The Health Care Improvement Foundation’s (HCIF) Partner Profiles highlight the efforts of valued and innovative health leaders. Our partners’ work supports HCIF’s vision of healthier communities through equitable, accessible, and quality health care.
We are pleased to feature Shannon Davila of ECRI to share more about her reflections on patient safety and quality improvement. Shannon currently serves as the Director of Total Systems Approach to Safety at ECRI and has a clinical background in adult critical care nursing and specializes in infection prevention and healthcare quality improvement. She is certified in infection control, healthcare quality, is a TeamSTEPPS Master Trainer and a High Reliability coach. Shannon is a current member of HCIF’s Clinical Advisory Committee as well as serving as our partner and facilitator for HCIF’s Safe Table program.
How did you first get involved or interested in Patient Safety?
Shortly after completing my enlistment in the United States Air Force, I went to nursing school. As a new graduate nurse, I worked in the ICU and immediately became aware of the safety risks that our patients face. As I have grown professionally, I have been drawn to focusing on how I can help reduce the risk of harm to patients.
ECRI and the Institute for Safe Medication Practices Patient Safety Organization (PSO) and HCIF have been partnering for the Partnership for Patient Care (PPC) Safe Table program for the past seven years. This program offers a framework for Patient Safety Officers to discuss and exchange best practices and solutions for current patient safety issues. Throughout that time, we’ve discussed over fifty different safety topics of concern. Reflecting on the program’s history, what do you see as some of the biggest accomplishments the Safe Table program has achieved?
First, I would say the longevity of the program is impressive! Additionally, the resilience of the participants to stay engaged over those years and through a pandemic demonstrates the power of those relationships. This program creates a safe space for safety leaders to talk, share and learn, and the value of that is evidenced by their continued commitment to the program.
“The Safe Table program serves as a valuable learning system for this region of Pennsylvania…This helps advance the application of safety principles and strategies across health systems, ultimately contributing to making our region safer.”
Shannon Davila
As an innovative model, how do you see the Safe Table program serving the general discipline of patient safety and overall contributing to making our region safer?
The Safe Table program serves as a valuable learning system for this region of Pennsylvania. Under the federal legal protections offered by the PSO, participants are able to share details of safety issues and learn from each other. This learning helps advance the application of safety principles and strategies across health systems, ultimately contributing to making our region safer.
One of the roles of HCIF’s Clinical Advisory Committee is to identify and address Southeastern Pennsylvania’s quality and patient safety priorities. We also know ECRI releases their annual Top 10 Patient Safety Concerns report. As a well-versed patient safety professional, what do you see as some of the biggest challenges ahead or shifts occurring in the field of Patient Safety? Are there any specific regional priorities that you are focusing on?
Issues related to staffing shortages have been something that ECRI has highlighted since the pandemic, and we still see many problems stemming from this issue. This includes problems with transitions of care, managing complex patient populations, and maintaining an adequate level of competent safety and quality improvement professionals. These professionals are critical for healthcare systems to both identify safety and quality issues and bring about transformative change.
As a longstanding partner of HCIF who has participated in several PPC programs over the years, what do you think makes HCIF unique and what have you found most valuable about working with HCIF?
I would say without a doubt, the HCIF team. I work closely with Pam and Liz and their dedication to their members and the program design is always evident.
Reflecting on your own career, what has been one of the proudest moments or greatest accomplishments of your career thus far?
In 2016 I was awarded the Heroes of Infection Prevention Award from Association for Professionals in Infection Control and Epidemiology (APIC), one of my mentors had nominated me and I was honored to have received it.
If you are interested in connecting with our partner, you can connect with Shannon via email at sdavila@ecri.org.
To get to know Shannon a bit more, she shared the following: A quote that she often returns to and inspires her in her work , “You can’t improve what you don’t measure.” Something most people don’t know about her is that she has a green thumb and loves to garden. To reflect back on her gardening hard work, she likes to document her plants as they grow by taking photos of them!
From May 16-18, the American Hospital Association (AHA) hosted their Accelerating Health Equity Conference in Minneapolis, Minnesota. Over 900 professionals gathered in Minneapolis to discuss innovative and strategic ways to accelerate health equity and improve community health.
I, along with my colleague, Liz Owens, had the privilege of traveling to the conference to present on HCIF’s Health Equity Data Strategy Collaborative. Our learning session titled, ”Starting with the Basics: Assembling and Activating REaL and SOGI data” was held during the second day of the conference and we were joined by Dr. Stormee Williams, Children’s Health in Texas, and Morgan Black, The Healthcare Association of New York State (HANYS) (pictured below). Each of our organizations were uniquely poised to share with the audience lessons learned about the collection and use of race, ethnicity, and language (REaL) and sexual orientation and gender identity (SOGI) data. Audience engagement was great, and reinforced that health systems are in very different places with this work – and that through collaboration we can learn so much from one another.
April Reilly, Dr. Stormee Williams, Morgan Black, and Liz Owens
Throughout the three days of the conference, the agenda was layered with noteworthy speakers and breakouts that encouraged attendees to think outside the hospital walls, create cross-sectional partnerships, and overcome challenges to address health inequities (just to name a few!). In total, we heard from 3 distinguished keynote speakers and attended around 10 breakout sessions learning from well over 20 different organizations on topics that ranged from addressing equity in ambulatory settings to creating community support for older adults to the intersection of health care and criminal justice. Day 1 kicked off with Pulitzer Prize winner and bestselling author Isabel Wilkerson who pulled back the curtain on the impact the American caste system has on our society, and on the inequitable medical care Black and Brown patients receive compared to White patients, while offering a path forward for creating a just and equitable future for all. “This is a national health crisis that should move anyone in a position of power to act,” Wilkerson said.
On Day 2, Dr. Ivor Horn, director of health equity and social determinants of health at Google, discussed the landscape of technology in health care – including its promising possibilities and potential perils. Horn also explained how health care and equity leaders can understand and challenge technology to support patients, employees and communities.
The conference concluded with remarks from Brian Smedley, equity scholar at the Urban Institute. He shared lessons learned and offered actionable steps as the U.S. and world move to further address structural racism. Smedley reminded the audience to reframe the conversation to center on “the sources of strength and resilience in the marginalized communities we serve.”
Overall, the themes of collaboration and lifting community voice resonated throughout each of the sessions we attended. We left the conference energized. We re-connected with colleagues. We made new connections. We had meaningful conversations. And we will hold ourselves accountable to take what we learned and turn it into action to inform our work.
Finally, a special thank you to Carol Vianna from AHA for her patience and help in getting our group prepared to present at the conference! We couldn’t have done it without you!
The Health Care Improvement Foundation’s (HCIF) Partner Profiles highlight the efforts of valued and innovative health leaders. Our partners’ work supports HCIF’s vision of healthier communities through equitable, accessible, and quality health care.
As HCIF celebrates Patient Safety Awareness Week (March 12 – March 18) this month, we’re excited to feature one of the longest-standing members of HCIF’s Clinical Advisory Committee, Dr. Charles Wagner of Redeemer Health. Learn more about how he applies patient safety principles to his everyday life, what changes in patient safety he’s witnessed throughout his career, and what he sees as the most important future priorities in patient safety. This conversation has been edited and condensed.
Charles I. Wagner, MD, FACP currently serves as the Medical Adviser for Patient Safety and Quality at Redeemer Health in Meadowbrook, PA. He has practiced gastroenterology in academic and community based settings and has served as the Chief Medical Officer and Patient Safety Officer at Redeemer Health. He is a member of the Clinical Advisory Committee of the Health Care Improvement Foundation and had served on the Board of Directors of the Pennsylvania Health Care Quality Alliance.
As a long-standing member of HCIF’s Clinical Advisory Committee since its inception, you’ve contributed to a number of the Partnership for Patient Care (PPC) programs. During your time as an advisor, in what ways do you think that PPC has helped advance quality and patient safety across the region? What is something you’ve learned through working with our organization?
It’s been a remarkable adventure to serve as an advisor and working in the patient safety space has opened my eyes a lot. There are patient safety principles that we use all the time in our everyday lives that you don’t really think about. Ultimately, though, it comes down to patient safety being a way to help people and prevent problems. The real advantage of HCIF and PPC is that we all want to do the same thing and doing it together has lots of advantages. For example, it combines the work allowing for organizations to share their experiences and move things faster. It also allows for institutions to provide care to their patients in their community through the full spectrum of their experience. Lastly, it allows for common definitions and approaches to be used by everyone.
Early on in my career as Chief Medical Officer, there were numerous requirements from regulatory bodies that wanted hospitals to look at many metrics. We developed a patient scorecard and thus began a big effort to standardize amongst ourselves and try to convince regulatory bodies to use the same indicators so there was common definitions and terminology. That’s also the kind of thing HCIF became useful in. For example, when we first started looking at falls, everyone had different definitions of what constituted a fall and how to respond to it. We adopted a common terminology that was used across the country and could then compare rates better. When you don’t have that common definition, it becomes problematic, and we saw that with COVID-19.
“There are patient safety principles that we use all the time in our everyday lives that you don’t really think about. Ultimately, though, it comes down to patient safety being a way to help people and prevent problems.”
Charles Wagner, MD
HCIF is celebrating Patient Safety Awareness Week from March 12-18, 2023 this year. Given your expertise, work, and advocacy in patient safety, what are some of the most significant changes or evolutions of patient safety that you’ve witnessed during your tenure?
I think that probably the most important factor is we’re now actively talking about and prioritizing Patient Safety. For a long time, we didn’t talk about it, and individually we had been aware of some problems, but we weren’t collectively collaborating or educating about them. The more people that are aware of patient safety, the more attention they can pay to helping prevent future problems.
Another important thing that has occurred is we’ve gotten patients involved in patient safety. By including and empowering them in their care, we’re asking for their help to identify problems. We’re aware that patients are a last step in preventing problems, such as double checking they are the right person to receive a certain surgery, or that they are receiving the correct medication. Patient involvement is crucial to the whole process of patient safety. One of the things [Redeemer] was recognized for years ago was about infection prevention regarding handwashing. We put a sign in every patient’s room that read “Did you ask your caregiver to wash their hands?” This allowed the patient to be an active participant in their care and put staff on notice that they were going to be asked if they washed their hands. Redeemer had such a successful initiative that our work got picked up by the local news and made its way to national news. This initiative helped educate the population about something as simple as handwashing and everyone’s involvement in doing that.
Lastly, it’s important to emphasize that everybody has a role that contributes to and makes up the bigger picture of patient safety. Having everybody involved—everyone from patients, nurses, clinicians, dieticians, cleaning staff—helps reinforce behavior and creates a culture of safety.
Looking ahead, what is something that excites you about where the field of patient safety is headed?
A crucial step along the way in the future of patient safety is understanding our own behavior. It’s important to understand how people think and act in order to anticipate what steps we may need to take in response to actions. The behavioral stuff of how we learn and how we respond, it’s everywhere in our lives. I spent time in the U.S. Public Health Service that provided health service to the U.S. Coast Guard, and from that experience I took away learnings of how the military practiced and completed drills in preparation for problems they may have encountered. I witnessed how everyone on the team had their assigned job and I was able to draw many parallels to the very same concepts of education, practice, and accountability that we carry out in health care.
Along those same lines, another big insight I had occurred when I started at a new institution during my graduate training and found that they were not doing things the same way I did or was taught. I realized that I was inculcated with the behavior and institutional approach of the people that previously taught me and worked with. When I went to another institution that had a different orientation or culture—it wasn’t a matter of who was right or wrong, but rather an opportunity to interface with and learn from each other. That same principle applies to the cross-fertilization that HCIF’s work promotes. As each institution learns about a safety issue or solution, sharing it or exchanging that information in collaboration with someone else has real value to it.
As you reflect on your career of being a health care provider and patient safety expert, how did you become interested in patient safety? What do you think is one of the most compelling or important components of patient safety that the general public might not yet know?
Paired with the landmark report “To Err is Human: Building a Safer Health System” from the Institute of Medicine in 1999, and witnessing things happen in the clinical setting, I realized how important patient safety was. From there and serving as Chief Medical Officer, I was involved in writing our organization’s first Patient Safety plan.
Two of the big tenents of patient safety is communication—we have to make sure we’re talking the same “language”—and education. Additionally, as I shared before, we have to keep in mind the human behaviors behind actions. Knowing how we react and what we do and why is really crucial. It’s important to understand what people are working with and why they’re reacting a certain way when you are educating and training them, especially as it applies to health care. Addressing the components of communication and education can ultimately have a profound impact on the outcomes of care and culture at an organization.
If you are interested in connecting with our partner, you can connect with Dr. Wagner via email at Cwagner@holyredeemer.com.
Something you may not know about Dr. Wagner…
His favorite book is Moby Dick, which he first read in high school and when the movie came out, he saw it fifty-six times while working as an usher in the movies! When reading Moby Dick, Dr. Wagner likes to reflect on what a case study of patient safety the story is. He draws parallels of the actors, actions, and lessons learned in the story to that in health care and appreciates looking at all those aspects of behavior, safety, and leadership in just one story.
Additionally, Dr. Wagner likes to garden as a hobby and form of exercise. With the help from his wife, he sees the everyday tasks of gardening following the same steps of a Plan, Do, Check, Act quality cycle. As he’s shared throughout this profile, he likes to seek and apply patient safety principles to his every day when he can!
Claude Wang, Summer Healthcare Quality Improvement Intern
September 27, 2022
This summer, I was able to join the Health Care Improvement Foundation for 8 weeks as an intern through the Whitehead Internship program. As someone who comes from a life sciences and engineering background, I want to work in a field where I can utilize the analytical and problem-solving skills I have developed, while also working directly with people to create an impact. Interning at the Health Care Improvement Foundation creates the perfect opportunity for me to hone these skills in a professional setting while creating tangible impact with the team.
During this internship, I was able to work on three projects within the Partnership for Patient Care program. There are multiple focuses within this program, and I was able to work on the Health Equity Data Strategy, the Delaware Valley Patient Safety and Quality Awards, as well as supporting the planning for the annual PPC Leadership Summit. Although I was staffed primarily on the PPC program, I also joined the ARC (Anti-Racism Collaborative), The Hospital and Healthsystem Association of Pennsylvania Racial Health Equity Learning Action Network (HAP RHELAN), as well as marketing meetings. As someone interested in project management work, I was impressed by the passion and the careful planning involved in the facilitation of these initiatives. These meetings with the HCIF team and the external stakeholders definitely demonstrates the nature of HCIF’s work: fostering collaborations and strengthening connections among stakeholders to improve health care quality and safety.
Apart from the fascinating work the team is doing, what also really stood out to me is the supportive and collegial culture of HCIF. Throughout my internship, I have received so much support and care from everyone, and they genuinely took an interest in my development and future career path. I can say with confidence that HCIF values everyone’s opinions on the team, and takes everyone’s suggestions into consideration. During the internal meetings, I was able to contribute to the anti-racism statement for HCIF, advice for COVID concerns for the in person HCIF events and also advocate for the inclusion of LGBTQ resources for our projects. I am extremely grateful to be in such an inclusive environment at an early stage of my professional life.
Overall, being at HCIF this summer has brought me closer to the inner workings of the health care field and exposed me to how different stakeholders collaborate to constantly improve care quality for the patients. I felt that I was contributing to a meaningful cause, and I was extremely fortunate to be around a group of people who are willing to mentor and inspire. I really enjoyed this internship experience and would like to thank CCPA, the Whitehead Internship Program, Liz Owens, and the rest of the HCIF team for making this possible.
Update: The Health Care Improvement Foundation (HCIF) has extended the deadline for this year’s Patient Safety and Quality Award to Thursday, January 21, 2021 in an effort to be mindful of regional organization’s continued pandemic responses. Please Click Here for further details and the criteria for submission.
HCIF has hosted the Delaware Valley Patient Safety and Quality Award for the past eighteen years. The Award program is one of the unique ways in which HCIF promotes and disseminates best practices in health care patient safety and quality throughout the region. At HCIF, we are committed to supporting a healthcare system that is just, equitable, and high quality. This year, we are expanding our call for submissions and invite improvement teams to submit their most innovative patient safety and quality improvement initiatives, including but not limited to exemplar COVID-19 response efforts, projects that include patient participation, and/or programs that address disparities in health outcomes. Note that we have delayed this year’s program to Fall 2020 in order to acknowledge organizational efforts in fighting the pandemic and provide an opportunity to showcase best practices and results.
At this time, we are inviting healthcare organizations—whether freestanding or within a multi-entity system—to submit up to 4 entries for projects undertaken at their site alone. A healthcare system may in addition submit up to 4 entries for system-wide projects that span multiple sites.
If you have any questions about this year’s award process, please feel free to contact Liz Owens, HCIF’s Project Manager, at 215.575.3738 or eowens@hcifonline.org.
