What happens when patients and families are invited as full members of patient safety event review committees—including those protected under Section 51? At Provincial Health Service Authority in B.C. (PHSA), we’re piloting a new approach that aims to move beyond consultation toward genuine partnership in safety learning and improvement.

This session will introduce PHSA’s framework for supporting the safe and effective inclusion of patient and family partners (PFPs) in safety event reviews. Designed to meet programs where they are, the framework provides tools, guiding principles, and a phased implementation approach that honours organizational readiness, cultural safety, and legal context.

Learning Objectives:

1) Explore how meaningful patient and family partner (PFP) involvement in patient safety event reviews can transform learning, uncover root causes, and drive system-wide safety improvements.
2) Learn how PHSA’s new framework and phased implementation approach support safe, effective, and context-sensitive inclusion of PFPs across programs—regardless of current organizational readiness.
3) Understand how involving PFPs in Section 51*-protected reviews strengthens person-centred partnerships, supports accreditation readiness, and reflects diverse perspectives in safety culture.

* BC’s quality assurance legislation falls under the Ministry of Attorney General’s Evidence Act
[RSBC1996]. Section 51 of the Evidence Act (Section 51); was developed to
promote quality assurance or quality improvement by supporting an environment where health
care providers could speak truthfully about the care they or others provided, without fear that
the information produced during a review could be used as evidence in a legal proceeding.
The legislation articulates a qualifying committee structure and sets out that information
provided to and produced by a qualifying committee is prohibited from being used in legal
proceedings. The intent is to provide a safe space for frank and open discussion amongst health
care professionals. 

Community engagement is a powerful tool to advance health equity and empower patients. When done well, community engagement builds trust, advances health equity, creates cost-savings and efficiencies for healthcare organizations, and leads to healthy and thriving communities. Unfortunately, too often, well-intentioned community engagement initiatives are limited in diversity, fail to achieve meaningful outcomes, and fall short of authentic power-sharing. INSPIRE (Initiating National Strategies for Partnership, Inclusion, and Real Engagement) is a national partnership project that brings together the Camden Coalition, Community Catalyst, the Center to Advance Consumer Partnership, PFCCpartners, the Institute for Patient-and Family-Centered Care, alongside a team of experts with lived experience. Together we are working to co-design a national strategy to advance meaningful partnerships between healthcare organizations and community members.

Learning Objectives:

1) Understand major finding from INSPIRE’s research efforts engaging over 300 healthcare stakeholders and community members from across the country.
2) Learn practical strategies to more meaningfully engage the patient community.
3) Strengthen their ability to make the “business case” for sustained investment in community engagement.

Four healthcare organizations present innovative processes and practices that enhance equity that result in measurable changes in access to, and quality of, care for patients, reductions in patient harm and improved outcomes.

Learning Objectives:

1) Learn innovative practices that address healthcare inequities leading to improved patient safety and outcomes.
2) Understand how different healthcare organizations embed equity principles into best practices.
3) Learn how specific quality improvement activities, that are focused on equity, are implemented in different healthcare environments.

Provides an overview of the key activity in Clinical Medicine – how we make decisions. The talk is centered on how we make clinical decisions in medicine and how they contribute to diagnostic failure, the most serious threat to patient safety. The argument will be made that current Root Cause Analysis (RCA) typically provides limited insight into how clinical decision making fails – an alternative system is proposed that brings into focus the distal causes of failed clinical decision making.

Learning Objectives:

1) To emphasize that along with the acquisition of medical knowledge, it is especially important to consider how we think about that knowledge.
2) To emphasize that the complexity of the diagnostic process requires changes in the way that   clinicians think and make decisions.
3) To reinforce that the development of well-calibrated rationality in clinical reasoning and decision making is the most important of a clinician’s skills

With supportive culture change enablers, and through significant engagement and many plan-do-study-act-cycles, we developed a process to report and review incidents of Indigenous-specific racism and discrimination (ISRD) that have caused patient harm.  These events are reported directly from patients and families as their lived experience, or from staff witnessing how racism and discrimination is operating in healthcare and contributing to harm.  The focus of this work is to effect system-level change to make improvements in the provision of culturally safe and anti-racist care and use restorative approaches for resolution to rebuild trust with harmed patients, families and communities.  This project is aligned with obligations from the Canadian government and related foundational documents (such as the Declaration of the Rights of Indigenous Peoples Act and the Truth and Reconciliation Commission of Canada’s Calls to Action) and with our Integrated Quality and Safety Strategy goal of achieving a culturally safe and anti-racist environment.  The work included launching Indigenous self-identification in patient safety event reporting, creation of an avenue for staff to report racism and discrimination as a contributing factor to a safety event, formation of an ISRD incident response committee, the development of an ISRD reporting and review protocol with associated tools, templates and resources, and creation of reporting accountability (tracking incident information, resolution approaches and recommendation implementation).  Early findings show increased confidence of leaders in reviewing ISRD and that many events have led to resolution, learning and action.

Learning Objectives:

1) Describe the historical and ongoing impacts settler colonialization has on Indigenous-specific racism and discrimination in healthcare, and explain why addressing these harms is essential to ensuring culturally safe, equitable, and high-quality care.   
2) Identify the key enablers of the culture change required to address Indigenous racism and embed cultural safety as a core component of patient safety.   
3) Gain practical skills in how to report and review incidents of patient harm resulting from Indigenous-specific racism and discrimination and explain how a structured reporting and review process enables follow-through on recommendations, fosters accountability at individual and system levels, and supports achieving resolution to restore trust with Indigenous patients and families.

Attendees will learn about how patients were affected after profit-oriented operators took control in various health care settings, including hospitals, nursing homes, physician practices, and even autism therapy providers. We’ll go over specific case studies and research involving publicly-traded hospital chains and private equity firms and discuss how quality, safety, and access can suffer when an operator’s first priority is generating a financial return. This session will also spotlight an example of how Medicare’s financial penalties can influence hospital policies over time — even at nonprofit academic hospitals — in ways that jeopardize patient safety.

Learning Objectives:

1. Describe the different types of health care services operators and how their priorities differ.
2. Explain the ways patient care can change after profit-driven operators take over and how it happens.
3. Describe Medicare’s financial penalties for reporting healthcare-acquired infections and how these influence hospitals’ policies with respect to testing for infections.

Intellectual humility (a willingness to acknowledge that we might be wrong) is a characteristic and a practice that we see rarely in public life, but research is increasingly suggesting that it may be key to reducing belief in misinformation. It may also facilitate meaningful connections with people who see us as outgroup members, thus opening pathways to future conversations that could promote patient care and positive health outcomes. Especially in a moment when trust in science and medicine is declining, finding ways to engage with patients of various political and social persuasions is necessary to promote public health. This presentation will explore the role of social identity in shaping public misperceptions about health and science, and how intellectual humility might be integrated into patient care in a way that helps to bridge these divides.

Learning Objectives:

1) Understand the concept of intellectual humility, what it is and what it looks like.
2) Understand the link between social and political identity and misperceptions in the realms of science and medicine.
3) Acquire specific methods and techniques to integrate intellectual humility and a shared political identity into patient care.

RAND is a nonprofit research organization that is leading an AHRQ-funded initiative to enhance diagnostic safety in healthcare and is seeking health care organizations that are interested in implementing one or more resources designed to improve diagnosis-related communication and decision-making: Calibrate Dx: A clinician tool for refining diagnostic reasoning; Measure Dx: A guide for identifying and learning from diagnostic safety events; and Toolkit for Engaging Patients To Improve Diagnostic Safety: Simple interventions to improve exchange of diagnosis-related information in office-based settings. This is a great opportunity for clinics, hospitals, and health systems to be involved in improving diagnostic safety and reducing patient harms at their site.

Learning objectives:
1) Describe the prevalence and impact of diagnostic safety events.
2) Understand the importance and salience of using previously developed resources to improve diagnostic safety in different settings.
3) Identify at least one available resource that could directly improve diagnostic safety at their site.

Presentation information pending

Patients and families and partnerships with them are essential to patient safety in all settings where individuals and families receive care and support. Specific examples of patient and family partnerships will be discussed as well key strategies for successful collaboration. The new CMS Patient Safety Structural Measure for many hospitals in the United States will be briefly described.

Learning Objectives:

1) Describe the evolution of patient and family partnerships in quality improvement and safety through a succinct history of patient safety.
2) Discuss specific ways to partner with patient and family advisors to enhance safety and reduce harm.
3) Model partnership with a patient/family leader and describe strategies to support successful participation.

The public is at greater risk of harm from medical misinformation now more than ever. How can we regain people’s trust and build their skills to navigate the current information landscape?

Learning Objectives:

1) Identify where we are and how we got here.
2) Identify some effective communication strategies.
3) Understand the importance of collaborations for amplification (Every single one of us needs every single one of us.)

LGBTQ people and their families have never been safe in the healthcare system. In fact, doctors and nurses have perpetuated some of the worst injustices many LGBTQ people have ever faced. But over the last 25 years great progress has been made to address this history and the pain faced by this growing patient population. Together, we will learn about the past, celebrate the progress, assess the current challenges, and find a path forward to ensure everyone is safe to receive the care they deserve.

Learning Objectives:

1) Appreciate the history of medical injustice towards LGBTQ patients.
2) Understand the great changes healthcare systems have made to address LGBTQ patient’s unique needs
3) Reflect on ways we can continue to move forward with better care for everyone

We will share a brief overview of the new B.C. Provincial Health Service Authority’s (PHSA) Patient Engagement Framework which provides a consistent and adaptable approach to engagement across PHSA. This will be expanded by sharing of two examples, and insights from these examples, related to patient and family engagement within the central Quality and Safety Team that incorporate the approaches and best practices of the framework – 1) Patient and Family Partner Engagement within the PHSA Speak Up for Patient Safety Procedure and 2) Patient and Family Partner Inclusion within the new PHSA Integrated Quality & Safety Steering Committee

Learning Objectives:

1) Describe the components of the PHSA’s Patient Engagement Framework.
2) Explain how the approaches and best practices of the Speak Up for Patient Safety Procedure contribute to improved patient safety and quality.
3) Explain how the new Integrated Quality & Safety Steering Committee has improved patient and family partner inclusion and led to improved safety and quality.

It’s been anywhere from three to five decades since high-quality evidence demonstrated the pervasiveness of medical error. While discussion of preventable patient harm has become radically more open, there’s been no corresponding radical decrease in its ubiquity. This presentation takes a hard look at why we still kill patients and what needs to change so we don’t.

Learning Objectives:

1)  Learn the medical literature on patient safety that predates the 1999 “To Err is Human” report
2) Understand the real-life barriers that have impeded progress towards safe care
3) Learn strategies for breaking through barriers in order to achieve significant progress towards the goal of zero preventable harm.

Andrea Walker

Andrea Walker is the Chief Quality, Patient Safety & Experience Officer for Provincial Health Services Authority, serving healthcare delivery in British Columbia, Canada, on the unceded, ancestorial, and traditional lands of the First Nations Peoples. She leads quality, patient safety and patient experience teams across the health authority, which provides specialized clinical service delivery programs for the Province in Cancer Care, Emergency Health Services, Children’s and Women’s Care, Mental Health & Substance Use Services and the Center for Disease Control. Andrea is a Registered Nurse with Bachelor’s and Master’s degrees in Nursing from the University of British Columbia, and she recently completed the Institute for Healthcare Improvement’s Global Chief Quality Officer Program. She has progressively taken on new leadership roles and responsibilities throughout her career, including clinical education, professional practice, operations and quality and safety. Her most recent initiative focused on the development of an Integrated Quality and Safety Strategy with prioritized projects and an accompanying measurement framework to demonstrate the impact of the work on improving health outcomes, safety culture, and patient experience.

Contact information:
andrea.walker@phsa.ca

Beverly H. Johnson, FAAN

Beverley H. Johnson, FAAN is President and Chief Executive Officer of the Institute for Patient- and Family-Centered Care (IPFCC). She has provided technical assistance for advancing patient- and family-centered care and creating effective partnerships with patients and families to over 300 hospitals, health systems, federal, state, provincial agencies, military facilities, and community organizations.

Bev is a member of the Selection Committee for the American Hospital Association Quest for Quality Prize. She served as a member of the Board of Directors for the Association of American Medical Colleges (AAMC) from 2017-2021, and as a member of the Board of Directors for the Primary Care Collaborative (PCC) from 2012-2021.

In 2007, Bev received The Gravens Award for leadership in promoting optimal environments and developmental care for high-risk infants and their families, and The Changemaker Award by the Board for the Center for Health Care Design. In 2017, she was recognized by the American College of Physicians with the Edward R. Loveland Memorial Award. In 2018, Bev was recognized as a fellow in the American Academy of Nursing.

Contact information:
bjohnson@ipfcc.org

Dannagal Young

Dannagal G. Young (Ph.D. University of Pennsylvania’s Annenberg School for Communication, 2007) is a Professor of Communication and Political Science at the University of Delaware and Director of the University’s Center for Political Communication.  She has published over seventy academic articles and book chapters on the content, psychology, and effects of political information, satire, and misinformation. Her latest book, “Wrong: How Media, Politics, and Identity Drive our Appetite for Misinformation” (JHU Press, 2023) explores the demand side of misinformation – that is, why we are attracted to falsehoods. Her first book “Irony and Outrage: The Polarized Landscape of Rage, Fear, and Laughter in the U.S.” examines satire and outrage as the logical extensions of the respective psychological profiles of liberals and conservatives (Oxford University Press, 2020) and is the winner of the 2021 Roderick Hart Book Award from the Political Communication division of the National Communication Association. Danna is a public scholar, TED Speaker, and an improvisational comedian, performing with ComedySportz Philadelphia since 1999.

Contact information:
dgyoung@udel.edu

Speaker information pending.

Jessica Halem, MBA

Jessica Halem, MBA brings over two decades of experience advancing health equity, inclusive communication, and systemic change in healthcare. As the inaugural LGBTQ Director at Harvard Medical School, she led curriculum reform, policy initiatives, and student mentoring that set a new standard for inclusive medical education. She later served as Senior Director at the University of Pennsylvania’s Eidos LGBTQ Health Initiative, advising start-ups, nonprofits, and government agencies.

Jessica’s work has been featured in the New England Journal of Medicine, NPR, and across international conferences. Trained in improv at Second City, she brings a rare mix of humor, heart, and strategy to her talks — reminding audiences that creating safety starts with how we show up.

Currently, she serves on the board of the Tegan and Sara Foundation and consults with clients from her home on Cape Cod. Whether in the clinic, classroom, or boardroom, Jessica is committed to reshaping healthcare so that every patient feels heard, respected, and safe.

Contact information:
jessica.halem@gmail.com

Kathryn Proudfoot

Kathryn Proudfoot (she/her) is the Senior Director of Patient and Family Partnerships and Experience at the Provincial Health Services Authority (PHSA) in British Columbia. A registered dietitian and epidemiologist by training, she brings over a decade of health system leadership focused on advancing people- and community-centered care.

Previously, Kathryn served as Director of Patient Experience at BC Mental Health and Substance Use Services, where her team received the Canadian College of Health Leaders’ Excellence in Patient Experience Award—a national recognition for innovation in enhancing the human experience in healthcare.

At PHSA, Kathryn leads strategies that embed patient, family, and community voices into quality improvement, safety event reviews, governance, and policy across multiple provincial programs. Her work is grounded in trauma-informed practice, cultural safety, and meaningful partnerships with Indigenous leaders and patient partners.

Kathryn has led the development of key system resources, including PHSA’s Patient Experience Strategy, the Beyond Grateful Playbook, and a framework for involving patient partners in safety reviews. She is known for her clarity, compassion, and collaborative approach to systems change.

Contact information:
kathryn.proudfoot@phsa.ca

Michael L. Millenson

Michael L. Millenson is internationally recognized as a thought leader whose writing, research and consulting encourage and enable the systematic use of information to make care better, safer and more patient-centered.

As author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age and president of Health Quality Advisors, Michael has advised a broad range of organizations on strategy; carried out research as adjunct faculty at Northwestern University’s Feinberg School of Medicine; and lectured at professional meetings worldwide. His work has been cited in the peer-reviewed literature and by major media outlets such as The New York Times, Washington Post and Consumer Reports.  National Public Radio called him ”in the vanguard of the movement” to measure and improve medicine.

Michael’s book inspired the first “zero harm” initiative, the Pittsburgh Regional Healthcare Initiative. He also helped launch the Leapfrog Group and was a founding member of the Chicago Patient Safety Forum and a board member of its successor, Project Patient Care. He is currently a member of the National Advisory Council of the Agency for Healthcare Research and Quality and part of a National Academy of Medicine workstream examining financial incentives in U.S. health care.

Prior to starting his own firm, Michael was a principal at a major human resources consulting firm. Before that, he was a health care reporter for the Chicago Tribune, where he was nominated three times for a Pulitzer Prize.

Contact information:
michael@healthqualityadvisors.com

MK Haber

MK Haber began public health work in the 1980s during the HIV epidemic in Los Angeles, focusing on interventions for psychological and physical safety and food security. They have master’s degrees in intercultural management and science in nursing. As a family nurse practitioner, they specialize in reproductive health, substance use, chronic pain, sexual health, harm reduction, and inclusive family support, advocating for food and housing security and destigmatization.

As executive director for Those Nerdy Girls, they nerd out with an amazing team of scientists and clinicians, cultivating a creative space for continually reimagining and reevaluating effective science and health communication practices.

When not working, and

sometimes while, they can be found

penning droll haiku.

Contact information:
mk@thosenerdygirls.org

Sandy Laping

Sandy Laping is the content manager of Those Nerdy Girls and is a burgeoning epidemiologist, studying vaccine readiness and hesitancy. She is also a physical therapist of 25 years, specializing in spinal cord injury and pain management.

Contact information:
sandylaping75@gmail.com

Speaker information pending.

Pat Croskerry M.D., PhD, FRCP(Edin)           

Pat Croskerry M.D., PhD, FRCP(Edin) is Professor in Emergency Medicine at Dalhousie University, Halifax, Nova Scotia, Canada. In addition to his medical training, he holds a doctorate in Experimental Psychology and Fellowship in Clinical Psychology.

His research is principally concerned with clinical decision-making, especially the processes that lead to diagnostic failure. He has published over 100 journal articles and 45 book chapters in the areas of patient safety, clinical decision making, and medical education reform. Two of his papers are in the top 3 cited papers in the Emergency Medicine education literature. He was senior author on 2 books Patient Safety in Emergency Medicine (2009), and Diagnosis: Making Sense of the Shadows published (2017), and author of The Cognitive Autopsy: A Root Cause analysis of Medical Decision Making, published in 2020. He is lead author of the upcoming Critical Thinking in Clinical Medicine in the Oxford Handbook Professional Series to be published in 2026. He has given over 400 presentations at leading universities around the world.

He was appointed to the US Institute of Medicine Committee on Diagnostic Error in Medicine in 2014. In 2015-16 he was a member of an expert advisory panel for the NASA Cognition and Space Flight Project. He was nominated to the Canadian Association of Emergency Physicians Top Ten List of most impactful Canadian medical educators in 2016. He was Director of the Critical Thinking Program at Dalhousie Medical School from 2012 – 2022.

Contact information:
pgcxkerry@gmail.com

Sangeeta Ahluwalia

Sangeeta Ahluwalia is a senior policy researcher and associate director of RAND Health Care leads studies to improve access and quality of palliative care, as well as to enhance diagnostic safety across health care settings. She is currently co-leading an AHRQ-funded initiative to implement diagnostic safety resources across 150 healthcare organizations in the US, and a Moore Foundation effort to assess the costs of delayed diagnosis across conditions. She also conducts evidence synthesis research and is a core investigator for the Southern California Evidence Review Center. Dr. Ahluwalia received her PhD from UC Berkeley in 2007 in health policy.

Contact information:
sahluwal@rand.org

Shaila Jiwa

Shaila Jiwa is the Director for Quality, Patient Safety and Accreditation at the Provincial Health Services Authority (PHSA). A registered nurse by background, she holds a Masters of Science in Population and Public Health and has worked in various roles over the past 20 years including being a front line public health nurse, then taking progressively more leadership roles in education, professional practice and now within quality and safety. While working at the BC Centre for Disease control she received the Canadian College of Health Leader’s Celebrating the Human Spirit Award. Shaila is passionate about, and committed to, systems level change and improving the lives of populations and communities. And she continues to work to improve health systems, health outcomes and patient and family experience.

Contact information:
Shaila.Jiwa@phsa.ca

Anna Ryan

Anna Ryan is the Manager of the Central Quality, Patient Safety, and Accreditation team at the Provincial Health Services Authority (PHSA), which holds a province-wide mandate to deliver and coordinate specialized health services for all residents of British Columbia, Canada. She is grateful to live, work and create safer care systems on the unceded, ancestorial and traditional lands of the First Nations Peoples. Anna is a Registered Nurse and holds a Bachelor’s degree from the University of Western Ontario and a Master’s degree in Nursing from the University of British Columbia. In her current role, Anna leads a team that is advancing quality and safety priorities across all 5 program areas that make up PHSA, the BC Centre for Disease Control, BC Emergency Health Services, BC Cancer, Children and Women’s and BC Mental Health and Substance Use Services, in an aligned, equitable and meaningful way. This includes advancing and evaluating work within PHSA’s Integrated Quality and Safety Strategy. Anna brings a background working in public health at local, provincial and federal levels to her current role and is passionate about equitable, system-wide change to create safer and better care.

Contact information:
anna.ryan@phsa.ca

Siena Ruggeri
Prounouns: she/her

Siena Ruggeri is a Community Engagement Consultant for the Center for Community Engagement in Health Innovation at Community Catalyst. In this role, she supports clients in meaningfully engaging with their communities, with the goal of improving health care services and the overall health of people with complex needs, particularly those from historically marginalized, excluded, or underrepresented communities.

In her role, she provides consulting services to a diversity of clients that serve older adults, people with disabilities, and people with complex health care needs. She delivers facilitation, training, and other services that assist clients with developing and implementing programs to better serve members/patients. Her work has focused on people dually enrolled in Medicare and Medicaid, older adults, family caregivers, and advancing opportunities to address social drivers of health and promote health equity.

Before joining Community Catalyst, Siena worked as a Government Relations Associate at NETWORK Lobby for Catholic Social Justice. Siena graduated from Regis University with a Bachelor of Arts in Politics and a minor in Peace & Justice Studies.

Contact information:
sruggeri@communitycatalyst.org

Tara Bannow

Tara Bannow is a reporter covering the business of health care at STAT, a national health and medicine news outlet produced by The Boston Globe. Her beat covers hospitals, health insurance, doctors, medical billing, private equity, and lots of other odds and ends. She reported on how UnitedHealth Group uses vertical integration, especially its physician empire, to boost profits, for a George Polk Award-winning series called Health Care’s Colossus. Prior to STAT, she wrote for Modern Healthcare and newspapers in Oregon and Iowa.

Contact information:
tara.bannow@statnews.com