In This Section      

Program Sessions

Safe Design Principles and Improving Patient Safety Culture

Introduction and overview

Introductions of participants and Armstrong Institute members and their roles. An overview of the expectations surrounding the course.

The science of safety: Principles in practice

  • Identify system failures that can have an impact on patient safety
  • Describe safe design approaches that can be used to improve patient safety and quality
  • Describe how adaptive work makes technical work effective
  • Describe the steps of CUSP and how CUSP processes integrate the science of safety into the day to day of unit activities

Patient safety culture: What is it? How do we improve?

  • Identify the core aspects of a positive safety culture
  • Describe the characteristics of a just culture
  • Classify examples of behaviors that lead to error and appropriate managerial responses
  • Explain the practices of high-reliability organizations
  • Develop strategies to assess and improve patient safety culture

Patient-centered care: An integral part of a safety culture

  • List various dimensions of patient-centered care (PCC)
  • Explain why delivering PCC is a quality improvement aim
  • Model good communication skills for providers
  • Develop an action plan for improving patient-centered care at the unit level and at the organization level

Panel discussion: The role of the patient in a patient care team

  • Ways to make patients the focus of patient care teams
  • How to incorporate patient values into a treatment plan
  • How to engage patients and their families in care strategies
  • Barriers to patient-provider communication and how to overcome them

Developing and Nurturing High-Performance Teams

Developing a high-performance team

  • Describe the competencies of high-performing teams
  • Explain the CUSP team model
  • Develop strategies for working effectively in interdisciplinary teams within a health care organization

Communicating for patient safety and quality

  • Explain the key attributes of effective communication.
  • Define the critical team interactions that can be standardized in a clinical area, and demonstrate characteristics of a good process for each
  • Evaluate handoff communication practices and recommend improvements


  • Develop shared leadership strategies for patient safety and quality teams
  • Develop effective partnerships with senior executives
  • Plan engagement efforts to reach patient care teams

Empowerment, conflict management

  • Model task-appropriate assertiveness for empowerment and patient advocacy
  • Develop strategies for dealing with task and interpersonal conflict
  • Identify unit-level structures that support team member empowerment and conflict management

CUSP readiness and overcoming CUSP barriers

  • Assess the readiness of teams for a CUSP approach
  • Develop strategies for overcoming barriers to effective functioning of a CUSP team
  • Develop a strategy for engaging leadership in CUSP processes
  • Develop plans for mitigating negative conflict while fostering communication in a CUSP team

Learning from Defects to Improve Patient Safety

Creating a culture that supports error reporting and disclosure

  • Describe the attributes of a good error reporting system
  • Develop strategies to reduce barriers to error reporting
  • Develop effective disclosure skills
  • Develop support for second victims of adverse events

Risk management

  • Describe risk management strategies that support error disclosure

Learning from defects: Brief overview

  • Explain how the Learning from Defects (LFD) tool encourages second-order problem solving
  • Describe how the LFD tool can be used to drive patient safety and quality improvement efforts

Learning from Defects: Asking What Happened

Identifying hazards, errors and risks

  • Use varied sources of data to characterize defects
  • Compare and contrast retrospective and prospective methods for analyzing defects

Prioritizing risks

  • Evaluate data to distinguish special causes from common causes (normal variation)
  • Apply strategies to prioritize risks

Learning from Defects: Asking Why a Mistake Occurred

Investigating causes: Human factors

  • Apply human factors principles to identify human system interactions that can have an impact on patient safety
  • Conduct heuristic evaluation to identify usability problems and recommend changes
  • Evaluate a task with human factors principles as a guide
  • Evaluate a space with human factors principles as a guide

Investigating causes: Using Lean Sigma tools

  • Apply lean methods to identify why a defect has occurred
  • Create a process map for a patient care process
  • Characterize the flow of people, equipment and information in a health care process to identify value-adding steps
  • Characterize waste, imbalance and burden in a health care system to identify improvement needs

Designing and Developing a Patient Safety Improvement Plan

Design thinking

  • Define a design problem in patient safety
  • Use exploration strategies to identify possible solutions for this design problem
  • Develop a prototype or sketch to illustrate implementation of one solution

Reducing hazards, risks and errors: Lean Sigma approaches

  • Identify and prioritize patient safety interventions
  • Incorporate at least one-error proofing strategy into an intervention
  • Apply 5S methodology in a health care setting
  • Use a visual flow method to improve a workspace
  • Develop a standardized work flow for a health care process

Learning from Defects: How Will You Know Risk is Reduced?

Measuring Success

  • Identify the types of data you should gather to evaluate the success of a patient safety initiative
  • Identify the attributes of an ideal metric
  • Develop a data dashboard to measure the success of your initiative

Quality improvement measures: Meeting industry standards

  • Describe industry standards for quality improvement measures and how these connect to local efforts

Developing Improvements and Sustaining Change

Lean Sigma approaches to sustaining change

  • Lean Sigma approaches to sustaining change
  • Explain how controls are used to ensure results don’t degrade
  • Describe how an Operational Method Sheet can be used to standardize and support a process
  • Develop a control plan to sustain improvement goals
  • Develop an Operational Method Sheet to implement an improvement
  • Create a Visual Team Action/Idea board and recommend team metrics for sustaining an improvement

Managing projects to keep improvement plans on track

  • Define the scope of a patient safety improvement project and identify stakeholders affected by the project
  • Develop a communication plan for a patient safety improvement project that includes engaging key stakeholders
  • Apply the work breakdown structure technique to define project tasks and their interdependencies

Building momentum

  • Describe techniques for making connections with stakeholders when making a case for safety and quality improvement efforts
  • Describe some of the challenges to building momentum for quality and patient safety improvement activities.
  • Apply techniques for building and sustaining momentum

Leading change

  • Describe leadership competencies
  • Develop a framework for leading change that includes adaptive work
  • Design strategies for spreading change throughout a health care organization