Wednesday, May 28, 2025
Thursday, May 29, 2025
8 a.m. – 12 p.m., PST
10 a.m. – 2 p.m., CST
11 a.m. – 3 p.m., EST
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Join us for this virtual summit that will teach you to break barriers and solve what keeps us up at night – keeping our patients safe. It will provide information to help health care professionals communicate better (internally and with patients) and improve patient care delivery. Presenters will address implementing the CMS Patient Safety Structural Measures using the Patient Safety Act protections, and programs that reduce costs, accelerate efficiency, and enhance reliability.
This Summit will include national safe-table discussions, topic-focused breakout sessions, and amazing keynote and general session presenters – all centered around health care innovation and patient safety evaluation systems.
Who should attend?
Health Care Executives, Quality and Patient Safety, Nurses, Risk Management, Clinical Operations
Please note – all times below are PT
8:00 – 8:15 a.m. | Welcome and Opening Remarks
Robert Imhoff, President, Hospital Quality Institute
8:15 – 9:45 a.m. | Keynote Session | Best Practices for Implementing PSSM using PSQIA Protections
Brett Powell, MPH, MBA, BSN, CPHQ, Assistant Vice President, Patient Safety, HCA Healthcare; Peggy Binzer, JD, Executive Director, Alliance for Quality Improvement and Patient Safety
This presentation will provide an overview of the process a large health system experienced when assisting its hospitals in becoming aware of, preparing for, and implementing the patient safety program elements outlines in the Centers for Medicaid & Medicare Services (CMS) Patient Safety Structural Measure (PSSM).
Learning Objectives:
- Key stakeholders involved in discussing and decision-making in relation to the various CMS PSSM elements
- Assessing baseline compliance with each element of the CMS PSSM
- Integrating a focused Leapfrog safety assessment with the CMS PSSM work
- Establishing taskforces charged with leading implementation efforts for challenging elements of the CMS PSSM
- Developing education, guidance, resources, and tools to aid in compliance with all elements of the CMS PSSM
9:45 – 10:45 a.m. | Concurrent Breakout Sessions (Choose one)
- Creating Transparency Between Quality and Risk Departments
Adam Novak, MA CPPS, Director, Safety Initiatives, Michigan Health & Hospital Association, Tamara Awald, DHA, MS, MBA RN, CPHRM, CPHQ, Vice President of Quality, Patient Safety, and Risk Management, Franciscan Alliance, and Nicole Pugh, Administrative Director of Risk Management and Patient Safety, Franciscan Alliance
This session will delve into the journey of a health system toward transparency through sharing risk and safety information across the organization. The presentation will highlight the relationship between the health system and its Patient Safety Organization (PSO), and detail how PSOs help improve efficiency by offering relevant education, additional data analysis and timely feedback. - Safe Medication Practices: Understanding and Managing System-Based Risks
Christina Michalek, BSc Pharm, RPh, FASHP, Director, Membership and PSO, Institute for Safe Medication Practices
The Institute for Safe Medication Procedures’ (ISMP) mission is to advance patient safety. Join ISMP and learn how to use their conceptual model, the Key Elements of the Medication Use System™ to identify system-based causes of medication errors.
Learning Objectives:- Define latent failures, active failures and the role each plays when a medication error occurs
- Recognize the elements included in ISMP’s Key Elements of the Medication Use System™
- Use ISMP’s Key Elements of the Medication Use System™ to identify system issues that contribute to medication errors
10:45 – 11:00 a.m. | Break
11:00 a.m. – 12 noon | Concurrent Breakout Sessions (Choose one)
- Learning From Emerging Legal Trends
Beth Ann Jackson, Esq., Principal, Post & Schell P.C.
Attendees will take a deep dive into select case law and its lessons in protecting the Patient Safety Work Product privilege. The impact of current federal initiatives will be addressed as well.
Learning Objectives:- How PSES policies can protect or undermine the PSWP privilege
- How to create documentation to support the PSWP privilege in discovery disputes
- How current federal initiatives may affect Patient Safety Evaluation Systems and PSOs
- Safe-Table | Diagnostic Safety Event Review and Analysis
Gerard (Gerry) Castro, Project Director, ATW Health Solutions
Health care organizations experience diagnostic safety events in care delivery, but do not typically analyze them for learning and system improvement. The traditional root cause analysis, as most hospitals have come to use it, is not sufficient for analyzing these types of events. In this presentation we will discuss the organizational infrastructure, processes, and adaptations necessary to review and analyze diagnostic safety events. We will also apply Safety II perspectives to improve diagnostic safety.
Learning Objectives:- Identify diagnostic safety events
- Analyze them appropriately for learning using adapting a formal systematic, comprehensive approach for identifying hazards and system interactions
- Use the Safety 2 perspective to identify how to improve diagnostic safety
Please note – all times below are PT
8:00 – 8:15 a.m. | Welcome
Robert Imhoff, President, Hospital Quality Institute
8:15 – 9:15 a.m. | General Session | Improving PSO Data Quality: CHPSO’s Member Engagement Initiative
Scott Masten, PhD, MA, Vice President of Measurement Science and Data Analytics and Kamali Jones, MSN, RN, PHN, AG-ACCNS, Safety and Reliability Clinical Advisor, Hospital Quality Institute
9:15 – 10:15 a.m. | Concurrent Breakout Sessions (Choose one)
- Safe Table | Reviewing Safety, Quality, and Accuracy: PSESs for Recording Pilot and Ethnographic Observations
Brittney Anderson-Montoya, Lead Human Factors Specialist, Valerie McCarthy, Senior Patient Safety Specialist, and Desirea Phillips, LVN, CPHQ, Teledoc Health, Inc.
This presentation will guide participants through the critical aspects of recording under a Patient Safety Organization (PSO), focusing on Patient Safety Evaluation System (PSES) development, legal and ethical considerations, and lessons learned. Additionally, the session will cover the establishment of a process for conducting ethnographic observations via telehealth, ensuring comprehensive and effective patient safety practices.
Learning Objectives:- Identifying legal and ethical considerations in recording under the PSO
- Understanding key components and criteria for the development of a Patient Safety Evaluation System (PSES) and scoring tool
- Establish a process to conduct ethnographic observations via telehealth
- Translation of a PSO Performance Improvement Project into a CMS Quality Measure
Brent Lee, MD, MPH, FASA, Director of Clinical Excellence and Performance Improvement and Emily Sareen, RN, MSN, Director of Quality Improvement at North American Partners in Anesthesia
Attendees will learn how an anesthesia-focused PSO analyzed PSO data using an AI-assisted software to identify an area of clinical improvement, aspiration prevention in high-risk patients. They will see how the team then created an evidence-based performance improvement activity that was tested within the PSO’s parent company and proposed to CMS for inclusion in the 2025 MIPS program through the ABG Qualified Clinical Data Registry.
Learning Objectives:- How PSO data can be analyzed with AI-assisted software
- How to create an evidence-based performance improvement activity
- How a quality measure can be submitted to CMS for inclusion in the MIPS program
10:15 – 10:30 a.m. | Break
10:30 – 12 noon | Safe Table | Looking at Telemetry with a Human Factors Lens
Lee Erikson, MD, LSSMBB, Chief Executive Officer, and Sharon Hickman, MBA, CPHQ, CPPS, CPXP, LSSMBB, President & Chief Operating Officer, Adaptient, LLC
Over the past several months, a working group of PSOs from across the country has used the Human Factors Analysis and Classification System (HFACS) to analyze real-world telemetry failures, identifying common causes of failure and systemic vulnerabilities by reviewing telemetry RCAs securely shared under the protections of the Patient Safety Act.
This is the first safe table of a three-part series that will share those findings, guide participants through the HFACS approach, and offer practical insights into how organizations can dive deeper into their own system failures. Understanding these patterns is the first step toward meaningful, sustainable improvement, setting the stage for the next two additional Safe Tables focused on designing solutions and embedding long-term change. This session is ideal for anyone that is looking to gain a deeper understanding of system failures and prepare for the next phase: building reliable, resilient telemetry systems that work in the real world.
Learning Objectives:
- Uncover Common Causes of Telemetry Failure
- Provide a Framework for Learning from System Failures by demonstrating how human factors analysis can provide deeper insights into breakdowns in telemetry
- Lay the Foundation for Systemic Change
- Participants will learn the foundation to implement using the HFACS to identify learning opportunities
12 noon | Closing Comments
Robert Imhoff, President, Hospital Quality Institute
Brittany Anderson-Montoya
Lead Human Factors Specialist
Teledoc Health
Ms. Anderson-Montoya has over 15 years of health care human factors and patient safety simulation experience and was awarded the Human Factors and Ergonomics Society A. R. Lauer Safety Award in 2024. Before joining Teladoc Health, she led the development of the Human Factors Program for Atrium Health, where she worked to develop a human factors approach for Root Cause Analysis, a human factors product framework for the system, and a framework for executing applied human factors work to support patient safety. She has actively conducted and published research integrating human factors, simulation, and healthcare for the advancement of patient safety.
Tamara Awald, DHA, MS, MBA RN, CPHRM, CPHQ
Vice President of Quality, Patient Safety, and Risk Management
Franciscan Alliance
Dr. Awald, a 35-year veteran in the Quality and Risk Management arena, has also served in dual leadership roles as a Chief Nurse Officer and Chief Operating Officer for many years of her robust health care leadership career. Her doctoral research focused on the relationship of frontline staffs’ perceptions of patient safety culture, and the relationship with patient experience and patient care outcomes. Awald’s passion is delivering well designed safe patient care with optimal outcomes to patients.
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. AQIPS fosters their members’ ability to improve the quality of healthcare delivery through the use of the Patient Safety Act protections. Ms. Binzer 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. Since that time she has been assisting PSOs and providers to improve the quality of patient care and implement the Patient Safety Act’s protections.
Lee Erickson, MD, LSSMBB
Chief Executive Officer
Adaptient, LLC
Lee has more than 25 years of experience in health care transformation. Before founding Adaptient, Lee held executive leadership roles at the University of Pennsylvania Health System, Memorial Sloan Kettering Cancer Center, and Tufts Medicine, working to improve safety, quality, and operations by redesigning the delivery of patient-centered care. As a primary care physician and Lean/Six-Sigma Master Black Belt, Lee maintained a clinical faculty role wherever she worked; she is an engaging and savvy teacher.
Sharon Hickman, MBA, CPHQ, CPPS, CPXP, LSSMBB
President & Chief Operating Officer
Adaptient, LLC
Sharon is a dynamic leader in health care transformation, known for driving large-scale improvements that balance safety and efficiency. She serves on the National Advisory Council for AHRQ, teaches Human Factors in Healthcare at Auburn University, and sits on the board of the Alliance for Quality Improvement and Patient Safety. She is an Industrial & Systems Engineer and holds a Lean/Six Sigma Master Black Belt. She has certifications in safety, quality, and coaching. Sharon’s ability to simplify complexity, drive lasting change, and foster collaboration makes her a respected leader in healthcare transformation.
Robert Imhoff
President
Hospital Quality Institute (HQI)
Robert Imhoff, President of the Hospital Quality Institute, has held positions of responsibility within the health care, non-profit and higher education fields. These positions include: President and CEO of the Maryland Patient Safety Center, Vice President of Development and External Relations for Mt. Washington Pediatric Hospital and Director of Corporate and Foundation Relations for Coppin State University. Mr. Imhoff currently serves on the executive committee of the California Maternal Quality Care Collaborative, the Board of Cal Hospital Compare and Alliance for Quality Improvement and Patient Safety (AQIPS).
Beth Anne Jackson, Esq.
Principal Health Care Practice Group
Post & Schell
Beth Anne Jackson is a principal in the firm’s Health Care Practice Group and has focused her career on advising providers on the transactional, compliance, and operational aspects of health care law. She counsels health care providers on the development and implementation of contracts, transactions, policies, and procedures to comply with and preserve available privilege protections under federal and state health care regulations. This encompasses the PSQIA, peer review/HCQIA, HIPAA, the Stark Law, the Anti-Kickback Statute, EMTALA, and the corporate practice of medicine. Her clients include hospitals and their medical staffs, ambulatory surgery centers, physician groups, other outpatient providers, and patient safety organizations.
Brent Lee, MD, MPH, FASA
Director of Clinical Excellence and Performance Improvement
North American Partners in Anesthesia (NAPA)
Brent Lee is an anesthesiologist and the Director of Clinical Excellence and Performance Improvement at North American Partners in Anesthesia (NAPA). Dr. Lee previously served in the U.S. Public Health Service as an Epidemic Intelligence Service Officer at the Centers for Disease Control and Prevention (CDC). Dr. Lee is a Fellow of the American Society of Anesthesiologists (ASA) and serves on the ASA’s Committee on Trauma and Emergency Preparedness.
Scott Masten, PhD
Vice President, Measurement Science & Performance Analytics
Hospital Quality Institute (HQI)
In his work for HQI, Dr. Masten focuses on improving health care data quality and reducing patient injury, including the development of both data intake and data analytics platforms. He does this by bringing over 20 years of applied research and data experience including teaching research methods and statistics courses at both the graduate and undergraduate levels.
Valerie McCarthy
Senior Patient Safety Specialist
Teledoc Health
Ms. McCarthy is currently working to establish a patient safety infrastructure for telemedicine. She has over 6 years of direct patient care experience, with a diverse background in Neuroscience, Neurosurgery, Critical Care, and Endoscopy. In 2013, she redirected her focus towards patient safety and now has over a decade of patient safety experience. Before joining Teladoc Health, she worked as a Patient Safety Coordinator at Atrium Health, eventually emerging as a leader, where she served as the Director of Patient Safety.
Christina Michalek, BS, RPh, FASHP
Director of Membership and Patient Safety Organization
Institute for Safe Medication Practices (ISMP)
At the ISMP, Ms. Michalek works with health system leaders and clinical staff to define, design, and improve medication safety initiatives. She collaborates with health care practitioners and shares best practices through educational programming from international to local-level professional conferences. She manages the update and analysis of ISMP’s Targeted Medication Safey Best Practices for Hospitals and is the ISMP lead for medication-related technology issues.
Adam Novak, MA, CPPS
Director, Safety & Quality
Michigan Health & Hospital Association
Mr. Novak manages all aspects of the MHA Keystone Center Patient Safety Organization and oversees the development and deployment of patient safety culture-improvement efforts across all departmental projects under the umbrella of high reliability. He led the design and launch of the MHA Keystone Center Speak-Up! Award, a proven tool to promote culture and reduce costs and harm in health care. He also spearheads the MHA workforce safety collaborative and oversees the implementation of maternal health and opioid safety efforts. Adam currently serves as an editorial review board member for the peer reviewed journal Patient Safety.
Desirae Phillips
Executive Director of The Institute of Patient Safety and Quality of Virtual Care
Teladoc Health, Inc.
Spearheading the listing and maintenance of the first Patient Safety Organization (PSO) in virtual medicine, Ms. Phillips has directed the PSO for 6 years. She has a BS in Clinical Services Management, 21 years of nursing experience, and is a Certified Professional in Healthcare Quality (CPHQ). Desirae has a passion for improving care delivery and innovating in the virtual care space. In her current role, her focus is on further growth of Teladoc Health’s component PSO, including maintaining high standards of care, improving care delivery by leveraging data-driven approaches, and implementing targeted strategies to help ensure the highest quality of health care is given to patients in her organization. Using novel strategies and collaborative efforts, she has assisted in cementing Teladoc Health as a leader in patient safety and clinical quality in virtual medicine. Enthusiastic about fostering a culture of safety, Desirae is dedicated to ensuring the highest quality of safe care for all patients.
Brett Powell, MPH, MBA, BSN, CPHQ
Assistant Vice President, Patient Safety
HCA Healthcare
After leaving the bedside of patient care, Mr. Powell spent time working in several capacities within Healthcare Quality Management leading the Quality and Regulatory Compliance program at an acute care hospital. He has participated in and led multiple accreditation and certification surveys as well as numerous RCAs, FMEAs, and other safety investigations, assessments, and improvement initiatives. As a patient safety leader of a large health care system, he has a passion for challenging the status quo in efforts to improve patient care. He knows everyone has a voice to share and has a passion for helping people find their voice.
Emily Sareen, RN, MSN
Director of Quality Improvement
North American Partners in Anesthesia (NAPA)
Emily Sareen, RN, MSN is the Director of Quality Improvement at North American Partners in Anesthesia (NAPA). As a leader in the NAPA Quality team, she supports the clinical quality data collection process, adverse event review process, clinician education, and CMS measure selection/submission. She has been a nurse for 15 years with a focus on anesthesia, adult surgery, pediatric surgery, and pediatric intensive care.
Member Early Bird: $99*
Nonmember Early Bird: $1000*
*Early bird pricing expires on April 27, 2025.
Member: $125
Nonmember: $1100
For this summit, those who qualify for the $99 registration fee are current members of: HQI, CHPSO, AQIPS or a member of an AQIPS PSO member.
For this summit, nonmembers who qualify for the $1000 rate are PSO’s who are not current members
Safe Table Confidentiality Agreement
The PSES Summit includes two National Safe Tables. To participate in the Safe Tables, you are required to agree to a confidentiality agreement that can be found here. You will be asked to agree prior to joining the Safe Table session.
Cancellation Policy
Cancellations must be made in writing seven or more days prior to the scheduled event and emailed to education@calhospital.org.
Substitutions are encouraged. Cancellation and substitution notification may be emailed to education@calhospital.org. In the unlikely event that the program is cancelled, refunds will be issued to paid registrants within 30 days.
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.