights into effective information sharing in ambulatory care. They target two important initiatives that benefited from defined methods of information sharing—organizational learning from adverse events or near misses and patient transitions from the hospital to primary care teams. The speakers will discuss their experiences to highlight value associated with taking the time to build processes to apply information and knowledge in support safe care.


Improvement through sharing lessons learned

PeaceHealth recognized that the work done to improve processes wasn’t reliably assimilated to help their organization learn. “We have learned that robust event investigation requires a system-level structure to triage outpatient safety events,” said Andrea Halliday, MD, patient safety officer, PeaceHealth.“Otherwise, problems are solved on a clinic level and we miss an important opportunity to learn from our events and to spread the lessons learned.”


To help their outpatient clinics design and implement improvement strategies drawn from system-reported adverse events and near misses, PeaceHealth:  

  • Established a leadership team to track and discuss events
  • Launched and supported communication opportunities over time
  • Encouraged accountability through documented improvement action plans
  • Monitored the initiative to track its impact

This structured approach didn’t leave learning to chance. It didn’t assume that sharing was happening. Instead the organization committed to a process that raised awareness of the importance of learning from what goes wrong.

"We have learned that robust event investigation

requires a system-level structure

to triage outpatient safety events.".

—Andrea Halliday, MD


Session 305 will discuss the methods used to enable improvements across the ambulatory care continuum of a large health care system.


Safe patient transition from hospital to the community

Transitions are ripe for communication gaps, missteps, and misunderstandings. Transitions from one environment to another offer extra challenges as the team who knows the patient best can be disconnected from their care due to the changed location. Adding to the complexity, the patients may not always be effectively engaged in the process to confirm that they have the information they need to ensure their safety once outside the hospital (See Horwitz et al. 2013)


Handoff tactics such as standardized information bundles and checklists have been noted to make information sharing more reliable in the hospital and after discharge. Breakout session 505 builds on those successes to highlight an improvement strategy at Iora Health for use as patients enter the primary care management space: transition navigators.


“Our experience has shown that involvement of primary care teams when patients are hospitalized is invaluable,” said Sumair Akhtar, MD, MS, associate medical director, culinary extra clinic, Iora Health. "We understand that in a busy practice, it is nearly impossible for most PCPs to directly engage with inpatient teams on every occasion, therefore, to improve the primary care team's influence and involvement in inpatient care, we have proposed a multidisciplinary model that leverages team nurses and clinically savvy non-clinicians (with solid process and simple tools) to be the liaisons between the patients, caregivers, and inpatient and primary care teams.”


The speakers will discuss how transition navigators help to ensure that communication is clear and concerns are addressed when patients transfer out of the acute care environment. They will share tools and measures that have supported the development of this innovative member of the care team. 


Both these sessions will discuss ways to ensure that information and knowledge sharing wasn’t left to chance. They support the value of resourcing and tending to processes of transferring information to ensure that organizations and care teams are prepared to safely serve patients and families.


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Patient Safety Beyond the Walls of the Hospital is one of six Breakout Tracks featured at the NPSF Congress May 17-19. View more details.

What methods do you employ at your organization to support effective information? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Among her publications, Ms. Zipperer recently served as editor for two texts, Knowledge Management in Healthcare and Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer, both published in 2014, and as a co-editor for the 2016 publication Inside Looking Up, published by The Risk Authority Stanford.

Tags:  2017 Patient Safety Congress  communication  transitions 

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