IHI Redesigning Event Review with Root Cause Analyses and Actions (RCA2) - March 2025

Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM, Quality, Safety and HRO Consultant, Aptive Resources, works in the areas of patient safety, workforce safety, and high reliability. She is faculty for the IHI Patient Safety Executive Development Program and on Redesigning Event Review with Root Cause Analysis and Action (RCA2). Prior to Joining Aptive Resources she served as the Senior Director at the Institute for Healthcare Improvement (IHI). She has also served as the Assistant Vice President of Quality & Patient Safety at Ochsner Health System where she helped set the strategic priorities in quality and patient safety and oversaw various projects involving patient safety, performance improvement, regulatory readiness, ambulatory nursing, and quality outcomes. She has presented her work on RCA2 and Improving the Culture of Safety at various regional and national meetings. She has also worked on research projects involving reduction in Sepsis mortality and access to healthcare for underserved populations. Jessica received her bachelor’s degree from Tulane University and her Master of Public Health Degree from the Louisiana State University School of Public Health. She is a Certified Professional in Patient Safety (CPPS), a Certified Professional in Healthcare Quality (CPHQ) and a Certified Professional in Healthcare Risk Management (CPHRM).

Rollin J. “Terry” Fairbanks MD, MS, CPPS, is Senior Vice President and Chief Quality & Safety Officer at MedStar Health, Executive Director of the MedStar Institute for Quality and Safety, and Professor Of Emergency Medicine at Georgetown University. Dr. Fairbanks started his career as a safety scientist focused on human factors engineering in the transportation industry, and later became a physician. He has become an expert in the application of safety science in health care. In 2010 he founded MedStar Health’s National Center for Human Factors in Healthcare, now one of the largest embedded health care human factors centers in the world. He has authored more than 200 publications and edited a book on health care safety and human factors engineering. He has served in safety advisory roles for several national organizations and for the United States, British, Spanish, and Australian governments, and serves in several national advisory roles in addition to his role as IHI faculty. Dr. Fairbanks is a former paramedic, EMS medical director, and general aviation pilot. He practices emergency medicine at the MedStar Washington Hospital Center in Washington DC.

Tejal K. Gandhi, MD, MPH, CPPS​, is the Chief Safety and Transformation Officer at Press Ganey. In this role, Dr. Gandhi is responsible for advancing the Zero Harm movement, improving patient and workforce safety, and developing innovative health care transformation strategies. ​Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programs focusing on improving patient and workforce safety. Prior to this, Dr. Gandhi was President and Chief Executive Officer of the National Patient Safety Foundation (NPSF) from 2013 until 2017, when NPSF merged with IHI. ​She has also served as President of the Lucian Leape Institute, a think tank founded by NPSF that now operates within the IHI Safety portfolio and was a board member of the Certification Board for Professionals in Patient Safety which administers the Certified Professional in Patient Safety credential.
​

Richard D. Guthrie, Jr., MD, CPE, is the System Chief Quality Officer of Ochsner Health.  As the Chief Quality Officer, Guthrie oversees the development and implementation of strategies and programs aimed at improving patient safety and quality for the health system. Dr. Guthrie previously served as the Regional Medical Director — Ochsner Medical Center from 1999–2014. As Medical Director, Guthrie oversaw the physician group and was responsible for physician recruitment, clinical program development, and professional affairs. Dr. Guthrie earned his Bachelor of Science degree from the University of New Orleans, summa cum laude, and graduated from Louisiana State University Medical School, Alpha Omega Alpha, in 1986. Dr. Guthrie received his internal medicine training, including residency and chief residency, at Alton Ochsner Medical Foundation.

Lauge Sokol-Hessner, MD, CPPS, is a practicing clinician, educator, researcher, innovator, and leader in patient safety & quality improvement.  He has operational quality & safety experience as a former Senior Medical Director of Patient Safety at Beth Israel Deaconess Medical Center in Boston.  He's passionate about helping develop the next generation of leaders in quality and safety and is a former quality & safety fellowship program director and masters program course director at Harvard Medical School.  Currently he is: a Clinical Associate Professor of Medicine and an attending hospitalist at the University of Washington (UW) & Harborview Medical Centers; a Quality Improvement Mentor at the UW Medicine Center for Scholarship in Patient Care Quality and Safety; and the Associate Director for the Collaborative for Accountability and Improvement and a Faculty Coach for the PACT Collaborative, both roles where he helps lead national work to sustain and spread more proactive, ethical, person-centered responses after harm events.