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Case Study


Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement

Four case studies document the progress achieved in the past five years by health care organizations that were early leaders in patient safety improvement. Their experience reflects an expansion of interventions from individual hospital units to whole facilities and delivery systems, including new settings such as home health care. Approaches include developing practical methods for training, coaching, and motivating staff to engage in patient safety work; designing effective tools and systems to minimize error and maximize learning; and leading change by setting ambitious goals, measuring and holding units accountable for performance, and sharing stories to convey values. Results include advancements in safety practices, reductions in serious events of patient harm, improved organizational safety climate and morale, and declines in malpractice claims. Keeping the commitment to patient safety has required sustained focus on making safety a core organizational value, a willingness to innovate and adapt, and perseverance in pursuing goals.

The four case-study sites are all multicampus, integrated health care delivery systems: Johns Hopkins Medicine (Johns Hopkins) in Maryland; OSF HealthCare, operated by the Sisters of the Third Order of St. Francis, in Illinois and Michigan; Sentara Healthcare in Virginia and North Carolina; and the U.S. Department of Veterans Affairs (VA), which operates facilities nationwide.

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions' experience that will be helpful in their own efforts to become high performers. Even the best-performing organizations may fall short in some areas or make mistakes—emphasizing the need for systematic approaches to improve quality and prevent harm to patients and staff. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study series is not an endorsement by the Fund for receipt of health care from the institution.

Publication Details



D. McCarthy and S. Klein, Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement, The Commonwealth Fund, March 2011.