· Executive Brief
Healthcare Quality Week 2026
Use the observance to review how people find information, enter the right route, and remain connected through follow-through.
Leadership signal
Recognition becomes useful when leaders inspect the real route.
The strongest use of the observance is operational. Map where questions enter, how requests move, when ownership changes, and how unresolved work becomes visible. The goal is not to make a clinical claim. It is to make the organization’s response easier to understand and manage.
Start by distinguishing what is known from what the organization still needs to learn. A campaign plan, communication volume, or meeting count does not establish that a route is usable. Leaders need direct listening, clear ownership, locally defined measures, and a method for keeping exceptions visible.
Executive opening
Quality Week is a chance to inspect the safety system, not only to celebrate it
Healthcare Quality Week arrives at a moment when the evidence on harm is specific and sobering. In a random sample of 2,809 admissions from 11 Massachusetts hospitals in 2018, reviewers identified at least one adverse event in 23.6% of admissions.[12] About one fourth of those events were judged preventable.[12]
Outpatient care carries its own risk. A companion review of 3,103 patients at 11 Massachusetts outpatient sites found that 7.0% had at least one adverse event during 2018.[7] The share varied from 1.8% to 23.6% across study sites.[7] Variation of that size suggests that local design, staffing and oversight choices matter. It also means that a single system-wide average can hide sites that need help.
These findings describe operating systems rather than isolated mistakes. Medication use, procedures, infection prevention and fall prevention all depend on routines that leaders fund, staff, measure and review. The question for executives is not whether harm happens in their organization. It is whether the organization sees it, learns from it and closes the loop before the same event happens to the next patient.
This part of the brief adds the research base behind the live page’s operating guidance. It concentrates on five levers that executives control: measurement of harm, the learning system, the reliability of handoffs, partnership with patients and families, and frontline improvement capacity. Each section separates what studies found from what leaders should ask next. It does not restate the route, measures or plan already on the page.
The observance is short, but the work it points to is not. Boards and executive teams that use this week to ask harder questions about detection, equity and workforce strain will get more from it than those that use it only for recognition. The evidence below is offered in that spirit, as material for the next quality committee meeting.
Current evidence
What the research says about harm, detection and learning
Inpatient harm remains common and often serious. Among 978 adverse events in the Massachusetts inpatient sample, 222 (22.7%) were judged preventable and 316 (32.3%) had a severity level of serious.[12] A preventable adverse event occurred in 6.8% of all admissions.[12] Adverse drug events were the most common type, at 39.0% of all events, followed by surgical or other procedural events at 30.4%.[12] There were seven deaths, one of which was deemed to be preventable.[12]
The outpatient profile points in the same direction. Adverse drug events made up 63.8% of outpatient adverse events, followed by health care-associated infections at 14.8% and surgical or procedural events at 14.2%.[7] Severity was serious in 17.4% of outpatient adverse events, and 23.2% were judged preventable.[7] Because medication harm leads in both settings, medication safety is an enterprise priority rather than a pharmacy-only concern. Ambulatory leaders should see these data, not only inpatient committees.
Reliability programs can change what an organization sees. A quality improvement project drew on data from 139 VA facilities from 2019 to 2023, with high reliability interventions starting at 18 facilities in 2019, 54 in 2020 and 67 in 2021.[5] Patient safety culture scores showed broad positive within-group trends across all sites.[5] In the first cohort, total events reported and close calls increased, and the ratio of close calls to adverse events also rose.[5] A rising report count after such a program can signal a healthier culture rather than more harm.
Detection is the weakest link. A 2022 national survey of 145,657 healthcare practitioners in 392 Saudi hospitals found that almost half had not reported any events in the preceding year.[9] Average positive response rates on reporting-culture items ranged between 50% and 70%.[9] The same study found a strong negative correlation between hospital bed capacity and reporting of safety events.[9] In that survey, larger hospitals tended to report less, not more. The setting differs from U.S. systems, but quiet reporting is a familiar pattern for many safety leaders.
Why do learning systems stall? A meta-synthesis of 22 qualitative studies named blame and a punitive environment, lack of training, lack of feedback and inadequate organizational support as barriers.[14] Facilitators included leaders as role models, anonymous reporting, user-friendly systems and tangible improvement.[14] Taken together, the evidence suggests that report counts measure culture as much as they measure harm. A low count should prompt questions, not reassurance.
Figure 1
Adverse events are common in hospital and outpatient care, and about one in four is preventable
Percent, as reported in each study: patients or admissions with at least one adverse event, and adverse events judged preventable. Values are copied from the cited studies [7], [12]; none is estimated.
Data note. The four values come from two related record-review studies of Massachusetts care in 2018 that use different settings and denominators (admissions, patients over a year, and adverse events), so this is an indirect comparison and the bars should not be read as one rate compared with another.
Limitation. Both studies reviewed records in one state in 2018; outpatient patients were mostly White, English-speaking and privately insured, and preventability depends on reviewer judgment.
Figure data (4 rows)
| Measure | Value | Population, setting and year as reported | Source |
|---|---|---|---|
| Admissions with at least one adverse event | 23.6% | 23.6% of a random sample of 2,809 admissions at 11 Massachusetts hospitals, 2018 | [12] |
| Inpatient adverse events judged preventable | 22.7% | 222 of 978 adverse events (22.7%) in the same inpatient sample, 2018 | [12] |
| Outpatients with at least one adverse event in a year | 7% | 7.0% of 3,103 patients at 11 Massachusetts outpatient sites, 2018 | [7] |
| Outpatient adverse events judged preventable | 23.2% | 23.2% of adverse events among the same 3,103 outpatients, 2018 | [7] |
Continuum of care
Where reliability breaks: handoffs, escalation and follow-through
Responsibility is most likely to blur when work changes hands. The I-PASS mentored implementation study tested a structured handoff program across 32 hospitals, 12 community and 20 academic, with external coaching over 18 months.[13] It involved 2,735 resident physicians and 760 faculty champions from several specialties, and 1,942 error surveillance reports were collected.[13] That scale makes the study unusually relevant to health systems that mix teaching and community hospitals.
The results were substantial. Major and minor handoff-related reported adverse events decreased 47% after implementation.[13] Major events fell from 1.7 to 0.9 per person-year, and minor events fell from 17.5 to 9.3 per person-year.[13] Inclusion of all five key handoff data elements rose from 20% to 66% in verbal handoffs and from 10% to 74% in written handoffs.[13] High-quality verbal patient summaries rose from 39% to 81%.[13]
The design matters as much as the result. The program paired a common standard with training, faculty champions and longitudinal coaching across community and academic settings.[13] Executives who buy a handoff template without that support should not expect the same effect. The investment is in people and practice, not paperwork, and it needs a budget line that survives the first year. Coaching also gives local teams a channel to report what is not working, which a template alone cannot do.
Transitions across settings carry the same risk. Adverse drug events are the leading outpatient adverse event type, so discharge, reconciliation and follow-up are shared control points between hospital and ambulatory teams.[7] Test result follow-up and referral completion are others, and they rarely belong to a single department. Both risks sit between departments, which is why they need an enterprise owner. That owner needs authority and data that reach across settings.
Reliability also depends on escalation inside the hospital. One academic medical center found that patients with limited English proficiency benefited less from its rapid response system, then redesigned the escalation route for them.[11] The redesign combined dashboard monitoring of early warning scores, rapid response nurse initiation of consults or full activation, and systematic engagement of interpreters.[11] The lesson is that a rescue system can be reliable for most patients and still fail a defined group. Rescue systems should be tested against the patients most likely to fall through them.
Figure 3
Why the pathway breaks
People
- Nurse burnout associated with lower safety climate and more missed care
- Supervisor responses to incidents that are exaggerated or sharp
- Silence rather than notification after an incident
Process
- Handoffs without a common standard, training and coaching
- Escalation routes that do not engage interpreters
- Patient engagement limited to information and prompts
Technology
- Reporting systems that are not user-friendly
- Early warning scores not monitored for groups at higher risk
- Medication management not tracked across settings
Environment
- Blame and a punitive environment
- Inadequate organizational support and resources
- Large hospitals with weaker reporting culture
Policy
- Disclosure practice not evaluated from the patient and family view
- Reliability programs not sustained beyond launch
- No targeted action when safety indicators differ by race or payer
Measurement
- Reliance on incident reports that undercount harm
- Safety indicators not stratified by race, ethnicity, language or payer
- No feedback to reporters on what changed
Unranked qualitative cause-and-effect diagram for the outcome in the box: Preventable harm recurs because events are not detected, learned from and closed across handoffs and settings Causes are assembled from the cited literature [1], [2], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]; categories are not weighted and their order carries no meaning.
Data note. Qualitative; no frequencies are implied.
Limitation. Causes drawn from published studies may not all apply locally; validate them with frontline teams.
Figure data (6 rows)
| Category | Causes drawn from the cited literature |
|---|---|
| People | Nurse burnout associated with lower safety climate and more missed care; Supervisor responses to incidents that are exaggerated or sharp; Silence rather than notification after an incident |
| Process | Handoffs without a common standard, training and coaching; Escalation routes that do not engage interpreters; Patient engagement limited to information and prompts |
| Technology | Reporting systems that are not user-friendly; Early warning scores not monitored for groups at higher risk; Medication management not tracked across settings |
| Environment | Blame and a punitive environment; Inadequate organizational support and resources; Large hospitals with weaker reporting culture |
| Policy | Disclosure practice not evaluated from the patient and family view; Reliability programs not sustained beyond launch; No targeted action when safety indicators differ by race or payer |
| Measurement | Reliance on incident reports that undercount harm; Safety indicators not stratified by race, ethnicity, language or payer; No feedback to reporters on what changed |
Access
Access to safe care in every setting where patients receive it
Most care happens outside the hospital, and so does a large share of risk. In the outpatient review, patients had a mean of 4 outpatient encounters in 2018, and adverse events occurred at a rate of 8.6 events per 100 patients annually.[7] Life-threatening severity applied to 2.1% of those outpatient events.[7] Ambulatory networks therefore need safety oversight that matches their volume, not a lighter version of inpatient review. Prescribing, monitoring and patient instruction sit at the center of that work, because adverse drug events were the most common outpatient event type.[7]
Many organizations still concentrate safety staff, record review and committee time on inpatient units. That allocation made sense when most complex care happened in hospitals. It fits less well when infusion, procedures, medication management and post-discharge care have moved into clinics, ambulatory surgery centers and the home. Executives can test the fit by comparing where adverse events occur with where safety resources sit. A mismatch is a resourcing decision, whether or not anyone made it deliberately.
Safe access also means access to the safety net itself. In the limited English proficiency project, 222 patients experienced at least one rapid response activation during the study period.[11] The team found no special cause variation in process measures, length of hospitalization or escalation of care, and judged the approach feasible to implement.[11] Interpreter access is part of the escalation route, not an add-on. Organizations that serve many languages should review rescue events by language at least as often as they review overall response times.
Patients and families can widen access to safety information, but only when engagement is designed with depth. A meta-analysis of primary care trials included 19 records, of which 12 reported completed randomized trials.[2] Only one intervention integrated patients and families into overall care safety.[2] Six aimed at enhancing skills and tools, while 12 informed patients and families how to engage and prompted them to do it.[2]
Those low-engagement designs did not deliver clear results. Engagement interventions did not significantly reduce adverse drug events, with an odds ratio of 0.86 and a 95% confidence interval of 0.70 to 1.08.[2] The finding is a caution against counting leaflets and reminders as partnership. It is also a reason to test deeper roles for patients in safety work and to measure them honestly. Executives can ask which safety tasks patients are invited to share, and whether those roles were designed with patients.
Executive guidance · System route
Map the path from first contact to verified follow-through.
Use this route as a discussion framework. Replace each stage with the organization’s approved process, qualified roles, current service capacity, and applicable requirements. Do not infer a clinical protocol from the observance title.
The route at a glance
- Listen
- Clarify entry
- Coordinate the partner route
- Protect transitions
- Verify and learn
Reliability rule: Every stage needs a named owner, an observable status, an approved escalation path, and a defined signal that shows whether responsibility moved or remained unresolved.
Listen
Gather questions and friction points from people using the route, frontline teams, and community-facing staff. Separate observed barriers from assumptions.
Clarify entry
Publish a plain-language first step and identify who receives requests through each approved channel.
Coordinate the partner route
Align internal teams and external partners around one current message, real entry point, receiving owner, escalation path, and follow-through signal.
Protect transitions
Use acknowledgment and status visibility when responsibility moves between services, locations, or organizations.
Verify and learn
Review unresolved work, repeat contacts, and avoidable handoffs. Use the findings to improve the route rather than blame individuals.
Figure 2
The system route as one flow
The five stages of the system route described in this brief, drawn as one flow with a learning loop back to the start. The stages are the page’s original executive guidance, not a clinical protocol.
Data note. Shows sequence and handoffs only; it carries no counts or rates.
Limitation. Local processes may add, merge or reorder stages under organizational policy.
Figure data (5 rows)
| Stage | What the stage requires |
|---|---|
| Listen | Gather questions and friction points from people using the route, frontline teams, and community-facing staff. Separate observed barriers from assumptions. |
| Clarify entry | Publish a plain-language first step and identify who receives requests through each approved channel. |
| Coordinate the partner route | Align internal teams and external partners around one current message, real entry point, receiving owner, escalation path, and follow-through signal. |
| Protect transitions | Use acknowledgment and status visibility when responsibility moves between services, locations, or organizations. |
| Verify and learn | Review unresolved work, repeat contacts, and avoidable handoffs. Use the findings to improve the route rather than blame individuals. |
Equity and trust
Who experiences harm, and whether they trust the response
Harm is not distributed evenly. A study of 5,243,750 pediatric discharges in a 2019 national sample of U.S. hospital stays found that Black and Hispanic children had significantly greater odds than white children in 5 of 7 pediatric safety indicators.[8] Medicaid-covered children had significantly greater odds than privately insured children in 4 of 7 indicators.[8] The rate of neonatal bloodstream infection was 331.4 per 10,000 discharges.[8]
Some gaps were large. Black patients had an adjusted odds ratio of 1.55 for postoperative sepsis, and Hispanic patients had an adjusted odds ratio of 1.34 for postoperative respiratory failure.[8] The authors concluded that targeted interventions are needed to improve patient safety in the hospital.[8] For children’s services, that conclusion turns a disparity finding into an operating assignment. Pediatric quality leaders can apply the same indicator definitions to their own data.
Adult outpatient data show similar signals. Outpatient adverse events were more often associated with Black race than with Asian race, with a standardized risk difference of 0.09.[7] That study population was 75.1% White and 90.8% English speakers, so smaller groups may be underrepresented.[7] Executives should ask whether their own safety data can be stratified at all, and whether the counts are large enough to act on. Small numbers can be pooled over longer periods or across facilities, but they should not become a reason to stop looking.
Language is a safety variable, and interpreter delays at the bedside can slow recognition of deterioration. One center that found patients with limited English proficiency gained less from its rapid response system responded by adding interpreter engagement and targeted monitoring.[11] Trust after harm matters too. Patients and families perceive safety incidents differently from healthcare providers and consider open disclosure vital for building trust and achieving resolution.[4] Language access should therefore be measured on the events that matter most, such as deterioration and escalation, not only on overall interpreter volume.
Yet routine assessment of patient and family experiences of disclosure remains infrequent.[4] An organization that does not ask cannot know whether its response to harm repaired or damaged trust. That gap matters most in communities that already have reason for doubt, and it should be reviewed with the same discipline as clinical outcomes. Disclosure follow-up should be offered in the patient’s preferred language.
Human infrastructure
The workforce that produces safety, and what wears it down
Safety is produced by people working inside systems, and their condition shows in outcomes. A meta-analysis of 85 studies involving 288,581 nurses from 32 countries reported a mean burnout prevalence of 30.7%.[6] Burnout was associated with lower safety climate or culture, with a standardized mean difference of -0.68.[6] The included nurses had a mean age of 33.9 years, and 82.7% were female.[6]
The same review linked burnout to more adverse events or patient safety incidents (standardized mean difference, -0.42) and more missed care (standardized mean difference, -0.58).[6] It was also associated with lower patient satisfaction ratings, with a standardized mean difference of -0.51.[6] Most included studies were cross-sectional, so the link is an association rather than proof of cause. Executives should still read burnout data next to harm data for the same units, rather than in a separate wellbeing report.
Psychological safety is often proposed as the bridge between staff wellbeing and patient safety, and it depends heavily on leaders. A scoping review of 16 studies from six countries in public safety and frontline healthcare found that inclusive leadership, ethical integrity and transformational leadership were strongly associated with psychological safety.[3] Overly rigid hierarchies often suppressed employee voice and innovation.[3] Leaders should treat their own behavior as part of the safety system, while recognizing that this evidence maps associations rather than tested interventions.
What happens after an incident shapes what staff do next. Interviews with 16 Slovak medical professionals identified eight responses to a patient safety incident, many active, such as notification, and some passive, such as silence.[10] Five responses from superiors were identified, ranging from supportive to exaggerated or sharp.[10] Supervisors are therefore part of the safety system, and their response to bad news deserves training and review. Peer support after an incident is one practical response that leaders can fund.
Organization-wide reliability programs may help retain the workforce. Across 723,290 employees at 125 VA medical centers, turnover had been rising from a 12.3% baseline, and after high reliability implementation its annual rate dropped by 1.04%.[1] For an average center of 3,056 employees, the authors estimated 16 fewer positions lost and 24 additional employees retained per year.[1] Quality improvement collaboratives may also build frontline capacity, though a review of 32 studies rated that evidence weak and pointed to external support, team functionality and leadership as influences.[15]
Executive guidance · Operating dashboard
Measure whether the operating route works as intended.
Do not publish a number until the organization defines its numerator, denominator where relevant, owner, source system, exclusions, review cadence, and limits. The candidates below are management prompts, not benchmarks or reported results.
Four operating signals
Each signal pairs an executive question with one candidate local measure, set out below.
Executive guidance · Signal
Entry-point clarity
Can people and staff identify the approved first step without searching across conflicting instructions?
- Candidate local measure
- Locally defined contact, routing, and repeat-contact signals by channel and service.
Executive guidance · Signal
Ownership reliability
Does a specific team accept each request and make its status visible?
- Candidate local measure
- Requests without an owner, aged work, transfers, and escalations using locally approved definitions.
Executive guidance · Signal
Partner-route reliability
Do participating teams share one current route and understand who owns each dependency?
- Candidate local measure
- Locally defined conflicting instructions, unaccepted handoffs, unresolved dependencies, repeat contacts, and partner feedback.
Executive guidance · Signal
Improvement closure
Does the organization correct recurring friction and report what changed?
- Candidate local measure
- Selected barriers, assigned actions, completion status, and post-change review.
Figure 4
The operating system behind the dashboard
The four operating signals from this brief’s dashboard, each tied to the candidate owner named in the executive scorecard, around one accountable route. Drawn from the page’s original executive guidance.
Data note. Structural diagram; no measured values.
Limitation. Owners are candidates to be confirmed locally.
Figure data (4 rows)
| Operating signal | Candidate owner |
|---|---|
| Entry-point clarity | Executive sponsor and operational lead |
| Ownership reliability | Operational owner and participating teams |
| Partner-route reliability | Sending and receiving owners |
| Improvement closure | Improvement owner and executive sponsor |
Executive guidance · Handoff workflow
Keep work owned when it crosses a boundary.
A handoff is reliable only when the sending party knows who is expected to receive the work, the receiving party acknowledges responsibility, and any unresolved exception remains visible. Local policy and qualified judgment control the actual process.
How responsibility moves
Lane A
From message to accepted ownership
- Confirm the approved message and intended audience.
- Publish the actual entry point and receiving role.
- Acknowledge receipt using the locally approved method.
- Escalate when ownership or response remains unclear.
Lane B
From accepted ownership to verified follow-through
- Record the next accountable owner and visible status.
- Name the sending and receiving owners, shared information, current status, and unresolved dependency.
- Keep unresolved work visible across boundaries.
- Confirm closure or document the continuing exception.
Executive guidance · Executive scorecard
Ask questions that connect intent, ownership, and results.
The scorecard keeps review focused on decisions. Leaders should set definitions locally, examine variation without overclaiming cause, and pair quantitative signals with the experience of people who use and operate the route.
Who reviews what
- Executive sponsor and operational lead
- Operational owner and participating teams
- Sending and receiving owners
- Improvement owner and executive sponsor
Candidate owners named in the scorecard, confirmed locally.
| Operating signal | Executive question | Candidate owner | Suggested review point |
|---|---|---|---|
| Entry-point clarity | Can people and staff identify the approved first step without searching across conflicting instructions? | Executive sponsor and operational lead | At campaign launch and close |
| Ownership reliability | Does a specific team accept each request and make its status visible? | Operational owner and participating teams | At a locally defined cadence |
| Partner-route reliability | Do participating teams share one current route and understand who owns each dependency? | Sending and receiving owners | At a locally defined cadence |
| Improvement closure | Does the organization correct recurring friction and report what changed? | Improvement owner and executive sponsor | Until action is verified |
Figure 5
Control points for a reliable quality and safety operating system
| Control point | Risk if missing | Owner | Evidence of control |
|---|---|---|---|
| Periodic structured record review alongside incident reports | Harm is undercounted when almost half of staff report no events in a year | Chief quality officer | Record-review adverse event rate compared with report volume by unit |
| Enterprise medication safety ownership across inpatient and outpatient care | Adverse drug events, the leading event type in both settings, fall between departments | Chief medical officer with pharmacy and ambulatory leaders | Adverse drug event trend reported for both settings at the same review |
| Structured handoff program with training, champions and coaching | Handoffs omit key data elements and handoff-related events persist | Chief medical officer and graduate medical education leaders | Audited share of handoffs with all key elements and reported handoff events |
| Interpreter engagement built into rapid response and escalation | Patients with limited English proficiency benefit less from rescue systems | Chief nursing officer and language services lead | Interpreter use documented on rapid response events, stratified by language |
| Safety indicators stratified by race, ethnicity, language and payer | Disparities in safety events remain invisible and unaddressed | Chief quality officer and equity lead with the board quality committee | Stratified safety report reviewed with named actions for each gap |
| Feedback loop to reporters and a just response to incidents | Staff stop reporting and choose silence after blame or sharp responses | Patient safety officer and department leaders | Share of reports closed with feedback to the reporter within a set time |
| Patient and family experience of disclosure assessed | Disclosure damages trust without the organization knowing | Chief experience officer and risk management lead | Routine follow-up with patients and families after disclosure, with themes reported |
Control points derived from the cited evidence [4], [7], [8], [9], [10], [11], [12], [13], [14] and this brief’s executive guidance.
Data note. Each row is a control to verify, not a measured result.
Limitation. Owners and evidence of control must follow local policy and applicable requirements.
Public communication
Communicating about quality in ways that earn credibility
Public messages during Healthcare Quality Week should match what the evidence shows. Harm is common and often preventable.[12] It is also unevenly distributed.[8] Messages that only celebrate rankings or awards can sound hollow to patients who have experienced harm and to staff who know where the gaps are. Patients notice when a hospital’s public story differs from their own experience, and so do the clinicians who care for them.
Disclosure is the most consequential safety communication an organization makes. A systematic review identified 26 studies from an initial 8,940, mostly qualitative, and synthesized five key themes in patient and family experiences of open disclosure.[4] The review is a reminder that the person harmed is the main audience for this communication, not the regulator or the press. Leaders should know who in the organization is trained to lead these conversations and how quickly they happen.
Internal communication shapes what reaches leaders. Feedback and tangible improvement help learning systems work, while blame and a punitive environment hold them back.[14] Staff responses after an incident range from notification to silence, and superiors’ responses range from supportive to exaggerated or sharp.[10] Telling reporters what changed because of their report is one of the simplest ways to keep reports coming. Anonymous reporting and user-friendly systems also signal that leaders want to hear about problems.[14]
Credible communication also states what is not yet known. Patient engagement trials in primary care have not yet shown a significant reduction in adverse drug events.[2] Evidence on quality improvement collaboratives remains weak.[15] Much of the evidence on psychological safety still comes from reviews that map associations rather than test interventions.[3] Leaders who say this plainly protect their credibility when results take longer than a campaign week. Honesty about uncertainty is a form of respect.
The most persuasive message is a specific one. An organization that names one recurring harm, one accountable owner and one measured change will earn more trust than one that lists every initiative. The workforce data support that discipline, because burnout among nurses is common and is associated with lower safety climate.[6] A focused message respects both the public and the people asked to deliver the change. It also gives staff a clear reason to believe that this year’s observance will lead somewhere.
Executive guidance · 90-day plan
Move from listening to a verified improvement in 90 days.
The time boxes below are a management framework, not a clinical timeline. Adjust them to risk, scope, governance, resources, stakeholder participation, and applicable review requirements.
Ninety days, three moves
- Days 1–30See the current route
- Days 31–60Build the reliable path
- Days 61–90Make the change visible
Days 1–30 · Listen and map
See the current route
- Name an executive sponsor and an operational owner.
- Listen to people using the route and representative frontline teams.
- Map how Healthcare Quality Week communications connect to real entry points, owners, transitions, and escalation.
- Select one recurring barrier that the organization can responsibly address.
Days 31–60 · Design and test
Build the reliable path
- Define the trigger, receiving owner, required information, acknowledgment, escalation, and closure signal.
- Validate the design with every sending and receiving team involved.
- Test one internal or partner handoff and correct a verified communication, dependency, or ownership gap.
- Test the route in more than one representative setting or operating period where practical.
Days 61–90 · Implement and verify
Make the change visible
- Launch the redesigned route with a small set of locally defined measures.
- Review unresolved work and recurring friction using a learning approach.
- Correct implementation barriers and record who owns each remaining dependency.
- Report what changed, what evidence was reviewed, and what still requires live oversight.
Figure 6
The 90-day plan on one timeline
The 90-day plan from this brief drawn as a timeline: each action sits in the 30-day window the plan assigns it. The full wording of each action is in the figure data and in the plan above.
Data note. Time boxes are a management framework, not a clinical timeline.
Limitation. Durations are uniform 30-day windows; real tasks may span windows.
Figure data (12 rows)
| Window | Action |
|---|---|
| Days 1–30 · Listen and map | Name an executive sponsor and an operational owner. |
| Days 1–30 · Listen and map | Listen to people using the route and representative frontline teams. |
| Days 1–30 · Listen and map | Map how Healthcare Quality Week communications connect to real entry points, owners, transitions, and escalation. |
| Days 1–30 · Listen and map | Select one recurring barrier that the organization can responsibly address. |
| Days 31–60 · Design and test | Define the trigger, receiving owner, required information, acknowledgment, escalation, and closure signal. |
| Days 31–60 · Design and test | Validate the design with every sending and receiving team involved. |
| Days 31–60 · Design and test | Test one internal or partner handoff and correct a verified communication, dependency, or ownership gap. |
| Days 31–60 · Design and test | Test the route in more than one representative setting or operating period where practical. |
| Days 61–90 · Implement and verify | Launch the redesigned route with a small set of locally defined measures. |
| Days 61–90 · Implement and verify | Review unresolved work and recurring friction using a learning approach. |
| Days 61–90 · Implement and verify | Correct implementation barriers and record who owns each remaining dependency. |
| Days 61–90 · Implement and verify | Report what changed, what evidence was reviewed, and what still requires live oversight. |
Executive guidance · Leadership close
Carry one accountable improvement beyond the campaign window.
Recognition matters. It becomes durable when leaders also listen, clarify the route, support the people operating it, close an identified gap, and report the result without claiming more than the evidence supports.
Leadership commitment
Listen to the people closest to the route, assign one barrier, and verify the change.
Executive action kit · Week observance
Turn Healthcare Quality Week into accountable action.
Use the observance to review how people find information, enter the right route, and remain connected through follow-through.
Leadership focus
Use this observance to examine safety signals, escalation, and learning without blame. Select one verified barrier, assign an accountable owner, and carry the improvement beyond the campaign window.
Workforce lens
Ask whether staffing, role clarity, training, tools, workload, and escalation support the people operating the information, access, coordination, and follow-through pathway.
Patient and community lens
Make the approved first step clear. Test whether a person can move from information to an acknowledged next action without navigating conflicting instructions.
Equity and access lens
Review language, disability, transportation, digital access, geography, trust, and other barriers using protected feedback and locally appropriate data.
Five-minute briefing
Inspect the operating sequence
Listen with people using the pathway, frontline teams, operational leaders, and community partners. Find one a message, request, referral, or handoff that does not reach an accountable owner, then test the locally approved route from entry through acknowledged follow-through.
- Listen
- Clarify entry
- Coordinate the partner route
- Protect transitions
- Verify and learn
Leadership actions for this week
- Name an executive sponsor and frontline operating owner.
- Ask people using and operating the pathway where ownership becomes unclear.
- Test one representative route from first question to acknowledged next step.
- Select one barrier that can be corrected without overstating the evidence.
- Set a review date and define how completion will be verified.
Candidate measures
Define every numerator, denominator where relevant, owner, data source, exclusions, cadence, and limitation locally. These are management prompts, not external benchmarks.
- Locally defined contact, routing, and repeat-contact signals by channel and service.
- Requests without an owner, aged work, transfers, and escalations using locally approved definitions.
- Locally defined conflicting instructions, unaccepted handoffs, unresolved dependencies, repeat contacts, and partner feedback.
Department readiness checklist
- The public and staff entry points match the actual approved process.
- A specific role accepts each request, referral, or escalation.
- Handoffs include acknowledgment and a visible unresolved state.
- Language, disability, digital, transportation, and trust barriers receive explicit review.
- Communications do not introduce unsupported themes, statistics, or clinical advice.
- A named leader will review what changed after the observance.
Intended audiences
- Executive and Operational Leaders
- Quality, Safety, and Operations Teams
Staff communication template
During Healthcare Quality Week, our organization will connect awareness with a practical review of the information, access, coordination, and follow-through pathway. Use approved information, identify the correct entry point, confirm ownership when work moves, protect privacy, and escalate unresolved barriers through local channels.
Community communication template
Healthcare Quality Week is an opportunity to share trustworthy information and make the next step easier to find. Use our approved channels for information and support. If a request changes hands, our goal is to keep ownership and follow-through visible.
Measurement worksheet
- Signal
- What observable condition will show whether the route works?
- Definition
- What is included, excluded, and counted?
- Owner
- Who reviews the signal and acts on exceptions?
- Cadence
- When will leaders review it?
- Equity check
- Which differences require protected, locally appropriate review?
- Closure
- What evidence will confirm the improvement was completed?
- Editorial review
- Completed
- Source records
- 2 listed under Authoritative resources
- Review standard
- Sourced facts remain separated from original executive guidance
- Clinical boundary
- No new statistical or clinical claim was added by this action kit
Sources and content boundary
Authoritative resources
Use note: All operating models, measures, scorecard questions, and action steps are original executive guidance. This article supports leadership planning and education. It does not replace clinical judgment, emergency procedures, legal advice, professional standards, organizational policy, or applicable federal, state, and local requirements.
Peer-reviewed references
References
Fifteen peer-reviewed sources, newest first. Each was individually verified against the publisher’s record. Bracketed numbers in the text link here; the original executive guidance on this page carries no citations because it is guidance, not a sourced claim. Sources last checked against their publishers’ records on .
- 1.Axon RN, Ward R, Mohamed A, Mauldin P, Buchanan C, Mengeling M, et al. Implementation of High Reliability Organization Principles in a Nationally Integrated Healthcare System: Initial Associations With Staff Turnover and Retention. Health Services Research. 2026;61(4):e70156. https://doi.org/10.1111/1475-6773.70156
- 2.Pang Y, Szücs A, Ricci-Cabello I, Gangannagaripalli J, Goh LH, Leong FL, et al. Patient and family engagement interventions in primary care patient safety: systematic review and meta-analysis of randomised controlled trials. British Journal of General Practice. 2025;75(756):e491-e499. https://doi.org/10.3399/BJGP.2024.0369
- 3.Ip E, Srivastava R, Lentz L, Jasinoski S, Anderson GS. Antecedents of Workplace Psychological Safety in Public Safety and Frontline Healthcare: A Scoping Review. International Journal of Environmental Research and Public Health. 2025;22(6):820. https://doi.org/10.3390/ijerph22060820
- 4.Rathnayake D, Sasame A, Radomska A, Ní Shé E, McAuliffe E, De Brún A. What can we learn from patient and family experiences of open disclosure and how they have been evaluated? A systematic review. BMC Health Services Research. 2025;25(1):238. https://doi.org/10.1186/s12913-025-12388-3
- 5.Sawyer AM, Thiyarajan S, Essen K, Pendley-Louis R, Sculli GL, Yackel EE. Implementation of a High-Reliability Organization Framework in a Large Integrated Health Care System: A Pre-Post Quasi-Experimental Quality Improvement Project. Military Medicine. 2025;190(5-6):e1190-e1197. https://doi.org/10.1093/milmed/usae511
- 6.Li LZ, Yang P, Singer SJ, Pfeffer J, Mathur MB, Shanafelt T. Nurse Burnout and Patient Safety, Satisfaction, and Quality of Care: A Systematic Review and Meta-Analysis. JAMA Network Open. 2024;7(11):e2443059. https://doi.org/10.1001/jamanetworkopen.2024.43059
- 7.Levine DM, Syrowatka A, Salmasian H, Shahian DM, Lipsitz S, Zebrowski JP, et al. The Safety of Outpatient Health Care: Review of Electronic Health Records. Annals of Internal Medicine. 2024;177(6):738-748. https://doi.org/10.7326/M23-2063
- 8.Parikh K, Hall M, Tieder JS, Dixon G, Ward MC, Hinds PS, et al. Disparities in Racial, Ethnic, and Payer Groups for Pediatric Safety Events in US Hospitals. Pediatrics. 2024;153(3):e2023063714. https://doi.org/10.1542/peds.2023-063714
- 9.Alkahf D, Alonazi W. Exploring the safety reporting culture among healthcare practitioners in Saudi hospitals: a comprehensive 2022 national study. BMC Health Services Research. 2024;24(1):769. https://doi.org/10.1186/s12913-024-11160-3
- 10.Kupkovicova L, Skoumalova I, Madarasova Geckova A, Dankulincova Veselska Z. Medical Professionals’ Responses to a Patient Safety Incident in Healthcare. International Journal of Public Health. 2024;69:1607273. https://doi.org/10.3389/ijph.2024.1607273
- 11.Raff L, Blank AG, Crespo Regalado R, Bulik-Sullivan E, Phillips L, Moore C, et al. A Quality Improvement Project to Reduce Rapid Response System Inequities for Patients with Limited English Proficiency at a Quaternary Academic Medical Center. Journal of General Internal Medicine. 2024;39(7):1103-1111. https://doi.org/10.1007/s11606-024-08678-x
- 12.Bates DW, Levine DM, Salmasian H, Syrowatka A, Shahian DM, Lipsitz S, et al. The Safety of Inpatient Health Care. New England Journal of Medicine. 2023;388(2):142-153. https://doi.org/10.1056/NEJMsa2206117
- 13.Starmer AJ, Spector ND, O’Toole JK, Bismilla Z, Calaman S, Campos ML, et al. Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. Journal of Hospital Medicine. 2023;18(1):5-14. https://doi.org/10.1002/jhm.12979
- 14.Mahmoud HA, Thavorn K, Mulpuru S, McIsaac D, Abdelrazek MA, Mahmoud AA, et al. Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis. BMJ Open Quality. 2023;12(2):e002134. https://doi.org/10.1136/bmjoq-2022-002134
- 15.Zamboni K, Baker U, Tyagi M, Schellenberg J, Hill Z, Hanson C. How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review. Implementation Science. 2020;15(1):27. https://doi.org/10.1186/s13012-020-0978-z
Claim-to-source matrix
What each source supports
Every sourced claim in the new sections maps to the references that support it, the section where it is used, and the limitation a reader should keep in mind. Original executive guidance carries no sources because it is guidance, not a finding.
| Claim group | Sources | Years | Used in | Limitation |
|---|---|---|---|---|
| Frequency, severity and preventability of inpatient adverse events | [12] | 2023 | Current evidence | Record review of 2,809 admissions at 11 Massachusetts hospitals in 2018; may not generalize to other regions or later years. |
| Frequency, type and preventability of outpatient adverse events | [7] | 2024 | Current evidence | Eleven Massachusetts outpatient sites in 2018; mostly White, English-speaking and privately insured patients. |
| High reliability implementation, safety culture and event reporting | [5] | 2025 | Current evidence | Pre-post quality improvement design in one federal system without randomization; abstract reports trends rather than effect sizes. |
| Under-reporting of safety events by practitioners | [9] | 2024 | Current evidence | Single national survey in Saudi hospitals in 2022; self-reported reporting behavior. |
| Barriers and facilitators to patient safety learning systems | [14] | 2023 | Current evidence | Meta-synthesis of 22 qualitative studies; describes perceptions rather than measured outcomes. |
| Structured handoff implementation and handoff-related adverse events | [13] | 2023 | Continuum of care | Pre-post design with reported adverse events among residents; no concurrent control group. |
| Rapid response redesign for patients with limited English proficiency | [11] | 2024 | Continuum of care | Single quaternary academic center quality improvement project; small sample of 222 patients. |
| Patient and family engagement interventions and medication safety in primary care | [2] | 2025 | Access | Few completed randomized trials; most interventions used low levels of engagement. |
| Racial, ethnic and payer disparities in pediatric safety events | [8] | 2024 | Equity and trust | Administrative 2019 data using safety indicators; coding differences may affect estimates. |
| Patient and family experiences of open disclosure | [4] | 2025 | Equity and trust | Mostly qualitative studies published between 2008 and 2023; few quantitative evaluations. |
| Nurse burnout and safety, satisfaction and quality outcomes | [6] | 2024 | Human infrastructure | Mostly cross-sectional studies; associations, not causal effects. |
| Leadership antecedents of workplace psychological safety | [3] | 2025 | Human infrastructure | Scoping review of 16 studies from six countries, including public safety workplaces; associations, not tested interventions. |
| Professional and supervisor responses after a patient safety incident | [10] | 2024 | Human infrastructure | Sixteen qualitative interviews in one country. |
| High reliability implementation and staff turnover and retention | [1] | 2026 | Human infrastructure | Interrupted time series in one national system; unobserved factors may contribute; modest, temporary changes. |
| Mechanisms of quality improvement collaboratives | [15] | 2020 | Human infrastructure | Review of 32 studies with weak evidence strength; program theory not yet tested. |
About the author
Greg Wahlstrom
MBAHCM
President and Chief Executive Officer, The Healthcare Executive
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