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 are 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 
  • Post-operative venous thromboembolism rate per 1,000 (PSI 12, adults only)  
  • Influenza immunization (pediatric patients only)


We have two goals: our "improvement target" is a 10 percent reduction in harm events from our prior fiscal year, and an "achievement target" is a 10 percent reduction from the index of other hospital organizations. We measure the goal site by site for our six hospitals.

How we are doing: For September 2015, we met our improvement target at 5 of 6 sites and met our achievement target at 4 of 6 sites. 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 1 to 5 percent improvement in handoffs and transitions in the by March 31, 2016, which is the end of our fiscal year.

How we’re doing: Staff members across the organization are on working on plans to improve the success of handoffs and transitions as different staff care for patients.

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   
  • Ventilator-associated pneumonia (VAP)


How we’re doing: For September 2015, the most current monthly reporting period: mortality was 83 deaths per 5,165 discharges; and there were no cases of VAP.