Discuss the types of errors that are classified in a Root Cause Analysis.

Discuss the types of errors that are classified in a Root Cause Analysis. Include a discussion of the accident models presented in Chapter 6 of the text and how these tools could be used to analyze the errors you identified.

Embed course material concepts, principles, and theories (which require supporting citations) in your initial response along with at least one scholarly, peer-reviewed journal article. Keep in mind that these scholarly references can be found in the Saudi Digital Library by conducting an advanced search specific to scholarly references. Use Saudi Electronic University academic writing standards and APA style guidelines.

Requirements: ……………………

123A Case-Based ApproachRahul K. ShahSandip A. GodambeEditorsPatient Safety and Quality Improvement in Healthcare

Patient Safety and Quality Improvement in Healthcare

Rahul K. Shah • Sandip A. GodambeEditorsPatient Safety and Quality Improvement in HealthcareA Case-Based Approach

ISBN 978-3-030-55828-4 ISBN 978-3-030-55829-1 (eBook)https://doi.org/10.1007/978-3-030-55829-1© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.This Springer imprint is published by the registered company Springer Nature Switzerland AGThe registered company address is: Gewerbestrasse 11, 6330 Cham, SwitzerlandEditorsRahul K. ShahChildren’s National Health SystemWashington, DCUSASandip A. GodambeChildren’s Hospital of The King’s DaughtersNorfolk, VAUSA

vEmily died in our hospital. She was 3 years old. She passed away following a preventable medical error. As recently as 20 years ago, an event such as this might only show up when a grieved family brings suit against the hospital and providers. Yet today, the national dialogue and focus on patient safety and transparent outcomes has dramatically changed. In most hospitals, not only would Emily’s passing be analyzed in meticulous detail, but the results would be promulgated within and across the hospital to ensure that providers and the hospital system minimize any chance of recurrence. Further, with resilience engineering and the growing concept of Safety II, hospital systems and indi-viduals may even learn to anticipate the circumstances that predispose to pre-ventable errors [1–3] and prevent them before they occur.A plethora of texts exist that are filled with theory and concepts intending to teach about making sure “Emily” never happens again—in any of our hos-pitals. In their text, Shah and Godambe have taken the conversation and teaching about quality and safety to a more practical level. They have not only challenged the talented group of chapter authors to discuss esoteric safety and quality theory, but also to bring these concepts to life through case-based scenarios. This approach brings important safety principles into stark reality as real clinical world events showcase practical approaches to imple-ment change and achieve results. Chapters such as Behavioral Economics by Jack Stevens, Workplace Safety by Joel Bundy, and Human Factors Engineering by Jon Gleason exemplify the innovation and creativity their text displays. Those chapters represent some of the most cutting edge and chal-lenging aspects of quality and safety.I applaud Drs. Shah and Godambe for compiling a different kind of quality and safety text. One well worth the read for both students and experts. There is something for everyone in this well-done epistle.ForewordColumbus, OH, USA Richard J. Brilli, MD, FAAP, MCCM References 1. Woodward S. Moving towards a safety II approach. J Pat Saf Risk Mgmt. 2019;24(3):96–9.

vi 2. Merandi J, Vannatta K, Davis JT, et al. Safety II behavior in a pediatric intensive care unit. Pediatrics. 2018;141(6). Pii:e20180018. 3. Hollnagel E. Safety II in Practice: developing the resilience potentials. London: Routledge, Taylor & Francis Group; 2018.Foreword

viiDo we really need another book about hospital safety and quality? There are journals, webinars, and myriad national conferences that help drive the field forward. The socio-political-legal environment in the United States has never been more focused on ensuring that American healthcare protects patients and drives quality. There are numerous safety and quality assessments, task-forces, and committees coupled with insurers, industry, and innovators work-ing towards the goal to create the best healthcare delivery system. So, do we really need another book about hospital safety and quality?The passionate authors of this text provide their insights as to where the field of improvement and safety science is with regard to the views and aspi-rations of the aforementioned healthcare advocates and customers. The authors are the top safety and quality leaders. We all have and continue to lead and participate in all of the aforementioned programmatic approaches towards hospital safety and quality. However, we still feel the void. We are inundated by theoretical frameworks, “what-ifs,” and extrapolations from one industry to another, all trying to help us drive safety and quality to new pla-teaus in our organizations. However, we still feel a void. The feeling can be summed up as such: “what about us?” A gap in the programmatic approach is that the materials, conferences, and teachings oftentimes fall short of provid-ing the audience with tangible, concrete examples, with direct linkages from a structure to measured processes to discrete outcomes.Additionally, our responsibility to train our teams and future leaders in improvement and safety science cannot be forgotten – “if the student has not learned, the teacher has not taught,” a phrase used often by our Toyota sensei (John Heer, Manager, Toyota Production System Support Center (TSSC) – Australia, personal communication). W. Edwards Deming eloquently said, “there is no substitute for knowledge” [1]. The lessons from healthcare are applicable to other work sectors and vice versa – some of our expert authors, not surprisingly, come from other industries.This textbook uses a case-based approach to share knowledge and tech-niques on how to operationalize much of the theoretical underpinnings of hospital quality and safety. We were fortunate to have the leaders in quality and safety embrace this concept as it resonated with their sentiments as well. Furthermore, they all stepped up to contribute to the 22 chapters in this edi-tion. We are confident that a case-based approach with vignettes through the chapters will help solidify the theoretical underpinnings and drive home the learnings. At the end of each chapter, there are comments by the editors which Preface

viiihighlight what we believe are important concepts or connections between the various chapters in the book.As we strive to reach zero harm to our patients and staff, we must embrace different ways of thinking. This textbook presents a novel approach towards hospital safety and quality with the goal to help us reach zero harm in our organizations. Reference 1. Deming WE. New economics for industry, government and education. 2nd ed. Cambridge: MIT Press; 2000.Washington, DC, USA Rahul K. ShahNorfolk, VA, USA Sandip A. GodambePreface

ixThis book is the result of the hard work of many dedicated authors with the support of their respective families. It has been a pleasure to work with them and make this dream concept of a case-based learning textbook a reality. We would especially like to thank the countless patients and families, trainees, and colleagues, past and present, whose thoughtful questions and expecta-tions of excellence have made us better improvement and safety scientists and clinicians. Finally, many thanks to our loving families, especially our wives, Banu and Libby, and children, Nisreen, Amir, Maya, Samir, and Riya, who have made sacrifices, yet have been there to support, entertain, and inspire us!We would like to remind everyone of our goal – to strive for and attain the goal of zero harm!Acknowledgement

xi 1 Introduction: A Case-Based Approach to Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Sandip A. Godambe and Rahul K. Shah 2 Organizational Safety Culture: The Foundation for Safety and Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . 15Michael F. Gutzeit, Holly O’Brien, and Jackie E. Valentine 3 Creation of Quality Management Systems: Frameworks for Performance Excellence . . . . . . . . . . . . . . . . . . . 37Adam M. Campbell, Donald E. Lighter, and Brigitta U. Mueller 4 Reliability, Resilience, and Developing a Problem-Solving Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55David P. Johnson and Heather S. McLean 5 Building an Engaging Toyota Production System Culture to Drive Winning Performance for Our Patients, Caregivers, Hospitals, and Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Jamie P. Bonini, Sandip A. Godambe, Christopher D. Mangum, John Heer, Susan Black, Denise Ranada, Annette Berbano, and Katherine Stringer 6 What to Do When an Event Happens: Building Trust in Every Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Michaeleen Green and Lee E. Budin 7 Communication with Disclosure and Its Importance in Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Kristin Cummins, Katherine A. Feley, Michele Saysana, and Brian Wagers 8 Using Data to Drive Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Lisa L. Schroeder 9 Quality Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Michael T. Bigham, Michael W. Bird, and Jodi L. Simon 10 Designing Improvement Teams for Success . . . . . . . . . . . . . . . . . 193Nicole M. Leone and Anupama SubramonyContents

xii 11 Handoffs: Reducing Harm Through High Reliability and Inter-Professional Communication . . . . . . . . . . . . . . . . . . . . . . . . 207Kheyandra D. Lewis, Stacy McConkey, and Shilpa J. Patel 12 Safety II: A Novel Approach to Reducing Harm . . . . . . . . . . . . . 219Thomas Bartman, Jenna Merandi, Tensing Maa, Tara C. Cosgrove, and Richard J. Brilli 13 Bundles and Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231Gary Frank, Rustin B. Morse, Proshad Efune, Nikhil K. Chanani, Cindy Darnell Bowens, and Joshua Wolovits 14 Pathways and Guidelines: An Approach to Operationalizing Patient Safety and Quality Improvement . . . . 245Andrew R. Buchert and Gabriella A. Butler 15 Accountable Justifications and Peer Comparisons as Behavioral Economic Nudges to Improve Clinical Practice . . . . 255Jack Stevens 16 Diagnostic Errors and Their Associated Cognitive Biases . . . . . 265Jennifer E. Melvin, Michael F. Perry, and Richard E. McClead Jr. 17 An Improvement Operating System: A Case for a Digital Infrastructure for Continuous Improvement . . . . . . . . . . . . . . . . 281Daniel Baily and Kapil Raj Nair 18 Patient Flow in Healthcare: A Key to Quality . . . . . . . . . . . . . . . 293Karen Murrell 19 It Takes Teamwork: Consideration of Difficult Hospital-Acquired Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309J. Wesley Diddle, Christine M. Riley, and Darren Klugman 20 Human Factors in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319Laurie Wolf, Sarah Henrickson Parker, and Jonathan L. Gleason 21 Workforce Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335Joel T. Bundy and Mary M. Morin 22 Changing the Improvement Paradigm for Our Kids . . . . . . . . . 353Daniel B. Wolfson, Jeffrey Scott Warshaw, and Julianne C. Coleman Afterword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377Contents

xiiiDaniel Baily, MSHS Beterra Health, Newnan, GA, USAThomas Bartman, MD, PhD Nationwide Children’s Hospital, Division of Neonatology, Columbus, OH, USAAnnette Berbano, MSN, RN, CCRN Kaizen Promotion Office, Harbor- UCLA Medical Center, Torrance, CA, USAMichael T. Bigham, MD, FAAP, FCCM Akron Children’s Hospital, Department of Quality Services, Akron, OH, USAMichael W. Bird, MD, MPH Akron Children’s Hospital, Department of Quality Services, Akron, OH, USASusan Black, MSN, NP Kaizen Promotion Office, Harbor-UCLA Medical Center, Torrance, CA, USAJamie P. Bonini, MS Toyota Production System Support Center (TSSC), Toyota Motor Corporation, Plano, TX, USACindy Darnell Bowens, MD, MSCS University of Texas Southwestern, Children’s Health Dallas, Department of Pediatric Critical Care, Dallas, TX, USARichard J. Brilli, MD, FAAP, MCCM Nationwide Children’s Hospital, Division of Pediatric Critical Care Medicine, Columbus, OH, USAAndrew R. Buchert, MD Clinical Resource Management, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USAGME Quality and Safety, Wolff Center at UPMC, Pittsburgh, PA, USAPediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USALee E. Budin, MD Driscoll Health System, Corpus Christi, TX, USAJoel T. Bundy, MD Sentara Healthcare, Virginia Beach, VA, USAGabriella A. Butler, MSN, RN Healthcare Analytics and Strategy, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USAContributors

xivAdam M. Campbell, PhD Children’s Hospital of The King’s Daughters, Department of Quality and Safety, Norfolk, VA, USANikhil K. Chanani, MD Quality and Outcomes, Cardiac Service Line, Children’s Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Atlanta, GA, USAJulianne C. Coleman, MA, EdD The CORE Districts, Sacramento, CA, USATara C. Cosgrove, MD Nationwide Children’s Hospital, The Heart Center, Columbus, OH, USAKristin Cummins, DNP, RN, NE-BC Children’s Health, Dallas, TX, USAJ. Wesley Diddle, MD Pediatric Cardiac Intensivist, Children’s National Hospital, Cardiac Critical Care Medicine, Washington, DC, USAProshad Efune, MD Children’s Health Dallas, University of Texas Southwestern, Department of Anesthesia and Pain Management, Dallas, TX, USAKatherine A. Feley, DNP, RN Indiana State Nurses Association, Indianapolis, IN, USAGary Frank, MD, MSEM Children’s Healthcare of Atlanta, Atlanta, GA, USAJonathan L. Gleason, MD Jefferson Health, Philadelphia, PA, USASandip A. Godambe, MD, PhD, MBA Children’s Hospital of The King’s Daughters, Norfolk, VA, USAMichaeleen Green, BA, Mathematics Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, USAMichael F. Gutzeit, MD Children’s Hospital of Wisconsin, Milwaukee, WI, USAJohn Heer, BEng, MBA Toyota Production System Support Center (TSSC), Toyota Motor Corporation Australia, Melbourne, AustraliaDavid P. Johnson, MD Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USADarren Klugman, MD, MS Cardiac Intensive Care Unit, Children’s National Heart Institute, Children’s National Hospital, Cardiac Critical Care Medicine, Washington, DC, USANicole M. Leone, MD Cohen Children’s Medical Center, Zucker School of Medicine at Hofstra/Northwell, Department of Pediatrics, New Hyde Park, NY, USAContributors

xvKheyandra D. Lewis, MD Drexel University College of Medicine, St. Christopher’s Hospital for Children, Department of Pediatrics, Philadelphia, PA, USADonald E. Lighter, MD, MBA, FAAP, FACHE Institute for Healthcare Quality Research and Education (IHQRE), and Physician Executive MBA Program, University of Tennessee, Department of Business Administration, Knoxville, TN, USATensing Maa, MD Nationwide Children’s Hospital, Division of Pediatric Critical Care Medicine, Columbus, OH, USAChristopher D. Mangum, CSSBB Children’s Hospital of The King’s Daughters, Department of Quality, Norfolk, VA, USARichard E. McClead Jr, MD, MHA Nationwide Children’s Hospital, Hospital Administration, Columbus, OH, USAStacy McConkey, MD Adventhealth for Children, Graduate Medical Education, Department of Pediatrics, Orlando, FL, USAHeather S. McLean, MD Duke Children’s Hospital, Department of Pediatrics, Duke University Medical Center, Durham, NC, USAJennifer E. Melvin, MD Nationwide Children’s Hospital, Department of Emergency Medicine, Columbus, OH, USAJenna Merandi, PharmD, MS, CPPS Nationwide Children’s Hospital, Pharmacy Department, Columbus, OH, USAMary M. Morin, RN, MSN Clinical Effectiveness and Employee Health Services, Sentara Healthcare, Virginia Beach, VA, USARustin B. Morse, MD, MMM Nationwide Children’s Hospital, Columbus, OH, USABrigitta U. Mueller, MD, MHCM ECRI, Plymouth Meeting, PA, USAKaren Murrell, MD, MBA Performance Improvement, TeamHealth, Knoxville, TN, USAKapil Raj Nair, MSHS Beterra Health, Newnan, GA, USAHolly O’Brien, MSN RN CPPS Children’s Hospital of Wisconsin, Department of Quality and Safety, Milwaukee, WI, USASarah Henrickson Parker, PhD Center for Simulation, Research and Patient Safety, Carilion Clinic and Fralin Biomedical Research Institute at Virginia Tech, Roanoke, VA, USAShilpa J. Patel, MD University of Hawaii, John A. Burns School of Medicine, Kapi‘olani Medical Center for Women & Children, Department of Pediatrics, Honolulu, HI, USAContributors

xviMichael F. Perry, MD Nationwide Children’s Hospital, Department of Hospital Medicine, Columbus, OH, USADenise Ranada, MSN, RN Kaizen Promotion Office, Harbor-UCLA Medical Center, Torrance, CA, USAChristine M. Riley, MSN, APRN, CPNP-AC Cardiac Intensive Care Unit, Children’s National Hospital, Washington, DC, USAMichele Saysana, MD Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USALisa L. Schroeder, MD Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Department of Medical Administration, Kansas City, MO, USARahul K. Shah, MD, MBA Children’s National Hospital, Washington, DC, USAJodi L. Simon, MSHA, BS Akron Children’s Hospital, Department of Quality Services, Akron, OH, USAJack Stevens, PhD Nationwide Children’s Hospital, Ohio State University Department of Pediatrics, Columbus, OH, USAKatherine Stringer, BSPH Kaizen Promotion Office, Harbor-UCLA Medical Center, Torrance, CA, USAAnupama Subramony, MD, MBA Cohen Children’s Medical Center, Zucker School of Medicine at Hofstra/Northwell, Department of Pediatrics, New Hyde Park, NY, USAJackie E. Valentine, RPh, MHA Seattle Children’s Hospital, Department of Patient Safety, Seattle, WA, USABrian Wagers, MD Indiana University School of Medicine, Riley Hospital for Children, Department of Emergency Medicine and Pediatrics, Indianapolis, IN, USAJeffrey Scott Warshaw, BA, MS San Diego County Office of Education, Learning and Leadership Services, San Diego, CA, USALaurie Wolf, PhD Carilion Clinic, Clinical Advancement and Patient Safety, Roanoke, VA, USADaniel B. Wolfson, AB, MA, EdD San Diego County Office of Education, Learning and Leadership Services, San Diego, CA, USAJoshua Wolovits, MD UT Southwestern Medical Center, Cardiac ICU, Children’s Health, Dallas, TX, USAContributors

xviiAbout the EditorsRahul K. Shah, MD, MBA obtained a combined BA/MD degree from Boston University School of Medicine (2000), thereafter completing an otolar-yngology residency (Tufts University) and a pediat-ric otolaryngology fellowship (Children’s Hospital Boston, Harvard University). He joined the faculty of Children’s National Medical Center (2006), ris-ing to the rank of Professor (2017) at George Washington University School of Medicine and Health Sciences. Dr. Shah’s research interests include resource utilization and outcomes, patient safety, and medical errors; he has received numer-ous awards for his research. He is recognized as a leader in patient safety and quality improvement, and has chaired and serves on myriad national com-mittees related to patient safety and quality improve-ment. Dr. Shah was Executive Director of the Global Tracheostomy Collaborative, an interna-tional not-for-profit quality improvement initiative. He was the inaugural Associate Surgeon-in-Chief at Children’s National Medical Center and the Medical Director of Peri-operative Services from 2011 to 2014. Dr. Shah served as President of the Medical Staff at Children’s National Medical Center from 2012 to 2014. In 2014, he was appointed the inau-gural Vice President, Chief Quality and Safety Officer for Children’s National Health System and in 2018 was appointed the inaugural Vice President, Medical Affairs as an additional executive responsi-bility; he has served as the acting Chief Medical Information Officer (July–December 2019). Dr. Shah has authored over 130 peer-reviewed articles and has given hundreds of national and international presentations. Under his leadership, Children’s National has received numerous safety and quality distinctions and is a recognized leader in pediatric safety and quality.

xviiiSandip A. Godambe, MD, PhD, MBA is a phy-sician leader who obtained a combined MD-PhD degree from Washington University School of Medicine’s Medical Scientist Training Program. He then completed a pediatrics residency (Boston Children’s Hospital, Harvard University) and pediatric emergency medicine (PEM) fellowship (University of Tennessee, Le Bonheur Children’s Hospital). He worked briefly at Norton Children’s Hospital and then joined the faculty at the University of Tennessee as the Co-Medical Director of Emergency Services. Dr. Godambe obtained his MBA degree with a focus on quality (University of Tennessee) and then became the inaugural Medical Director of Medical Staff Quality. He moved to Children’s Hospital of The King’s Daughters (Norfolk, VA) where he became the inaugural Vice President of Clinical Integration and Quality and the Chief Quality and Safety Officer. Dr. Godambe has led CHKD to numerous quality and safety awards on their journey to becoming a high-reliability organization. As a Professor of Pediatrics, Vice Chair of Pediatrics – Quality and Safety, and Co-Program Director of the Improvement Science Fellowship with Eastern Virginia Medical School, he leads many educa-tional venues for students and trainees with regard to quality and safety. He is recognized as a leader in patient safety and quality improvement and has led or served on a myriad of state and national committees related to healthcare quality, safety, and emergency medicine. He is the regional co-leader for the Atlantic subsection of Children’s Hospital Solutions for Patient Safety (CH-SPS) and a clinical steering committee member for the National CH-SPS and Child Health PSO. He has served as a Senior Examiner for the Baldrige Performance Excellence Program. He is well versed in Improvement Science through his work experience and training in Lean, Six Sigma, Institute of Healthcare Improvement (IHI) Model for Improvement, and the Toyota Production System. He is currently an IHI Improvement Advisor. He has authored over 100 publications, chapters, and abstracts in emergency medicine, quality, and immunology. He is the co-editor of About the Editors

xixfive books: multiple editions of the 5-Minute Fleisher and Ludwig’s Pediatric Emergency Medicine Consult, PEM Question Book, and this textbook. He currently serves on the editorial boards of two journals and is a reviewer for mul-tiple clinical, safety, and quality journals. He has given over 200 national and international presentations.About the Editors

1© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 R. K. Shah, S. A. Godambe (eds.), Patient Safety and Quality Improvement in Healthcare, https://doi.org/10.1007/978-3-030-55829-1_1Introduction: A Case-Based Approach to Quality ImprovementSandip A. Godambe and Rahul K. ShahS. A. Godambe (*) Children’s Hospital of The King’s Daughters Health System, Norfolk, VA, USAe-mail: [email protected] R. K. Shah Children’s National Hospital, Washington, DC, USAe-mail: [email protected] 1.1A tertiary care free-standing hospital has a problem with catheter-associated urinary tract infections (CAUTIs). This problem is not new. The organization tackled CAUTIs 4 years prior with the creation of an over-arching structure which resulted in new processes and better outcomes. As the com-pliance with these refined processes improved, the absolute number of CAUTIs went down. However, in the past 18 months, the number of CAUTIs has slowly crept back up. This issue is further compounded by the fact that the rate has significantly worsened even as the organization has reduced their Foley catheter days dramati-cally. The clinicians only place catheters when they are most needed; hence the numerator has increased, while the denom-inator has decreased in the CAUTI rate equation. The executive leadership and Hospital Board demand an improvement from the quality and safety team. This can be the self-defeating prophecy for many teams trying to reduce the CAUTI rate – the absolute number of events is decreasing but the rate (which is used for benchmark-ing) continues to increase.Chapter Objectives• To demonstrate the burning platform of patient safety and quality improvement in the current healthcare era as it relates to the achievement of zero harm• To explain how varying improvement methodologies can co-exist to drive improvement in an organization with the use of an adapted simple, common language that fosters improvement across all layers of the enterprise• To connect the work of patient safety and quality improvement to the mission, vision, and values of an organization• To understand the value of learning best practices and methods from non- healthcare industries

2 Opening Question/ProblemThis chapter is not about CAUTIs or specific tac-tics to reduce these infections – that will be dis-cussed elsewhere in this text. Rather, this chapter discusses the improvement framework and approach toward patient safety and quality improvement that transcends individual hospital acquired conditions and can be broadly applied to quality improvement initiatives in the organization. Introduction/OverviewThere have been significant strides made to advance patient safety and quality improvement in the past two decades. Hospitals, and other organizations, reacted to the clarion call from the Institute of Medicine’s seminal work, To Err is Human [1]. Since this publication, hospitals and healthcare systems have made tremendous invest-ments in people, processes, and technology – all with an aim to improve the quality and safety of care delivery. We have seen improvement; how-ever, there are issues that still persist and have not improved at the same rate as other measures. Many organizations are struggling with their progress toward zero harm; they have seen a pla-teau in their improvement and are looking for novel approaches and strategies.Early in the journey, there was an educational component which was missing in this work. As such, initial efforts were appropriately targeted toward increasing capability (the ability, from a skills perspective, of healthcare workers to embark upon quality improvement initiatives) (Key Point Box 1.1).Much of the efforts immediately after To Err is Human focused on extrapolating the theoreti-cal underpinnings from systems science, reli-ability, and quality improvement from other industries to educate those of us in healthcare. This was initially quite successful, as there was a whole new lexicon introduced into healthcare. Previously fertile ground was now inundated with theoretical quality improvement applica-tions. As expected, improvement followed as the proverbial low-hanging fruit (Fig. 1.1) was harvested. Some of the success in the early 2000s was a result of the Hawthorne effect (which states that improvement will occur when those performing the work know they are being observed); however, not surprisingly, in many instances, these results were not sustained (Key Point Box 1.2).Nevertheless, healthcare was quick to embrace this renewed interest in the safety of their patients Sweet fruitGround fruitBulk of fruit5,6 σ : Address designs 1,2 σ : Logic and intuition4 σ : Improve internally3 σ : Demand improvementLow hanging fruitConcept and design : Rahul K. ShahFig. 1.1 Climbing the quality tree. (Image courtesy of Rahul K. Shah)Key Point Box 1.2 SustainA common prob

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