Patient Safety Improvement Corps: an AHRQ/VA Partnership

The Patient Safety Improvement Corps seeks to improve patient safety by providing knowledge and skills to teams of hospital and other staff, including patient safety officers and those responsible for patient safety reporting and analysis, as well as, intervention initiatives.

Background

The Patient Safety Improvement Corps (PSIC) is a partnership program between the Agency for Healthcare Research and Quality (AHRQ) and the Department of Veterans Affairs (VA). The primary goal is to improve patient safety by providing the knowledge and skills necessary to:

• Conduct effective investigations of reports of medical errors (e.g., close calls, errors with and without patient injury) by identifying their root causes with an emphasis on underlying system causes.
• Prepare meaningful reports on the findings.
• Develop and implement sustainable system interventions based on report findings.
• Measure and evaluate the impact of the safety intervention (i.e., that will mitigate, reduce, or eliminate the opportunity for error and patient injury).
• Ensure the sustainability of effective safety interventions by transforming them into standard clinical practice.

From 2003 through 2006, the PSIC program was focused primarily on States and their selected hospital partners. Because of the past success of the PSIC program, it is being extended an additional year and the participant focus is being expanded beyond State teams.

Content of the PSIC Program

The program content includes a number of topics, tools, and methods designed to help participants reduce medical error and improve patient safety. Topics include patient safety science, human factors, root cause analysis, health care failure mode and effects analysis, probabilistic risk assessment, medical error reporting and analysis, and measurement, evaluation. Topics focused on institutional issues include communication, leading and sustaining organizational change, safety culture assessment, high reliability organizations' characteristics and operations, TeamSTEPPS™ team training, mistake-proofing in the delivery of health care, just culture, persuasion through storytelling, the Patient Safety and Quality Improvement Act of 2005, patient safety organizations, patient safety indicators, and the National Healthcare Quality and National Healthcare Disparities Reports.

Class of 2007-08

The PSIC class of 2007-08 includes the following organizations:

Eligibility

Participants eligible for this expanded PSIC program are teams of patient safety officers in large hospitals or health care systems, critical access or rural hospitals or health care systems, long term care facilities or systems, ambulatory centers and large clinics, and those responsible for patient safety reporting and analysis as well as intervention initiatives in other relevant organizations such as quality improvement organizations and Federal government agencies such as Centers for Medicare and Medicaid Services, Health Resources and Services Administration, Indian Health Service, and others. It is anticipated that teams will be composed of clinical and/or administrative leaders. Note that team participation is a requirement, and an application from a single individual will not be accepted.

Dates and Place

The annual PSIC program consists of three 1-week sessions—1 week each in September, January, and May. In addition to the week-long sessions, there will be course-related team "homework" during the year (e.g., completion of a patient safety project of the team's choice).

Starting dates and general locations for the training sessions are: September 17, 2007 (Washington, DC metropolitan area); January 28, 2008 (outside the Washington, DC metropolitan area); and May 12, 2008 (Washington, DC metropolitan area).

Costs

The PSIC program is tuition-free. Teams selected to participate will be reimbursed for air fare, lodging, per diem, and local travel costs consistent with federal regulations (i.e., GSA, VA) following the completion of each 1-week session and within approximately 1 month of submission of a completed travel voucher.