The Journal Blog

The blog of The Joint Commission Journal on Quality and Patient Safety features news and comments from the Journal’s Executive Editor, Steven Berman, and provides readers with an online forum to share opinions, concerns, and ideas about issues and approaches in improving quality and patient safety. 



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February 2012 issue of The Joint Commission Journal on Quality and Patient Safety

• 1/26/2012
• Author: Steven Berman
• 88 Views
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Now available for your online access is the February 2012 issue of The Joint Commission Journal on Quality and Patient Safety. Here is a look at this issue: PERFORMANCE IMPROVEMENT Spreading a Medication Administration Intervention Organizationwide in Six Hospitals ... more >>

January 2012 Issue Available Online!

• 1/3/2012
• Author: Steven Berman
• 269 Views
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Now available for your online access is the January 2012 issue of The Joint Commission Journal on Quality and Patient Safety. Here is a look at this issue: HEALTH PROFESSIONS EDUCATION Designing Education to Improve CareFive levels for defining and developing competence apply to physicians, nurses, and other members of an interprofessional QI team: novice, advanced beginner, comp... more >>

The July 2011 Issue of The Joint Commission Journal on Quality and Patient Safety Is Now Out

• 6/21/2011
• Author: Steven Berman
• 833 Views
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Here is a look at the issue: Safety Strategies in an Academic Radiation Oncology Department and Recommendations for Action Stephanie A. Terezakis, M.D.; Peter Pronovost, M.D., Ph.D.; Kendra Harris, M.D., M.Sc.; Theodore DeWeese, M.D.; Eric Ford, Ph.D.A radiation oncology department has undertaken a variety of risk identification and mitigation strategies. However, coordination ac... more >>

Joint Commission Annual Conference on Quality & Patient Safety: Leading Ideas in Quality & Safety

• 5/20/2011
• Author: Steven Berman
• 754 Views
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To follow up on my blog from April 13, 2001, “Overcoming Challenges and Implementing Solutions,” I wanted to let you know that you can still register for the Joint Commission Annual Conference on Quality and Patient Safety, “Come Together – A Gathering of Leading Ideas in Quality and Safety,” which will be held June 8–10 in Chicago. Faculty will provide best case practices, solutions, obstacle... more >>

Managing Conflict Within Health Care Organizations as a Patient Safety Imperative

• 5/17/2011
• Author: Steven Berman
• 1022 Views
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This week, Debra Gerardi, the author, along with Charity Scott, of a two-part article that appeared in the February 2011 issue of the Journal—“A Strategic Approach for Managing Conflict in Hospitals: Responding to the Joint Commission Leadership Standard, Parts 1 and 2” (access part 1 here and part 2 here)— provides some additional reflections. We welcome your comments. As Cha... more >>

Further Progress in Standardizing Hospital Discharge Planning at the Mayo Clinic

• 4/14/2011
• Author: Steven Berman
• 1008 Views
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Early this year, in Standardizing Hospital Discharge Planning at the Mayo Clinic ,  Diane E. Holland and Michele A. Hemann at the Mayo Clinic reported how discharge planning–practice changes, entailing deployment of nurse specialists and the use of two specially developed electronic tools, resulted in a clinically meaningful decrease in length of stay for older patients... more >>

Overcoming Challenges and Implementing Solutions

• 4/13/2011
• Author: Steven Berman
• 726 Views
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As you may know, The Joint Commission Annual Conference on Quality and Patient Safety, “Come Together – A Gathering of Leading Ideas in Quality and Safety,” will be held June 8–10 in Chicago. This conference will focus on how health care executives can seek to improve quality and reduce errors, contain costs, increase productivity, enhance execution, achieve organizational greatness, and build... more >>

Joint Commission Releases Animated Speak Up Videos for Patient Participation in Health Care

• 3/14/2011
• Author: Steven Berman
• 908 Views
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On March 9, 2011, in celebration of National Patient Safety Awareness Week,  Joint Commission Online announced the release of the first in a series of animated Speak Up™ videos, “Prevent Errors in Your Care,” to encourage patients to speak up and be active participants in their health care. Produced by The Joint Commission, these entertaining 60-second videos are intended as public servi... more >>

Talking to Patients About Their Goals of Care

• 2/15/2011
• Author: Steven Berman
• 1077 Views
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This week, Lauris Kaldjian, who, along with Ann Broderick, contributed an article, “Developing a Policy for Do Not Resuscitate Orders Within a Framework of Goals of Care,”   guests on the Journal blog. In the article, the authors describe why and how the University of Iowa Ethics Committee changed the policy on DNR decisions by placing DNR orders and end-of-lif... more >>

Praise and Critiques for Using Human Factors Engineering to Improve Patient Safety: Problem Solving

• 2/15/2011
• Author: Steven Berman
• 1127 Views
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This week, John W. Gosbee, M.D., M.S., and Laura Lin Gosbee, M.A.Sc., editors of a new JCR book, Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, Second Edition , follow up on their guest blog on September 4, 2010 about the book to share two reviews and comment on an issue raised by one of the reviewers. You can join in the dis... more >>

2010 John M. Eisenberg Patient Safety and Quality Award Recipients Announced

• 1/14/2011
• Author: Steven Berman
• 1142 Views
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As you may have noticed, on January 12, 2011, Joint Commission Online reported the recipients of the 2010 John M. Eisenberg Patient Safety and Quality Award, as announced by The Quality Forum (NQF) and The Joint Commission.The patient safety awards program, launched in 2002 by TNQF and The Joint Commission, honors John M. Eisenberg, M.D., M.B.A., former administrator of the Agency for He... more >>

An Update on the "forYou Team"

• 1/14/2011
• Author: Steven Berman
• 940 Views
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This week, Laura Hirschinger, a co-author of “Caring for Our Own: Deploying a Systemwide Second Rapid Response Team,” which appeared in the May 2010 issue, guests on the Journal blog. As Hirschinger and her co-authors reported in the article, they and colleagues developed a unique rapid response system to provide social, psychological, emotional, and professional support for heal... more >>

Now Published! The Value of Close Calls in Improving Patient Safety

• 12/14/2010
• Author: Steven Berman
• 1300 Views
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This week, Joint Commission Resources is publishing The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm, which I have had the privilege of working on with Albert Wu, M.D., M.P.H., a member of the Journal’s Editorial Advisory Board. Because close calls, often also termed near misses, don’t raise the same concerns about malpractice ... more >>

Reflections on Adapting a Quality of Care Model for Global Implementation

• 12/7/2010
• Author: Steven Berman
• 1085 Views
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This week, Bruce D. Agins, M.D., M.P.H., a co-author of " Pediatric HIVQUAL-T: Measuring and Improving the Quality of Pediatric HIV Care in Thailand, 2005-2007 ,”  in the December  2010 issue, guests on the Journal blog. The article describes the implementation of Pediatric HIVQUAL-T, a model for performance measurement and quality improvement (QI) of pedi... more >>

Preventing Suicide Outside Mental Health Units

• 11/23/2010
• Author: Steven Berman
• 2077 Views
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A new Joint Commission Sentinel Event Alert urges greater attention to the risk of suicide for nonpsychiatric patients in emergency departments (EDs) and medical/surgical inpatient units and recommends education for caregivers about warning signs that may indicate when these patients are contemplating harming themselves. The Alert cautions that many patients who kill them... more >>

The Danger of “Rogue” Health Care Workers

• 11/18/2010
• Author: Steven Berman
• 1273 Views
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In a previous blog, “Addressing Violence in Health Care Facilities,” Kenneth W. Kizer and Beatrice C. Yorker, authors of the Journal article, “Health Care Serial Murder: A Patient Safety Orphan,"  commended The Joint Commission for its Sentinel Event Alert, Preventing Violence in the Health Care Setting.Dr George Lundberg, in a recent online column, “Murder... more >>

What’s Next for the “Necessary First Steps” on Medication Reconciliation?

• 11/11/2010
• Author: Steven Berman
• 942 Views
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The November 2010 issue of the Journal includes a white paper prepared for the Society of Hospital Medicine which addresses the issues in medication reconciliation and their potential solutions. The article, “Making Inpatient Medication Reconciliation Patient Centered, Clinically Relevant, and Implementable: A Consensus Statement on Key Principles and Necessary First Steps,” authored by Jeffre... more >>

Using the Push/Pull Point-of-Dispensing (POD) Vaccination Model: Update on the 2010–2011 Season

• 10/26/2010
• Author: Steven Berman
• 1787 Views
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This week, Robert S. Crupi, the lead author of “Linking Emergency Preparedness and Health Care Worker Vaccination Against Influenza: A Novel Approach,”  which appears in the November 2010 issue, guests on the Journal blog. In the article, Dr. Crupi, Chairman of the Department of Emergency Medicine, Flushing Hospital Medical Center, Flushing, New York, and... more >>

Joint Commission Center for Transforming Healthcare’s Hand-off Communications Solutions

• 10/26/2010
• Author: Steven Berman
• 1733 Views
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On October 21, the Joint Commission Center for Transforming Healthcare released its second set of solutions, which focus on improving hand-off communications (transitions in care).  The first set of solutions, which were pilot tested, addressed hand hygiene compliance, as I discussed in an earlier blog. Ten leading U.S. hospitals and health care systems teamed up with the Center in August ... more >>

The Joint Commission’s Annual Report Highlights Progress

• 9/22/2010
• Author: Steven Berman
• 3885 Views
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Today—September 22, 2010—The Joint Commission released its annual quality and safety report, Improving America’s Hospitals: The Joint Commission’s Report on Quality and Safety 2010. According to the report, accredited hospitals in the United States are providing higher-quality, evidence-based care for heart attack, pneumonia, surgical care, and children’s asthma care. This fifth-annual report ... more >>

The Joint Commission Launches Targeted Solutions Tool™

• 9/16/2010
• Author: Steven Berman
• 3927 Views
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As you may know, on September 13, 2010, The Joint Commission launched its Targeted Solutions Tool™ (TST), which encapsulates the work of the Joint Commission Center for Transforming Healthcare. The TST is an interactive tool that simplifies the process for solving the most persistent health care quality and safety problems that exist within our health care system—such as hand hygiene compl... more >>

Editors of New JCR Book on Human Factors Engineering Discuss Recent Work

• 9/4/2010
• Author: Steven Berman
• 6276 Views
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This week, John W. Gosbee, M.D., M.S., and Laura Lin Gosbee, M.A.Sc., editors of a new JCR book, Using Human Factors Engineering to Improve Patient Safety: Problem Solving on the Front Line, Second Edition, and longtime contributors to the Journal, discuss their recent work. You can reach the Gosbees at info@redforestconsulting.com. Using Human Factors Engineering to Improve Pa... more >>

Addressing the Issue of Violence in Health Care Facilities

• 6/17/2010
• Author: Steven Berman
• 9553 Views
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A new Joint Commission Sentinel Event Alert, Preventing Violence in the Health Care Setting, warns that health care organizations and their patients and visitors are now confronting steadily increasing rates of crime, including assault, rape, and murder. The Alert advises that while it is imperative to control access to the facility and maintain ongoing surveillance of the ground... more >>

Safety of Test Result Follow-Up: Challenges, Progress, and More Challenges

• 5/15/2010
• Author: Steven Berman
• 10720 Views
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This week, Hardeep Singh and Meena S. Vij, the authors of “Eight Recommendations for Policies for Communicating Abnormal Test Results,”  which appeared in the May 2010 issue, are guests on the Journal blog. The evidence- and experience-based recommendations provided in the article are intended to help organizations ensure safe and timely abnormal test-result communicat... more >>

The Joint Commission Annual Conference on Quality and Patient Safety:

• 4/30/2010
• Author: Steven Berman
• 11685 Views
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A Preview of "Evidence-Informed Value Improvement" As you may know, The Joint Commission Annual Conference on Quality and Patient Safety will be held June 23–25 in Chicago. This conference will focus on organizational greatness and decisions and actions for health care executives seeking to improve quality, reduce errors, contain costs, increase p... more >>

Improving Tdap Vaccination Rates: A Case Study

• 4/9/2010
• Author: Steven Berman
• 12901 Views
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A recent issue of The Joint Commission Online  included a call for strategies to improve tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates in health care organizations. The Joint Commission is asking health care organizations to share their approaches for implementing vaccination programs for patients and health care workers. The information will be... more >>

An Emergency Department Clinical Information System: Continuing Improvement and Benefits

• 3/31/2010
• Author: Steven Berman
• 13907 Views
• 1 Comments
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This week, Kevin M. Baumlin, the lead author of " Clinical Information System and Process Redesign Improves Emergency Department Efficiency ” in the April 2010 issue, guests on the Journal blog. Dr. Baumlin’s article describes how Mount Sinai Medical Center, a hospital in Manhattan, coordinated a variety of efforts—including changes in patient registration... more >>

Medication Administration Article Circulates Across Switzerland

• 3/26/2010
• Author: Steven Berman
• 13255 Views
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To follow up on the previous blog, I have recently learned that Dr. David Schwappach, the Scientific Head of the Swiss Patient Safety Foundation, has selected the Kliger et al. article, “Empowering Frontline Nurses: A Structured Intervention Enables Nurses to Improve Medication Administration Accuracy” (December 2009 issue of the Journal), as “Paper of the Month.” This means that the fou... more >>

Building in Strategic Communication as Key to Leadership in Improvement

• 3/24/2010
• Author: Steven Berman
• 14312 Views
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This week, Julie Kliger, lead author of “Empowering Frontline Nurses: A Structured Intervention Enables Nurses to Improve Medication Administration Accuracy,” which appeared in the December 2009 issue, guests on the Journal blog. As you will recall, the article reported how a 36-month demonstration program led to a 87.7% reduction in medication administra... more >>

Incident Reporting Still Lacking Among Many Doctors-in-Training

• 3/13/2010
• Author: Steven Berman
• 13965 Views
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To follow up on my previous blog, the deficiencies in patient safety education described in the Lucian Leape Institute report, Unmet Needs: Teaching Physicians to Provide Safe Patient Care, are reflected in another Journal article—cited yesterday in an article in the New York Times, “Learning to Keep Patients Safe in a Culture of Fear” (http://www.nytimes.com/2010/03/11/health/11chen.html?emc=... more >>

Quality and Patient Safety Education Needs for Physicians—and Nurses

• 3/12/2010
• Author: Steven Berman
• 13631 Views
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On March 11, 2010, the Lucian Leape Institute at the National Patient Safety Foundation released a report that finds that medical schools are failing to do an adequate job of “facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care,” resulting in greater risk to patients. Lucian L. Leape, M.D., chair of the Institute, ... more >>

Radiation Hazards and Challenges in Reporting Adverse Events: A Human Factors Perspective

• 3/5/2010
• Author: Steven Berman
• 14610 Views
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In his January 29, 2010 guest blog, Kurt Herzer commented on the two recent investigative articles in the New York Times on the incidence and impact of rare accidents in radiation therapy. Shortly after, the American Society for Radiation Oncology issued a six-point plan for improving safety and quality and reducing the chances of medical errors—including working with oth... more >>

The Joint Commission Invites Eisenberg Award Nominations

• 2/24/2010
• Author: Steven Berman
• 13241 Views
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As you may know, The Joint Commission has recently invited nominations for the 2010 John M. Eisenberg Patient Safety and Quality Award. Information about the awards and the and nomination process can be found at http://www.jointcommission.org/PatientSafety/EisenbergAward/ . Every year since 2002, when John M. Eisenberg died, it has been an honored ... more >>

Reducing Inpatient Suicide Hazards at Veterans Administration Hospitals

• 2/12/2010
• Author: Steven Berman
• 14665 Views
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This week, Peter Mills, the senior author of " A Checklist to Identify Inpatient Suicide Hazards in Veterans Affairs Hospitals,” which appears in the February 2010 issue, guests on the Journal blog. In the article, Dr Mills and his colleagues report on the first study to examine the implementation and effectiveness of a standardized checklist for mental health units. Dr. Mills, a... more >>

Reflections on Integrating Electronically Generated Sign-out Documents into the EMR

• 2/4/2010
• Author: Steven Berman
• 14662 Views
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A Case Where What Is Good for Doctors May Also Be Good for Patients This week, Jonathan A. Bernstein, the lead author of “Improved Physician Work Flow after Integrating Sign-out Notes into the Electronic Medical Record,” which appears in the February 2010 issue, guests on the Journal blog. As the authors reported in t... more >>

Identifying and Mitigating Hazards in Radiation Therapy

• 1/29/2010
• Author: Steven Berman
• 17071 Views
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2:22:04 PM   This week, I asked Kurt R. Herzer, Marshall Scholar, University of Oxford, and Woodrow Wilson Research Fellow, Johns Hopkins University, to guest on the Journal blog. Mr. Herzer comments on two recent investigative articles in the New York Times reporting on the incidence and impact of rare accidents in radiation therapy, many of which can cause irrev... more >>

Adding a Layer of Safety Through Rapid Response Systems

• 1/22/2010
• Author: Steven Berman
• 16037 Views
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This week, Michael DeVita, M.D., chief editor of the Journal’s department Rapid Response Systems: The Stories, which began in the July 2006 issue, guests on the blog. Dr DeVita, Professor of both Critical and Internal Medicine in the University of Pittsburgh’s School of Medicine and Executive Vice President of Medical Affairs for West Penn Allegheny Health System, refle... more >>

Emerging Issues with the VA Shift Handoff Tool

• 1/14/2010
• Author: Steven Berman
• 16399 Views
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This week, Peter Kaboli, the senior author of “The Veterans Affairs Shift Change Physician-to-Physician Handoff Project,” which appears in the February 2010 issue, guests on the Journal blog. The development team designed an electronic medical record (EMR) handoff tool to provide a standardized approach to handoff commun... more >>

Additional Reflections on Preventing Venous Thromboembolism

• 10/29/2009
• Author: Steven Berman
• 20446 Views
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This week, Alpesh Amin, author (with Steven Deitelzweig) of “Optimizing the Prevention of Venous Thromboembolism: Recent Quality Initiatives and Strategies to Drive Improvement,” which published in the November 2009 issue, guests on the blog. In the article, they review the quality indicators, public reporting initiatives, incentive programs, and “negative rei... more >>

Hand Hygiene Leads to More Preventive Efforts

• 10/16/2009
• Author: Steven Berman
• 20754 Views
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This week, Mark Bittle, lead author of "Engaging the Patient as Observer to Promote Hand Hygiene Compliance in Ambulatory Care,” which appeared in the October 2009 issue, guests on the blog .In the article, Dr. Bittle and Suzanne LaMarche describe how involving the patient is a simple and cost-effective way to monitor hand hygiene in the ambulatory setting. In this blog, Dr... more >>

Coaching Physicians Involved in Disclosure Cases

• 10/9/2009
• Author: Steven Berman
• 20960 Views
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 This week, Randy Peto, lead author of "One System’s Journey in Creating a Disclosure and Apology Program,” which appeared in the October 2009 issue, guests on the blog. In the article, Dr. Peto and his colleagues describe the disclosure and apology program at the four-hospital Baystate Health system. In this blog, Dr. Peto discusses his experience, which occurred while the artic... more >>

Why Policy Should Not Precede the Science: The Case of Briefings and Debriefings

• 10/1/2009
• Author: Steven Berman
• 21655 Views
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This week, Sean Berenholtz, the lead author of “Implementing Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center,” which appeared in the July 2009 issue, guests on the Journal blog. Briefings and debriefings involve a discussion among all members of the surgical team before incision and then before leaving the OR. Drawing on 37,113 briefings a... more >>

Issues and Trends in Rapid Response Systems

• 9/29/2009
• Author: Steven Berman
• 22288 Views
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The Journal has been running articles in Rapid Response Systems: The Stories, since this department premiered in July 2006. As Michael DeVita, the chief editor of the series then remarked (see article, attached), we launched the series “to provide a resource to those who are just getting started or are interested in advancing their programs already underway.” I encourage you, as he did t... more >>

How to Sustain the New Practice–and Continuous Quality Improvement—After the Initial Success?

• 9/17/2009
• Author: Steven Berman
• 21830 Views
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This week, John Q. Young, author (with Robert M. Wachter) of “Applying Toyota Production System Principles to a Psychiatric Hospital: Making Transfers Safer and More Timely,” which appeared in the September 2009 issue, guests on the blog. As you may remember, they described how Langley Porter Psychiatric Hospital and Clinics at the University of California San Francis... more >>

The Joint Commission Launches its Center for Transforming Healthcare

• 9/10/2009
• Author: Steven Berman
• 22307 Views
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Today, at the National Press Club in Washington, D.C., The Joint Commission announced its Center for Transforming Healthcare. In a letter sent to more than 16,000 accredited health care organizations or programs across the United States, Mark R. Chassin, M.D., M.P.P., M.P.H., President of The Joint Commission, stated, “The Center is developing solutions by using the same Robust Process Improve... more >>

Using an Electronic Medical Record for Continuity of Care

• 8/13/2009
• Author: Steven Berman
• 25355 Views
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This week, Allen Hsiao, the lead author of  “Dropping the Baton During the Handoff from ED to Primary Care: Pediatric Asthma Continuity Errors,” which appears in the September 2009 issue, guests on the Journal blog. As part of the AHRQ-sponsored “Electronic Records to Improve Care for Children” (ERICCA) project, the authors examined the handoff of care for asthmatic children betw... more >>

What Does the U.S. House Bill Say About Hospital Complications and Payment?

• 7/23/2009
• Author: Steven Berman
• 24441 Views
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This week, Richard Averill, the lead author of Forum, “Hospital Complications: Linking Payment Reduction to Preventability,” which appeared in the May 2009 issue, guests on the Journal blog. As you’ll recall, in the article, Mr. Averill and his colleagues proposed that the Center for Medicare & Medicaid Services (CMS) policy of denying payment for certain in-hospital complica... more >>

More on Implementing E-Surveys (a Practical Enhancement to Tracer Methodology)

• 7/17/2009
• Author: Steven Berman
• 24673 Views
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This week, Frederick North, the lead author of  a Tool Tutorial, “E-Surveys as a Practical Enhancement to Tracer Methodology for Continuous Joint Commission Accreditation Readiness, “which appears in the August 2009 issue, guests on the Journal blog. In the article’s conclusion, the authors stated, “We now have regular interdisciplinary group meetings with physician, nursing, secretarial... more >>

On Developing and Adapting Tools

• 7/10/2009
• Author: Steven Berman
• 24301 Views
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Quality and patient safety professionals and clinicians need to have useful and efficient tools at their disposal to collect data to identify opportunities for improvement and to then address them. In an article in the October 2008 issue of the Journal, “Developing Process-Support Tools for Patient Safety: Finding the Balance Between Validity and Feasibility,” Jill Marsteller and her coauthors... more >>

Thinking about Patient Safety for Chronically Ill Outpatients

• 7/2/2009
• Author: Steven Berman
• 24921 Views
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  This week, Urmimala Sarkar, the lead author of “Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care,” which appears in the July 2009 issue, guests on the Journal blog. She reflects on the origins of the article and on the need to engage patients, especially the large population of patients with chronic conditions, in improving safety. D... more >>

On Planning Improvement Projects as if Publishing

• 6/22/2009
• Author: Steven Berman
• 25528 Views
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In my recent blog regarding the new Joint Commission Resources book, A Guide to The Joint Commission's Medication Management Standards, Second Edition. I noted Brigham and Women's Hospital (Boston)'s efforts to improve medication safety. I recently had the opportunity to chat with the hospital's executive director of pharmacy, Bill Churchill, who took the lead with his team in writing the chap... more >>

A Guide to Medication Management Standards

• 6/15/2009
• Author: Steven Berman
• 28388 Views
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We at Joint Commission Resources have just published A Guide to The Joint Commission’s Medication Management Standards, Second Edition. In developing the book, I asked a number of hospitals and other health care organizations to describe medication management practices that they improved to address The Joint Commission standards. I vetted the topics to ensure that they would provide educationa... more >>

Antibiotic Resistance

• 6/9/2009
• Author: Steven Berman
• 26178 Views
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Have you heard about the Joint Commission Resources audioconference scheduled for June 12, 2 p.m. C.S. T., on Reducing Antibiotic Resistance and Multidrug-Resistant Organisms? Hospital executives and their leadership teams are invited to learn more about the clinical and financial cost of antibiotic resistance and effective prevention and control techniques. (Registration can be conducted at http:... more >>

Guest Blog: Laura Damshroder

• 4/30/2009
• Author: Steven Berman
• 29932 Views
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Frequently, I will be asking authors of articles published in The Joint Commission Journal on Quality and Patient Safety to “guest” on the blog to provide “the story behind the story.” Laura Damshroder, one of the authors of “How Active Resisters and Organizational Constipators Aff... more >>

An Introduction

• 4/21/2009
• Author: Steven Berman
• 28586 Views
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Greetings! I’m Steven Berman. For 20 years, I’ve had the privilege to not only witness but also participate in the tremendous growth of the field of quality and patient safety in health care. When I first started, the Joint Commission—in fact it was still the Joint Commission on Accreditation of Hospitals—journal was called Quality Review Bulletin. Later, we called it o... more >>