Educational objectives: To demonstrate how a structure and systems of a large interdisciplinary division  ensures that all patient safety initiatives are assessed, analyzed and monitored. To demonstrate how a division makes a committment to ensure adequate systems are in place that effectively reduce errors and provide evidence based practices for patient populations.

Purpose: To share how to create a patient and family centered healing experience through the provision of excellent care, quality service and a partnership among physicians and caregivers.

Description: A collaborative team composed of leadership from patient care services, home care, behavioral helath, nutrition, pharmancy and the laboratory  with the Vice-President  of Operations shared in the development of the quality improvement plan.  A clear connection between overall strategic aims and projects were established.

Summary: Alignment of key performance indicators, the hospital's high priority quality initiatives and identifying other sources of evidence-based practices. Incorporating benchmarking data utilizing well-respected sources. Visually displaying cohorted data to the decision makers in a timely way proves effective. Transparency about quality performance within the organization channels the attention to the work.  Quality is a standing item on meeting agendas.

Implications;  Operations strategy initiatives linked to performance measures.  Leaders organized the system of improvement so that all who work in the system know their part and how it fits.  Solid measures of system level performance and aims are established.