The University of Mississippi Medical Center's Path for Quality Improvement

[...]being the state's only academic medical center, UMMC had come to embrace its role and responsibility as the leader of health care delivery in the state and developed aspirations to be a regional health care leader alongside other outstanding academic medical centers in the southeast. UMMC was in the process of implementing a newly developed institutional strategic plan designed to further transform the institution's preexisting self-limiting insular approach (with a reputation as the state's charity hospital fueled largely by house staff care) into becoming recognized as a resource jewel for the state, run by faculty physicians offering patient-centric care, especially for those in need of high-end services. UMMC chose "high reliability" as the infrastructure on which to build its quality improvement program and began a journey toward becoming a high-reliability organization (HRO).3 Although several entities have espoused high reliability as the basis for driving change, UMMC specifically chose to use the model developed by The Joint Commission's Center for Transforming Healthcare.4 During the prior decade, the Center for Transforming Healthcare developed high-reliability tools that are applicable to health care and was in the process of expanding this work more broadly. Translating this goal to frontline improvement work requires making the gap understandable by converting the publicly reported standardized infection ratio, which is based on a rate per 1000 eligible patients/lines/catheters to the actual number of infections in an agreed time. [...]for a specific HAI, a standardized infection ratio of 1.206 may translate to a baseline of 10 HAIs per month which can then lead to setting a specific improvement target of a reduction such as 6 HAIs per month within 12 months.