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In Conversation with…Jennifer Daley, MD
Editor's note: Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the organization for the 6000 physicians employed/affiliated with Partners HealthCare System (which includes Massachusetts General and Brigham & Women's Hospitals). From 2002 to 2007, she was the Chief Medical Officer for Tenet Healthcare, one of the nation's largest hospital systems, where she was responsible for the development and implementation of Tenet's Commitment to Quality (C2Q). Her academic background (including her previous directorship of the Center for Health Systems Design and Evaluation in the Institute for Health Policy at Massachusetts General Hospital and Partners HealthCare) and her years of leadership at a huge multistate private sector system provide her with a unique perch from which to view patient safety implementation in complex systems.
Dr. Robert Wachter, Editor, AHRQ WebM&M: You've now been involved in trying to improve safety in both a community-based, very large multihospital organization and at very large academic institutions. What are the major differences and the major similarities?
Dr. Jennifer Daley: Let me start with the similarities. I think they're all equally challenged in improving patient safety. Regardless of whether it's academic or community hospitals, people are so focused on making sure the trains run on time in patient care that they often don't have the time to sit back and decide what to focus on in terms of improving safety. Then they have a hard time assessing in a comprehensive way the clinical and operational systems that need fixing so that they're safer. One of the contrasts between Tenet and Partners is the role of the corporate center. At Tenet, the staff at the corporate center would do the research on what the latest advances in patient safety were. Then we sent "transformation teams" to work side by side with the hospital staff to figure out what the opportunities were at the local level and then work with them on site for a few weeks to help them implement new ways to make patient care safer. We could document the improvements and support achieving the safety targets we had established as a system (like reducing hospital-associated infections). In the system I'm in now, there are so many capable resources at both the community hospitals and the academic centers that at the corporate level we have more of a convening function. Still, it involves a lot of coordination, a lot of dialogue, and a lot of encouragement. Sometimes safety improvements are generated when bad things happen to good people. Creating an environment where people feel safe in sharing a serious adverse occurrence and sharing what other hospitals or other practices in the system have done to close the gap is absolutely essential.
RW: When you're sitting in "mission control," how can you have a handle on what's happening in 100 different hospitals around the country?
JD: We had an occurrence reporting system. If anything was reported to a state Department of Public Health or the Joint Commission, those all came through my office and my staff reviewed them all. The average size of a Tenet Hospital is about 150 beds, so these things happen infrequently. But we could identify patterns that individual hospitals couldn't see. For example, how many wrong-site, wrong-side surgeries did they have, and then come up with the policies, procedures, and oversight system to make sure that changes were made. We took on the NQF Safe Practices. In many community hospitals with only 150 beds, they just don't have the staff to keep up with everything that's happening in the field of safety. So they were appreciative that we had a corporate-wide committee with hospital, corporate, and specialist represpresentation that was proactively coming up with policies, procedures, and implementation and tracking tools.
RW: What's the role of data when you're sitting centrally in a large organization? What are the elements of a dashboard that you might follow centrally?
JD: We built a very comprehensive clinical quality dashboard for the company. It incorporated a lot of things other than safety. But in the safety arena, I'll just pick one example. We had some process and structure measures when we began because we had to make sure that everybody had the infrastructure needed to do this appropriately. When I left, we were installing a very robust risk management and patient safety system from a company called Quantros. It replaced a somewhat rickety risk management system that the hospitals had. The risk managers and the patient safety officers just love this new system. So we did a combination of make and buy. What we did have to make was a hospital-associated infection reporting system, which was built with our IT partner, Perot Systems, which basically tracks device days and hospital-associated infections for central venous lines, catheter-associated urinary tract infections (UTIs), and ventilator-associated pneumonias. When I left, they were building up the modules for MRSA [methicillin-resistant Staphylococcus aureus], C-Diff [Clostridium difficile], and vancomycin resistance. In time, it will also have the antibiotic resistance patterns on them so that we could actually look at patterns across hospitals. Accurately tracking hospital-associated infections per thousand device days created a lot of conversations! I think some hospital administrators believe that hospital-associated infections are the "cost of doing business." But we were able to show them that it was possible to reduce the incidence of these infections. And we gave them an incentive in that 10% of their entire annual at-risk compensation was driven by their ability to drive down the rates of health care–associated infections. Although skeptics in the group doubted that would actually result in improvement, we saw the overall rate of those health care–associated infections drop by 50% within 18 months of implementation. Some hospitals had moved to such a low rate that they were actually measuring days since last infection. We were implementing all the best practices that came from IHI [Institute for Healthcare Improvement] and other sources. But it resulted in a dramatic decrease in hospital-associated infections.
RW: Can you talk about the role of physicians and the challenges of working with physicians in a very large organization like Tenet, where I assume that most of the physicians don't work for the organization?
JD: As a matter of fact, out of 21,000 affiliated physicians, only about 400 were employed by the organization. Many physicians were hard to engage because they're so busy. But the administration of the hospitals engaged them—the intensivists in the ICUs and the surgeons placing central lines. And we were transparent about the results. We also knew that most of the states in which Tenet operates were shifting to public reporting within a short time. I won't tell you that there weren't a few doctors here and there who didn't want a nurse assisting in a central line placement to stop them when they weren't appropriately gowned and gloved. We had good regional leadership on the part of our regional CMOs [Chief Medical Officers], and, in the larger hospitals, a Vice President of Medical Affairs or CMOs. When one of them presented the data and the ways in which one could improve, most of the doctors got on board.
RW: Talk about the role of reporting. I can imagine that you might hear about a case with a terrible outcome from one particular hospital, and your instinct might be that it would be great to have 50 hospitals learn of this case. Yet all of the understandable challenges of disseminating that kind of information—with medical-legal challenges and newspapers—how do you balance that?
JD: Because we could track what was happening within the system and we knew what the incidence of "serious reportable events" was, as I was leaving, we were creating what I call Post-it Notes. They aren't really policies and procedures. They look more like a Post-it Note on an 8 by 11 piece of paper. And it would summarize a case in a de-identified way, and then it would have all the things that front-line clinical staff could do to improve. The intent was to disseminate those broadly to nursing units and doctors' lounges. So rather than a dry policy and procedure, it was more like, "Here's a little vignette of what happens when patients are harmed and here's what you can do about it." You could never trace it to any particular hospital, but it captured all the salient features of some of the terrible things that happened. And then there would be, for example, the four things you or your unit can do, to make sure this doesn't happen at your hospital.
RW: How do you structure things so that, at the level of an individual hospital, people feel comfortable with the central office? That it doesn't feel punitive, it feels supportive. I assume there's some tension there—even though centrally you are trying to help, at the level of an individual hospital, sometimes it feels like Big Brother watching.
JD: When I got to Tenet, people would say—and this is my favorite statement about corporate—"People from corporate are like seagulls. They fly in, eat your lunch, dump on your head, and fly out." And it took us a lot of education and training and feedback to change that. The system had always had 25 or so people who had been going out and working with the hospitals to ensure that they were Joint Commission ready at any time. Those people always had a great reputation, because everyone knew they were there to help. Over the time I was at Tenet, we went from announced to unannounced visits. Then we built the transformation team approach, when we were going in and picking the top things that a particular hospital could improve from a balanced scorecard perspective. Initially people were skeptical, but when you start addressing problems that really bother the doctors and nurses, which they haven't been able to get fixed because there are system problems—when you show them a system approach, most of them really go for it because it's the scientific method applied to hospital operations. But it was never our intent to go in and be punitive or critical. It was to help them provide better patient care. And I think that over time (I just kept saying it until I was blue in the face), most of them believed me.
RW: You talk about the scientific method and people instinctively appreciating that. I can imagine that the reaction to the science of safety probably differs substantially as you do things at Tenet versus doing things at Partners. Can you contrast the differences? I imagine that sometimes it's easier and sometimes it's harder in both places.
JD: In some of the community hospitals in Tenet, I would say that, because people are so busy, they don't actually have the time to read or explore current evidence and "best practices" as much as in academic settings. So we could bring them the latest evidence and we could classify the evidence in such a way that we would bring them the most accurate, reliable, and compelling reasons to change a particular approach. At Tenet, the resistance was often from people who hadn't kept up as much with the latest. My experience was that I would get calls from physicians or nurses who say, "This isn't right." I would send them a précis of the latest evidence and say: "Well can you show me evidence to the contrary?" Sometimes it was awkward, but generally they would come around. I think here at Partners, the level of evidence has to be so pristine that sometimes it gets in the way of meaningful change. Every "i" and "t" has to be dotted. I think the evidence that we need to make improvements in safety probably doesn't have to meet the 95% confidence interval, but it has to be high enough so that it's meaningful and directional. We're willing to make experiments of change and follow what happens and make sure we don't have any unintended consequences. Sometimes requiring absolutely randomized controlled trial evidence that a particular safety intervention works just isn't going to happen.
For example, we're not going to do a randomized trial of washing your hands. I do think that there are some recent experiences here at both the Brigham and the Mass General where they've made extraordinary improvements in hand washing. We all know that that's the right thing to do, but concomitantly they've seen a dramatic decrease in MRSA. It's hard to know in massive tests of change whether that is association or causation, but I'll tell you people feel pretty good about it. It wasn't just the infection control people; the CEO of the hospital, who happens to be a physician, took a personal interest in this issue. And he talks about it all the time. So there is leadership. And then there's a small bonus to every employee in the hospital associated with hand washing, which really—I mean it's nominal, but it empowers everybody. So the anecdote that I heard recently is: There was a chaplain visiting a patient at the Mass General, and a caregiver came in and the chaplain reminded the caregiver to wash his hands! So everybody is invested, from the CEO of the hospital right down to front-line staff, and environmental services and the chaplain service. And they've gone from 60% adherence (the national rate) to 90%.
RW: What was the role at Tenet of shared IT? Was there shared IT across all the institutions, and how important is that to try to centrally manage something this complex?
JD: Tenet has no shared common informatics platform for clinical care. They're working toward that, but it will take a while. The clinical information systems are extremely diverse. We did build a common platform for any important clinical data relevant to either core measures or patient safety or utilization management—whatever was in our portfolio for improvement. We were able to build interfaces with the existing clinical systems so that it powered a real-time quality monitoring system. On the other hand, Partners is deeply invested in electronic medical records for computerized physician order entry in the hospital, and by 2 weeks from now, 96% of our primary care physicians in the network, which is about 2000 of them, will be on an entirely electronic ambulatory medical record. The specialists have a target for next year to achieve 100% use of the ambulatory medical record. Having worked in an environment where there's nothing like that and an environment where there is something like that, I can see they both have their strengths. The ability of smaller community hospitals, critical access hospitals, or even significant good-sized community hospitals to have the capital and resources to install a progressive computerized physician order entry and data repository is out of the reach of many hospitals financially. As much as I would like to see it as the end all–be all of solving all the safety problems that we have, I think it's not realistic. We have to come up with other systems or toolkits to help them achieve standardization of systems that don't rely on having an electronic record.
RW: An organization like Tenet that's a for-profit organization and has been the subject of some media scrutiny, how does that change the burden as it relates to safety?
JD: I was brought to Tenet to transform the level of quality in those hospitals after enormous public scrutiny of their clinical care as well as some of their financial practices. We accomplished a great deal in the 5 years I was there. For Tenet, it created a burning platform, because they were in so much trouble with the public's perception of their quality of care. One of them was the utilization of procedures in patients who didn't need them, and the general perception that the level of care was not as good as it could be. They had to do something about it. As a result, they were very supportive, both financially and in terms of leadership. I had the distinct privilege of having my CEO be the sponsor for the entire Commitment to Quality program. Tenet considered it a wonderful investment because, with the tracking system we created, they were able to see that the quality of the care kept getting better every quarter. We had the data to show skeptics that we were improving. It also made the people at the bedside feel really good that they had been able to change and improve. They could tell their neighbors about it and talk to the patients about it. So it was a transformative experience for them. Here at Partners, people do an exceptional job, but they are very devastated, just like anyone would be or any organization would be, if they have a serious medical error. They take it very seriously and are very committed to systems change, root cause analysis, best practice sharing, and problem solving. Everyone knows that it happens at every hospital at some point, but they are totally dedicated to fixing the system problems when they identify them.
Perspective
Hospitals and health systems across the United States are struggling to put strategies and structures in place to improve patient safety at their institutions. This article will share the safety and quality journey of Adventist Heath System (AHS), the largest Protestant not-for-profit health care system in the United States.
Background and Philosophy
AHS consists of 36 hospital campuses in geographically varied locations, ranging from small rural facilities to large tertiary urban medical centers. The AHS hospitals are located in ten states. Seven of these hospitals have fewer than 100 beds, twelve have between 100 and 250 beds, and four have more than 250 beds; the total number of beds in the system is 6156. The largest AHS hospital includes approximately 2000 beds on seven campuses, making it essentially a "health system within a health system." In calendar year 2006, AHS hospitals had 302,784 admissions.(1)
The AHS journey toward high quality and reliability, patient safety, and cost effectiveness began with the vision of two key AHS executives. The first, Donald Jernigan, PhD, served as AHS's Executive Vice President in the mid-1990s. The second was Tom Werner, who became the CEO of AHS in 1999. Both of these leaders had a passion for excellence and a strategic vision that embraced the above goals. Both also recognized that, in a health care system as large and diverse as AHS, the journey needed to be incremental and methodical.
Structure and Organization
AHS hospitals are individually managed facilities, with local Boards of Directors, administration, and medical staff. The AHS corporate office provides multiple support services to the system hospitals. The corporate Office of Clinical Effectiveness (OCE), led by the Chief Medical Officer, has responsibilities for patient safety, quality, computerized provider order entry (CPOE) content development and maintenance, clinical decision support and outcomes measurement, and direction and support for other system-wide clinical initiatives. The OCE provides clinical support to each hospital as requested. There is no line of authority between the hospitals and the Office of Clinical Effectiveness. Because of this, it was vital that local hospitals "bought into" the corporate vision for quality, safety, and efficiency—a fully top-down approach was destined to fail.
Nevertheless, it was also important for the central corporate vision to be bold and clinically meaningful to local personnel. For example, the 2007 AHS Corporate Clinical priorities are:
- Implementing and optimizing clinical information systems
- Developing a culture of reliability and patient safety
- Hospital and medical staff alignment that supports mission, quality, and patient safety initiatives
- Alignment of AHS clinical outcomes and quality measures with national trends in data reporting and transparency
To achieve this goal of linking local efforts to central leaders and resources, we established a corporate clinical committee structure. This structure provides wide representation and participation from the system hospitals on multiple clinical committees, all of which ultimately report to the Corporate Clinical Council. This structure creates forums where clinical issues are discussed, actions approved, and implementation planned at the corporate level. Most germane to this paper, a Patient Safety/Evidence-based Practice Committee helps to formulate and implement evidence-based corporate quality and patient safety initiatives and recommends that certain initiatives be incorporated into our Annual Corporate Accountabilities, which determine the bonuses of senior leaders.
One of the most important activities in our patient safety efforts has been our biannual Patient Safety/Evidence-based Practice Summit. Attendees include physicians, other clinicians, and operations leadership from all AHS hospitals. Nationally renowned experts on patient safety and evidence-based practice have presented at these Summits. In addition, individual hospitals have presented their experiences and outcomes from their work in a variety of areas, including safety culture assessment, teamwork and communication, and designing for high reliability. Our Summits facilitate networking and relationship-building between hospitals' attendees. We believe that they have been critical to our success, by allowing for sharing of ideas, success stories, and challenges.
Milestones on Our Patient Safety Journey
Early Engagement and Education
In 1996, AHS began a strategy of using evidence-based best practices and physician engagement to improve quality, patient safety, and cost effectiveness. Initially, this program involved creating paper order sets and clinical pathways for selected diseases and conditions. Our study on pneumonia patients using this strategy showed an improvement in patient outcomes, as measured by a reduction in mortality, acute renal failure, use of mechanical ventilation, length of stay, and cost per case.(2)
After the 1999 Institute of Medicine (IOM) report To Err Is Human (3) was released, our CEO responded by challenging each AHS hospital to add patient safety to our Corporate Clinical Accountabilities. In 2000, we began a program of requiring each hospital to implement one major patient safety initiative annually. In the years since the initial IOM report, AHS has developed and endorsed (at the corporate level) several significant strategic initiatives; these were integrated into the annual Clinical Accountabilities for every AHS facility. One example is our current 3-year initiative (2007–2009) to improve hyperglycemia management in our hospitals using IV insulin infusion therapy. This initiative is being rolled out initially in intensive care units (ICUs) but will eventually be expanded to telemetry and step-down units, surgery and postanesthesia care units (PACUs), labor and delivery floors, and emergency departments.
To succeed in these ambitious plans, we needed to engage and educate our physicians, other clinicians, and executive leadership. Our plan to achieve this included leveraging biannual corporate clinical meetings to further the quality and safety agenda. Beginning in 2004, we brought in a series of nationally recognized experts (including Drs. Jim Reinertsen, Michael Leonard, Allan Frankel, Bryan Sexton, Bob Wachter, and Charles Denham) to speak to our leadership, both local and corporate, at these meetings. Moreover, we have held additional focused sessions for hospital physician leaders, again bringing in nationally known speakers (such as Dr. Ken Kizer and Michael Millenson) to carry this message.
The Role of Computerization
Since 2004, AHS has been implementing an electronic medical record (Cerner Millennium) at every hospital campus in the system. This implementation will be completed in February 2008. We believe that a systemwide electronic health record (EHR) is an essential foundational element for achieving safe and reliable care, and we plan a series of initiatives that will leverage this foundation. But we also know that information technology will not, by itself, achieve this result.
In addition for laying the groundwork through our systemwide EHR, in 2005 we initiated a parallel project of creating evidence-based content for our CPOE system. We set a goal to create CPOE content for 80% of our admission diagnosis/procedures and for the majority of emergency department presenting symptoms. This massive project will be completed by early 2008. At that time, we will have approximately 365 pre-built electronic order sets with imbedded hyperlinks to the supporting evidence. Pilot CPOE sites will go live by the end of 2008. Zynx Health is the AHS vendor for electronic evidence-based content, order set development, and the maintenance of the order set content, which will be regularly reviewed and updated perpetually as the evidence changes.
The Link to the Institute for Healthcare Improvement
In December 2004, Dr. Donald Berwick, president of the Institute for Healthcare Improvement (IHI), came to Orlando, Florida, for IHI's annual National Forum. In an emotional appeal, Dr. Berwick challenged hospitals to join IHI in a campaign to save 100,000 lives from needless deaths. AHS leaders, many of whom were present at the IHI conference, immediately recognized this as a major patient safety opportunity. In February 2005, our CEO, Tom Werner, called a special meeting of corporate and regional leaders in Orlando (our corporate home). At that meeting, AHS agreed to actively participate in IHI's 100,000 Lives Campaign. Also, at that meeting our corporate CEO proposed increasing the portion of each hospital CEO's total annual Accountability that was related to clinical quality and patient safety from 10% to 25%—another major milestone in our patient safety journey. In addition to 100% hospital participation in the IHI campaign, the Office of Clinical Effectiveness operated as an IHI "system node" and provided coordination between 100,000 Lives Campaign representatives and system hospitals.
In 2004, AHS Corporate representatives attended the IHI's Patient Safety Officer training program in Boston. After that meeting, we adopted a curriculum built on the "Achieving Safe and Reliable Healthcare" (4) framework. Each AHS hospital was asked to identify a facility Patient Safety Officer (PSO). Subsequent PSO training sessions have been held corporately, regionally, and at individual local hospitals to disseminate this knowledge and training.
In addition to these efforts, the AHS Office of Clinical Effectiveness joined the IHI IMPACT community as a corporate member. This membership provides a conduit for a relationship with international experts in patient safety, along with hospital leaders throughout the United States. Select AHS hospitals were asked to join specific IMPACT Communities for improvement. Criteria used to select hospitals for membership included commitment of the leadership team, organizational readiness to embrace a significant change in culture and practice, and available resources. Based on the success of our initial IMPACT engagements, we have allowed additional AHS hospitals to join IMPACT communities.
Beginning in 2005, baseline measurement of organizational safety culture was obtained utilizing 2 culture survey tools. Most of our hospitals chose to utilize the Safety Attitude Questionnaire (SAQ).(5) Aggregate response rates for the SAQ were greater than 80%. Dr. Bryan Sexton attended various corporate meetings to provide context and meaning to the survey results. Our largest hospital chose to utilize the AHRQ culture survey tool.(6) Dr. Edwardo Salas from the University of Central Florida assisted with analysis of their survey results.
Focus on a Specific Service Line
On top of these efforts, after our Risk Management Department found system-wide opportunities for improvement, we implemented a corporate patient safety initiative in obstetrical services. A system-wide review of obstetrical practices at each hospital was undertaken by the consultants, Drs. Eric Knox and Kathleen Simpson. A corporate OB Task Force was created, chaired by one of our regional Chief Medical Officers. From the Knox and Simpson reviews at each hospital, 11 common problems were identified. The Task Force spent the next year creating a strategy for mitigating risk and improving fetal and maternal safety around those 11 issues. Finally, we convened an OB Summit that brought together at least one obstetrician and one nurse from the obstetrics department of each of our hospitals. National speakers plus our own OB Task Force leadership presented the results and recommendations. Each hospital is now in the process of implementing these patient safety measures locally.
A Link to the Johns Hopkins Safety Group
AHS is currently participating with the Johns Hopkins Quality and Safety Research Group in a randomized control trial funded by the Robert Wood Johnson Foundation. AHS was selected to participate in this study because of significant findings of the Michigan Keystone project, which found a tremendous and statistically significant reduction in central line–associated bloodstream infections with the systematic implementation of a series of evidence-based practices.(7) One very interesting finding of the Keystone project was that faith-based community hospitals enjoyed the greatest improvement in the least amount of time. In part due to the relationship between AHS and the Johns Hopkins research team, AHS was selected to participate in a focused study to eliminate central line catheter–related bloodstream infections (CRBSI) in adult ICUs by September 15, 2008. In addition, the study seeks to identify the causal relationship between specific national nursing measures such as Nursing Turnover, Nursing Skill Mix, and Nursing Hours Per Patient Day and CRBSI rates. Every one of AHS's adult ICUs are participating. This kind of broad engagement—from the Board of Directors to front-line clinical staff—is further evidence of AHS's ongoing commitment to safety and of our success in linking our corporate strategic focus with activities at each of our member institutions.
Alignment with the National Quality Forum's "Safe Practices"
The revised 2006 National Quality Forum (NQF) Safe Practices (8) harmonizes important safety initiatives and measures among Joint Commission, NQF, Centers for Medicare and Medicaid Services (CMS), AHRQ, IHI, and Leapfrog. The revisions include clearly defined process, outcome, structure, and patient measures. Each of the 30 safe practices is assigned points based on defined criteria. A total of 1000 points are available to earn, based on the Leapfrog methodology. Safe Practice #1, "Improving Patient Safety by Developing and Creating a Culture of Safety," constitutes 30% of the total points for all of the current 30 Safe Practices. We believe that the NQF emphasis on safety culture is the right one; in our view, the creation and maintenance of such a culture are essential for the successful, sustainable implementation of the remainder of the Safe Practices. For 2008–2009, AHS is focusing its Corporate Clinical Accountabilities on becoming fully compliant with Safe Practice #1.
In 2008, AHS is planning for each hospital to conduct a self-assessment of their current degree of compliance with the 30 Safe Practices using the NQF scoring assessment tool. Future corporate patient safety initiatives will be built around systematically implementing and achieving full compliance with the current 30 and future NQF Safe Practices.
Mortality as an Outcome Measure
Since 2001, we have tracked our unadjusted system and hospital mortality as the "ultimate outcome measure." Compared to a Thomson Healthcare (Solucient) national database of more than 20 million discharges, AHS system mortality from 2001 through 2006 experienced a relative reduction of 17% (Figure), compared with the national relative mortality reduction of 13.8% (Kaveh Safavi, MD, JD, e-mail communication, September 2007). We believe that this improvement is reflective of many of the activities outlined above.
Conclusion
The path to a totally safe hospital or health system can be best described as a journey. This report has described steps from our particular journey at AHS. We have done much and made significant progress, but considerable work remains to be done. In a challenging health care environment, replete with financial, operational, and human resource issues, it takes the combined commitment of the board, administration, physicians, other clinicians, and support staff to make a patient safety vision into a reality.
This report has described one large and diverse health system's structure and strategy to advance a patient safety agenda. We offer it in the hope that others, particularly those in large, multisite systems, might benefit from the experiences and lessons learned along our journey.
Loran Hauck, MDSenior Vice President, Chief Medical OfficerAdventist Health System
Jan Jacob, MBA, RNCorporate Patient Safety OfficerAdventist Health System
References
1. Adventist Health System 2006 Annual Report. Adventist Health System Web site. Available at: https://ahiglobal.org/sites/ahiglobal.org/files/docs/about/annual-reports/ahi-annualreport-06r.pdf . Accessed December 18, 2007.
2. Hauck LD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia. Ann Epidemiol. 2004;14:669-675. [go to PubMed]
3. Kohn L, Corrigan J, Donaldson M, eds. To Err is Human: Building A Safer Health System. Washington, DC: National Academy Press; 2000.
4. Leonard M, Frankel A, Simmonds T, Vega K. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Chicago, IL: Health Administration Press; 2004. ISBN: 1567932274.
5. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44. [go to PubMed]
6. Patient Safety Culture Surveys. Agency for Healthcare Research and Quality Web site. Available at: http://www.ahrq.gov/qual/hospculture/ Accessed December 18, 2007.
7. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732. [go to PubMed]
8. Safe Practices for Better Healthcare 2006 Update: A Consensus Report. Washington DC: National Quality Forum; 2007.
Figure
Figure. AHS system mortality from 2001 through 2006 compared to a Thomson Healthcare (Solucient) national database of more than 20 million discharges.(Go to figure citation in commentary) 
