Patient Safety and

Quality
Improvement
 Objectives

• To understand why Patient Safety and Quality

Improvement is foundational to today’s healthcare
delivery

• To know the meaning of the basic vocabulary of patient

safety/quality improvement

• To Understand the basic PS/QI methods

Traditional Patient Safety/Quality Improvement

“To Cure Sometimes

To Relieve Often

To Educate Unceasingly

To Comfort Always”
 Overarching Aim for HC

•In the patient’s words: “They give me exactly the help I

need and want exactly when I need and want it”

•Thus the ideal 21st Century HC System evaluates the

care through the patient’s eyes
 Why Bother with Pt Safety/Quality?
 Do You Have an Ethical
Responsibility to Consistently
Provide Good Patient Care?
Is your community better off
because your healthcare facility is
present in it?
 Questions to ask in Evaluating
Healthcare Outcomes – Evidence
Based Medicine
1. What portion of your patients are receiving care in line
with current best practice (evidence-based medicine)?
2. How does the healthcare you provide need to change to
reflect best practice (evidence-based medicine)?
3. Do your healthcare professionals / managers have the
skills and support to make these necessary changes?
Which is the Most Dangerous?
 How Hazardous is Health Care?
DANGEROUS REGULATE ULTRA-SAFE
(>1/1000) (<1/100K)
100,000
Driving
10,000

1,000 Healthcare
Scheduled
Airlines
100
Mountain Chemical European
10
Manufacturing
Climbing Chartered Railroads
Bungee Flights Nuclea
1 Jumping r
1 10 10,000 1,000,000 Power
10,000,00
10 100,000 0
0
Number of encounters for each fatality
1,0
00
 Patient Safety

•HC has two implicit moral/ethical promises to patients that

entrust their care to us, we promise to:

• Do everything possible to help them

• Not hurt them

 Patient Safety
•Patient Safety is the prevention of medical errors and
adverse events
•Integrating PS into practice is a very complex process in that
it interacts with both clinician practice and the institutional
“System”
•HC systems must be built on a “Culture of Safety”
• A system designed to prevent errors while empowering
individual staff members to promote safety and recognize and
respond to errors that occur
 Patient Safety
•An 80-90% success rate to an institution sounds “great”
• But from a patients’ standpoint, it is unacceptable
• For the individual patient, reliability is an “all-or-none” matter
• Safety is Quality for an “n” of one

•Optimal Patient Safety requires a framework for improving

reliability - standardized protocols for care that are
evidence- based and widely agreed upon is essential
 Current Variation in Practice

• Study of Content of Care to Adults between 1996 and 1998:

•Only 55% of patients received “recommended” care
(439 process-of-care measures)
•Up to 10,000 lives per year savable from pneumonia could be
prevented annually

•The “Gap” between what we know works and what is actually

done is so large it requires attention

McGlynn, Asch, Adams, Keesey, Hicks, De Christofaro and Kerr NEJM 348;(26) 2635-2645 June 26, 2003
 Patient Safety – Systems Thinking

•No system will ever be able to “eliminate all errors.”

•A key principle: all patient safety programs that are
focused exclusively on eliminating errors will fail
•We are human. We will never eliminate all errors.
The real goal is to prevent harm to patients
•How: by taking a systems approach to problem solving
 Medical Errors

•IOM Definition:
“The failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an aim
(including problems in practice, products, procedures or
system)”
•“A Process that does not proceed the way it was intended
by its designers/managers”
• A more practical definition:
“Freedom from accidental injury due to medical
care”
 Patient Safety Errors

•Preventable harm is the third leading cause of death

•Medicine squanders ~ 30-40% of monies spent on HC

•Surgical instruments left in patients, overdoses in pediatric patients with

blood-thinners, Operates on the wrong side of the body, delivers
appropriate therapy (all of them) only about 55% of the time, and kills ~
100k per year.
• About 17% of hospitalized patients suffer a diagnostic error and ~ 7%
suffer a med error
 The Swiss Cheese Model (Reason, 1991)

Latent
Production
Pressures
Failure
Lack of Attention
Distractionss
Zero fault
Procedures
Mixed tolerance Deferred
Punitiv Sporadic Maintenanc
Trigger e
Messa
g es Training e
s policies
Clumsy
Technolog
y

Defense
s
Advers
e
Event
 Sentinel Event

An unexpected occurrence involving death or serious physical or

psychological injury, or the risk thereof

Serious injury includes loss of limb or function. “or the risk

thereof” includes any process variation for which a recurrence
would carry a significant chance of a serious adverse outcome
 “Near Misses”

•"Near misses are the huge iceberg below the surface where all
the future errors are occurring”
•Close calls are given the same level of scrutiny as adverse events that
result in actual harm
• They are 3 to 300 times more common than actual adverse events
• A willingness and an way (means) to report problems is essential to safe care because you can’t fix
what you don’t know about
•As important, if not more important to evaluate a new miss
than evaluating an actual misadventure that resulted in patient
harm
 Normal Response to a Medical Error
•Go directly to the staff members involved (the sharp end of the chisel)
• The Physician/medical residents
• The Nurse
•However, this is counter to a Safety Culture (“Just Culture”) concept:
• Do not automatically blames the caregiver
• Instead, thoroughly investigate the incident
• Root Cause Analysis:
• RCA is the process that seeks to explore all of the possible factors associated with
the incident by asking what happened, why it happened and what can be done to
prevent it from happening again
 Just Culture

An atmosphere of trust in which people are encouraged

(even rewarded) for providing essential safety-related
information. Individuals trust that they will not be held
accountable for system failures; but, are also clear about
where the line must be drawn between acceptable and
unacceptable behavior
 System Characteristics That
Promote a Culture of Patient
Safety
•Culture Change: is it Safe to report adverse events?

•Simple: one-page (or less) report

•Share Feedback: in an Effective system – adverse events

are analyzed by experts and all share in feedback
 Patient Safety and QI Gurus
•Walter Shewhart: first to describe the PDSA cycle and statistical control
•W. Edwards Deming: focus on process improvement, management has the final
responsibility for quality
• Special Causes of variation: unnecessary variation associated with specific causes:
equipment, people
• Common Causes of variation: those associated with systems aspects such as design,
training, machines or working conditions
•Joseph Juran: QI is a never-ending process, Quality goals must be specific
•Ishikawa/Taguchi: statistical techniques / quality tools
•Paul Betalden, Donald Berwick, Lucien Leape, and Brent James
 The Catalyst
“To Err is Human” 1999
~ 98,000 preventable deaths
This was the “what”

“Crossing the Quality

Chasm”

2001
Quality as aFor
The Six Aims systems issue
Improvement
Safe Effective
This was the “how”
Patient-centered Timely
Efficient Equitable
 Patient Safety Goals
1. Improve the accuracy of patient identification:
a. Two patient identifiers
b. “Time Out Process:” Prior to the start of any
invasive procedure conduct a final verification
process to confirm that all team members
understand:
1. You have the correct patient
2. You are doing the correct procedure
3. On the correct site,
4. With the availability of appropriate ancillary data
5. “Time-Out” is documented
 Patient Safety Goals

2.Improve the effectiveness of Communication among

caregivers:
• Verbal and telephone orders or critical test results –
require “read-back” verification
• Never document with unapproved abbreviations,
acronyms or symbols (“Do Not Use” list)
• Reporting and receipt of critical test results and values
must be timely (<60 minutes)
• Standardize “hand off” communications including time to
ask and answer questions (such as SBAR)
 Communication: SBAR
•Situation:
• “I am calling about Mrs. Smith; I am worried about her vital signs”
•Background:
• She was admitted 2 days ago with chest and abdominal trauma”
•Assessment:
• “She is hypotensive and tachycardic; I think she is going into shock”
•Recommendation:
• “I need to you come see her NOW. Are you available?”
 Patient Safety Goals
3. Improve medication safety:
• Drug concentrations have a standardized list that limits the amount
that can be given
• Actions are taken to prevent look-alike and sound-alike medication
errors
• Label all medications and solutions used in OR and Procedure
areas
4. Reduce the risk of health care-acquired infections
• Comply with hand hygiene guidelines: wash hands for at least 15
seconds before and after delivering care or use alcohol-base hand gel
• Manage all unanticipated death (s) or major permanent loss of
function associated with a healthcare acquired infection as a sentinel
events
 Written Medication Orders: Illegible Handwriting

•16% of physicians have illegible handwriting.1

•Common cause of prescribing errors.2, 3, 4
•Delays medication administration.5
•Interrupts workflow. 5
•Prevalent and expensive claim in malpractice cases.3

1. Anonymous. JAMA 1979; 242: 2429-30; 2. Brodell RT. Arch Fam Med 1997; 6: 296-8;
3. Cabral JDT. JAMA 1997; 278: 1116-7; 4. ASHP. Am J Hosp Pharm 1993; 50: 305-14;
5. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Can you read
this?
 Medication Errors
PRESCRIPTION FAULTS: PRESCRIPTION ERRORS:

• Error in drug dose

• Inappropriate prescribing
• Underprescribing
• Overprescribing

• Route of administration
Duplicative errors
• Frequency of use
• Duration of therapy
Prescribing drugs that interact

Given to the wrong patient

 Surgical Check List

•A 2007 WHO effort to reduce the number of surgical deaths

•Aim: to reinforce accepted safety practices and foster better

communication and teamwork between clinical disciplines

•A tool for clinicians to improve the safety of their operations

and reduce unnecessary morbidity and mortality
 Patient Safety Errors –
Hospital-Acquired Infections

•CLABSI checklist: in SICU (Johns Hopkins) – resulted in a

70% reduction in CLABSI in the 100 ICUs in Michigan:
• But the checklist is only one aspect
• Culture and Behavior change with Robust
measurement

•9 preventable harms: adverse drug events, CAUTI,

CLABSI, Fall injuries, Pressure ulcers, Venous
Thromboembolism, VAE, Obstetrical adverse events
 Systems Thinking:
•Systems thinking is not easy
•Not a natural act: we see the parts not the whole
•But to master the art of Quality (system) Improvement we must
have a deep and fundamental understanding of how the parts
are connected in our entire complex Healthcare system
•“ We must accept human error as inevitable – and design
around that fact.” - Don Berwick, M.D.
•“The Search for zero error rates is doomed from the
start”
 Systems Thinking

“Running a Hospital isn’t

Brain Surgery….

It’s
Harder!
”
 Systems Behavior

80
%

20%
Joseph Poor Poor Performance
Juran
Performance due to the
Due to the efforts of the
Design of the People in the
System System
 System Thinking

“Healthcare Organizations are the most

complex organizations to manage”

Peter Drucker
 Quality Improvement (QI)

•Quality is the “extent to which the clinician or organization

meets or exceeds the needs and expectations of patients”

•QI involves the systematic and continuous implementation of

changes that measurably improve patient care
• QI is based on the understanding that it is easier to improve
that which can be measured, thus QI entails monitoring
and assessment
 Continuous Quality Improvement
•CQI is both a management philosophy (management’s job is
optimize
to the system” Deming) and a management method:
• It is rigorously based in fact-based decision making
• It is systems-based
• It involves unit-based teams
• It emphasizes continuing the system analysis and improvement
• It is organization learning
• It uses Quality Tools
• It is based in a facility-wide Quality Council
• It is based on Senior Management Commitment to make processes effective
• It uses Statistical analysis
• It uses appropriate benchmarking (peer comparisons) to identify best practices
 The 6 Fundamental Domains of Quality
IOM

1. Safety: as safe in healthcare as in our home

2. Effectiveness: matching care to science; only “Appropriate” care -
avoiding overuse of ineffective care and underuse of effective care
3. Patient (Person) Centeredness: honoring the individual, and
respecting choices
4. Timeliness: less waiting for both patients and those who
give care
5. Efficiency: reducing waste: “Improving my work is my work”
6. Equity: closing gaps in health status amongst groups
 “Crossing the Quality
Chasm”
Our Task: “Quality Improvement”

Goal:
Where We Evidence
Think We Base
Are Medicine
Chasm

Where We
“One doesn’t leap over a chasm in two steps” Actually Are
 Classic Way to Define Impaired Quality

•Overuse (of procedures that cannot help) [Up to 15%

of actions]
•Underuse (of procedures that can help) [Up to 50% of
actions]
•Misuse (errors of execution)
 “Science of (Q) Improvement”

•Basically the Scientific Method:

• Measure the current process (baseline status)
• Analyze the steps in the process (process mapping)
• Create a “Hypothesis” (change part of the process)
• Experiments changing the process (RCI: PDSA Cycle)
• Measuring the new results (QI and Pt safety)
• Analysis: accept (incorporate into your processes) or reject
the change studied
 The “First Law of Q Improvement” [Step
#1]

•“Every System is perfectly designed to get the results it gets”

Paul Betalden, M.D.

•This reframes Performance from a matter of effort to a matter of

system design (change from existing form)….

If you want to improve results

you must change the system!
Second “Law of Q Improvement:” Transparency

•Be open and honest about “failed” tests:

• These are often the most valuable RCIs
• It is natural for humans (HC workers) to want to forget about
experiments that don’t work

•But all scientists know that learning from failure is just as

important as learning from success
 Third “Law of Q Improvement:”
Attitude
•To learn something new is Humbling. It requires that we put
aside our “expert” status and become learners: disciples,
open, teachable, obedient

•We don’t like feeling stupid; we’d much rather be the

Teacher, the one with all the answers, but first we must
embrace the humility discipleship requires

•Willingness to Fail
 Fourth “Law of Q Improvement:” Agility

How do I implement this the new information in this

Thursday’s Lancet into next Tuesday’s new practice?

“What can I do by Next Tuesday?”

Fifth “Law of Q Improvement” is “Team
Based”
Staff need a culture that acknowledges that the best care comes
from people working as a team, not as “lone rangers” with the
sole responsibility for the success or failure of their actions
◦ T ogether
◦ E veryone
◦ A cheives
◦ M ore
“Doctors still perceive that they are the
center of the healthcare universe. Healthcare
is a team sport, and we don’t optimally work
in teams”
 Project Name:
Date Chartered Start Date: Target Completion Date:

Project Team Phone Title

Fill in team members names

and contact information

Process Owner Phone Title

Tea Problem Statement

m  Include a summary of the problem and impact (a.k.a. PAIN).
Goal Statement
 Describe the team’s improvement objective
 Begin with the words “reduce, eliminate, control”
 Should be ‘SMART’ – specific, measurable, attainable, relevant, timebound
Project Scope
 Where does the process under investigation start?
 Where does this process stop?
 What is inside of the project scope?
 What is outside of the project scope?
Deliverables
 What end result(s) do are expected to be achieved from this project?
 How will you know that any changes have resulted in improvements?
 Quality Improvement Methods
[EBM for H C Organizations]

1. Betalden and IHI – Model of Improvement [Rapid Cycle

Improvement]
2. Lean Thinking
3. Theory of Constraints
4. Queuing Theory
5.Six Sigma
6. ISO 9001
7. Baldrige Criteria for
Performance Excellence
 Model for improvement
What are we trying to goals and
accomplish?
aims
How will
change isweanknow that a measures
improvement?
What changes can we
that will result in
make change
improvements that we
the
seek ?
principles

Act
Plan testing
ideas
Study before
Do implementi
ng changes
 AIM Skill #1

•Use the Acronym of “SMART” (to help choose an appropriate “aim”)

• Specific
• Measurable
• Attainable
• Reliable
• Timely

•Aims should be ambitious – stretch goals

• Make it obvious that the current system is inadequate - a new one is
required
 Examples of Strong Aim Statements

• Improve (i.e. increase) the number of inpatients meeting "continued"

stay criteria (these criteria are Governmental criteria that have to be
met in order for insurance to pay for that day's stay in the hospital.
• By Jan. ‘21, the # pts transferred from ER to ward < 1 hour
from decision to admit will decrease by 40%
• To reduce the percentage of Observation stays converted to an
Admission stay from 48.5% in FY20 to 30% or less by the end of CY21
• To reduce the average length of stay from 5.48 to 5.00 by January 1,
2021
53
 Measurement [Skill 2]

•You “can’t fix something you don’t Measure”

•Remember: Measurement is not the Goal – Improvement
is the goal
•You need just enough data to know whether the
changes you put in place are leading to improvement
• Do not wait for a big “Master Plan”
• Be agile: “What can I do by next Tuesday?”
• Track and trend your data over time (Run Chart)
 Einstein on Data Collection

“Not everything that counts can be counted,

and not everything that can be counted counts"
 “Six Sigma”
•In statistics, a ‘sigma’ refers to the standard deviation from the
mean of a population
•Std Dev describes the likelihood of your next data point deviating
form the mean of the whole data set
•Six Sigma is all about variance reduction
• Variance is a symptom of waste
• High variance means lots of waste (low sigma)

•Six Sigma is very problem focused- It uses DMAIC to analyze a

problem
• Define, Measure, Analyze, Improve and Control
• Thus, very similar to PDSA cycles/Rapid Cycle Improvement
 Lean Thinking
Lean is an improvement methodology and mindset that
centers on:
• Eliminating waste
• The consistent delivery of Value
• The resolution of bottlenecks and constraints that affect the
consistent delivery of value by maximizing flow

In Lean, Value is defined by the Patient and family

*Leveraging Lean in Healthcare: Transforming Your Enterprise into a High Quality Patient Care Delivery System: Charles Protzman, George Mayzell, Joyce KerpcharAuerbach Publication: 2011
 Continuous
Gemba Improvement
The starting place
for finding value Eliminating
waste

What is
LEAN
The thinking? The
5 S’s 7 W’s

Process / Developing
Flow an Eye
Mapping For Waste
 5 S:
Sort, Set in Order, Shine, Standardize, Systematize
• 5 S: an organized, never ending, effort to
• Remove all physical waste out of the workplace that is not required
for doing work in that area
• Setting things in order
• Identify, label, allocate a place to store it so that it can be easily
found, retrieved and put away
Average Time To Get 8 Drugs = 3:07
Average Time To Get 8 Drugs = 1:08
“Quality Improvement” - Measurement Tool Kit

•QI Tools: (the most common ones)

• Run Chart [relates data over time; has improvement been secondary to changes?]
• Pareto Chart [helps stratify causes]
• Flow Mapping (Process) Charts [describes a process: current and ideal]
• Cause and Effect diagrams (Fishbone/Ishikawa Charts) [identifies
sources of variation]
• [Statistical Process] Control Charts [Shewhart: Is the process “in control”]
• A 3 Diagrams [A structured cycle of improvement that makes problem
solving visual by telling a story]
 Run Charts

• Measures what we are trying to improve over time

• It helps answer the Q: Are we doing better since

implementing the changes we made?

• Does it tell us what we need to do?

• No!
 k
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 QI Tool – Pareto Chart
•A pareto diagram is a vertical bar chart with the bars arranged
from the longest first on the left and moving successively
towards the shortest

•The arrangement of the vertical bars gives a visual indication of

the relative frequency of the contributing causes of the problem
with each bar representing one cause
 Pareto Chart for Late Lab Work
n=60

60 100%
95%
55 90%
87%
50
80%
45

Number of Delays
68% 70%
40
Break Point 60%
35

30 50%
26
25 43%
40%
20
15 30%
15
11
20%
10
5
5 3 10%

0 0%

Causes of Delays
 QI Tools – Process Mapping (Flow) Chart

Used to understand the current

process and identify opportunities for
improvement. It shows the workflow
Activity through the process including all
Start/End
Decisio activities, decisions, delays, and
n measurement points
Document
A pictorial representation of how a process works – the sequence of actions that
must be carried out to complete a specific task
Arrows ( ) are used
to connect the
symbols
– shows sequence and
interrelationships
Process Mapping: Current State to Future
State Not enough
Escorts
Patient Patient Patient
Clerk requests Patient escorted to Arrives at
Arrives at Yes
ID + medical Pre- Outpatient Outpatient
registered? Radiology Radiology
Registration
Desk
card

Not enough No
Registrars
Clerk
Registrar enters
assigns patient
patient to information into
system
Registrar

Patient
Patient Clerk/Registrar Patient information Arrives at
Arrives at requests ID + scanned into Outpatient
medical card System and Verified Radiology
Registration
Desk

Potential Solutions:
 Cross train clerks/registrars
 Card Reader + IT Integration into registration system
 Move Radiology Clerk Station Closer to Radiology
 Better Signs and Directions from registration to Radiology
 The Cause-And-Effect Diagram
Used to systematically analyze the special causes of a problem. It begins with
major causes and works backwards to the root causes. It organizes the results

of the brainstorm. Also known as the fish-bone diagram and the Ishikawa
diagram (named after its inventor, Dr. Kaoru Ishikawa of Japan)
MAJOR CAUSE 1 MAJOR CAUSE 2 MAJOR CAUSE 3
Common Categories of Major Causes
(5Ms + E):
• Man (People)
THE EFFECT
• Methods (Policies and Procedures)
(The Problem) • Materials (Supplies)
• Machine (Equipment)
• Money
• Environment
MAJOR CAUSE 4 MAJOR CAUSE 5
 Control Chart

• Is a “run chart” that shows the “control” limits of +/- three

Standard Deviations
• It is derived from simple statistics [Many statistical packages will
automatically derive these charts]: mean, Std Dev and range
• It doesn’t tell us what to do; It shows if the system ‘in’ or ‘out’ of
control?
• Two types of “variation”
• Common cause – the object of CQI
• Variation inherent in the process- usually random in nature
• Only reduced by improving the underlying system
(process)!
• Special cause - the object of QA
Control Chart
 Lean A3 Thinking
•A standardized approach to problem solving:
• For Executive Leadership – Facility-wide problems/Administrative issues
• For Front-line clinical staff – very helpful in solving unit-based problems
•A step by step direction to problem solving
• Continuous Quality Improvement (Patient Care + Admin. Systems)
•The A3 provides a clear, concise, one-page overview
• It can consolidate large amounts of information in an understandable format
using visual display
•The A3 process should become the “default” way of strategic
planning/improvements
 LEAN A3
1. Reason 4. Gap Analysis: 7. Completion Plan:
for Action: Change Sustain new process
VISION / Analysis Spread
Team and AIM

2. 5. Solution 8.
Current State: Approach: Change Confirmed State:
Map Process Ideas Sustain & Spread
Baseline
measurement

3. Target (or Future) State: 6. Rapid Experiments (PDSA 9. Insights:

Map Ideal/Target State Cycles =RCI) Ideas to help sustain and
Measure Change spread
 Business Case for “Quality”

•“Quality” (optimum patient outcomes, safety and service)

is a moral imperative
•The principal source of financial return (providing high Quality
care) comes from removing “waste” from your ‘system’
• Process inefficiency
• Overuse
• Preventable harm
•Who benefits: Patients, clinicians, staff, your hospital’s
reputation and “He who pays”
Evaluation of Board’s Quality/Pt. Safety
Role/Responsibility
1. Do high-quality hospital have better management
practices than low-quality hospitals?

2. Is there a relationship between hospital board

performance and management performance?

3. Do certain types of board practices correlate with

comparable management practices?
 Board’s Role in Quality What
Does The Evidence Tell Us?
•Hospitals with high management attention on Quality are more likely
• To be High-quality hospitals (p < 0.01) [43% vs. 14%]
• One Std Dev increase in management performance was associated with a 20%
increase in being a high-quality hospital
• To have higher Board performance ( p < 0.001)

•How:
• Attention to Quality by Board Time spent (~25%) monitoring Quality: tracking effective use
of Board approved Metrics
•Result: Effective Board governance improves a hospital’s overall
performance – not just on Quality!
◦
Tsai, Jha, Gawande, Huckman, Bloom and Sadun. “Hospital Board and Management Practices Are Strongly Related to Hospital Performance on Clinical
Quality Metrics.” Health Affairs, 34 (8) (2015): 1304-1311.
 “Board” Role in PS/QI

•The Ultimate responsibility for your Hospital delivering High

Quality Care (via Patient Safety and Quality Improvement) lies
with the Hospital Board of Trustees
•Having a Board level “Patient Safety and Quality Improvement”
subcommittee is equally important to having a Board “Finance”
subcommittee
•A minimum of 25% of every Board of Trustees’ Agenda should
be devoted to that hospital’s Patient Safety and Quality
Improvement program
 Caution

•The QI Principles are Tools to mold your local environment….

Not the actual work to make needed change
• Goal: improved Efficiency, Quality and Patient Safety in your
facility

•Unless RCI (many PDSA test cycles) take place, you won’t get any “change”
•“QI” principles cannot be implemented by Senior Management mandate –
instead, it comes from front-line teams
•Different sites using same “QI” principles may lead to different processes in
different places (freedom to innovate)
Quality Improvement is a
Journey, not a
Destination

Some Marvel at the

Mountains before them,
Others climb them
Institute for Healthcare Improvement

IHI’s Open School

http://www.ihi.org/education/
ihiopenschool/overview/Pages/default.aspx