• Patient Harm: Attaining & Sustaining Dramatic Improvements

    By Lola Butcher May 01, 2015

    As healthcare organizations double down on patient infections, falls, pressure ulcers, and other healthcare-associated conditions, they are questioning common approaches, testing innovative technologies, and remodeling their cultures in the quest for zero harm.

    First, the good news: The focus on patient safety is paying off. Hospital-acquired conditions (HACs) declined by 17 percent between 2010 and 2013, according to an Agency for Healthcare Research and Quality (AHRQ) study. That translates into 50,000 fewer HAC-related deaths and approximately $12 billion in savings (AHRQ, Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013, December 2014).

    In addition, the use of antipsychotic drugs by long-stay nursing home residents declined 17.1 percent between 2011 and 2014, according to the Centers for Medicare & Medicaid Services (CMS) (Data Show National Partnership to Improve Dementia Care Exceeds Goals to Reduce Unnecessary Antipsychotic Medications in Nursing Homes, Sept. 19, 2014).

    However, when these statistics are flipped, it becomes clear that a lot more improvement is needed: For instance, about 12 percent of hospital patients still suffer needlessly due to a HAC, based on the AHRQ study.

    Vowing to do better, prevention-oriented leaders are scrapping outdated ideas and finding new approaches and technologies that are making a big difference:

    Anne Arundel Medical Center: A Focus on Decolonizing
    Minnesota Masonic Home: Preventing Falls
    University of Vermont Medical Center: A Culture of Safety
    El Camino Hospital: Reducing Pressure Ulcers
    Challenges to Overcome

    In the process, they are not only reducing patient suffering and associated treatment costs, but also avoiding associated payment penalties. Under CMS's value-based purchasing program, hospitals and health systems stand to lose 1 percent of their Medicare payments for high rates of certain HACs, including pressure ulcers and postoperative sepsis. Some state and commercial payers are following suit with similar penalties.

    Anne Arundel Medical Center: A Focus on Decolonizing

    When Mary R. Clance, MD, MPH, began her career in infection control in the 1980s, everyone agreed that improving hand hygiene was the primary answer to reducing healthcare-acquired infections. While many in health care continue to believe that, Clance and other infection control experts realize that is not true.

    Mary R. Clance, MD, hospital epidemiologist, Anne Arundel Medical Center

    Anne Arundel’s Mary R. Clance, MD, MPH, poses with the UV-emitting robot that has helped to reduce C. diff and other dangerous infections at the hospital. (Photo: Anne Arundel Health System)

    "We should never stop focusing on hand hygiene, but there has been a sea change in how experts are approaching infection control in hospitals," says Clance, hospital epidemiologist and president of the medical staff, Anne Arundel Medical Center, Annapolis, Md. "There has been a shift over the past decade to focus more on patients and the hospital environment because we now understand that those are the two primary sources of infection transmission."

    Indeed, a study of 166 acute care hospitals found that hand-hygiene compliance improved every year between 2008 and 2011. Yet, at the same time, the rates of two dangerous infections—Clostridium difficile (C. diff) and methicillin-resistant Staphylococcus aureus (MRSA)—did not decrease (DiDiodato, G., "Has Improved Hand Hygiene Compliance Reduced the Risk of Hospital-Acquired Infections among Hospitalized Patients in Ontario?" Infection Control Hospital Epidemiology, 2013, vol. 34, no. 6, pp. 605-610).

    Decolonizing patients. "Patients are not sterile. They come into the hospital with a complex host ecology of pathogens," Clance says.

    To avoid the spread of those pathogens, Anne Arundel nurses started bathing all patients with antibacterial chlorhexidine cloths—technically called patient decolonization—in 2007. That was well before a randomized clinical trial of 43 hospitals found that universal decolonization in intensive care unit (ICU) patients resulted in a 37 percent reduction in MRSA clinical cultures and a 44 percent reduction in bloodstream infections (AHRQ, Universal ICU Decolonization: An Enhanced Protocol, September 2013).

    The business case for decolonization is easy to make. "Do the math: Universal bathing versus the cost of having X number of central line bloodstream or ventilator-associated infections," Clance says.

    One study reports a net savings of approximately $1.2 million in avoided surgical infections per 1,000 total knee arthroplasty patients. And that's just from using chlorhexidine cloths preoperatively for one procedure (Kapadia, B.H., et al., "Economic Evaluation of Chlorhexidine Cloths on Healthcare Costs due to Surgical Site Infections Following Total Knee Arthroplasty," The Journal of Arthroplasty, August 2013, vol. 28, no. 7, pp. 1061-1065).

    Using probiotics and UV-emitting robots. Anne Arundel used a similar cost/benefit case to justify two major anti-infection interventions in 2013: probiotics in conjunction with antibiotics and a germ-killing robot that disinfects hospital rooms. Together, the two protocols reduced the hospital's incidence of C. diff by 30 percent in the two years following implementation, Clance says.

    Antibiotics are known to kill beneficial intestinal bacteria that keep C. diff in check. To counteract this, Anne Arundel physicians began prescribing probiotics to all patients on antibiotics, which has been shown to significantly reduce C. diff (Johnston, B.C., et al., "Probiotics for the Prevention of Clostridium Difficile-Associated Diarrhea: A Systematic Review and Meta-analysis," Annals of Internal Medicine, Dec. 18, 2012, vol. 157, no. 12, pp. 878-888).

    "The use of probiotics has generated a measurable cost savings of $225,000 per year," Clance says. "Prevention of only six cases of hospital-acquired C. diff covers the cost of the probiotic program."

    Meanwhile, the robot uses ultraviolet (UV) emissions to kill pathogens, including influenza, norovirus, C. diff, MRSA, and others. Environmental service staff at Anne Arundel wheel the robot into rooms every day using a triage protocol: Rooms that have been inhabited by patients with C. diff are given first priority, then rooms that housed patients infected with a multi-resistant organism, then the dialysis unit, wound care center, operating rooms (ORs) and other rooms, depending on time availability.

    The ROI for the UV machine has not been calculated yet, but Clance says the rise of value-oriented health care makes the investment easy to justify. "In the era of nearly untreatable antibiotic-resistant organisms and payment reform regarding hospital-acquired conditions, the implementation of UV disinfection to augment traditional cleaning makes both clinical and economic sense," she says.

    Monitoring environmental cleaning. The robot is not available for every room, so Anne Arundel also uses enhanced environmental cleaning to ensure hospital rooms are being properly disinfected.

    In general, most hospital rooms are not. Several studies have shown that, on average, only 40 percent of surfaces that patients frequently touch are cleaned in accordance with a given hospital's own cleaning policies (Carling, P.C., et al., "Evaluating Hygienic Cleaning in Health Care Settings: What You Do Not Know Can Harm Your Patients," American Journal of Infection Control, June 2010, vol. 38, pp. S41-50).

    Anne Arundel's enhanced protocol means that 10 percent of rooms are randomly chosen each day for monitoring. Supervisors use a UV light to "mark" high-risk surfaces (e.g., bedside rails, toilets, door handles, and other frequently touched objects) before rooms are cleaned. After a room is cleaned, the supervisors check to see if any areas are still "marked," which indicates that the surfaces were inadequately cleaned.

    "Knowing that 10 percent of the rooms are going to be checked truly does improve performance," Clance says. "Also we make certain that our environmental services workers understand they are professionals and ensure they are given the time to do an appropriate, professional job."

    Anne Arundel monitors the cleaning compliance rates by individual member of the environmental staff and by unit—and it also tracks infection rates. "We can't just monitor the behavior," she says. "We also have to monitor the outcome."

    Achieving results. Anne Arundel's multi-pronged assault strategy appears to be working. The medical center has sustained a 30 percent decrease in C. diff infections throughout 2013 and 2014 and avoided any hospital transmission of two problematic villains: the multi-drug resistant Acinetobacter and carbapenemase-resistant Enterobacteriaceae. Central line-associated bloodstream infections (CLABSIs) have also declined.

    Minnesota Masonic Home: Preventing Falls

    Jean Jorlett, quality assurance and fall risk coordinator at the Minnesota Masonic Home in Bloomington, remembers the prevailing attitude among the nursing home's staff when the organization's falls-prevention initiative first launched in 2008. "People really thought, 'The residents are frail, they are elderly, they are confused, and they are going to fall,'" she says. "Our work was more about taking care of residents after the fall than it was preventing the fall."

    In 2012, 11.3 percent of nursing home residents fell, with 5.3 percent suffering an injury, according to CMS data.

    Today, job candidates at Minnesota Masonic are quizzed about fall scenarios, and every new employee goes through a 1.5-hour fall-prevention training session. "If anybody would say to me, 'There's really nothing you can do about falls,' they are in the wrong environment," Jorlett says.

    That is because the skilled nursing facility has proven that falls can be prevented. The 214-bed facility currently averages five falls per 1,000 resident days, down from seven in late 2008. Jorlett says the organization is its own best benchmark. She believes even one fall is unacceptable and that each facility should measure its progress compared to its historical performance.

    Eliminating fall alarms. Along the way, however, Jorlett and her colleagues have also discovered just how difficult it is to prevent falls. Minnesota Masonic received a three-year grant that required working with 15 other nursing homes that are also trying to reduce falls. Participants experimented with more than 30 interventions, many of which did not work.

    For example, they tried to identify the appropriate bed height for a given patient to ensure safe transfers (e.g., from bed to chair) and marking the wall so that the same bed height would be consistently used. However, the tape used to mark the wall generally fell off, and using markers proved impractical. "While bed height is important to consider at the time of transfer, beds are raised and lowered so often, and residents change so frequently, that this process was just not worth the effort," Jorlett says.

    But some things seem to be helping. Most notable, perhaps, is the elimination of fall alarms—or detectors attached to mattresses, chair pads, or clothing that emit a signal to alert nursing home staff when a patient is trying to get up and move around. One study found no difference in fall rates at an urban hospital between nursing units that actively used alarms and those that did not, calling into question the effectiveness of this common and pricey technology (Shorr, R.I., et al, "Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial," Annals of Internal Medicine, 2012, vol. 157, no. 10, pp. 692-699).

    The alarms can also agitate and distract patients, Jorlett says. Plus, anecdotal reports suggest that nursing home residents may be inclined to move less—contributing to muscle loss and frailty—because they are afraid to set off the alarms and disturb roommates or staff ("Nursing Homes Find Bed, Chair Alarms Do More Harm than Good," The Boston Globe, March 15, 2015).

    Jorlett's staff replaced the alarms with hourly "peace-of-mind rounds." When looking in on all residents, staff members assess four P's, as defined by Nurses Improving Care for Healthsystem Elders:
    • Personal needs: For example, do residents need to go the bathroom?
    • Position: Do they need to be turned, get up in the chair, return to bed?
    • Placement of personal items: Do they have their tissues, water, glasses, phone, and call bell close at hand?
    • Pain: Is their pain under control?

    By administering to those needs frequently, Minnesota Masonic staff proactively eliminate the necessity for a nursing home resident to get up and move unattended.

    These rounds also help staff see the importance of building relationships with residents. "The better you know your residents," Jorlett says, "the better able you are to anticipate their needs and the less likely they are to do dangerous things like self-transferring—and the more likely you are to prevent a fall."

    Measuring performance. Minnesota Masonic leaders also believe that falls have declined because the nursing home gives staff data on how well they are preventing falls. Jorlett devised a formula to determine the "fall rate" for each nurse or nurses aide, using the number of hours worked, the shifts worked, the number of residents he or she is responsible for, and other factors. The rate is reported annually to each staff member, showing how he or she compares to peers.

    "We congratulate the nurses and aides who are on the top end, praise those who are in the middle, and encourage the ones who are on the other end to get better," she says. "Once they got the fact that we were measuring, they owned the responsibility more."

    Spreading the responsibility. However, leaders at Minnesota Masonic have been careful to ensure that fall prevention is embraced as a priority for all staff—and not only seen as a nursing responsibility. That is why Jorlett, the quality assurance coordinator, reports directly to the nursing home administrator, rather than the director of nursing. In addition, fall prevention by specific resident is discussed daily in interdepartmental team meetings and in weekly "fall committee" meetings on each unit. Meanwhile, housekeeping and maintenance staff are trained to alert nursing staff if they notice a patient who is trying to move or if they identify a possible fall hazard that needs to be remediated.

    The nursing home's fall-prevention work was initially supported by a three-year grant from the state of Minnesota that tied the organization's progress in reducing falls to its Medicaid payments. That created a laser-like focus on falls prevention.

    "Our administrator wanted a report on how we were doing at every staff meeting she had (daily, weekly, and monthly), and she would say to everyone present: 'Money is tied to this. You will be doing this. This is not optional. If you're thinking that you can't prevent falls, get on board, because we are going to be preventing falls,'" Jorlett says.

    University of Vermont Medical Center: A Culture of Safety

    When University of Vermont Medical Center (UVMC) standardized its central line insertion kits, every clinician who conducts the procedure was required to be retrained in the simulation lab. Anna Noonan, RN, vice president of UVMC's Jeffords Institute for Quality, was thrilled to see highly experienced physicians acknowledge their shortcomings.

    Anna Noonan, RN, vice president, University of Vermont Medical Center

    UVMC’s Anna Noonan, RN, cites a culture of safety as key to the medical center’s success in preventing approximately 150 infections over five years—avoiding more than $5 million in related treatment costs. (Photo: University of Vermont Medical Center)

    "It is very powerful when a senior physician turns to a junior physician and says, 'Just so you know, I was doing it incorrectly, and here's how I've learned to do it correctly,'" she says. "That really helps spread the whole culture of safety."

    Going for zero. That culture of safety is behind UVMC's success at dramatically reducing infection rates and sustaining them for years. Among its accomplishments:

    • No surgical site infections in knee replacements in the past four years
    • A three-year run of zero CLABSIs in the neonatal intensive care unit (NICU) and near-zero rates in other ICUs
    • Only 0.8 bloodstream infections associated with dialysis access per 100 patient months in its six outpatient dialysis clinics, down from 4.8 infections per 100 patient months in 2008

    Starting at the top. UVMC's success has stemmed from the medical center's decision in 2008 to make the elimination of healthcare-acquired infections an organizational priority. One of the top success factors, in Noonan's view, is executive leadership support.

    "We got full commitment from our CEO that getting to zero infections was the right thing to do, which meant building that into our strategic priorities," she says. "We're an academic medical center, so getting support from the departmental chairs, and in turn, the board of trustees, was absolutely critical."

    Combining infection prevention and quality. The next most important factor: moving infection prevention specialists into the Jeffords Institute for Quality, which supports UVMC's goal of providing high-value care. Typically, infection prevention is under the purview of epidemiology, with a focus on surveillance rather than quality improvement. Bringing infection prevention and performance improvement expertise into the same group prompted a "major shift in our effectiveness," Noonan says. Infection prevention specialists shared their knowledge with quality improvement experts, who in turn trained the infection prevention specialists in quality improvement methodologies.

    The work started by identifying priorities to focus on. After comparing the medical center's infection rates with benchmark data from the Centers for Disease Control and Prevention (CDC) and a consortium of academic medical centers, UVMC identified five areas where it was lagging and needed to improve:
    • Total joint replacement surgical-site infections
    • Orthopedic spinal fusion surgical-site infections
    • Medical intensive care: CLABSIs
    • Neonatal intensive care: CLABSIs
    • Outpatient dialysis centers: central line access-related bloodstream infections

    Creating new workflows. Multidisciplinary teams were formed for each priority area. For example, the total joint replacement team included orthopedic surgeons, an epidemiologist, a pharmacist, an orthopedic inpatient nurse manager, outpatient clinic staff, perioperative services staff, an orthopedic OR clinical specialist, and an infection prevention specialist.

    For each type of infection targeted, the teams used Plan-Do-Study-Act and other improvement methods/tools to identify, test, and standardize new protocols. To combat spinal fusion surgical-site infections, surgeons initiated a triple-play pause for complex cases: antibiotic redose, glove change, and wound irrigation every three hours. Air quality is now monitored monthly, and OR disinfection was improved, among other things.

    "What's really critical is to make sure that the changes that you are trying to implement are built into the workflow so it makes it easy for people to do the right thing," Noonan says.

    For example, one team determined that a lack of standardization was contributing to the bloodstream infection rate: Clinicians were using more than 200 types of central line insertion kits. Today, only six types of kits are stocked, and each is specific to a particular segment of the patient population. "In our organization, it is impossible to order something else," she says.

    Creating a culture of safety. UVMC was well positioned to push for "getting to zero" because staff have become accustomed to talking openly about patient safety problems. For more than two decades the medical center has been focused on promoting a culture of quality and safety. One example is the Good Catch award given to staff members who report something that could have caused patient harm. Award recipients are heralded in internal publications and entered into a drawing for a cash reward. "That sends a message that we want you to catch defects and identify when something has not gone optimally," Noonan says.

    Additionally, the medical center continually emphasizes the importance of improving patient safety performance. At its annual Quality Forum in 2014, more than 100 projects were presented in storyboard format at an off-site conference center. "When you walk around the room and look at all of these performance improvement projects, it's clear that our organization has embraced a culture of quality and patient safety," she says.

    UVMC also holds its annual Quality Symposium, featuring national and local experts who discuss topics such as high-reliability organizations and innovation.

    Calculating results. UVMC leaders estimate their organization has prevented approximately 150 infections in the five focus areas over five years—and avoided more than $5 million in related treatment costs.

    The number of infections prevented was determined using the UVMC baseline rate along with the expected number of infections, as calculated by the CDC's National Healthcare Safety Network. The cost savings was calculated using the attributable cost figures identified in a recent study (Zimlichman, E., et al., "Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the U.S. Health Care System," Journal of the American Medical Association Internal Medicine, 2013, vol. 173, no. 22, pp. 2039-46).

    Those results and others prompted the U.S. Department of Health and Human Services and two epidemiology societies to honor UVMC with the 2014 Partnership in Prevention Award for sustainable improvements in eliminating healthcare-associated infections.

    El Camino Hospital: Reducing Pressure Ulcers

    Both CMS and the state of California require hospitals to report serious (i.e., Stages 3 and 4) hospital-acquired pressure ulcers as adverse events. One study found that 4.5 percent of newly admitted Medicare patients developed a pressure ulcer while hospitalized. These patients generally had longer lengths of stay (11.2 days compared to 4.8 days) and a greater risk of readmission and death (Lyder, C.H., et al., "Hospital-Acquired Pressure Ulcers: Results from the National Medicare Patient Safety Monitoring System Study," Journal of the American Geriatrics Society, September 2012, vol. 60, no. 9, pp. 1603-8).

    When 25 patients at El Camino Hospital suffered reportable pressure ulcers in 2011, it was time for emergency action. Since then, many interventions have contributed to the dramatic decrease in serious pressure ulcers at El Camino, which has campuses in Mountain View and Los Gatos. But the obvious key to its success is an unrelenting focus on fixing a fixable problem.

    Huddling every day. Every day, all charge nurses meet to report on all pressure ulcers (both hospital acquired and those present on admission). And all hospital-acquired pressure ulcers are reported at the daily enterprise huddle, which includes the hospital's clinical managers and executives.

    "Skin is one of the things that nurses are completely responsible for. It's not physician care, it's nursing care," says Chris Tarver, RN, nursing director of medical/surgical services. "By talking about it every day, we demonstrate our commitment that this is important."

    Tarver headed the pressure ulcer rapid improvement team that kicked into action after the disturbing performance in 2011. The team identified the three most common types of serious pressure ulcers among El Camino patients: coccyx (or tailbone), heel, and mechanical device related. Then it developed a three-year plan to get to zero hospital-acquired pressure ulcers.

    The plan worked. The number of reportable hospital-acquired pressure ulcers decreased every year. So far in the fiscal year that began July 1, 2014, the hospital has had zero.

    Getting to Zero Reportable Pressure Ulcers
    Getting to Zero Reportable Pressure Ulcers at El Camino Hospital

    Implementing a range of interventions. Tarver attributes the progress not to any single intervention, but to the cumulative effect of many, ranging from expensive and innovative technology to basic education. "For a few years we had 'Wound Care Wednesday,' during which I asked the nurses 'What's wrong with this picture?' to provide education about preventing pressure ulcers," she says.

    The first big victory came from an experiment to see if silicone dressings would reduce El Camino's single biggest pressure ulcer problem: coccyx ulcers suffered by critical care patients. "We halted the study early because our results were so good," she says. "Now we do proactive placement of silicone dressings on any patient who is at risk for coccyx breakdown."

    In addition, protocols were developed for proactive placement of silicone dressings for patients having back surgery and other medical situations that put them at high risk for pressure ulcers.

    El Camino also found success with a wound therapy that delivers low-frequency ultrasound energy through a saline mist. The treatment, which is applied three times per week for up to 20 minutes per treatment, speeds healing and can help Stage 2 pressure ulcers from further deterioration.

    In addition, the hospital began using special fluid immersion beds—originally developed for out-of-water transport of dolphins and seals—that simulate the effects of a body floating in fluid. Immobilized patients, such as those awaiting surgery to repair broken hips, are placed in the beds, which reduce the likelihood of skin breakdown.

    Plus, the hospital introduced a new technology that helps ensure patients get turned on the appropriate schedule, which helps prevent pressure ulcers from forming. A wireless sensor attached to the patient's sternum tracks his or her position and movements. The sensor communicates with a monitor at the nurse's station, which is counting down the two hours between scheduled turns.

    The monitor informs nurses when it is time to turn a patient—and if the patient has turned without assistance. In a test of the technology on a single unit, El Camino found that turn compliance increased to 98 percent, up from 64 percent before the sensor system was used.

    "If a patient has moved enough to make a difference in his or her position, the two-hour clock automatically starts over," Tarver says. "It helps with patient satisfaction because we aren't waking patients up with 'It's time to turn' when they have already turned themselves."

    Chris Tarver, RN, nursing director of medical/surgical services, El Camino Hospital

    Chris Tarver, RN, nursing director of medical/surgical services, led El Camino’s rapid improvement team that developed a three-year plan for getting to zero reportable hospital-acquired pressure ulcers. (Photo: El Camino Hospital)

    Preventing mild ulcers. While the hospital appears to have found sustainable ways of reducing pressure ulcers, Tarver is not ready to declare the problem is solved. Now that serious pressure ulcers are under control, she is turning her attention to prevention of mild to moderate (Stages 1 and 2) pressure ulcers. And that means discussing them at each daily huddle.

    "I fear that if we turn away, something will slip," she says. "This is too important—until we get to zero at all stages."

    Challenges to Overcome

    Some patient safety practices are so common and so ingrained in institutional operations that it is difficult to let them go—even when evidence emerges that they are not effective. For example, when Minnesota Masonic joined a group of 16 nursing homes collaborating around fall prevention, the members were presented with information against using fall alarms. But Jorlett and others were slow to embrace the idea because it was so counter-intuitive. "Not only were we resistant to that idea, our staffs were very resistant," she says.

    After months of no progress, the group set a deadline for eliminating alarms at all participating facilities. "That would be the only way this was really going to happen. Don't talk about it anymore. Just roll out a plan, and do it," she says.

    Having the deadline prompted Minnesota Masonic staff to start hourly rounds, which decreased the likelihood that patients would try to get up on their own. Since 2010, the facility has been alarm-free and falls have continued to decline.

    Another patient safety challenge: evaluating new products and equipment. "The field of wound care and dressings and ointments is so fast-changing," Tarver says. "Every time our nurses go to a conference they come back with 57 new things to try."

    That statement is true for almost every aspect of patient safety. And it can pose a dilemma for the health system's supply purchasers who need to stock as few items as possible and are always on the lookout for cost-effectiveness.

    Thus, Tarver says, patient safety advocates must engage materials management staff by including them on improvement teams and working with them to evaluate products and equipment.

    Is Zero the Goal?

    Many health systems say their goal is to eliminate patient harm, but that may be setting an unrealistic bar. That is the case with hospital-acquired infections, Clance says.

    "The idea that we can have zero healthcare-acquired infections is misplaced because our patients are not sterile, and we perforate them with devices," she says. "Many infections can be reduced, but the idea of zero is just not biologically plausible."

    Noonan and Tarver would agree. When UVMC started its "getting to zero" campaign, leaders recognized that even if a certain type of infection were eliminated for a period of time, sustaining that forever was unrealistic. That said, no patient or family member wants a healthcare team that considers a certain number of infections to be acceptable. "You have to set a target, and zero is the right target," Noonan says.

    When El Camino began its work to reduce reportable pressure ulcers, Tarver worried that setting a goal of zero might be demoralizing for the nursing staff. "If we cut the number by half, that is excellent work," she says. "And if we cut it in half again, I don't want them to feel bad because we have one patient affected when we took care of thousands of patients so well."

    She decided to frame their work this way: "It is a journey to zero, and we will get to zero for as long as we can," she says. "If something bad happens, then we start the journey again."

    Lola Butcher is a freelance writer and editor based in Missouri and a contributing writer/editor to Leadership.

    Quoted in this article:
    Mary R. Clance, MD, MPH, is hospital epidemiologist and vice president of the medical staff, Anne Arundel Medical Center, Annapolis, Md.

    Jean Jorlett, RN, is quality assurance coordinator and fall risk coordinator, Minnesota Masonic Home-Bloomington, Bloomington, Minn.

    Anna Noonan, RN, is vice president, Jeffords Institute for Quality, University of Vermont Medical Center, Burlington, Vt.

    Christine Tarver, DNP(c), RN, is director of medical and surgical services and Magnet program director, El Camino Hospital, Mountain View, Calif.

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