• Implement a plan that includes fundamentals of change outlined in the National Quality Forum safe practices, including awareness, accountability, and action.
  • Hospital governance and senior administrative and medical and nursing leadership commit to become aware of this major performance gap in their own healthcare system.
  • Hospital governance, senior administrative leadership, and clinical/safety leadership close their own performance gap by implementing a comprehensive approach to addressing the performance gap
  • Set a goal date to implement the plan to address the gap with measurable quality indicators.
  • Allocate a budget for the plan to be evaluated by governance boards and senior administrative leaders.
  • Clinical/safety leadership endorse the plan and drive implementation across all providers and systems.
  • Conduct data collection and analysis to be used for implementation and assessment of outcomes.