Lafayette Medical Education Foundation, Inc.
Program Evaluation
“Overview of the Science of Safety in Healthcare”
James Bien, MD, FAAP
May 21, 2015
IU Health Arnett Hospital
What are your professional Credentials?
O
O
O
MD/DO
PA/NP
Other__________
Overall Thoughts on the Program
The program met my professional expectations and needs.
O
O
O
O
O
Strongly
Agree
Neutral
Disagree
Strongly
Agree
Disagree
O
N/A
The program provided tools which are helpful to my practice.
O
O
O
O
O
Strongly
Agree
Neutral
Disagree
Strongly
Agree
Disagree
O
N/A
The program content was at appropriate level for audience.
O
O
O
O
O
Strongly
Agree
Neutral
Disagree
Strongly
Agree
Disagree
O
N/A
Which of the following professional organization core competencies have been
addressed by this program?(check all that apply)
 PATIENT CENTERED CARE: Identify, respect, and care about patients’ differences, values, preferences,
and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate
with, and educate patients; share decision making and management; and continuously advocate disease prevention,
wellness, and promotion of health lifestyles, including a focus on population health.
 EVIDENCE BASED PRACTICE: Integrate best research with clinical expertise and patient values for
optimum care, and participate in learning and research activities to the extent feasible.
 QUALITY IMPROVEMENT: Identify errors and hazards in care; understand and implement basic safety
design principles, such as standardization and simplification; continually understand and measure quality of care in
terms of structure , process, and outcomes in relation to patient and community needs; and design and test interventions
to change processes and systems of care, with the objective of improving quality.
 INTERDISCIPLINARY TEAMS: Facilitating collaboration with other members of the health care team to
ensure that care is coordinated, continuous, and reliable.
 INFORMATICS: Utilizing information technology to improve communication and support decisionmaking systems.
 MEDICAL KNOWLEDGE: Helping learners become aware of established or evolving clinical and
research data and explaining how this information can be applied to the improvement of patient care.

PATIENT SAFETY:
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Based on your participation in this program, which of the following do you expect to
improve? (check all that apply)





KNOWLEDGE (awareness, recollection, and understanding)
COMPETENCE (ability to apply knowledge, skills, and judgment)
PERFORMANCE (what is actually being done in professional practice)
PATIENT OUTCOMES
NONE
Based on your participation in this program, how do you plan to change your
clinical practice? (check all that apply)
 Develop/revise and implement new or revised protocols, processes, policies, and
procedures (please explain below)
 Apply new strategies to better manage my patients and develop more effective
treatment plans (please explain below)
 N.A, the sessions validated my current practice
 Other (please explain below)
If you need to explain any of your answers from the previous question-do so here:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Which of the following barriers do you expect to encounter in implementing these
changes? (check all that apply)





Resources/economic
Lack of time to assess/counsel patients
Patient compliance
None
Other
Please suggest any other topics that may be of interest to you:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Additional comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Course Objectives
As a result of attending this program, I will be better able to:
Describe a general understanding of the science of patient safety and how it is being
applied within a specific regional health center.
O
O
O
O
O
O
Strongly
Agree
Neutral
Disagree
Strongly
N/A
Agree
Disagree
As a result of attending this program, I will be better able to:
Recognize the concept of Situation Awareness as it is applied to healthcare settings and
be able to describe one specific tool used locally to improve team-member situation
awareness.
O
O
O
O
O
O
Strongly
Agree
Neutral
Disagree
Strongly
N/A
Agree
Disagree
As a result of attending this program, I will be better able to:
Apply the James Reason’s “Swiss Cheese Model” for error occurrence and to recognize
the concepts of the latent and active error.
O
O
O
O
O
O
Strongly
Agree
Neutral
Disagree
Strongly
N/A
Agree
Disagree
Speaker Evaluation
James Bien, MD, FAAP
The speaker demonstrated expertise and presented high quality scientific content
based on the best available evidence.
O
O
O
O
O
Strongly
Agree
Neutral
Disagree
Strongly
Agree
Disagree
The scientific content was presented appropriately for the target audience and
related to your current scope of practice.
O
O
O
O
O
O
Strongly
Agree
Neutral
Disagree
Strongly N/A
Agree
Disagree
Do you feel this presentation was objective, fair, and balanced?
O Yes
O No
Was this presentation free of commercial bias or influence?
O Yes
O No (please explain) ___________________________________
FACULTY DISCLOSURE STATEMENT - Full disclosure of all commercial relationships must be made in writing to the
audience prior to the activity. James Bien, MD, FAAP does not have any financial disclosures to disclose. All additional planning
committee members, and the Lafayette Medical Education Foundation, Inc. staff have no relationships to disclose.
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REQUEST FOR CREDIT
If you wish to receive acknowledgement of participations for this activity, please fill in your
contact information and return this form to the registration desk upon your departure.
Degree (please mark appropriate box and circle appropriate degree)
Social
worker
MD/DO
PharmD/RPh
RN
Family
Practice
Internal
Medicine
Adv.
Practice
Nurse
Last Name
PA
OTHER
FirstName
MI
Street Address:
City:
State or Province
Telephone:
Ext.
Postal Code
-
Fax
-
-
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E-Mail Address
Specialty:
Signature___________________________________________ Date________________________________
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