Memorial Hermann Healthcare System

Every day, health care professionals at the sharp end create safety by compensating for risk-prone conditions. Predicting and preventing those risk-prone conditions is the goal of the zone strategy. Katharine Luther, director of performance improvement at Memorial Hermann Healthcare System, Houston, created the zone strategy to predict when conditions exist that have the potential to overwhelm a team s ability to protect patients. 

Katharine Luther, director of performance improvement at Memorial Hermann Healthcare System, has developed ways to encourage health professionals, from assistants to nurses to physicians to specialists, to resist the authority gradient in their environments. For example, she has identified a variety of reasons why a nurse may not want to question the authority of a physician. 

Copyright Memorial Hermann Healthcare Systems. Used by permission. 

We also recognize the fiaUowing individuals, most of whom serve at the sharp end, who participated in case study preparation either by giving us interviews or by writing material Allan Frankel, M.D., director of Patient Safety, Partners Health Care, and senior fellow for the Institute for Healthcare Improvement, Boston Caryl Lee, R.N., M.S.N., program director. Veterans Administration Center for Patient Safety, Ann Arbor, Michigan Katharine Luther, R.N., M.PA., director of performance improvement, and Ann-Claire France, Ph.D., former director for the center of healthcare improvement at Memorial Hermann Healthcare System,... 

The contributions of the following reviewers vastly improved the content of the book Roger Rezar, M.D., Luther-Midelfort Hospital, Eau Claire, Wisconsin Della Lin, M.D., the Queen s Medical Center, Honolulu, Hawaii Richard Cook, M.D., Cognitive Technologies Laboratories, University of Chicago Peter Provonost, M.D., Ph.D., critical care medicine, Johns Hopkins University Jim Conway, Dana-Farber Cancer Institute Linda Connell, M.A., R.N., the NASA Ames Research Center and Anne-Claire France, Ph.D., the Center for Healthcare Improvement, Memorial Hermann Healthcare System, Houston. 

The implementation of a voluntary blameless reporting system is a deep cultural intervention in an organization that legitimizes transparency of system vulnerability, nurtures an alert field, and empowers front-line providers to expose risks. In turn, the front line learns to expect responses from managers at the blunt end to support the work of improvement. The few organizations in health care that have developed reporting systems believe that the effort is 75 percent social and only 25 percent technical (personal communication from Anne-Claire France, former director of the Center for Healthcare Improvement, Memorial Hermann Healthcare... 

For example. Memorial Hermann used nine measures developed by the Institute for Healthcare Improvement as a starting point for reducing ventilator-acquired pneumonias (VAPs) and increasing safety and quality of care for ventilated patients. Individuals traveled to an IHI collaborative meeting and then returned to Memorial Hermann and passed on what they had learned to multidisciplinary teams from each of the hospital system s ICUs. 

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