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VA Sunshine Healthcare Network

 

PSCI Home

Patient Safety Center Mission/Objectives

Tampa VA Hospital

The mission of our Center is to support clinicians in providing safe patient care by designing and testing safety defenses related to the patient, provider, technology, and organization. Specifically, our PSCI goals are to:

1. prevent injurious falls (specifically focusing on the most serious injuries: hip fractures and intracranial hemorrhages) and minimize adverse events associated with hazardous wandering;
2. promote the safe use of technology associated with injurious falls and hazardous wandering; and
3. promote a culture of safety to support clinicians in providing safe patient mobility.

The VISN 8 Patient Safety Center of Inquiry (PSCI) is part of the James A. Haley Veterans' Hospital in Tampa, Florida. Our PSCI has a track record of evaluating and translating patient safety research findings into standard practices that are disseminated and implemented to improve patient safety across the entire VHA system.

We evaluate the science and determine when research is ready to be "translated." Translation involves designing and testing clinical tools (e.g. algorithms, protocols, policy templates, resource guides, patient and staff education materials) to facilitate patient safety and reduce adverse events.

We pilot test these tools at the Tampa VA and then at VISN 8 facilities. Successful program elements are then exported to the NCPS (National Center for Patient Safety) for national implementation. The following PSCI objectives have been identified:

• Evaluate the strength of the evidence to identify knowledge gaps to target for future inquiry and findings ready for translation to practice;
• Define existing practice patterns and outcomes across the VA and determine current variation from established best practices;
• Identify and implement interventions to change practices to strengthen patient, provider, and systems level safety defenses, through the design of tools and products specifically designed to promote patient safety, such as clinical tools; cognitive aids; educational materials; policy reports, VHA information letters, handouts, and/or directives; and others;
• Improve technology safety defenses through biomechanics, human factors engineering, and other principles of design;
• Evaluate and document the process and outcomes of best practices at the patient, facility, VISN, and VHA level; and
• Collaborate with NCPS to develop a VHA business case and implementation plan to export evidence into practice.

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NEWS


December 12, 2018...

VA selects 10 Patient Safety Centers of Inquiry for special funding

WASHINGTON — The U.S. Department of Veterans Affairs (VA) is funding 10 VA Patient Safety Centers of Inquiry (PSCI) over the next three years (2019-2021) to develop innovations to improve patient safety throughout VA.

“The PSCI program is the pre-eminent patient safety innovation network in the Veterans Health Administration (VHA),” said VA Secretary Robert Wilkie. “Since 1999, the interventions implemented through the PSCI program have significantly contributed to our Veterans receiving the safest care anywhere.”

PSCI initiatives that have led to key improvements in patient safety include the creation of toolkits for the prevention of patient falls, moderate sedation techniques for use by non-anesthesiologists, protocols for reducing hospital-acquired infections, suicide prevention strategies and a cancer care tracking system.

The 10 centers were selected by an interdisciplinary review committee from the VA National Center for Patient Safety that consists of patient safety experts, including physicians, nurses, psychologists and pharmacists. There were 36 applicants. The 10 centers selected, including a description of their PSCI initiatives, are listed below:

1. The VA Ann Arbor, Michigan, PSCI will focus on appropriate use of catheters and Peripherally Inserted Central Catheter lines.

2. The Center for Medication Safety in Aging located at the James J. Peters VA Medical Center will serve as a communications hub for efforts to reduce adverse medication effects in older adults and those with dementia.

3. The Ralph H. Johnson VA Medical Center’s  PSCI in Charleston, South Carolina, works to improve outcomes for Veterans moving back and forth from VA and non-VA care, specifically focusing on medication safety.

4. The Michael E. DeBakey Houston VA’s Diagnosis Improvement Safety Center (DISCovery) works to prevent diagnostic errors by improving timely follow-up of abnormal test results.

5. The goal of the Iowa City VA’s Center for Antimicrobial Stewardship and Prevention of Antimicrobial Resistance program is to create automated risk-adjusted metrics that are adaptable to the diverse care settings across VA’s health system.

6. The VA Greater Los Angeles Healthcare System’s PSCI will focus on transitions for elderly Veterans and those with complex conditions. They will test the impact of these transitions on 30-day readmissions and patient satisfaction.

7. The VA Puget Sound Health Care System’s Supporting Primary Care Providers in Opioid Risk Reduction and Treatment program identifies patients at high risk for adverse opioid events and monitors their opioid use. It provides guidance on tapering opioid prescriptions and provides supportive connections among patients with opioid use disorders.

8. The PSCI at the James A. Haley Veterans Hospital in Tampa, Florida, works to prevent adverse events related to mobility/immobility focusing on prevention of injurious falls, safe patient handling/mobility and pressure ulcer prevention.

9. The Doris Miller VA Medical Center PSCI in Waco, Texas, is developing practical solutions to reduce suicide among Veterans not receiving VA care.

10. The White River Junction, Vermont VA PSCI’s goal is to test evidence-based programs to decrease suicide risk following psychiatric discharges of Veterans.

VA’s National Center for Patient Safety — headquartered in Ann Arbor, Michigan — was established in 1999 to develop and nurture a culture of safety throughout VHA. The primary goal of NCPS is the nationwide reduction and prevention of inadvertent harm to patients. For more information, visit http://www.patientsafety.va.gov/.



Below is information on current and future fellowship opportunities as well as links to VA resources for training and Fellowship programs

Interdisciplinary Fellowship in Patient Safety 

The purpose of this 1-year fellowship program is to develop leaders with vision, knowledge, and commitment to lead patient safety efforts in the 21st century. The fellowship is located at the Patient Safety Center of Inquiry at the James A. Haley Veterans Hospital, Tampa, FL, in collaboration with the VA National Center for Patient Safety and in partnership with the University of South Florida.

Eligibility
• US citizenship and completion of all requirements needed to be a fully credentialed independent practitioner in their field at a VA facility.
• Demonstrate interest in pursuing a VA career with health services research and healthcare improvement as significant foci.
• Physician Fellows must have graduated from an Accreditation Council for Graduate Medical Education (ACGME) accredited residency; be board certified or board eligible; and have an active, unrestricted U.S. medical license.
• Clinical fields that recognize independent practitioners possessing degree levels below that of Master's Degree (e.g., Registered Nurse or Registered Dietician) must have completed a Master's Degree (or all requirements for the degree) to be eligible.
• Nurses, social workers, and health care administrators must possess at least a master's degree.
• Applicants in academic fields that do not involve clinical certification or licensure but that can be applicable to health systems (e.g. anthropology, sociology, computer science/medical informatics, engineering, etc.) must have received a PhD in their field.

Funding Stipend rates: Determined by VA Office of Academic Affiliations, depending on the discipline and previous education of the trainee. Fellows are eligible to participate in the Federal Employees Health Benefits Program and the Federal Employees Group Life Insurance Program.

Application and Start Dates: The deadline for application is January 15 for fellowships beginning July 1.

Application Process:  Submission of an application that includes (1) a letter, of no more than three pages, stating short and long term professional goals, clinical or other pertinent background, a statement of personal goals for the fellowship, (2) a full curriculum vitae, and (3) three letters of recommendation. Applicants are strongly encouraged to talk to Dr. Cowan before applying.
Selection and Selection Criteria:  A selection committee will review and rank applications based on the following criteria: quality of credentials and experience, commitment to remain in the VA system, match between personal goals and planned program activities, and strength of recommendations.

For information about these and other fellowships in the VA:
• VA’s web page at https://www.va.gov/oaa
• The Center web page at https://www.cindrr.research.va.gov/
• Contact Dr. Linda Cowan at (813) 558-3932 or linda.cowan@va.gov

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Postdoctoral Fellowship in Health Services Research and Development in Rehabilitation 

The HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR) will provide content expertise, mentoring, and educational infrastructure in Gainesville, FL (affiliated with the University of Florida) and Tampa, FL (affiliated with the University of South Florida), in collaboration with the VA HSR&D Service, for PhDs interested in pursuing careers in VA health services research. The purpose of this 2-year fellowship is to develop a cadre of scientists with health services expertise for the VA healthcare system and to foster the development of high quality health services research and development at local and national levels.

Eligibility

• US citizenship and completion of all requirements needed to be a fully credentialed independent practitioner in their field at a VA facility.
• Demonstrate interest in pursuing a VA career with health services research and healthcare improvement as significant foci.
• Physician Fellows must have graduated from an Accreditation Council for Graduate Medical Education (ACGME) accredited residency; be board certified or board eligible; and have an active, unrestricted U.S. medical license.
• Nurse Fellows must have graduated (or completed all requirements for award of degree) from a doctoral program at a recognized academic institution, either Ph.D. or D.N.P. or in a non-clinical field relevant to Health Care Quality.
• Clinical and Counseling Psychology Fellows must possess a doctoral degree (or demonstrate that all requirements for such a degree have been completed and award of the diploma is pending) from an American Psychological Association (APA) accredited program and have completed an APA accredited internship.
• Associated Health Fellows, e.g., Occupational and Physical Therapists, must possess a doctoral degree from an accredited program that would make them eligible for VA hire Other Associated Health Fellows must have completed all requirements to become a fully credentialed independent practitioner at a VA facility and have an active, unrestricted license to practice in the U.S., if such licenses are required for VA employment in the candidate’s profession.

Funding Stipend Rates: Determined by VA Office of Academic Affiliations, depending on the discipline and previous education of the trainee. Fellows are eligible to participate in the Federal Employees Health Benefits Program and the Federal Employees Group Life Insurance Program.

Application and Start Dates: The deadline for application is January 15 for fellowships beginning July 1.

Application Process:  Submission of an application that includes (1) a letter, of no more than three pages, stating short and long term professional goals, clinical or other pertinent background, a statement of personal goals for the fellowship, (2) a full curriculum vitae, and (3) three letters of recommendation. Applicants are strongly encouraged to talk to Dr. Winkler before applying.
Selection and Selection Criteria:  A selection committee will review and rank applications based on the following criteria: quality of credentials and experience, commitment to remain in the VA system, match between personal goals and planned program activities, and strength of recommendations.

For information about these and other fellowships in the VA:
• VA’s web page at https://www.va.gov/oaa/specialfellows/programs/SF_HSRD.asp?p=5
• The Center web page at https://www.cindrr.research.va.gov/
• Contact Dr. Sandra Winkler at Sandra.Winkler@va.gov or (813) 558-3949

Download information on these Fellowships

VHA Office of Academic Affiliations

VHA Office of Academic Affiliations training programs are available for clinical trainees, VA staff and education affiliates. Included is information about residencies and fellowships including the pre and postdoctoral nursing fellowships, the pre and postdoctoral fellowships in rehabilitation and VA Advanced Fellowship Program in Interprofessional Polytrauma and Traumatic Brain Injury Rehabilitation. For information about training opportunities contact Dr. Linda Cowan at Linda.Cowan@va.gov.

VHA Office of Research and Development Training Site

This site contains information about VHA training programs in research postdoctoral fellowships and the career development program.

Contact Information

VISN 8 Patient Safety Center of Inquiry (151R)
James A. Haley VA Medical Center, Grand Oak Plaza, 8900 Grand Oaks Circle, Tampa, FL 33637-1022

-Linda Cowan, (813) 558-3932, Linda.Cowan@va.gov


2019 Safe Patient Handling and Mobility Conference

The presentations below are from our 2019 Safe Patient Handling and Mobility Conference, in 2020 it wil be held at the Omni Championsgate in Orlando, FL, June 1-5, 2020. More information to come, but please contact Valerie.Kelleher@va.gov with your questions.

The following presentations will be available online until April 12, 2019. After that, you can contact Valerie.Kelleher@va.gov.

Keynote: The STRIDE Program
Outcomes of Patient Engaged Video Surveillance on Falls, Other Adverse Events, and Workforce Safety
Safe Resident Handling in Long Term Care: One for All and All for One
Thinking Outside the Safe Patient Mobility Box: Protecting Our Patients by Mobilizing Them Earlier and Often
Updated 2019 AHA HRET Falls and Injury Change Package
Training Development Method for SPHM Facility Coordinators
Is the Sliding Sheet Good Enough? Guidelines for Practice Based on Biomechanical Evaluation of Repositioning Technology
Practical Applications of SPHM in Ambulatory Settings
Integration of SPH, Falls Prevention and Early Mobility Principles to Maximize Your Rehabilitation Goals
Automated Patient Repositioning Improves Quality, Safety and Satistaction for both patients and caregivers in two states
Promoting Highest Level of SAFE Mobility in All Care Environments Using SPHM; Hands on Session
How High Reliability Organizations (HRO) Benefit from an Interdisciplinary Team Perspective for Safe Patient Handing and Mobility
The GateWay to Safe Patient Handling in Higher Education: Creating Safe Patient Handling Champions for the Future
SPHM Implications--How One Health System's Ambulatory Clinics AAccommodate Patient with Mobility Disabilities
The Hygiene/Access Sling Assessment Tool (HASAT): Consensus Approach to Promote Safe Prescription
Patient Repositioning Challenges Resolved by Patient Safe Staff Innovation
Passport to Competency: Brave Steps to Increasing Safety and Skills in Safe Patient Handling
Patient Repositioning from Hospital to Laboratory: The Stody of the Nurse and the Patient
Defeating that "Drive-Thru" Mentality When it Comes to Injury Prevention and Patient Safety
Bridging Concepts and Practice Across Academic Programs: SPHM & Early Mobility Across Nursing Programs
Clean up Your Laundry Process Using a High-Reliability Framework
Do We Really Need Two Caregivers to Safely Move People?
Addressing the Challenges of SPHM and Home Health Care Workers
The Power of the Tu Tu: Together We Can Change Healthcare
Preventing Falls and Fall-Related Injuries
Why Mobilizing Patients is Important: Latest Research on Complications of Immobility
Partnering with the Patient to Prevent Falls in the Medical Surgical Area
Patient Advocacy: What Does it Mean to You?
BMAT Bingo: Patient Scenarios Linking Assessment and SPHM Practice--Interactive and Fun!
Mobility is Medicine



Leadership and Staff

Tatjana Bulat, MD, CMD is the Director of the Tampa Patient Safety Center of Inquiry (PSCI), a translational research center; Medical Director of the Falls Clinic there, and a Co-Director of the Interprofessional Fellowship Program in Patient Safety. Her research interests are in the area of falls and fall-related injury prevention in frail elderly, as well as medication management to reduce falls risk in the same population. Click here to download Dr. Bulat's CV.

Staff

Blake Barrett, MSPH
Nina Ferguson, MD
Yvonne Friedman, MA, OTR/L | Administrative Officer
Karl Hayworth
Valere Kelleher | Visual Information Specialist
Jason Lind, PhD, MPH
Steve Luther, PhD
Alfred Mbah, PhD | Evaluation and Analysis
Sam Phillips, PhD
Anita Ramrattan, MSPT
Deborah Rugs, PhD 
Susan Schultz, MD | Team Leader
Keith White, MD 

Research Trainees

Kandyce Bailou-Cox | Patient Safety Fellow

Christopher Fowler, PhD | HSR&D Postdoc
Vanessa Panaite | HSR&D Postdoc

Other Sites of Interest

National Center for Patient Safety

The following websites are not affiliated with the Department of Veterans Affairs. VA does not endorse and is not responsible for the content. 

Agency for Healthcare Research and Quality
Healthcare Accreditation Supersite
Joint Commission on Accreditation of Healthcare Organizations
National Patient Safety Foundation
U.S. Food and Drug Administration
U.S. Occupational Safety and Health Administration