PATIENT SAFETY SUMMER 2005
LEADERSHIP TRANSITIONS IN PATIENT SAFETY PROGRAM
s I make plans for civilian life aftertwenty-eight years in the Navy,Ireflect on the past three years of accomplishments in the Patient Safety Pro-gram.It has been an extraordinary journey ofgrowth thanks to a group ofpassionate,talented professionals that make up thePatient Safety Planning and CoordinationCommittee.When I arrived on the scene three yearsago as the first Director ofthe DoD PatientSafety Program,my initial thought was“What have I gotten myselfinto?”The Safety Program was still in its infancy following the2001 NDAA mandate directing the MHS tohave a Patient Safety Program.Programs andinitiatives were scattered throughout differ-ent agencies like newspaper clippings.Through the vision ofDr.David Torn-berg,ChiefMedical Officer ofthe TRICAREManagement Activity,the pieces ofthe PSPwere collected and housed under one roofatTMA.Enter the talented,passionate leadersofPatient Safety.Heidi King took ownershipofa fledgling medical team training programand over time,collaborating with the Agency for Healthcare Research and Quality,createdthe gold-standard for medical team trainingfor not only the MHS,but the nation.DrGeoffRake became the Director ofthePatient Safety Center,designated as thePatient Safety Registry,and transformed asketchy system ofunreliable data captureinto a robust center ofdata driven processes,resources and patient safety tools for Mili-tary Treatment Facilities (MTFs).We stillhave a long way to go in perfecting meaning-ful data capture and interpretation.Hopeful-ly,the automated Patient Safety Reportingtool to be released throughout the MHS inFY 06 will go a long way toward taking usthere.The third component ofthe DoDPatient Safety program,the Center for Edu-cation and Research in Patient Safety (CERPS) has also grown by leaps andbounds thanks to the direction and leader-ship ofCAPT Glenn Merchant,Dr.EricMarks,and Dr.Howard Steed.From its rudi-mentary beginning,Patient Safety traininghas grown to include several curriculafocused on advancing the skills ofthe MTFPatient Safety Managers,and educating ourMTF leaders on the vigilance required to runa safe,efficient facility.Incorporated into thisprogram has been the world-wide training of MEDMARX,an automated medicationerror reporting system,and TapRoot®,a rootcause analysis tool designed to detect systemfailures rather than identify individual errorand assess blame.This explosion ofgrowth in the PatientSafety Program would have lay fallow were itnot for the vital link to the field provided by the Service Patient Safety Representatives:Ms Carmen Birk (Navy),LTC Steve Grimes(Army),LtCol Kathryn Robinson,MeganSnide,and LtCol (Ret) Beth Kosin (AirForce).These individuals have truly been thechampions in seeding,cultivating and reap-ing the rewards ofgetting the message out towhat we in the Navy refer to as “the deck-plates”– the invaluable providers at thesharp end ofcare.I look forward now to watching thePatient Safety Program continue to growunder the very capable direction ofLTCSteve Grimes.I also look forward to life as aretired beneficiary and the knowledge that Iwill receive safe,quality healthcare when Iwalk into a Medical Treatment Facility.
Welcome…..To LTCSteve Grimes
Incoming Director Shares Visionand Goals
LTC Steve Grimes,the incoming Directorofthe DoD Patient Safety Program,whilenew to this position,is not a newcomer tothe field ofmilitary patient safety.After var-ious assignments with the Army NurseCorps during the course ofhis eighteen yearcareer,LTC Grimes completed a one year fel-lowship at the Joint Commission for theAccreditation ofHealthcare Organizations(JCAHO) in 2003,and has served since asthe Director ofthe Army Medical Depart-ment (AMEDD) Patient Safety Program,where he has been responsible for develop-ing,coordinating and implementingAMEDD patient safety initiatives.He con-currently has represented the Army on theDoD Patient Safety Planning CoordinationCommittee (PSPCC),the leadership body which directs patient safety activities acrossthe military healthcare system.As he assumes his new responsibilities,LTC Grimes shares a clear vision ofProgramand personal goals.On a Program level,he ismost proud ofthe efforts ofthe PSPCC overthe last three years to align patient safety efforts among the three services.He intendsto continue working on alignment with and
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CAPT McKay addresses the Patient Safety Leadership Forum training session in June.
Farewell.....FromCAPT Deborah McKay
Patient Safety DivisionDirector Retiring