Background: In 2002 Ascension Health, a 67-hospital not-for-profit health care system, articulated a call to action to provide excellent clinical care with no preventable injuries or deaths by July 2008. It embarked on a journey of clinical transformation. Transformational change implies a much greater pace of change than that reflected in traditional, incremental change processes. The Journey Begins: Progressing from vision to action plan required setting the clinical transformation agenda, identifying challenges to this agenda, and establishing measurements of progress. Environmental changes that must be addressed to successfully implement a transformational change process include culture, making the business case, infrastructure investments, standardization, and how we work together. Taking Action: Improvement activities focused on eight priorities for action, including preventable mortality and areas such as adverse drug events, falls, and surgical complications. "Alpha" sites would develop the best clinical and implementation practices for eliminating the preventable adverse events related to these areas. Early Results: The observed decrease in the mortality rate among non–end-of-life-care patients was 21% (p < .001), exceeding the 15% goal set for July 2008 and corresponding to 1,200 deaths prevented across the system. The alpha sites reported initial results in June 2004, with more than 50% reductions in adverse events for all the priorities for action areas.
Document Type: Research Article
Publication date: June 1, 2006
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Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety