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Quality and safety initiatives

Big Aims

Our overarching quality program is aimed at three results:

  1. Eliminate needless deaths 
  2. Eliminate preventable harm
  3. Minimize readmissions


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  

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 hospitals.

How we are doing: 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 to close the gap between baseline and 75th percentile by 20 percent in hand offs and transitions.

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