Journal of General Internal Medicine

, Volume 30, Issue 4, pp 425–433 | Cite as

The TRANSFORM Patient Safety Project: A Microsystem Approach to Improving Outcomes on Inpatient Units

  • Clarence H. BraddockIIIEmail author
  • Nancy Szaflarski
  • Lynn Forsey
  • Lynn Abel
  • Tina Hernandez-Boussard
  • John Morton
Original Research



Improvements in hospital patient safety have been made, but innovative approaches are needed to accelerate progress. Evidence is emerging that microsystem approaches to quality and safety improvement in hospital care are effective.


We aimed to evaluate the effects of a multifaceted, microsystem-level patient safety program on clinical outcomes and safety culture on inpatient units.


A 1-year prospective interventional study was conducted, followed by a 6-month sustainability phase.


Four medical and surgical inpatient units within an academic university medical center were included, with registered nurses and residents representing study participants.


In situ simulation training; debriefing of medical emergencies; monthly patient safety team meetings; patient safety champion role; interdisciplinary patient safety conferences; recognition program for exemplary teamwork.


Hospital-acquired severe sepsis/septic shock and acute respiratory failure; unplanned transfers to higher level of care (HLOC); weighted risk-adjusted mortality. Safety culture was measured using a widely accepted, validated survey.


Rates of hospital-acquired severe sepsis/septic shock and acute respiratory failure decreased on study units, from 1.78 to 0.64 (p = 0.04) and 2.44 to 0.43 per 1,000 unit discharges (p = 0.03), respectively. The mean number of days between cases of severe sepsis/septic shock increased from baseline to the intervention period (p = 0.03). Unplanned transfers to HLOC increased from 715 to 764 per 1,000 unit transfers (p = 0.08). The weighted risk-adjusted observed-to-expected mortality ratio on all study units decreased from 0.50 to 0.40 (p < 0.001). Overall scores of safety culture on study units improved after the 1-year intervention, significantly for nurses (p < 0.001), but not for residents (p = 0.06). Scores significantly improved in nine of twelve survey dimensions for nurses, compared to in four dimensions for residents.


A multifaceted patient safety program suggested an association with improved hospital-acquired complications and weighted, risk-adjusted mortality, and improved nurses’ perceptions of safety culture on inpatient study units.


patient safety clinical microsystem safety culture teamwork simulation training 



We wish to acknowledge the senior leadership of Stanford Hospital & Clinics for their guidance and support: Kevin Tabb, MD, Former Chief Medical Officer; Kim Pardini-Kiely, RN, MS, Former Vice President, Quality and Effectiveness; and Nancy Lee, RN, MSN, Chief Nursing Officer, Vice President, Patient Care Services. We thank our unit-based medical directors (Benny Gavi, MD; Lisa Shieh, MD, PhD; Randall Vagelos, MD; Mark Welton, MD), clinical nurse specialists (Molly Kuzman, RN, MSN; Annette Haynes, RN, MS; Christine Thompson, RN, MS), unit managers (Rudy Arthofer, RN, MHA; Theresa Cotter, RN, BS; Cindy Deporte, RN, MSN; Myra Lang RN, MS), Jeffrey Chi, MD, John Kugler, MD and Mari Campbell, RN and Olga Grujic for their sustained commitment to this patient safety program. This research was supported by the Gordon and Betty Moore Foundation.

Conflict of Interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Institute of Medicine. To Err is human: building a safer health system. Washington, DC: National Academy Press, 1999.Google Scholar
  2. 2.
    Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124–34.CrossRefPubMedGoogle Scholar
  3. 3.
    Birkmeyer NJ, Finks JF, Greenberg CK, et al. Safety culture and complications after bariatric surgery. Ann Surg. 2013 ;257:260–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Buist M, Jarmolowski E, Burton P, et al. Recognizing clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary care hospital. Med J Aust 1999;171:22–25.PubMedGoogle Scholar
  5. 5.
    Downey, AW, Quach JL, Haase M, et al. Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias. Crit Care Med 2008;36:477–481.CrossRefPubMedGoogle Scholar
  6. 6.
    Shearer B, Marshall S, Buist MD, et al. What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service. BMJ Qual Saf 2012;21:569–75.CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Peebles E, Subbe CP, Hughes P, et al. Timing and teamwork—An observational pilot study of patients referred to a Rapid Response Team with the aim of identifying factors amenable to re-design of a Rapid Response System. Resuscitation 2012;83:782–87.CrossRefPubMedGoogle Scholar
  8. 8.
    Huang DT, Clermont G, Sexton JB, et al. Perceptions of safety culture vary across in the intensive care units of a single institution. Crit Care Med 2007;35:165–76.CrossRefPubMedGoogle Scholar
  9. 9.
    Campbell EG, Singer S, Kitch BT, et al. Patient safety climate in hospitals: act locally on variation across units. Jt Comm J Qual Patient Saf. 2010 ;36:319–26.PubMedGoogle Scholar
  10. 10.
    Singer SJ, Gaba DM, Falwell A, et al. Patient safety climate in 92 US hospitals: differences by work areas and discipline. Med Care 2009;47:23–31.CrossRefPubMedGoogle Scholar
  11. 11.
    Weaver SJ, Lubomksi, LH, Wilson RF, et al. Promoting a culture of safety as a patient safety strategy. Ann Intern Med 2013;158:369–374.CrossRefPubMedGoogle Scholar
  12. 12.
    Mohr JJ, Batalden PB. Improving safety on the front lines: the role of clinical microsystems. Qual Saf Health Care 2002;11:45–50.CrossRefPubMedGoogle Scholar
  13. 13.
    Mohr JJ, Balalden P, Barach P. Integrating patient safety into the clinical microsytem. Qual Saf Health Care 2004;13(Suppl II):ii34-ii38.PubMedCentralPubMedGoogle Scholar
  14. 14.
    Pardini-Kiely K, Greenlee E, Hopkins J, et al. Improving and sustaining core measure performance through effective accountability of clinical microsystems in an academic medical center. Jt Comm J Qual Patient Saf 2010;36:387–98.PubMedGoogle Scholar
  15. 15.
    Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005;1:33–40.CrossRefGoogle Scholar
  16. 16.
    Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732.CrossRefPubMedGoogle Scholar
  17. 17.
    Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010;340:c309. doi: 10.1136/bmj.c309.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Blegen MA, Sehgal NL, Alldredge BK, et al. Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project. Qual Saf Health Care 2010;19:346–350.CrossRefPubMedGoogle Scholar
  19. 19.
    Godfrey MM, Melin CN, Muething SE, et al. Clinical Microsystems, Part 3. Transformation of two hospitals using microsystem, mesosystem and macrosystem strategies. Jt Comm J Qual Patient Saf 2008;34:591–603.PubMedGoogle Scholar
  20. 20.
    Mitchell IA, McKay H, Van Leuvan C, et al. A prospective controlled trial of the effect of a multifaceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation. 2010;81:658–66.CrossRefPubMedGoogle Scholar
  21. 21.
    Rosen MA, Hunt EA, Pronovost PJ, et al. In situ simulation in continuing education for the health care professions: A systematic review. J Contin Educ Health Prof 2012;32:243–54.CrossRefPubMedGoogle Scholar
  22. 22.
    Riley W, Davis S, Miller K, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm J Qual Patient Saf 2011;37:357–364.PubMedGoogle Scholar
  23. 23.
    Steineman S, Berg B, Skinner A, et al. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ 2011;68:472–477.CrossRefGoogle Scholar
  24. 24.
    Miller D, Crandall C, Washington C, et al. Improving teamwork and communication in trauma care through in situ simulations. Acad Emerg Med 2012;19:608–612.CrossRefPubMedGoogle Scholar
  25. 25.
    Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296–327.CrossRefPubMedGoogle Scholar
  26. 26.
    Southern DA, Quan H, Ghali WA. Comparison of the Elixhauser and Charlson/Deyo methods of comorbidity measurement in administrative data. Med Care 2004;42:355–360.CrossRefPubMedGoogle Scholar
  27. 27.
    Li B, Evans D, Faris P, Dean S, Quan H. Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases. Health Serv Res 2008;8:12.CrossRefGoogle Scholar
  28. 28.
    Safety Culture. (last accessed August 18, 2014).Google Scholar
  29. 29.
    Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med 2011;39:934–939.CrossRefPubMedGoogle Scholar
  30. 30.
    Timmel J, Kent PS, Holzmueller CG, et al. Impact of a comprehensive unit-based safety program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36:252–260.PubMedGoogle Scholar
  31. 31.
    Krimsky WS, Mroz B, McIllwaine JK, et al. A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. Qual Saf Health Care 2009;18:74–80.CrossRefPubMedGoogle Scholar
  32. 32.
    Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics 2013;131:e298-308.CrossRefPubMedGoogle Scholar
  33. 33.
    Huang DT, Clermont G, Kong L, et al. Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care 2010;22:151–61.CrossRefPubMedCentralPubMedGoogle Scholar
  34. 34.
    Singer S, Lin S, Falwell A, et al. Relationship of safety climate and safety performance in hospitals. Health Serv Res 2009;44:399–421.CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg 2007;205:778–84.CrossRefPubMedGoogle Scholar
  36. 36.
    Cevasco M, Borzecki AM, Chen Q, et al. Positive predictive value of the AHRQ patient safety indicator “Postoperative Sepsis”: Implications for practice and policy. J Am Coll Surg 2011;212:954–961.CrossRefPubMedGoogle Scholar
  37. 37.
    Utter GH, Cuny J, Strater A, et al. Variation in academic medical centers’ coding practices for postoperative respiratory complications: Implications for the AHRQ postoperative respiratory failure patient safety indicator. Medical Care 2012;50:792–800.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Clarence H. BraddockIII
    • 1
    Email author
  • Nancy Szaflarski
    • 2
  • Lynn Forsey
    • 3
  • Lynn Abel
    • 4
  • Tina Hernandez-Boussard
    • 5
  • John Morton
    • 5
  1. 1.Department of MedicineDavid Geffen School of Medicine University of CaliforniaLos AngelesUSA
  2. 2.Quality & Effectiveness DepartmentStanford Health CareStanfordUSA
  3. 3.Department of NursingMills-Peninsula Health ServicesBurlingameUSA
  4. 4.Patient Care ServicesStanford Health CareStanfordUSA
  5. 5.Department of SurgeryStanford University School of MedicineStanfordUSA

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