IHI Redesigning Event Review with Root Cause Analyses and Actions (RCA2)

Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM, Quality, Safety and HRO Consultant, Aptive Resources, works in the areas of patient safety, workforce safety, and high reliability. She is faculty for the IHI Patient Safety Executive Development Program and on Redesigning Event Review with Root Cause Analysis and Action (RCA2). Prior to Joining Aptive Resources she served as the Senior Director at the Institute for Healthcare Improvement (IHI). She has also served as the Assistant Vice President of Quality & Patient Safety at Ochsner Health System where she helped set the strategic priorities in quality and patient safety and oversaw various projects involving patient safety, performance improvement, regulatory readiness, ambulatory nursing, and quality outcomes. She has presented her work on RCA2 and Improving the Culture of Safety at various regional and national meetings. She has also worked on research projects involving reduction in Sepsis mortality and access to healthcare for underserved populations. Jessica received her bachelor’s degree from Tulane University and her Master of Public Health Degree from the Louisiana State University School of Public Health. She is a Certified Professional in Patient Safety (CPPS), a Certified Professional in Healthcare Quality (CPHQ) and a Certified Professional in Healthcare Risk Management (CPHRM).

Rollin J. "Terry" Fairbanks, MD, MS, CPPS, is Vice President for Quality and Safety at MedStar Health, Professor of Emergency Medicine at Georgetown University, and Founding Director of the National Center for Human Factors in Healthcare. A board-certified emergency physician, he practices in the MedStar Washington Hospital Center emergency department. Dr. Fairbanks also holds an academic appointment as adjunct associate professor of industrial systems engineering at the University at Buffalo. He earned a bachelor's degree in mathematics and physics and a master's degree in industrial systems engineering/human factors engineering. After medical school he completed specialty training in emergency medicine, the HRET/NPSF Patient Safety Leadership Fellowship, and Wharton's Physician Leadership Certificate Program at MedStar Health. Trained in safety science prior to entering the medical field, Dr. Fairbanks is also a former paramedic, EMS medical director, and general aviation pilot. He is known for inspiring people to think differently about health care's approach to quality, safety, and risk. As a member of the MedStar Health leadership team, he is responsible for system-wide quality and safety. Dr. Fairbanks has contributed more than 120 publications to the health care quality and safety, human factors engineering, and medical literature and co-edited a book on cognitive systems engineering in health care. 
 

Tejal K. Gandhi, MD, MPH, CPPS​, is the Chief Safety and Transformation Officer at Press Ganey. In this role, Dr. Gandhi is responsible for advancing the Zero Harm movement, improving patient and workforce safety, and developing innovative health care transformation strategies. ​Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programs focusing on improving patient and workforce safety. Prior to this, Dr. Gandhi was President and Chief Executive Officer of the National Patient Safety Foundation (NPSF) from 2013 until 2017, when NPSF merged with IHI. ​She has also served as President of the Lucian Leape Institute, a think tank founded by NPSF that now operates within the IHI Safety portfolio and was a board member of the Certification Board for Professionals in Patient Safety which administers the Certified Professional in Patient Safety credential.
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Lauge Sokol-Hessner, MD, CPPS is a practicing clinician, educator, researcher, innovator, and leader in patient safety & quality improvement.  He has operational quality & safety experience as a former Senior Medical Director of Patient Safety at Beth Israel Deaconess Medical Center in Boston.  He's passionate about helping develop the next generation of leaders in quality and safety and is a former quality & safety fellowship program director and masters program course director at Harvard Medical School.  Currently he is: a Clinical Associate Professor of Medicine and an attending hospitalist at the University of Washington (UW) & Harborview Medical Centers; a Quality Improvement Mentor at the UW Medicine Center for Scholarship in Patient Care Quality and Safety; and the Associate Director for the Collaborative for Accountability and Improvement and a Faculty Coach for the PACT Collaborative, both roles where he helps lead national work to sustain and spread more proactive, ethical, person-centered responses after harm events.

Jeff Salvon-Harman, MD, CPE, CPPS, Vice President, Safety, Institute for Healthcare Improvement (IHI), is a Certified Physician Executive, Certified Professional in Patient Safety and IHI Fellow who is resolute about creating Safety and Belonging for patients and the healthcare workforce.  He provides strategic leadership in Safety with deep operational expertise implementing change initiatives and applying quality improvement methods. He is a recognized subject matter expert in high reliability, patient and workforce safety, Human Factors application to Root Cause Analysis, and system level management of quality and safety.  Previously, Dr. Salvon-Harman was the Chief Patient Safety Officer/VP, Quality Institute and Medical Director of Infection Prevention and Control for Presbyterian Healthcare Services in New Mexico.  He is retired from the US Public Health Service where he dedicated 20 years to the Indian Health Service and the US Coast Guard in roles ranging from clinical service delivery to management and leadership. Dr. Salvon-Harman completed his residency in Family Medicine at Carilion Health System in Roanoke, VA after graduating from Tufts University School of Medicine in Boston, MA.