The safety checklist program: creating a culture of safety in intensive care units

BACKGROUND: In 1999 the VA Ann Arbor Healthcare System began a safety checklist program to help build a culture of safety among nurses, respiratory therapists, and unit maintenance providers in the intensive care units (ICUs). Program objectives were to (a) create the opportunity for each participating staff member to view his or her work and unit environment in a broader safety context; (b) establish clear, concise, and measurable standards that staff would identify and value as important safety factors; (c) develop a data collection methodology that would minimize confirmation bias; and (d) correct safety deficits immediately. DATA MANAGEMENT: Staff measure compliance with safety standards twice daily and record results on a form specifically designed for the project. Data are transferred to a spreadsheet, and graphic presentations are posted in each ICU. Staff periodically adjust both standards and data collection procedures. SUMMARY: Staff can articulate how the program is making the ICU a safer environment. Nursing response to a recent major error reflects the growth that has occurred since the program's inception. Safety checks performed by ICU staff are critical in maintaining a constant level of safety. Although the effect on untoward events was not measured, the potential for incidents, including medication and intravenous errors, nosocomial infections, ventilator complications, and restraint complications may be reduced. The program invests bedside clinicians in writing safety standards, creates a partnership between staff and the clinical risk manager, and provides executive leaders an opportunity to demonstrate support of a culture beyond blame.     

Who may not benefit from continuous renal replacement therapy in acute kidney injury?

This study aimed to identify factors that may predict early kidney recovery (less than 48 hours) or early death (within 48 hours) after initiating continuous renal replacement therapy (CRRT) in acute kidney injury (AKI) patients. This is a multicenter retrospective observational study of 14 Japanese Intensive care units (ICUs) in 12 tertiary hospitals. Consecutive adult patients with severe AKI requiring CRRT admitted to the participating ICUs in 2010 (n = 343) were included. Patient characteristics, variables at CRRT initiation, settings, and outcomes were collected. Patients were grouped into early kidney recovery group (CRRT discontinuation within 48 hours after initiation, n = 52), early death group (death within 48 hours after CRRT initiation, n = 52), and the rest as the control group (n = 239). The mean duration of CRRT in the early kidney recovery group and early death group was 1.3 and 0.9 days, respectively. In multivariable regression analysis, in comparison with the control group, urine output (mL/h) (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01–1.03), duration between ICU admission to CRRT initiation (days) (OR: 0.65, 95% CI: 0.43–0.87), and the sepsis‐related organ failure assessment score (OR: 0.87, 95% CI; 0.78–0.96) were related to early kidney recovery. Serum lactate (mmol/L) (OR: 1.19, 95% CI: 1.11–1.28), albumin (g/dL) (OR: 0.52, 95% CI: 0.28–0.92), vasopressor use (OR: 3.68, 95% CI: 1.37–12.16), and neurological disease (OR: 9.64, 96% CI: 1.22–92.95) were related to early death. Identifying AKI patients who do not benefit from CRRT and differentiating such patients from the study cohort may allow previous and future studies to effectively evaluate the indication and role of CRRT.     

Expanding a performance improvement initiative in critical care from hospital to system

BACKGROUND: Concern about the expense and effects of intensive care prompted the development and implementation of a hospital-based performance improvement initiative in critical care at North Shore University Hospital, Manhasset, New York, a 730-bed acute care teaching hospital. THE HOSPITAL-BASED PERFORMANCE IMPROVEMENT INITIATIVE IN CRITICAL CARE: The initiative was intended to use a uniform set of measurements and guidelines to improve patient care and resource utilization in the intensive care units (ICUs), to establish and implement best practices (regarding admission and discharge criteria, nursing competency, unplanned extubations, and end-of-life care), and to improve performance in the other hospitals in the North Shore-Long Island Jewish Health System. In the medical ICU, the percentage of low-risk (low-acuity) patients was reduced from 42% to 22%. ICU length of stay was reduced from 4.6 days to 4.1 days. IMPLEMENTING THE CRITICAL CARE PROJECT SYSTEMWIDE: A system-level critical care committee was convened in 1996 and charged with replicating the initiative. By and large, system efforts to integrate and implement policies have been successful. The critical care initiative has provided important comparative data and information from which to gauge individual hospital performance. DISCUSSION: Changing the critical care delivered on multiple units at multiple hospitals required sensitivity to existing organizational cultures and leadership styles. Merging organizational cultures is most successful when senior leadership set clear expectations that support the need for change. The process of collecting, trending, and communicating quality data has been instrumental in improving care practices and fostering a culture of safety throughout the health care system.     

Improved nursing home end-stage renal disease patient participation in physical therapy with onsite,more frequent dialysis

Introduction

For end-stage renal disease (ESRD) patients residing in skilled nursing facilities (SNFs), the logistics and physical exhaustion of life-saving hemodialysis therapy often conflict with rehabilitation goals. Integration of dialysis care with rehabilitation programs in a scalable and cost-efficient manner has been a significant challenge. SNF-resident ESRD patients receiving onsite, more frequent hemodialysis (MFD) have reported rapid post-dialysis recovery. We examined whether such patients have improved Physical Therapy (PT) participation.

Methods

We conducted a retrospective electronic medical records review of SNF-resident PT participation rates within a multistate provider of SNF rehabilitation care from January 1, 2022 to June 1, 2022. We compared three groups: ESRD patients receiving onsite MFD (Onsite-MFD), ESRD patients receiving offsite, conventional 3×/week dialysis (Offsite-Conventional-HD), and the general non-ESRD SNF rehabilitation population (Non-ESRD). We evaluated physical therapy participation rates based on a predefined metric of missed or shortened (<15 min) therapy days. Baseline demographics and functional status were assessed.

Findings

Ninety-two Onsite-MFD had 2084 PT sessions scheduled, 12,916 Non-ESRD had 225,496 PT sessions scheduled, and 562 Offsite-Conventional-HD had 9082 PT sessions scheduled. In mixed model logistic regression, Onsite-MFD achieved higher PT participation rates than Offsite-Conventional-HD (odds ratio: 1.8, CI: 1.1–3.0; p < 0.03), and Onsite-MFD achieved equivalent PT participation rates to Non-ESRD (odds ratio: 1.2, CI: 0.3–1.9; p < 0.46). Baseline mean ± SD Charlson Comorbidity score was significantly higher in Onsite-MFD (4.9 ± 2.0) and Offsite-Conventional-HD (4.9 ± 1.8) versus Non-ESRD (2.6 ± 2.0; p < 0.001). Baseline mean self-care and mobility scores were significantly lower in Onsite-MFD versus Non-ESRD or Offsite-Conventional-HD.

Discussion

SNF-resident ESRD patients receiving MFD colocated with rehabilitation had higher PT participation rates than those conventionally dialyzed offsite and equivalent PT participation rates to the non-ESRD SNF-rehabilitation general population, despite being sicker, less independent, and less mobile. We report a scalable program integrating dialysis and rehabilitation care as a potential solution for ESRD patients recovering from acute hospitalization.     

Transmission dynamics of methicillin-resistant Staphylococcus aureus in a medical intensive care unit

Intensive care units (ICUs) play an important role in the epidemiology of methicillin-resistant Staphyloccocus aureus (MRSA). Although successful interventions are multi-modal, the relative efficacy of single measures remains unknown. We developed a discrete time, individual-based, stochastic mathematical model calibrated on cross-transmission observed through prospective surveillance to explore the transmission dynamics of MRSA in a medical ICU. Most input parameters were derived from locally acquired data. After fitting the model to the 46 observed cross-transmission events and performing sensitivity analysis, several screening and isolation policies were evaluated by simulating the number of cross-transmissions and isolation-days. The number of all cross-transmission events increased from 54 to 72 if only patients with a past history of MRSA colonization are screened and isolated at admission, to 75 if isolation is put in place only after the results of the admission screening become available, to 82 in the absence of admission screening and with a similar reactive isolation policy, and to 95 when no isolation policy is in place. The method used (culture or polymerase chain reaction) for admission screening had no impact on the number of cross-transmissions. Systematic regular screening during ICU stay provides no added-value, but aggressive admission screening and isolation effectively reduce the number of cross-transmissions. Critically, colonized healthcare workers may play an important role in MRSA transmission and their screening should be reinforced.     

The forgotten component of the quality triad: can we still learn something from "structure"?

BACKGROUND: Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found. A ROAD MAP FOR MEASURES DEVELOPMENT: The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings. CONCLUSION: Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.     

Seasonal patterns of fatal and nonfatal falls among older adults in the U.S

INTRODUCTION: While many believe that older adults fall more often during the winter months, research on this is inconclusive. This study used nationally representative data from 2001 to 2002 to examine unintentional fatal fall rates among older men and women by season and climate, and nonfatal fall rates by season. METHODS: We studied fatal and nonfatal unintentional falls among U.S. adults aged > or =65 during December 2001-November 2002 by season. Fatal fall data were obtained from National Center for Health Statistics' annual mortality tapes; nonfatal fall data for injuries treated in emergency departments were obtained from the National Electronic Injury Surveillance System All Injury Program. Fatal falls were also analyzed by climate based on each state's average January 1, 2001 temperature (colder climates < or =32 degrees F (0 degrees C) and warmer climates >32 degrees F (0 degrees C)). RESULTS: From December 2001 through November 2002, neither fatal nor nonfatal fall injury rates showed any seasonal patterns. For fatal falls, the average rate was 9.1 percent higher in colder climates, regardless of season. CONCLUSION: Among older adults, fatal fall rates appear to be influenced more by climate than by season. Additional research is needed to clarify the mechanisms underlying these observations.     

Radiation exposure to children in intraoral dental radiology

In this study, dose area product (DAP) measurements have been performed aiming at establishing diagnostic reference levels (DRLs) in paediatric intraoral dental radiology. Measurements were carried out at 52 X-ray units for all types of intraoral examinations performed in clinical routine. Not all X-ray units have pre-set child exposure settings with reduced exposure time or in some cases lower tube voltage. Child examinations are carried out using adult exposure settings at these units, which increases the DAP third quartile values by up to 50%. For example, third quartile values for periapical examination ranges from 14.4 to 40.9 mGy cm(2) for child settings and 20.6 to 48.8 mGy cm(2) when the adult settings are included. The results show that there exists a large difference between the patient exposures among different dental facilities. It was also observed that clinics working with faster film type or higher tube voltage are not always associated with lower exposure.     

Reducing inappropriate restraint use in Colorado's long-term care facilities

BACKGROUND: Many physical and psychosocial complications arise from the use of physical restraints. Restraints in nursing homes have been estimated to cause approximately 1 in every 1,000 nursing home deaths. When restraints are removed, quality of life and functional status improve; there does not appear to be an increase in serious falls, and serious injuries may even decline. METHODS: To assess the current status in Colorado nursing homes, in 1997 the Colorado Foundation for Medical Care mailed a questionnaire to 214 nursing homes to identify remaining barriers to restraint reduction. Results were used to plan interventions to further reduce inappropriate use that met most providers' needs. Given providers' need for greater family and public awareness of the risks associated with restraints, the project team developed educational tools for distribution to families and a media campaign for the public. In addition, an assessment tool and educational materials were created to facilitate appropriate use of devices and implementation of least-restrictive interventions. Data were collected before and after the intervention phase on remaining barriers, frequency of assessment, and perceived level of success of restraint reduction. RESULTS: Most of the 175 (82%) of Colorado's 214 long-term care providers who received educational materials found them very useful and recommended expansion to other states. Facilities indicated a higher perceived level of success in reducing restraints, an increase in the frequency of assessments, and a decrease in barriers to restraint reduction. The public awareness campaign, performed in tandem with the state health department, reached more than a half-million people in Colorado, using the slogan, "Restraints Have Risks!"     

Noninvasive near-infrared blood glucose monitoring using a calibration model built by a numerical simulation method: Trial application to patients in an intensive care unit

We have applied a new methodology for noninvasive continuous blood glucose monitoring, proposed in our previous paper, to patients in ICU (intensive care unit), where strict controls of blood glucose levels are required. The new methodology can build calibration models essentially from numerical simulation, while the conventional methodology requires pre-experiments such as sugar tolerance tests, which are impossible to perform on ICU patients in most cases. The in vivo experiments in this study consisted of two stages, the first stage conducted on healthy subjects as preliminary experiments, and the second stage on ICU patients. The prediction performance of the first stage was obtained as a correlation coefficient (r) of 0.71 and standard error of prediction (SEP) of 28.7 mg/dL. Of the 323 total data, 71.5% were in the A zone, 28.5% were in the B zone, and none were in the C, D, and E zones for the Clarke error-grid analysis. The prediction performance of the second stage was obtained as an r of 0.97 and SEP of 27.2 mg/dL. Of the 304 total data, 80.3% were in the A zone, 19.7% were in the B zone, and none were in the C, D, and E zones. These prediction results suggest that the new methodology has the potential to realize a noninvasive blood glucose monitoring system using near-infrared spectroscopy (NIRS) in ICUs. Although the total performance of the present monitoring system has not yet reached a satisfactory level as a stand-alone system, it can be developed as a complementary system to the conventional one used in ICUs for routine blood glucose management, which checks the blood glucose levels of patients every few hours.     

Does patient-centered care pay off?

BACKGROUND: Hospitals have adopted patient-centered practices that focus on patients' needs, values, and preferences in hopes of improving quality and controlling costs. Patient-centered practices are intended to involve patients in treatment decisions, increase communication between patients and care-givers, and increase interaction with family members and friends. Rapid adoption of these practices has occurred, even though little is known about the effects of patient-centered care on outcomes and cost. METHODS: A simultaneous equations regression model was developed to examine the reciprocal relationships between patient-centeredness, outcomes, and cost. A consortium of employers obtained data from 52 hospital units in southeastern Michigan. Two hundred randomly selected patients were sampled from all discharges on the medical, surgical, and obstetric units at each hospital for the first three months of 1997; the patients were sent the survey in May. Patient-centeredness was measured by patient reports of whether key clinical events occurred (The Picker Inpatient Survey). Outcomes were assessed by rates of unexpected mortality and complications. Cost was defined by self-insured purchaser payments. RESULTS: Hospital units that were more patient centered were associated with statistically significantly better outcomes and higher costs than those that were less patient centered. The joint relations between outcomes and cost were insignificant. CONCLUSIONS: Patient-centeredness was associated with better outcomes and higher cost. For either the short run or long run, managers, patients, and purchasers should determine whether the improvement in outcomes and patient satisfaction associated with becoming patient centered is worth the investment in costs.     

Using a unit assessment tool to optimize patient flow and staffing in a community hospital.

BACKGROUND: Hospital environments are too often characterized by delays for patients receiving diagnostic testing and prolonged waiting times to complete needed therapy. Frequently there is confusion in scheduling, related at least in part to the complex interplay of clinical acuity and highly individualized care. Luther Midelfort recently began to change the process of patient flow to improve access to care, optimize outcomes by enabling timely intervention, and decrease the wasting of resources. UNIT ASSESSMENT TOOL: The hospital developed a unit assessment tool based on the traffic light concept, which consisted of an assessment of current capacity and a graded, color-coded "workload tolerance" for each hospital unit. Each unit can instantly update its own status and query those of other work environments in the hospital. EXPERIENCE WITH THE UNIT ASSESSMENT TOOL: For most of the January-July 2001 period, there was generally a progressive decrease in the percentage of time that the units were coded as red (unit closed to new admissions), with concurrent increases in the percentage of time that the units were coded as green (unit open). Use of the tool appears to have contributed to a dramatic increase in staff satisfaction. SUMMARY AND CONCLUSIONS: The key to regulating patient flow has been to adopt a nursing-initiated capping trust policy whereby nurses are given the authority to limit new admissions. Initiatives are now under way to provide different units with novel models of resource sharing, ranging from flexible housekeeping to "flying nurse squads" to assist units that have become red.     

Association between major injuries and seat locations in a motorcoach rollover accident

Motorcoaches and buses have the highest accident rate among different kinds of vehicles in Taiwan. It is, therefore, important to modify motorcoach designs so that they increase passenger safety. We collected patient data from a motorcoach rollover accident to assess the major injuries of the passengers and the associated risk factors for each type of injury. The accident occurred on a summer day in 2003 in central eastern Taiwan. A double-decker motorcoach carrying 46 passengers and a driver rolled over onto its left side on a downhill path because the coach's brakes failed. On the upper deck, the coach had four columns of seats, two on either side of a center aisle: 12 pairs on the left side, and 10 pairs on the right. Of the 41 seated people on the upper deck, the passengers in the down side (left seats) of each pair of seats had higher Injury Severity Scores than those in the up side (right seats), and passengers >or=65 years old had relatively higher rates of hemothorax and head injuries with subarachnoid hemorrhage or intracranial hemorrhage than those <65. Multivariate analysis showed that age >or=65 years and sitting on the down side at the time of rollover were independent risk factors for major injuries. Our analysis of the data from this motorcoach rollover accident showed that most major injuries occurred as passengers in the up side seats were thrown from their seats and compressed the neighboring passengers in the down side. We hypothesize that occupant restraint devices, such as seat belts, might prevent or reduce some injuries in motorcoach rollover accidents.     

Falls from moving motor vehicles in New Zealand

Injuries due to falls from moving motor vehicles have received relatively little attention from the research community. Injury events of this type in New Zealand were examined using national injury mortality and hospitalisation data from the New Zealand National Health Statistics Centre (NHSC). Also used were data obtained from the New Zealand Post Motor Registration Centre and from coroner's investigation reports held by the Department of Justice. Fifty-six fatal falls from moving motor vehicles occurred during the period 1977–1986 (0.18 per 100,000 population per year). The average age of fatalities was 23. The total potential years of life lost due to these fatalities was 2,696, or an average of 48 years per person. Thirty-nine persons (70%) fell while riding on the exterior of a vehicle. None of the 56 fatalities was using a belt restraint when he/she fell. Four hundred and twenty-three admissions to hospital occurred during 1986 and 1987 (6.5 per 100,000 persons per year). The average age of those hospitalised was 18. Incidence rates were highest in the 0–4, 15–19, and 20–24 year age groups. In the case of both deaths and hospitalisations, the incidence rate for males was approximately double the rate for females. In addition, the rate of falls (per unit registered motor vehicle) from trucks was significantly higher than the rate offalls from cars. Means of preventing falls from motor vehicles are discussed.     

Identifying medical center units with disproportionate shares of patient complaints.

BACKGROUND: A pilot study was conducted to learn whether an academic medical center's database of patient complaints would reveal particular service units (or clinics) with disproportionate shares of patient complaints, the types of complaints patients have about those units, and the types of personnel about whom the complaints were made. RESULTS: During the seven-year (December 1991-November 1998) study period, Office of Patient Affairs staff recorded 6,419 reports containing 15,631 individual complaints. More than 40% of the reports contained a single complaint. One-third of the reports contained three or more complaints. Complaints were associated with negative perceptions of care and treatment (29%), communication (22%), billing and payment (20%), humaneness of staff (13%), access to staff (9%), and cleanliness or safety of the environment (7%). Complaints were not evenly distributed across the medical center's various units, even when the data were corrected for numbers of patient visits to clinics or bed days in the hospital. The greatest proportion of complaints were associated with physicians. DISCUSSION: Complaint-based report cards may be used in interventions in which peers share the data with unit managers and seek to learn the nature of the problems, if any, that underlie the complaints. Such interventions should influence behavioral and systems changes in some units. SUMMARY AND CONCLUSIONS: Further experience should indicate how different types of complaints lead to different kinds of interventions and improvements in care. Tests of the system are also currently under way in several nonacademic community medical centers.     

Can twice weekly hemodialysis expand patient access under resource constraints?

The convention of prescribing hemodialysis on a thrice weekly schedule began empirically when it seemed that this frequency was convenient and likely to treat symptoms for a majority of patients. Later, when urea was identified as the main target and marker of clearance, studies supported the prevailing notion that thrice weekly dialysis provided appropriate clearance of urea. Today, national guidelines on hemodialysis from most countries recommend patients receive at least thrice weekly therapy. However, resource constraints in low‐ and middle‐income countries (LMIC) have resulted in a substantial proportion of patients using less frequent hemodialysis in these settings. Observational studies of patients on twice weekly dialysis show that twice weekly therapy has noninferior survival rates compared with thrice weekly therapy. In fact, models of urea clearance also show that twice weekly therapy can meet urea clearance “targets” if patients have significant residual function or if they follow a protein‐restricted diet, as may be common in LMIC. Greater reliance on twice weekly therapy, at least at the start of hemodialysis, therefore has potential to reduce health care costs and increase access to renal replacement therapy in low‐resource settings; however, randomized control trials are needed to better understand long‐term outcomes of twice versus thrice weekly therapy.     

The impact of staffing and the organization of work on patient outcomes and health care workers in health care organizations

BACKGROUND: Numerous reports in the popular press express concern about the restructuring or lowering of staffing levels in health care organizations and the impact on the quality of patient care. Overtime and other extended shifts also represent work stresses for health care workers. This article reviews the research literature on the relationships among staffing, organization of work, and patient outcomes, and it discusses research findings on the relationship between staffing and the health of health care workers. RESEARCH ON STAFFING, ORGANIZATION, AND PATIENT OUTCOMES/STAFF WELL-BEING: Safe staffing level requirements have been identified for nursing homes, but only in extremely limited cases for hospitals, home care, or other health settings. There is little information about the impact of staffing levels and the organization of work on health personnel or on patient outcomes. There is almost no information about staffing and patient outcomes in home health and ambulatory care. Much of the research on staffing and quality has been discipline specific; future research should reflect the interdisciplinary nature of health care delivery rather than the impact of a particular occupation. RESEARCH USE: Research is conducted to increase the scientific base per se and to inform decision making. Who should decide staffing levels and the organization of work? Professionals, employers/owners, the government, and consumers all have significant interest in staffing levels and the organization of care. Improving health care quality requires research about the critical staffing and organization of work variables. This requires obtaining appropriate data, conducting the research, and widely disseminating the findings.     

Acceptability and concurrent validity of measures to predict older driver involvement in motor vehicle crashes: an Emergency Department pilot case-control study

INTRODUCTION: Older drivers have one of the highest motor vehicle crash (MVC) rates per kilometer driven, largely due to the functional effects of the accumulation, and progression of age-associated medical conditions that eventually impact on fitness-to-drive. Consequently, physicians in many jurisdictions are legally mandated to report to licensing authorities patients who are judged to be medically at risk for MVCs. Unfortunately, physicians lack evidence-based tools to assess the fitness-to-drive of their older patients. This paper reports on a pilot study that examines the acceptability and association with MVC of components of a comprehensive clinical assessment battery. OBJECTIVES: To evaluate the acceptability to participants of components of a comprehensive assessment battery, and to explore potential predictors of MVC that can be employed in front-line clinical settings. METHODS: Case-control study of 10 older drivers presenting to a tertiary care hospital emergency department after involvement in an MVC and 20 age-matched controls. RESULTS: The measures tested were generally found to be acceptable to participants. Positive associations (p相似文献   

Moving out of the red zone: addressing staff allocation to improve patient satisfaction.

BACKGROUND: Each summer, Hermann Hospital (Houston), like virtually all health care organizations, faces staffing challenges because of employee vacations, increased patient load, and staff turnover. A "zone" system was developed to address staff allocation, which was identified as a factor in deterioration of the hospital's patient satisfaction performance. ZONE SYSTEM: Every day, each unit or department designated the zone most appropriate based on factors identified in root cause analysis--high patient census, high patient acuity, emergent activity, and the number of float, agency, or unfamiliar staff members. A green zone defines conditions where the staff is very comfortable; yellow reflects increased activity; and red indicates that staff members are stressed and overwhelmed with patient needs. ACTION STEPS: Management's action steps included decreasing the nursing vacancy rate to minimize reliance on agency and float staff members and securing longer-term commitments from temporary staff members. Individual units also generated contingency plans, such as identifying a "partner unit" to provide shared staff members, supplies, and other assistance. RESULTS: The percentage of patients rating their overall experience at Hermann Hospital as "good" or "excellent" increased from 83% in August 1997 to 89% in August 1998, despite increases in admissions, patient days, operating room cases, and emergency department visits. DISCUSSION: The zone system provides a rapid way to quantify contributing factors to patient dissatisfaction and respond to them. Hermann Hospital is currently developing a broader zone system to include staff vacancy rates by departments, areas of increased patient census for prolonged periods, and balancing episodic zones with prolonged zones.