312.678.01 | AY 2013-2014 - 3rd Term | 2 Credit(s)
W 10:30:00 AM
  • Contact Information
    Sean Berenholtz
    Chris Goeschel
  • Course Learning Objectives

    Upon successfully completing this course, students will be able to:

    • Explain the national policy, regulatory, and advocacy pressures to improve patient safety
    • Identify organizational structures and processes designed to improve quality and patient safety
    • Describe the role of accountability and how it is used to guide costs, quality and outcomes
    • Explain strategies designed to increase the use of evidence based patient safety interventions
    • Analyze the relationship between patient safety organizational culture and communication that influence patient outcomes successfully used to improve safety culture and communication at The Johns Hopkins and in hundreds of Michigan hospitals
    • Describe the elements of Risk Management and their contribution towards patient safety strategies
    • Explain strategies for building a business case for improving safety.
  • Course Description

    This course will examine healthcare quality and patient safety from a strategic viewpoint. The goal is to build capacity at the level of healthcare administrators and develop skills needed to become effective decision makers. We will introduce contemporary thinking on patient safety improvement through didactic sessions, interactive exercises and case studies that have direct relevance for the, healthcare administrator, public health practitioner or clinician. The course will focus on several specific domains of patient safety based on strategies recommended by the Institute of Medicine report, To Err is Human, and on our experience in leading large scale patient safety efforts.

    Lapses in patient safety are a significant global problem and result in preventable morbidity, mortality, and costs of care. In the 1999 landmark report, To Err is Human, the Institute of Medicine (IOM) shocked the health care industry with estimates that up to 98,000 people die from medical errors annually in the United States. This glaring report was amplified by a 2003 RAND study suggesting that hospitalized patients in the US on average receive half the recommended therapies. The impact of these reports damaged consumer confidence in the health care industry and galvanized broad industry support to improve patient safety.

    Given the magnitude of the patient safety problem, the number of skilled clinical and administrative leaders prepared to improve patient safety is likely insufficient. One major challenge for improving patient safety is to increase the number of individuals with the skills to develop, implement and evaluate organizational patient safety improvement efforts.

    This course’s framework is built around 6 domains. These domains are outlined below along with the instructional content that will be used to teach these domains during the course sessions.

    The instructional content used to teach each domain represents ‘state of the art’ thinking regarding patient safety and is applicable to health care organizations and public health practitioners in a wide range of settings in the US and internationally. Yet this very dynamic area is the subject of frequent national and state level policy changes. Students will be expected to incorporate “current” thinking based on national news and emerging health policy issues.

    1. Evaluating Progress in Patient Safety: Explain current national and local methods of evaluating patient safety and quality improvement progress.  Instructional content: The course sessions will focus on the importance of valid and feasible measures, and national and regional policy as a driver of quality and patient safety efforts.
    2. Translating Evidence into Practice:  Describe the evidence continuum from population health to patient health and present a model that increases the extent to which patients receive evidence-based care. Instructional content: Implementation examples at the organizational level will be used to teach this domain.  
    3. Assessing and Improving Culture: Review organizational strategies to assess and improve safety culture, teamwork and communication.  Instructional content: Culture assessment tools and their capacity to inform organizational improvement efforts will be used to teach this domain.
    4. Identifying and Mitigating Hazards: Review use of retrospective and prospective analyses to identify and mitigate safety hazards. Instructional content: Case studies, highlighting both the microscopic perspective (unit or department, in-depth evaluation) and macroscopic perspective (institutional, country) levels will be used in course sessions to teach this domain. The relationship between patient safety, quality improvement activities and Risk Management will be explored.
    5. Evaluating the Association between Organizational Characteristics and Outcomes:  Explore the evidence and ongoing challenges related to identifying organizational characteristics that help or hinder patient safety practices, including the challenges of building capacity to do this work.  Instructional content: Major patient safety and quality improvement projects, databases and reports will be used as examples to clarify the importance of project design, data collection and management, and using them in practice and in research.
    6. Building a Business Case for Improving Safety: Examine current literature and national efforts to evaluate the cost-benefit ratio of safety improvements. Instructional content: Methods and Information flow that organization leaders can use to make informed decisions about approving and accepting safe practice recommendations for use and allocating the adequate resources for them.
  • Intended Audience
    MHA students
  • Methods of Assessment

    Much of the learning in this course will come from the lectures, your individual work and from interacting with other students.  Note that since this is a graduate course, your performance in class will be judged accordingly. Students are allowed one excused absence during the term [approved by instructor prior to class. Emergencies are dealt with individually]. If a student misses an additional class to the one excused absence, his/her grade will be lowered by 1 grade [B]; 2 classes [C]; 3 classes [D]. No extra credit assignments may negate missing a class.

  • Prerequisites


  • Required Text(s)

    You are expected to keep up with the reading assignments.  In some cases, the material from the readings will not be specifically covered in class; these readings are considered an independent part of your learning experience and will enable you to participate in class discussions and activities and complete assignments. The course will also cover current events (ie healthcare reform) and additional readings may be required.

  • Course Schedule

    Please see the course Session for a full list of dates and items for this course.

  • Academic Ethics Code

    Students enrolled in the Bloomberg School of Public Health of The Johns Hopkins University assume an obligation to conduct themselves in a manner appropriate to the University's mission as an institution of higher education. A student is obligated to refrain from acts which he or she knows, or under the circumstances has reason to know, impair the academic integrity of the University. Violations of academic integrity include, but are not limited to: cheating; plagiarism; knowingly furnishing false information to any agent of the University for inclusion in the academic record; violation of the rights and welfare of animal or human subjects in research; and misconduct as a member of either School or University committees or recognized groups or organizations.

  • Disability Support Services
    If you are a student with a documented disability who requires an academic accommodation, please contact the Office of Student Life Services at 410-955-3034 or via email at