SSF 2023 Grand Rounds 4/6/23 Local Leadership HRO Training

April 6, 2023

Goal: To familiarize clinical as well as non-clinical leaders and with the HRO principles and language, so that leaders, physician and staff may recognize opportunities to lean in and embrace failures, in an effort to learn and make our organization better and thus driving improved care for our members/patients.  Studies have shown that when there is a consistent application of HRO principles across an organization, there will be a perceived increase in psychological safety, improved "Speak Up" culture, as well as reduction in serious, adverse safety events.  

Cultural and Linguistic Competency/ Implicit Bias: 

When we debrief member grievances, reportable and patient safety events, those members clearly identified as having English as a second language, are of a different gender identity, elderly and/or disabled generate themes by which our care team does not apply a consistent approach in patient care, patient communication, or service recovery. Enacting HRO principles ensures that these themes are considered with every patient encounter and are factored into decision-making to ensure high-quality, consistent patient care for every member/patient.


  • Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected (3rd ed.). John Wiley & Sons
  • Strategies for overcoming language barriers in healthcare doi:10.1097/01.NUMA.0000531166.24481.15
  • Impacts of English language proficiency on healthcare access, use, and outcomes among immigrants: a qualitative study Pandey et al. BMC Health Services Research (2021) 21:741
  • Implications of Language Barriers for Healthcare: A Systematic Review: DOI 10.5001/omj.2020.40  

Target Audience

All physicians and staff involved with existing workflows and processes that could affect the outcome of safe patient care.


Learning Objectives

1. To promote and reinforce a culture of high reliability, safety, and respect through successfully spreading evidence-based methods and a common set of behavioral expectations.

2. Provide a framework to:
- Deliver innovative and engaging learning experiences in a psychologically safe manner 
- Integrate HRO practices into local leadership standard work to ensure sustainability 

3. A reduction in SSF CAUTI and CLABSI by PY 2023.

Additional Information

Course summary
Available credit: 
  • 2.00 AMA PRA Category 1 Credit(s)™
Course opens: 
Course expires: 
Event starts: 
04/06/2023 - 3:30pm PDT
Event ends: 
04/06/2023 - 5:30pm PDT
Kaiser Permanente MS Teams Meeting
Redwood City, CA 94063
United States

Speaker(s) Varies:

  • Kevin Worth, RN, PHN, MS, CNS, CPHQ Executive Director, Risk Management, Patient Safety and Person and Family Centered Care
  • Rachel M. Crosby MHA, RRT, RCP Regional Leader, Risk Management and Safety
  • Jocelyn Alimboyoguen, MSN, RN, CPHQ Clinical Practice Consultant
  • Maria Faulve-Montojo, RN, MSN, CPHQ Area Quality Leader & Patient Safety Officer Safety, Quality & Regulatory Services San Mateo Service Area

Planning Committee:

  • Maria Faulve-Montojo, RN, MSN, CPHQ Area Quality Leader & Patient Safety Officer Safety, Quality & Regulatory Services San Mateo Service Area
  • Gary Leicht Area Portfolio Leader Administration/San Mateo Service Area
  • Tina Bray, RN, MSN, MBA, DNP Chief Operating Officer/Chief Nurse Executive Administration/South San Francisco
  • Isabel Uibel, DNP, RN Medical Group Administrator Administration/Redwood City
  • Alan Underwood, MBA, MPH Associate Medical Group Administrator Administration/South San Francisco
  • Julia Carranza, CME Coordinator, KP Redwood City
  • Jie Zheng, MD, COE, KP South San Francisco


Accreditation Statement:

Kaiser Permanente South San Francisco is accredited by the California Medical Association (CMA) to provide continuing medical education for physicians.

Credit Statement:

The South San Francisco Medical Kaiser Permanente Medical Center (South San Francisco, CA 94080) designates this live activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nurses may report up to a maximum total of 2.0 AMA PRA Category 1 Credit(s)™ towards the Continuing Medical Education requirements for license renewal by the California Board of Registered Nurses.

Disclosure Statement (as appropriate):

None of the planners, faculty, committee members or reviewers for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patient.

FOR CME CREDIT: Scan the QR code and claim credit through the link provided or use the link sent with the flyer . A survey will be emailed to all who participate. Please complete the survey. The survey will be open for 10 days.


Available Credit

  • 2.00 AMA PRA Category 1 Credit(s)™
Please login or register to take this course.

Required Hardware/software

MS Teams