- Email: [email protected]
2016 Editorial Advisory Board
The Joint Commission Journal on Quality and Patient Safety Editor-in-Chief: David W. Baker, MD, MPH, FACP Executive Editor: Steven Berman Project Manager: Lisa King
Executive Director, Publications: Catherine Chopp Hinckley, PhD Associate Director, Publications: Helen M. Fry, MA Statistical Consultant: Stephen Schmaltz, PhD
2016 Editorial Advisory Board John Øvretveit, MPhil, PhD, CPsychol, AFBPsS, CSci Karolinska Institutet Medical Management Centre Stockholm
Gerry Armitage, PhD, FHEA University of Bradford Bradford, United Kingdom
John B. Hertig, PharmD, MS, CPPS Purdue University Indianapolis
Vineet M. Arora, MD, MAPP University of Chicago Pritzker School of Medicine Chicago
Jeanne M. Huddleston, MD, MS Center for Innovation Mayo Clinic Rochester, Minnesota
Abdullah M. Assiri, MD, FACP Ministry of Health Riyadh, Saudi Arabia
Rick Iedema, PhD, FASSA University of Tasmania Chatswood, Australia
Sean M. Berenholtz, MD, MHS, FCCM Armstrong Institute for Patient Safety and Quality Johns Hopkins Schools of Medicine and Bloomberg School of Public Health Baltimore
Lianne P. Jeffs, RN, BSCN, MSC, PHD, FAAN St. Michael’s Hospital Toronto
Karl Bilimoria, MD, MS Northwestern University Chicago
Kedar S. Mate, MD Institute for Healthcare Improvement Cambridge, Massachusetts
Marcy Carty, MD, MPH Blue Cross Blue Shield of Massachusetts Boston
Shivan J. Mehta, MD, MBA, MSHP Penn Medicine Center for Health Care Innovation Philadelphia
Urmimala Sarkar, MD, MPH University of California, San Francisco
Lorraine C. Mion, PhD, RN, FAAN Vanderbilt University School of Nursing Nashville, Tennessee
State University of New York at Buffalo Buffalo
Michael DeVita MD, FCCM, FACP Harlem Hospital Center New York City Erin DuPree, MD, FACOG Joint Commission Center for Transforming Healthcare Oakbrook Terrace, Illinois Kimberly D. Gregory, MD, MPH Cedars-Sinai Medical Center Los Angeles
Peter K. Lindenauer, MD, MSc Baystate Medical Center Springfield, Massachusetts
Susan D. Moffatt-Bruce, MD, PhD, FACS, FRCS(C) The Ohio State University Wexner Medical Center Columbus, Ohio
The Joint Commission Journal on Quality and Patient Safety (http://www.jcrinc.com/the -joint-commission-journal-on-quality-and-patient-safety/) serves as a peer-reviewed forum for practical approaches to improving quality and safety in health care. For more information about The Joint Commission, visit http://www.jointcommission.org. For more information about Joint Commission Resources, visit http://www.jcrinc.com. Journal content. 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. No statement in The Joint Commission Journal on Quality and Patient Safety should be construed as an official position of The Joint Commission or Joint Commission Resources unless otherwise stated. In particular, there has been no official review with regard to matters of standards interpretation or compliance.
434
October 2016
Emily S. Patterson, PhD Ohio State University Columbus, Ohio James W. Pichert, PhD Vanderbilt University Nashville, Tennessee Peter Pronovost, MD, PhD Armstrong Institute for Patient Safety and Quality Baltimore Eduardo Salas, PhD Rice University Houston Pedro Ramos, MD, FHM University of California, San Diego
Ranjit Singh, MA, MBBChir (Cantab), MBA
Olanrewaju A. Soremekun, MD, MBA Thomas Jefferson University Philadelphia
Gautham Suresh, MD, DM, MS, FAAP Texas Children’s Hospital Houston Nancy Szaflarski, PhD, RN, FCCM Stanford Health Care Stanford, California Sean R. Townsend, MD Sutter Health, California Pacific Medical Center San Francisco Cordula Wagner, PhD Institute for Health and Care Research (EMGO+), VU Medical Center, Amsterdam The Netherlands Institute of Health Services Research (NIVEL), Utrecht Brook Watts, MD, MS Louis Stokes Cleveland VA Medical Center Cleveland Anthony Weiss, MD, MBA Upstate Medical University Syracuse, New York Mark V. Williams, MD, FACP, MHM University of Kentucky Lexington Iain E. Yardley, BM, MPH, FRCS Evelina London Children’s Hospital London
Patricia W. Stone, PhD, RN, FAAN Columbia University Medical Center New York City
October 2016. The Joint Commission Journal on Quality and Patient Safety (ISSN 1553-7250) is published monthly (12 issues per year, 1 volume per year) by Joint Commission Resources, 1515 West 22nd Street, Suite 1300W, Oak Brook, IL 60523. Third-class nonprofit postage paid at Oak Brook, IL, and at additional mailing offices. Send address changes to [email protected] or 877/223-6866. Annual subscription rates for 2016: United States/Canada, $319 for print and online, $299 for online only; ROW, $410 for print and online, $299 for online only. Printed in the USA. Copyright © 2016 by the Joint Commission on Accreditation of Healthcare Organizations. Joint Commission Resources, Inc. (JCR), an affiliate of the The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. The mission of JCR is to continuously improve the safety and quality of care in the United States and in the international community through the provision of education and consultation services and international accreditation.
Volume 42 Number 10
Copyright 2016 The Joint Commission
Executive Director, Publications: Catherine Chopp Hinckley, PhD Associate Director, Publications: Helen M. Fry, MA Statistical Consultant: Stephen Schmaltz, PhD
2016 Editorial Advisory Board John Øvretveit, MPhil, PhD, CPsychol, AFBPsS, CSci Karolinska Institutet Medical Management Centre Stockholm
Gerry Armitage, PhD, FHEA University of Bradford Bradford, United Kingdom
John B. Hertig, PharmD, MS, CPPS Purdue University Indianapolis
Vineet M. Arora, MD, MAPP University of Chicago Pritzker School of Medicine Chicago
Jeanne M. Huddleston, MD, MS Center for Innovation Mayo Clinic Rochester, Minnesota
Abdullah M. Assiri, MD, FACP Ministry of Health Riyadh, Saudi Arabia
Rick Iedema, PhD, FASSA University of Tasmania Chatswood, Australia
Sean M. Berenholtz, MD, MHS, FCCM Armstrong Institute for Patient Safety and Quality Johns Hopkins Schools of Medicine and Bloomberg School of Public Health Baltimore
Lianne P. Jeffs, RN, BSCN, MSC, PHD, FAAN St. Michael’s Hospital Toronto
Karl Bilimoria, MD, MS Northwestern University Chicago
Kedar S. Mate, MD Institute for Healthcare Improvement Cambridge, Massachusetts
Marcy Carty, MD, MPH Blue Cross Blue Shield of Massachusetts Boston
Shivan J. Mehta, MD, MBA, MSHP Penn Medicine Center for Health Care Innovation Philadelphia
Urmimala Sarkar, MD, MPH University of California, San Francisco
Lorraine C. Mion, PhD, RN, FAAN Vanderbilt University School of Nursing Nashville, Tennessee
State University of New York at Buffalo Buffalo
Michael DeVita MD, FCCM, FACP Harlem Hospital Center New York City Erin DuPree, MD, FACOG Joint Commission Center for Transforming Healthcare Oakbrook Terrace, Illinois Kimberly D. Gregory, MD, MPH Cedars-Sinai Medical Center Los Angeles
Peter K. Lindenauer, MD, MSc Baystate Medical Center Springfield, Massachusetts
Susan D. Moffatt-Bruce, MD, PhD, FACS, FRCS(C) The Ohio State University Wexner Medical Center Columbus, Ohio
The Joint Commission Journal on Quality and Patient Safety (http://www.jcrinc.com/the -joint-commission-journal-on-quality-and-patient-safety/) serves as a peer-reviewed forum for practical approaches to improving quality and safety in health care. For more information about The Joint Commission, visit http://www.jointcommission.org. For more information about Joint Commission Resources, visit http://www.jcrinc.com. Journal content. 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. No statement in The Joint Commission Journal on Quality and Patient Safety should be construed as an official position of The Joint Commission or Joint Commission Resources unless otherwise stated. In particular, there has been no official review with regard to matters of standards interpretation or compliance.
434
October 2016
Emily S. Patterson, PhD Ohio State University Columbus, Ohio James W. Pichert, PhD Vanderbilt University Nashville, Tennessee Peter Pronovost, MD, PhD Armstrong Institute for Patient Safety and Quality Baltimore Eduardo Salas, PhD Rice University Houston Pedro Ramos, MD, FHM University of California, San Diego
Ranjit Singh, MA, MBBChir (Cantab), MBA
Olanrewaju A. Soremekun, MD, MBA Thomas Jefferson University Philadelphia
Gautham Suresh, MD, DM, MS, FAAP Texas Children’s Hospital Houston Nancy Szaflarski, PhD, RN, FCCM Stanford Health Care Stanford, California Sean R. Townsend, MD Sutter Health, California Pacific Medical Center San Francisco Cordula Wagner, PhD Institute for Health and Care Research (EMGO+), VU Medical Center, Amsterdam The Netherlands Institute of Health Services Research (NIVEL), Utrecht Brook Watts, MD, MS Louis Stokes Cleveland VA Medical Center Cleveland Anthony Weiss, MD, MBA Upstate Medical University Syracuse, New York Mark V. Williams, MD, FACP, MHM University of Kentucky Lexington Iain E. Yardley, BM, MPH, FRCS Evelina London Children’s Hospital London
Patricia W. Stone, PhD, RN, FAAN Columbia University Medical Center New York City
October 2016. The Joint Commission Journal on Quality and Patient Safety (ISSN 1553-7250) is published monthly (12 issues per year, 1 volume per year) by Joint Commission Resources, 1515 West 22nd Street, Suite 1300W, Oak Brook, IL 60523. Third-class nonprofit postage paid at Oak Brook, IL, and at additional mailing offices. Send address changes to [email protected] or 877/223-6866. Annual subscription rates for 2016: United States/Canada, $319 for print and online, $299 for online only; ROW, $410 for print and online, $299 for online only. Printed in the USA. Copyright © 2016 by the Joint Commission on Accreditation of Healthcare Organizations. Joint Commission Resources, Inc. (JCR), an affiliate of the The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. The mission of JCR is to continuously improve the safety and quality of care in the United States and in the international community through the provision of education and consultation services and international accreditation.
Volume 42 Number 10
Copyright 2016 The Joint Commission