Quality and safety initiatives

Big Aims

Our overarching quality program is aimed at two results:

  1. Eliminate needless deaths. 
  2. Eliminate preventable harm.


These are our goals as we pursue our Big Aims:

Harm Index

The Harm Index includes events that can cause harm to patients. We're focused on these events this year: 

  • Hospital acquired stage 3 and 4 pressure ulcers 
  • Catheter-associated urinary tract infections (CA-UTI) 
  • Central line associated blood stream infections (CLA-BSI) 
  • Surgical site infections (SSI) 
  • Patient falls with injury 
  • Hospital acquired potentially preventable thromboembolism (blood clot) 
  • Serious safety events


Our goal was to reduce harm events by 7%-15% from March 31, 2014, to March 31, 2015, which is the end of our fiscal year. The baseline adjusted average of that target was 9.92 harm events per month. To put this in context, Legacy sees an average of 5,000 hospitalized patients per month. To achieve our goal, our adjusted average needed to be less than 8.93.

How we did: We did not meet our goal, despite a trend in the right direction for the last five months. Our year-to-date adjusted average was 9.97. Legacy leaders are using the performance excellence model to work on continual improvement and harm reduction in their areas.

Culture of Safety

We survey our staff each year to determine our progress in creating a culture in which staff feel free to identify potential errors, take steps to prevent harm, share learning and focus on delivering safe care.

Our goal is a 1% to 5% improvement in staff survey scores about hand-offs and transitions.

How we’re doing: Staff across the organization on working on plans to improve the success of handoffs and transitions as different staff care for patients. The next annual staff survey will be Spring 2015.

Maintain or Improve Gains from Baseline:

We want to ensure that we don’t lose ground and that we gain ground over time. We are tracking: 

  • Mortality 
  • Number of inpatient falls for injury 
  • Ventilator-associated pneumonia (VAP)


How we’re doing: For April, the most current monthly reporting period: mortality was 84 deaths per 5,384 discharges; there were no falls for injury among inpatients; and there no cases of VAP.