Nurturing a Culture of Patient Safety

1. 1 Nurturing a Culture of Patient Safety

2. 2 Objectives Safety�it is a matter of perspective Nurturing a culture of patient safety Toolkits Success stories There is no question that quality and patient safety have become a key focus within health care delivery systems. But the progress made and the commitment to further progress is a matter of perspective. This program will focus on how to nurture a culture of quality and patient safety within a health care organization. Examples of tools and resources will be provided. In addition, success stories from different hospitals will be shared.There is no question that quality and patient safety have become a key focus within health care delivery systems. But the progress made and the commitment to further progress is a matter of perspective. This program will focus on how to nurture a culture of quality and patient safety within a health care organization. Examples of tools and resources will be provided. In addition, success stories from different hospitals will be shared.

3. 3 Where Does Patient Safety Fit Into aHealth Care Organization�s Mission? Hippocrates: �First do no harm� Institute of Medicine1,2 Joint Commission National Patient Safety Goals3 US Centers for Medicare & Medicaid Services Never events4 Patient safety has been a cornerstone of health care professionals and organizations since the time of Hippocrates who purportedly admonished �First do no harm.� Over the past decade, patient safety has been a focus of many organizations and stakeholders. Since its� 1999 landmark report To Err Is Human: Building A Safer Health System, the Institute of Medicine has issued several reports describing the failure of health care organizations to adequately provide for patient safety, [IOM To Err/1] as well as recommendations for improvement. [IOM Chasm/1] The 2009 National Patient Safety Goals issued by The Joint Commission emphasize the importance of quality and patient safety across all aspects of the healthcare delivery system. [JC/10] Among these goals, the labeling of medications and anticoagulant therapy is highlighted. Non-compliance can result in an adverse accreditation standing. The US Centers for Medicare and Medicaid Services also has taken a tough stand by refusing to reimburse hospitals for �never events.� [CMS/6] Among these never events is death or disability due to a medication error.Patient safety has been a cornerstone of health care professionals and organizations since the time of Hippocrates who purportedly admonished �First do no harm.� Over the past decade, patient safety has been a focus of many organizations and stakeholders. Since its� 1999 landmark report To Err Is Human: Building A Safer Health System, the Institute of Medicine has issued several reports describing the failure of health care organizations to adequately provide for patient safety, [IOM To Err/1] as well as recommendations for improvement. [IOM Chasm/1] The 2009 National Patient Safety Goals issued by The Joint Commission emphasize the importance of quality and patient safety across all aspects of the healthcare delivery system. [JC/10] Among these goals, the labeling of medications and anticoagulant therapy is highlighted. Non-compliance can result in an adverse accreditation standing. The US Centers for Medicare and Medicaid Services also has taken a tough stand by refusing to reimburse hospitals for �never events.� [CMS/6] Among these never events is death or disability due to a medication error.

4. 4 Healthcare Organization Leaders� Priorities The heads of health care organizations also report that they take patient safety very seriously. A 2009 survey of chief executive officers (CEOs) and chief financial officers (CFOs) of hospitals, physician practice groups, ambulatory clinics, and health plans found that quality and patient safety were overwhelmingly ranked their number one priority. [HealthLeaders Media/5] [HealthLeaders Finance/6] The heads of health care organizations also report that they take patient safety very seriously. A 2009 survey of chief executive officers (CEOs) and chief financial officers (CFOs) of hospitals, physician practice groups, ambulatory clinics, and health plans found that quality and patient safety were overwhelmingly ranked their number one priority. [HealthLeaders Media/5] [HealthLeaders Finance/6]

5. 5 Safety Score Varies by Staff Type However, there appears to be differences among hospital personnel in terms of the culture of patient safety. A 2008 survey of 42,378 employees across 75 hospitals/facilities found a significant disconnect between administration and other staff, especially those involved in medication prescribing, preparation, and administration. [Pulse Report/7] A 2009 report by the Agency for Healthcare Research and Quality provides some insight into this disconnect. More than half of hospital staff reported that hospital management seems interested in patient safety only after an adverse event happens. [AHRQ/37] This disconnect appears to be especially large between front-line staff and their supervisors/ managers. More than three-quarters of hospital staff indicated that their supervisor/manager overlooks patient safety problems that happen over and over. [AHRQ/36] However, there appears to be differences among hospital personnel in terms of the culture of patient safety. A 2008 survey of 42,378 employees across 75 hospitals/facilities found a significant disconnect between administration and other staff, especially those involved in medication prescribing, preparation, and administration. [Pulse Report/7] A 2009 report by the Agency for Healthcare Research and Quality provides some insight into this disconnect. More than half of hospital staff reported that hospital management seems interested in patient safety only after an adverse event happens. [AHRQ/37] This disconnect appears to be especially large between front-line staff and their supervisors/ managers. More than three-quarters of hospital staff indicated that their supervisor/manager overlooks patient safety problems that happen over and over. [AHRQ/36]

6. 6 According to The Joint Commission �� inadequate leadership was a contributing factor in 50% of the sentinel events reported toThe Joint Commission in 2006.� The Joint Commission places much of the responsibility for failures in patient safety on poor leadership. In an August 2009 Sentinel Event Alert, The Joint Commission stated that inadequate leadership was a contributing factor in 50% of the sentinel events reported to the Joint Commission in 2006. [JC Sentinel/1] The Sentinel Event Database is part of one of the most comprehensive voluntary reporting systems for serious adverse events in the US health care system. The Alert also noted that leadership is a critical function in promoting high quality, safe health care. The Joint Commission urged leaders to create a culture of safety and to provide the resources necessary for patient safety. The creation of an organization-wide safety culture is one of 14 specific steps recommended by The Joint Commission to improve patient safety. [JC News Release/1] The Joint Commission places much of the responsibility for failures in patient safety on poor leadership. In an August 2009 Sentinel Event Alert, The Joint Commission stated that inadequate leadership was a contributing factor in 50% of the sentinel events reported to the Joint Commission in 2006. [JC Sentinel/1] The Sentinel Event Database is part of one of the most comprehensive voluntary reporting systems for serious adverse events in the US health care system. The Alert also noted that leadership is a critical function in promoting high quality, safe health care. The Joint Commission urged leaders to create a culture of safety and to provide the resources necessary for patient safety. The creation of an organization-wide safety culture is one of 14 specific steps recommended by The Joint Commission to improve patient safety. [JC News Release/1]

7. 7 �Improving patient safety is a team sport� �John Eisenberg* The different perspectives about patient safety point to the need for an organization-wide approach to patient safety. As noted by the former head of the Agency for Healthcare Research and Quality John Eisenberg, �Improving patient safety is a team sport.� (Clancy/1) The different perspectives about patient safety point to the need for an organization-wide approach to patient safety. As noted by the former head of the Agency for Healthcare Research and Quality John Eisenberg, �Improving patient safety is a team sport.� (Clancy/1)

8. 8 The Key Questions So what is needed for the team to play together? And will the result achieve the desired objective in terms of quality and patient safety?

9. 9 Nurturing a Culture of Patient Safety Committed leadership1 Requires vigilance, learning, accountability2 Emphasize2 Safety > Productivity Teamwork > Individual autonomy Increased standardization, simplification2 Conducive environment2 Since a lack of leadership has been noted by The Joint Commission as a major factor contributing to poor patient safety, the importance of strong and committed leadership is clear. [JC Sentinel/1] Leadership must come from all levels of the organization, including health care practitioners, not just senior management. [Shortell/446] Shortell and Singer suggest several additional changes that are needed to nurture a culture of patient safety among the health care team. This includes continuous vigilance or mindfulness, learning, and accountability. Instead of emphasizing productivity, safety should be the focus. Similarly, teamwork should be emphasized instead of individual autonomy. Other needed changes include increased standardization and simplification, as well as a conducive environment in which staff are encouraged and made to feel comfortable to report errors and mistakes. [Shortell/445] Since a lack of leadership has been noted by The Joint Commission as a major factor contributing to poor patient safety, the importance of strong and committed leadership is clear. [JC Sentinel/1] Leadership must come from all levels of the organization, including health care practitioners, not just senior management. [Shortell/446] Shortell and Singer suggest several additional changes that are needed to nurture a culture of patient safety among the health care team. This includes continuous vigilance or mindfulness, learning, and accountability. Instead of emphasizing productivity, safety should be the focus. Similarly, teamwork should be emphasized instead of individual autonomy. Other needed changes include increased standardization and simplification, as well as a conducive environment in which staff are encouraged and made to feel comfortable to report errors and mistakes. [Shortell/445]

10. 10 Systems Improvements:The Other Piece to the Solution Aviation, nuclear energy, military found that nurturing a safety culture was not enough Nurturing systems improvements is also required Other industries such as aviation and nuclear energy found that marked improvement in safety occurred only after addressing failures resulting from systems. Systems issues are also a core concern in the military. System failures were noted by the Institute of Medicine in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, as a major factor contributing to patient harm. [IOM Chasm/1] System failures have been found to be a common factor contributing to compromised patient safety within health care as well. [Wong/715-722] A 2007 survey of nurses found that systems errors were the most common causes of medication errors, including errors involving injectable medications. These system errors included too rushed/busy environment, poor/illegible handwriting, and similar drug names or medication appearance. [ANA/1] Other industries such as aviation and nuclear energy found that marked improvement in safety occurred only after addressing failures resulting from systems. Systems issues are also a core concern in the military. System failures were noted by the Institute of Medicine in its 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, as a major factor contributing to patient harm. [IOM Chasm/1] System failures have been found to be a common factor contributing to compromised patient safety within health care as well. [Wong/715-722] A 2007 survey of nurses found that systems errors were the most common causes of medication errors, including errors involving injectable medications. These system errors included too rushed/busy environment, poor/illegible handwriting, and similar drug names or medication appearance. [ANA/1]

11. 11 Systems Improvements:Principles Organization-wide and across organizations Development and empowerment of teams Foundation of information for accountability and learning Shared responsibility Must address strategic, cultural, structural, and technical barriers Because the treatment of patients is routed in a complex system that includes a wide variety of health care professionals, as well as laws, rules, payment mechanisms, and accreditation requirements, it is mandatory that shortcomings in the system be addressed if patient safety is to be improved. [Shortell/445] To take systems improvement seriously requires implementation of systems thinking throughout the organization and across the health care delivery system that includes other organizations. Other requirements include the development and empowerment of teams, a foundation of information that is used for accountability and learning, and shared responsibility for systems improvement. [Shortell/446] It is also necessary that the strategic, cultural, structural, and technical barriers to patient safety be included. [Shortell/446] Because the treatment of patients is routed in a complex system that includes a wide variety of health care professionals, as well as laws, rules, payment mechanisms, and accreditation requirements, it is mandatory that shortcomings in the system be addressed if patient safety is to be improved. [Shortell/445] To take systems improvement seriously requires implementation of systems thinking throughout the organization and across the health care delivery system that includes other organizations. Other requirements include the development and empowerment of teams, a foundation of information that is used for accountability and learning, and shared responsibility for systems improvement. [Shortell/446] It is also necessary that the strategic, cultural, structural, and technical barriers to patient safety be included. [Shortell/446]

12. 12 Systems Improvements:Toolkits A multitude of toolkits have been developed May be useful as a starting point Critical barriers to systems improvement is determining where to start and how to proceed. Fortunately, a wide variety of �toolkits� or blueprints with supportive materials have been developed by organizations across the health care delivery system. These toolkits may require modification to meet a particular organization�s needs, but nonetheless serve as a good starting point. The following are some examples.Critical barriers to systems improvement is determining where to start and how to proceed. Fortunately, a wide variety of �toolkits� or blueprints with supportive materials have been developed by organizations across the health care delivery system. These toolkits may require modification to meet a particular organization�s needs, but nonetheless serve as a good starting point. The following are some examples.

13. 13 Toolkit:Pathways for Medication SafetySM Goal: Provide hospitals with a process for making fundamental, wide-ranging improvements to their medication delivery systems 3 Tools: Leading a strategic planning effort Looking collectively at risk Assessing bedside bar-coding readiness The Pathways for Medication SafetySM was developed by the American Hospital Association, the Health Research and Educational Trust, and the Institute for Safe Medication Practices, with support from The Commonwealth Fund. The goal is to provide hospitals with a process for making fundamental, wide-ranging improvements to their medication delivery systems. [Pathways/1] A multidisciplinary panel of health care experts and leaders collaborated to develop three educational tools for reducing medication errors. Each tool addresses a discrete organizational component: strategic planning, risk assessment, and information technology. The tools are: 1) Leading a strategic planning effort; 2) Looking collectively at risk; and 3) Assessing bedside bar-coding readiness. These three tools provide hospitals with a process to: 1) incorporate medication safety initiatives into their strategic plans; 2) perform an organization-wide risk assessment to identify areas for improvement; and 3) assess the organization�s readiness to implement a bar-coding system for administering medications. [Pathways/1, 5,6,7] The Pathways for Medication SafetySM was developed by the American Hospital Association, the Health Research and Educational Trust, and the Institute for Safe Medication Practices, with support from The Commonwealth Fund. The goal is to provide hospitals with a process for making fundamental, wide-ranging improvements to their medication delivery systems. [Pathways/1] A multidisciplinary panel of health care experts and leaders collaborated to develop three educational tools for reducing medication errors. Each tool addresses a discrete organizational component: strategic planning, risk assessment, and information technology. The tools are: 1) Leading a strategic planning effort; 2) Looking collectively at risk; and 3) Assessing bedside bar-coding readiness. These three tools provide hospitals with a process to: 1) incorporate medication safety initiatives into their strategic plans; 2) perform an organization-wide risk assessment to identify areas for improvement; and 3) assess the organization�s readiness to implement a bar-coding system for administering medications. [Pathways/1, 5,6,7]

14. 14 Toolkit:Institute for Healthcare Improvement Patient Safety Leadership WalkRounds� Provides an informal method for leaders to talk with front-line staff regarding safety Includes goals, instructions for WalkRounds�, script, measures of success The Institute for Healthcare Improvement has developed and adapted a multitude of tools to help health care organizations improve patient safety and develop a culture of safety. An example of one such tool is Patient Safety Leadership WalkRounds�. The WalkRounds� tool provides an informal method for leaders to talk with front-line staff about safety and show their support for the reporting of errors. Included in the tool are goals, instructions, a script for talking with staff, and measures of success. [PSLWR/1] The Institute for Healthcare Improvement has developed and adapted a multitude of tools to help health care organizations improve patient safety and develop a culture of safety. An example of one such tool is Patient Safety Leadership WalkRounds�. The WalkRounds� tool provides an informal method for leaders to talk with front-line staff about safety and show their support for the reporting of errors. Included in the tool are goals, instructions, a script for talking with staff, and measures of success. [PSLWR/1]

15. 15 Toolkit:Institute for Healthcare Improvement (cont.) Safety Briefings Increase staff awareness of safety issues Share information without fear of reprisal Integrate reporting medication safety issues into daily work Another tool is Safety Briefings. This is a tool that front-line staff can use to share information about potential safety problems and concerns on a daily basis. Use of Safety Briefings helps increase staff awareness of patient safety issues, creates an environment in which staff share information without fear of reprisal, and integrate the reporting of medication safety issues into daily work. With continued use, Safety Briefings help organizations create a culture of safety, reduce the risk of medication errors, and improve quality of care. [IHI-Safety Briefings/1] A wide variety of other patient safety tools are available related to services provided across the health care delivery system. These include successful protocols, order sets and forms, and instructions and guidelines for implementing key changes. Another, Trigger Tools, is used to begin identifying adverse events as a measure of overall harm from medical care in a health care organization. [IHI-Tools/1] Another tool is Safety Briefings. This is a tool that front-line staff can use to share information about potential safety problems and concerns on a daily basis. Use of Safety Briefings helps increase staff awareness of patient safety issues, creates an environment in which staff share information without fear of reprisal, and integrate the reporting of medication safety issues into daily work. With continued use, Safety Briefings help organizations create a culture of safety, reduce the risk of medication errors, and improve quality of care. [IHI-Safety Briefings/1] A wide variety of other patient safety tools are available related to services provided across the health care delivery system. These include successful protocols, order sets and forms, and instructions and guidelines for implementing key changes. Another, Trigger Tools, is used to begin identifying adverse events as a measure of overall harm from medical care in a health care organization. [IHI-Tools/1]

16. 16 Toolkit:Agency for Healthcare Research and Quality TeamSTEPPS� Evidence-based teamwork system to improve communication and teamwork skills among health care professionals Ready-to-use materials and training curriculum The Agency for Healthcare Research and Quality developed TeamSTEPPS�, an evidence-based teamwork system to improve communication and teamwork skills among health care professionals. TeamSTEPPS� consists of ready-to-use materials and a training curriculum intended to help integrate teamwork principles into all areas of the health care system. [TeamSTEPPS�/1] The Agency for Healthcare Research and Quality developed TeamSTEPPS�, an evidence-based teamwork system to improve communication and teamwork skills among health care professionals. TeamSTEPPS� consists of ready-to-use materials and a training curriculum intended to help integrate teamwork principles into all areas of the health care system. [TeamSTEPPS�/1]

17. 17 Toolkit:Agency for Healthcare Research and Quality TeamSTEPPS� (cont.) Three-phased process A pretraining assessment for site readiness Training for onsite trainers and health care staff Implementation and sustainment TeamSTEPPS� has a three-phased process aimed at creating and sustaining a culture of safety with [TeamSTEPPS�-About/1]: Pre-training assessment for site readiness Training for on-site trainers and health care staff Implementation and sustainment TeamSTEPPS� provides higher quality, safer patient care by [TeamSTEPPS�-About/1, 2]: Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best possible outcomes for patients Increasing team awareness and clarifying team roles and responsibilities Resolving conflicts and improving information sharing Eliminating barriers to quality and patient safety. TeamSTEPPS� has a three-phased process aimed at creating and sustaining a culture of safety with [TeamSTEPPS�-About/1]: Pre-training assessment for site readiness Training for on-site trainers and health care staff Implementation and sustainment TeamSTEPPS� provides higher quality, safer patient care by [TeamSTEPPS�-About/1, 2]: Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best possible outcomes for patients Increasing team awareness and clarifying team roles and responsibilities Resolving conflicts and improving information sharing Eliminating barriers to quality and patient safety.

18. 18 Toolkit:Dana-Farber Cancer InstituteStrategies for Leadership Self-assessment tool for health care executives Five parts Personal education Call to action Practicing a culture of safety Advancing the field Next steps One of the earliest patient safety toolkits was developed by Dana-Farber Cancer Institute following two tragic medication errors. The toolkit is a collection of leadership strategies that have been combined into a self-assessment tool for health care executives. [Conway/3] The tool, which is formatted as a checklist, is organized into five parts [Conway/4, 5, 6, 7, 8]: Personal education Call to action Practicing a culture of safety Advancing the field Next steps Each section identifies resources, as well as steps to be taken by the executive to promote and support patient safety among the health care team. One of the earliest patient safety toolkits was developed by Dana-Farber Cancer Institute following two tragic medication errors. The toolkit is a collection of leadership strategies that have been combined into a self-assessment tool for health care executives. [Conway/3] The tool, which is formatted as a checklist, is organized into five parts [Conway/4, 5, 6, 7, 8]: Personal education Call to action Practicing a culture of safety Advancing the field Next steps Each section identifies resources, as well as steps to be taken by the executive to promote and support patient safety among the health care team.

19. 19 Toolkit:San Diego Patient Safety ConsortiumSafe Administration of High-Risk IV Medications Goal: Standardize high-risk IV drug concentrations and dosage units to reduce the likelihood of adverse drug events Toolkit includes: Strategies and tactics to mobilize a group and develop consensus Implementation tips List of standardized adult IV infusions As a means to improve patient and medication safety, the San Diego Patient Safety Consortium developed a toolkit on standardizing intravenous infusion medication concentrations and dosage units so as to reduce the likelihood of adverse drug events. [San Diego/1, 3] The toolkit includes the following [San Diego/2]: Creating a shared need: The case for standardization Mobilizing commitment Developing a standardized list Planning for implementation: Tips from the field Monitoring change: Sharing success Standard adult IV infusions The toolkit was developed by hospitals across San Diego County. As a means to improve patient and medication safety, the San Diego Patient Safety Consortium developed a toolkit on standardizing intravenous infusion medication concentrations and dosage units so as to reduce the likelihood of adverse drug events. [San Diego/1, 3] The toolkit includes the following [San Diego/2]: Creating a shared need: The case for standardization Mobilizing commitment Developing a standardized list Planning for implementation: Tips from the field Monitoring change: Sharing success Standard adult IV infusions The toolkit was developed by hospitals across San Diego County.

20. 20 Hospitals That Provide The Best Quality Also Fare Better Financially Hospitals and health care delivery systems across the United States have implemented programs aimed at improving patient safety. Organizations that provide the highest quality also fare better financially. In fact, the results of the 2008 survey �100 Top Hospitals: National Benchmarks for Success� showed that these top hospitals scored better than their peer hospitals on all eight measures of clinical quality, operating efficiency, and financial performance. [Wilson/2] For example, the patient safety index was 0.85 in the top 100 hospitals, which was 14.1% lower than the score of 0.99 at peer facilities. At the same time, the expense per adjusted discharge was $4,775 at the top hospitals, 13.2% lower than the $5,503 at peer hospitals. This is likely due, in part, to a 10% shorter length of stay at the top hospitals compared with peer hospitals (4.93 vs 5.48 days). [Wilson/2] Hospitals and health care delivery systems across the United States have implemented programs aimed at improving patient safety. Organizations that provide the highest quality also fare better financially. In fact, the results of the 2008 survey �100 Top Hospitals: National Benchmarks for Success� showed that these top hospitals scored better than their peer hospitals on all eight measures of clinical quality, operating efficiency, and financial performance. [Wilson/2] For example, the patient safety index was 0.85 in the top 100 hospitals, which was 14.1% lower than the score of 0.99 at peer facilities. At the same time, the expense per adjusted discharge was $4,775 at the top hospitals, 13.2% lower than the $5,503 at peer hospitals. This is likely due, in part, to a 10% shorter length of stay at the top hospitals compared with peer hospitals (4.93 vs 5.48 days). [Wilson/2]

21. 21 Success Stories The following describes some success stories related to patient safety. The following describes some success stories related to patient safety.

22. 22 Success Story:Institute for Healthcare Improvement5 Million Lives Campaign Goal prevent 5 million incidents of medical harm during 2007-2008 Objectives Prevent pressure ulcers Reduce methicillin-resistant S. aureus infection Prevent harm from high-alert medications Reduce surgical complications Deliver reliable, evidence-based care for congestive heart failure Gets boards on board The goal of the 5 Million Lives Campaign, which was sponsored by the Institute for Healthcare Improvement, was to support the improvement of medical care in the US by significantly reducing current levels of morbidity and mortality. The specific goal was to prevent 5 million incidents of medical harm during the period December 12, 2006 through December 9, 2008. [IHI-5 Million/4] In addition to the six goals of the 100,000 Lives Campaign, the 5 Million Lives Campaign encouraged hospitals and other health care providers to take the following steps to reduce harm and deaths {IHI-5 Million/10]: Prevent pressure ulcers by reliably using science-based guidelines. Reduce methicillin-resistant Staphylococcus aureus (MRSA) infection through basic changes in infection control processes throughout the hospital. Prevent harm from high-alert medications starting with a focus on anticoagulants, sedatives, narcotics, and insulin. Reduce surgical complications by reliably implementing the changes in care recommended by the Surgical Care Improvement Project. Deliver reliable, evidence-based care for congestive heart failure to reduce readmission. Get boards on board by defining and spreading new and leveraged processes for hospital boards of directors so that they can become far more effective in accelerating the improvement of care. The goal of the 5 Million Lives Campaign, which was sponsored by the Institute for Healthcare Improvement, was to support the improvement of medical care in the US by significantly reducing current levels of morbidity and mortality. The specific goal was to prevent 5 million incidents of medical harm during the period December 12, 2006 through December 9, 2008. [IHI-5 Million/4] In addition to the six goals of the 100,000 Lives Campaign, the 5 Million Lives Campaign encouraged hospitals and other health care providers to take the following steps to reduce harm and deaths {IHI-5 Million/10]: Prevent pressure ulcers by reliably using science-based guidelines. Reduce methicillin-resistant Staphylococcus aureus (MRSA) infection through basic changes in infection control processes throughout the hospital. Prevent harm from high-alert medications starting with a focus on anticoagulants, sedatives, narcotics, and insulin. Reduce surgical complications by reliably implementing the changes in care recommended by the Surgical Care Improvement Project. Deliver reliable, evidence-based care for congestive heart failure to reduce readmission. Get boards on board by defining and spreading new and leveraged processes for hospital boards of directors so that they can become far more effective in accelerating the improvement of care.

23. 23 Success Story:Institute for Healthcare Improvement5 Million Lives Campaign (cont.) 4050 hospitals enrolled Results 65 hospitals had no cases of ventilator-associated pneumonia for a year or more 35 hospitals had no cases of a central-line associated bloodstream infection in at least 1 ICU In New Jersey, the incidence of pressure ulcers declined 70% By the end of the campaign in December 2008, 4050 hospitals had enrolled in the campaign. [IHI-5 Million/2] Preliminary results of the 5 Million Lives Campaign (and 100,000 Lives Campaign) indicate the following [IHI/3]: 65 hospital reported going a year or more without a case of ventilator-associated pneumonia 35 hospitals reported going a year or more without a case of central line-associated bloodstream infection in at least one ICU New Jersey reported a 70% reduction in pressure ulcers Rhode Island reported a 42% decrease in central-line associated bloodstream infections from 2006-2007 By the end of the campaign in December 2008, 4050 hospitals had enrolled in the campaign. [IHI-5 Million/2] Preliminary results of the 5 Million Lives Campaign (and 100,000 Lives Campaign) indicate the following [IHI/3]: 65 hospital reported going a year or more without a case of ventilator-associated pneumonia 35 hospitals reported going a year or more without a case of central line-associated bloodstream infection in at least one ICU New Jersey reported a 70% reduction in pressure ulcers Rhode Island reported a 42% decrease in central-line associated bloodstream infections from 2006-2007

24. 24 Success Story:Butler County Health Care CenterImplementation of TeamSTEPPS Goal: Overcome communication barriers among staff and improve workplace culture Implementation of TeamSTEPPS Our Iceberg Is Melting The Magic Wand exercise Butler County Health Care Center began to implement the TeamSTEPPS� program developed by the Institute for Healthcare Improvement. During this process, it was realized that a culture change within the organization was needed to overcome communication and work barriers among staff. [Butler/1, 2] Training included reading the book Our Iceberg Is Melting and participating in The Magic Wand exercise. Following implementation, a variety of tactics were employed to reinforce the culture change and keep the TeamSTEPPS� program in front of the staff. [Butler/1, 2] Butler County Health Care Center began to implement the TeamSTEPPS� program developed by the Institute for Healthcare Improvement. During this process, it was realized that a culture change within the organization was needed to overcome communication and work barriers among staff. [Butler/1, 2] Training included reading the book Our Iceberg Is Melting and participating in The Magic Wand exercise. Following implementation, a variety of tactics were employed to reinforce the culture change and keep the TeamSTEPPS� program in front of the staff. [Butler/1, 2]

25. 25 Success Story:Butler County Health Care CenterImplementation of TeamSTEPPS (cont.) Results: Improved staff collaboration, especially at times when patient conditions and workloads were challenging The results included staff feedback describing examples of how staff have worked together better, especially at times when patient conditions and workloads were challenging. [Butler/1, 3] The results included staff feedback describing examples of how staff have worked together better, especially at times when patient conditions and workloads were challenging. [Butler/1, 3]

26. 26 Success Story:UMass MemorialUSP Chapter <797> Goal: Comply with USP Chapter <797> Multidisciplinary approach that examined: Product selection Medication storage Dispensing methods The University of Massachusetts Memorial Medical Center sought to comply with USP Chapter <797>. To accomplish this, they involved medical, surgical, and nursing staff to examine their current process for providing IV medications. This examination considered product selection, medication storage, and dispensing methods. [Brown/1, 2, 4] The University of Massachusetts Memorial Medical Center sought to comply with USP Chapter <797>. To accomplish this, they involved medical, surgical, and nursing staff to examine their current process for providing IV medications. This examination considered product selection, medication storage, and dispensing methods. [Brown/1, 2, 4]

27. 27 Success Story:UMass MemorialUSP Chapter <797> (cont.) Steps Assess current risk level Perform gap analysis Develop source hierarchy for compounded IV solutions Training & implementation Monitoring The first step was to assess the risk level of compounding services currently performed by the hospital pharmacy. [Brown/2] The next step was to perform a gap analysis to compare the hospital�s current compounding practices and operational facilities to those recommended in USP Chapter <797>. [Brown/2, 3] The first step in the action plan was to establish a new source hierarchy for compounded IV solutions within the hospital pharmacy. The hierarchy was developed based on the proceedings of the ASHP Consensus Conference, as well as guidelines included in USP Chapter <797> itself and by the Joint Commission. The hierarchy provided a framework for pharmacists to use when a compounded product was required. [Brown/2, 5] Implementation of the source hierarchy was used to reduce the level of compounding risk. This resulted in maximizing the use of automated dispensing machine storage of premixed and point-of-care activated IV medications. [Brown/2, 7] Staff education was the most significant part of the process and took more time and resources than initially anticipated. [Brown/2, 1] Follow up monitoring was accomplished. [Brown/3, 7] The first step was to assess the risk level of compounding services currently performed by the hospital pharmacy. [Brown/2] The next step was to perform a gap analysis to compare the hospital�s current compounding practices and operational facilities to those recommended in USP Chapter <797>. [Brown/2, 3] The first step in the action plan was to establish a new source hierarchy for compounded IV solutions within the hospital pharmacy. The hierarchy was developed based on the proceedings of the ASHP Consensus Conference, as well as guidelines included in USP Chapter <797> itself and by the Joint Commission. The hierarchy provided a framework for pharmacists to use when a compounded product was required. [Brown/2, 5] Implementation of the source hierarchy was used to reduce the level of compounding risk. This resulted in maximizing the use of automated dispensing machine storage of premixed and point-of-care activated IV medications. [Brown/2, 7] Staff education was the most significant part of the process and took more time and resources than initially anticipated. [Brown/2, 1] Follow up monitoring was accomplished. [Brown/3, 7]

28. 28 Success Story:UMass MemorialUSP Chapter <797> (cont.) General benefits Increase in patient safety, improved efficiency, improved documentation Specific benefits included: Improved integrity of each sterile product Improved labeling Tighter drug security Better accessibility of first doses Increased production capacity by the Pharmacy Decreased waste expense Improved relations between Nursing and Pharmacy staff The general benefits of complying with USP Chapter <797> requirements were an increase in patient safety, improved efficiency, and improved documentation. [Brown/3, 6] Specific benefits included [Brown/3, 5]: Improved integrity of each sterile product Improved labeling Tighter drug security Better accessibility of first doses Increased production capacity by the Pharmacy Decreased waste expense Improved relations between Nursing and Pharmacy staff In addition, greater use of the automated dispensing machine resulted in decreased turnaround time for profiled orders compared to pharmacy compounded patient specific doses. Discontinued doses became immediately not available when the order was profiled, which added to patient safety. The use of ready-to-use medications reduced delays in administration and eliminated omitted and extra doses. [Brown/2, 3, 7] The general benefits of complying with USP Chapter <797> requirements were an increase in patient safety, improved efficiency, and improved documentation. [Brown/3, 6] Specific benefits included [Brown/3, 5]: Improved integrity of each sterile product Improved labeling Tighter drug security Better accessibility of first doses Increased production capacity by the Pharmacy Decreased waste expense Improved relations between Nursing and Pharmacy staff In addition, greater use of the automated dispensing machine resulted in decreased turnaround time for profiled orders compared to pharmacy compounded patient specific doses. Discontinued doses became immediately not available when the order was profiled, which added to patient safety. The use of ready-to-use medications reduced delays in administration and eliminated omitted and extra doses. [Brown/2, 3, 7]

29. 29 Success Story:OSF/St. Joseph Medical CenterAdverse Drug Events Goal: Reduce the number of adverse drug events Multidisciplinary training in collaboration with the Institute for Healthcare Improvement The Order of St. Francis/St. Joseph Medical Center sought to reduce the incidence of adverse drug events by 50%. To accomplish this, they collaborated with the Institute for Healthcare Improvement. A multidisciplinary team representing administration, medical staff, nursing, and pharmacy underwent training over one year. [OSF/1, 4] The Order of St. Francis/St. Joseph Medical Center sought to reduce the incidence of adverse drug events by 50%. To accomplish this, they collaborated with the Institute for Healthcare Improvement. A multidisciplinary team representing administration, medical staff, nursing, and pharmacy underwent training over one year. [OSF/1, 4]

30. 30 Success Story:OSF/St. Joseph Medical CenterAdverse Drug Events (cont.) Tools Cultural survey Medication reconciliation process Dispensing failure mode effect analysis High-risk medication events A variety of services were established Aims and goals were established using tools and other resources developed by the Institute for Healthcare Improvement. These included maintaining a cultural survey score above 4, use of the medication reconciliation process, reduction in the dispensing failure mode effect analysis, and reduction of events occurring with high-risk medications. [OSF/1, 2] The hospital also established a variety of services, including a standardized heparin nomogram; pharmacy coumadin, total parenteral nutrition, and renal dosing services; patient-controlled analgesia and total peripheral nutrition order sets. Pharmacists were also made available on patient units to review and enter medication orders. [OSF/5] Aims and goals were established using tools and other resources developed by the Institute for Healthcare Improvement. These included maintaining a cultural survey score above 4, use of the medication reconciliation process, reduction in the dispensing failure mode effect analysis, and reduction of events occurring with high-risk medications. [OSF/1, 2] The hospital also established a variety of services, including a standardized heparin nomogram; pharmacy coumadin, total parenteral nutrition, and renal dosing services; patient-controlled analgesia and total peripheral nutrition order sets. Pharmacists were also made available on patient units to review and enter medication orders. [OSF/5]

31. 31 Success Story:OSF/St. Joseph Medical CenterAdverse Drug Events (cont.) After 2 years, the adverse event rate declined from 5.8 (June 2001) to 0.50 (May 2003) per 1000 doses dispensed. [OSF/2] This decrease occurred despite the implementation of a hotline for anonymously reporting a suspected adverse drug event. [OSF/2] Implementation of a medication reconciliation process at admission, transfer, and discharge was believed to be important in the decline of adverse drug events. [OSF/3] After 2 years, the adverse event rate declined from 5.8 (June 2001) to 0.50 (May 2003) per 1000 doses dispensed. [OSF/2] This decrease occurred despite the implementation of a hotline for anonymously reporting a suspected adverse drug event. [OSF/2] Implementation of a medication reconciliation process at admission, transfer, and discharge was believed to be important in the decline of adverse drug events. [OSF/3]

32. 32 Success Story:DuBois Regional Medical CenterMedication Reconciliation Goal: To address problems related to medication reconciliation Multidisciplinary committee drafted a policy, process, and departmental responsibilities To comply with The Joint Commission mandate for medication reconciliation, DuBois Medical Regional Medical Center convened a multidisciplinary committee to address problems related to medication reconciliation. The committee consisted of representatives from nursing, pharmacy, performance improvement, management information systems, risk management and regulatory compliance, patient safety, and ad hoc physicians from the medical staff, health information management, and education and utilization review. As part of the process, the committee reviewed policies and procedures from other institutions. [Wortman/2048] A draft policy was developed along with a flow chart outlining the process and defining responsibilities for reconciliation at each step from admission through discharge. Preprinted order forms and prescriptions were formatted and added to the process. [Wortman/2048] To comply with The Joint Commission mandate for medication reconciliation, DuBois Medical Regional Medical Center convened a multidisciplinary committee to address problems related to medication reconciliation. The committee consisted of representatives from nursing, pharmacy, performance improvement, management information systems, risk management and regulatory compliance, patient safety, and ad hoc physicians from the medical staff, health information management, and education and utilization review. As part of the process, the committee reviewed policies and procedures from other institutions. [Wortman/2048] A draft policy was developed along with a flow chart outlining the process and defining responsibilities for reconciliation at each step from admission through discharge. Preprinted order forms and prescriptions were formatted and added to the process. [Wortman/2048]

33. 33 Success Story:DuBois Regional Medical CenterMedication Reconciliation (cont.) Unreconciled medications (24 months) Admission: 14% ? < 5% Discharge: 15% ? < 5% Postoperative and transfer: 9.7% A pilot program was implemented and the medication reconciliation system fine-tuned. Implementation hospital-wide followed. Twenty-four months following implementation, the percentage of unreconciled medications decreased from 14% to less than 5% at admission and from 15% to less than 5% at discharge. At study end, 9.7% of medications were unreconciled postoperatively and at transfer. [Wortman/2052, 2053] A pilot program was implemented and the medication reconciliation system fine-tuned. Implementation hospital-wide followed. Twenty-four months following implementation, the percentage of unreconciled medications decreased from 14% to less than 5% at admission and from 15% to less than 5% at discharge. At study end, 9.7% of medications were unreconciled postoperatively and at transfer. [Wortman/2052, 2053]

34. 34 Success Story:Children�s Hospital of Eastern OntarioStandard Concentrations of High-Alert Infusions Goal: Reduce the risk of medication errors involving high-alert infusions in pediatric patients Standardized concentrations were implemented following stakeholder consultations, development of a computer program, and educating and testing staff To reduce the risk of medication errors in pediatric patients, the Children�s Hospital of Eastern Ontario implemented a practice of standard concentrations of high-alert drug infusions in the emergency department, operating room, and pediatric intensive care unit. [Irwin/371] The change in practice involved addressing concerns raised during stakeholder consultations, developing a computer program, and educating and testing staff in the new method. [Irwin/371] To reduce the risk of medication errors in pediatric patients, the Children�s Hospital of Eastern Ontario implemented a practice of standard concentrations of high-alert drug infusions in the emergency department, operating room, and pediatric intensive care unit. [Irwin/371] The change in practice involved addressing concerns raised during stakeholder consultations, developing a computer program, and educating and testing staff in the new method. [Irwin/371]

35. 35 Fluid overload in lower weight children was a concern, but found to not occur The incidence of adverse events involving high-alert medications remained unchanged from pre-implementation Reporting pre-implementation was low Reporting doubled following the availability of online reporting The major barrier to acceptance was possible fluid overload in lower weight patients. Investigation showed this to not be a problem. [Irwin/371] A survey of nurses and physicians showed that 95% believed that standard concentrations improved patient safety, 95% believed that standard concentrations improved continuity of care, and 77% believed that standard concentrations decreased drug delivery time. [Irwin/374] The incidence of related events, which was low prior to implementation, remained low. During 19 months post-implementation, only three errors were reported. [Irwin/374] The number of medication-related incidents reported doubled over three months following implementation of online reporting. [Irwin/374] The major barrier to acceptance was possible fluid overload in lower weight patients. Investigation showed this to not be a problem. [Irwin/371] A survey of nurses and physicians showed that 95% believed that standard concentrations improved patient safety, 95% believed that standard concentrations improved continuity of care, and 77% believed that standard concentrations decreased drug delivery time. [Irwin/374] The incidence of related events, which was low prior to implementation, remained low. During 19 months post-implementation, only three errors were reported. [Irwin/374] The number of medication-related incidents reported doubled over three months following implementation of online reporting. [Irwin/374]

36. 36 Success Story:Poudre Valley HospitalMedical Response Team Goal: To help patients whose health might quickly decline and act before a change turns into an emergency Implementation of a medical response team Poudre Valley Hospital implemented a medial response team to help patients whose health might quickly decline and act before a change turns into an emergency. [PVH/3] The medical response team was a mobile intensive care unit that consisted of a highly trained ICU nurse and a respiratory therapist. [PVH/3] The team responded to a call from a nurse in another part of the hospital who felt the patient�s condition was deteriorating, but needed specialized assistance. [PVH/3] Poudre Valley Hospital implemented a medial response team to help patients whose health might quickly decline and act before a change turns into an emergency. [PVH/3] The medical response team was a mobile intensive care unit that consisted of a highly trained ICU nurse and a respiratory therapist. [PVH/3] The team responded to a call from a nurse in another part of the hospital who felt the patient�s condition was deteriorating, but needed specialized assistance. [PVH/3]

37. 37 Success Story:Poudre Valley HospitalMedical Response Team Result: 33 patients rescued over a 3-month period Assistance provided to 34 more inpatients Code blue rate dropped from 7.3 to 4.8 per 1000 inpatients Nursing satisfaction: 4.75 out of 5 After a brief pilot period, which proved very successful, the program was quickly implemented hospital-wide. During a 3-month period, the team rescued 33 patients whose conditions were getting worse or were in danger of doing so. The team lent assistance to the care of an additional 34 patients. [PVH/3] As a result of the medical response team, the code blue rate dropped from 7.3 to 4.8 per 1000 inpatients. [PVH/3] In addition, nursing staff gave the medical response team a rating of 4.75 out of 5. After a brief pilot period, which proved very successful, the program was quickly implemented hospital-wide. During a 3-month period, the team rescued 33 patients whose conditions were getting worse or were in danger of doing so. The team lent assistance to the care of an additional 34 patients. [PVH/3] As a result of the medical response team, the code blue rate dropped from 7.3 to 4.8 per 1000 inpatients. [PVH/3] In addition, nursing staff gave the medical response team a rating of 4.75 out of 5.

38. 38 Success Stories Successful hospitals don�t go it alone Collaboration with Employers Payers Competitors Patients Success isn�t necessarily limited to involving hospital staff. Analysis of the 100 Top Hospitals: National Benchmarks for Success list from Thomson Reuters Corp. show that many of these successful hospitals have taken collaboration to new heights. For example, the Wisconsin Collaborative for Healthcare Quality included hospitals, competitors, and employers. The Michigan Health & Hospital Association's Keystone Center for Patient Safety & Quality involved competitors and Blue Cross and Blue Shield of Michigan. Genesys Regional Medical Center in Grand Blanc, Michigan, and General Motors shared cost/quality data to make rate negotiations clearer and more rational. [Chenoweth/1] The Order of St. Francis/St. Joseph Medical Center has taken numerous steps to involve patients in their care and to critique their care. Examples include interviewing 10 patients per month, providing health information via the hospital�s television system, and encouraging patients to be actively involved in their care by asking questions about their treatment and reminding staff and visitors of the importance of handwashing. [OSF/7] Success isn�t necessarily limited to involving hospital staff. Analysis of the 100 Top Hospitals: National Benchmarks for Success list from Thomson Reuters Corp. show that many of these successful hospitals have taken collaboration to new heights. For example, the Wisconsin Collaborative for Healthcare Quality included hospitals, competitors, and employers. The Michigan Health & Hospital Association's Keystone Center for Patient Safety & Quality involved competitors and Blue Cross and Blue Shield of Michigan. Genesys Regional Medical Center in Grand Blanc, Michigan, and General Motors shared cost/quality data to make rate negotiations clearer and more rational. [Chenoweth/1] The Order of St. Francis/St. Joseph Medical Center has taken numerous steps to involve patients in their care and to critique their care. Examples include interviewing 10 patients per month, providing health information via the hospital�s television system, and encouraging patients to be actively involved in their care by asking questions about their treatment and reminding staff and visitors of the importance of handwashing. [OSF/7]

39. 39 Summary Quality and patient safety is a team sport The team should not be limited to staff Numerous toolkits and resources are available Improved quality and patient safety often leads to reduced costs

40. 40 References Institute of Medicine. To Err Is Human: Building A Better Health System. Available at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf. Accessed September 28, 2009. 2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Available at: http://www.iom.edu/CMS/8089/5432/27184.aspx. Accessed September 28, 2009. 3. The Joint Commission. 2009 National patient safety goals hospital program. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_hap_npsgs.htm Accessed September 28, 2009. 4. Centers for Medicare and Medicaid Services. CMS improves patient safety for medicare and medicaid by addressing �never events.� Available at: http://www.workforce.com/tools/misc/fs11_never_events_081001.pdf. Accessed September 28 , 2009. 5. Healthleaders Media. Industry survey- CEO. 2009. Available at: http://www.healthleadersmedia.com/pdf/survey_project/2008-2009/CEO_final.pdf. Accessed September 28, 2009. Healthleaders Media. Industry survey- Finance. 2009. Available at: http://www.healthleadersmedia.com/pdf/survey_project/2008-2009/Finance_final.pdf. Accessed September 28, 2009. 7. Pulse Report 2009. Safety culture- Staff Perspectives on American Health Care. Available at: http://www.pressganey.com/galleries/default-file/Safety_Culture_Pulse_Report_2009.pdf. Accessed September 28, 2009. 8. Agency for Healthcare Research and Quality. Hospital survey on patient safety culture: 2009 comparative database report. Available at: . Accessed September 28, 2009.

41. 41 References (cont.) 9. Institute of Medicine. To Err Is Human: Building A Better Health System. Available at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf. Accessed September 28, 2009. The Joint Commission. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_43.htm. Accessed September 28, 2009. The Joint Commission. Available at: http://www.jointcommission.org/NewsRoom/NewsReleases/nr_8_27_09.htm. Accessed September 28, 2009. Clancy C. Physicians and nurses together can improve patient safety. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2270882. Accessed September 28, 2009. The Joint Commission. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_43.htm. Accessed September 28, 2009. Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA. 2008;299:445-447. 15. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Available at: http://www.iom.edu/CMS/8089/5432/27184.aspx. Accessed September 28, 2009. 16. Wong DR, Torchiana DF, Vander Salm TJ, Agnihotri AK, Bohmer RM, Ali IS. Impact of cardiac intraoperative precursor events on adverse outcomes. Surgery. 2007;141:715-722. 17. American Nurses Association. 2007 Study of injectable medication errors. Available at: http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/OccupationalResources/ANA2007StudyofInjectableMedicationErrors.aspx. Accessed September 29, 2009.

42. 42 References (cont.) Pathways for Medication Safety. Available at: http://www.medpathways.info/medpathways/content/Pathways_brochure.pdf. Accessed September 29, 2009. Institute for Healthcare Improvement. Patient safety leadership walkrounds. Available at: http://www.ihi.org/NR/rdonlyres/53C62FFD-CC4A-4DEA-A869-83B575DCEED8/640/WalkRounds1.pdf. Accessed September 29, 2009. Institute for Healthcare Improvement. Safety briefings. Available at: http://www.ihi.org/NR/rdonlyres/971CB2E8-4E23-448D-92BD-D680B4F62EA3/639/SafetyBriefings.pdf. Accessed September 29, 2009. Institute for Healthcare Improvement. Tools. Safety: General. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/. Accessed September 29, 2009. Agency for Healthcare Research and Quality. TeamSTEPPS. Available at: http://teamstepps.ahrq.gov/about-2cl_3.htm. Accessed September 29, 2009 Conway J. Strategies for leadership. Hospital executives and their role in patient safety. Available at: http://www.dana-farber.org/pat/patient-safety/patient-safety-resources/docs/patient-safety-organizational-assessment.pdf. Accessed September 30, 2009. San Diego Patient Safety Consortium. Getting started kit: Safe administration of high-risk IV medications. Available at: http://www.hasdic.org/documents/Tool-Kit-High-Risk.pdf. Accessed September 30, 2009.

43. 43 References (cont.) Wilson L. Rising to the top. Modern Healthcare. 2008;38:26,28-30. The Institute for Healthcare Improvement. Protecting 5 million lives from harm. Available at: http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=6. Accessed September 30, 2009. Institute for Healthcare Improvement. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/ImprovementStories/ProactiveApproachesReduceHarmHighAlertMeds.htm. Accessed October 2, 2009. Brown D. Implementing the recommendations of the consensus development conference: The road to compliance. In press. Institute for Healthcare Improvement. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/ImprovementStories/JourneyTowardsSafetyACulturalRevolution.htm. Accessed September 30, 2009. Wortman SB. Medication reconciliation in a community, nonteaching hospital. Am J Health-Syst Pharm. 2008;65:2047-2054. Irwin D, Vaillancourt R, Dalgleish D, et al. Standard concentrations of high-alert infusions across paediatric acute care. Paediatr Child Health. 2008;13:371-376. Poudre Valley Hospital. New teamwork helps patients. Available at: https://vic.pvhs.org/pls/portal/docs/PAGE/PVHS/PVHS_DOCUMENT_MGMT2/DOC_ABOUT_US/ABOUT%20PVHS%20QR%20%2311%20PATIENT%20SAFETY%20WEB%20FINAL.PDF. Accessed October 2, 2009. 33. Chenoweth J. Midwest raises the bar. Modern Healthcare. 2008;38(Suppl6):1.