VHA's role is to gather and share data and also provide an ongoing forum for members to share experiences. "Hospitals have always had to deal with risk management," says Sweeney. "But that's like playing 'Whack-a-Mole' – you're tackling issues as they come up. Think of it as always putting out forest fires instead of practicing fire prevention."

Maximizing the power of technology and people
Sharing the experiences of more than 200 hospitals that are seeking to create the core operating principles behind Target Zero is Craig Clapper, founding member and chief knowledge officer of Healthcare Performance Improvement. This group brings not only new ways to create profound cultural change within health care organizations but also extensive experience with High Reliability Organizations such as nuclear power plants and airlines where even one mistake can be one too many.

"One of the basic problems that must be addressed – and can be key to creating the sort of change needed to improve outcomes in hospitals and achieve alignment with the new health care mandates – is to better understand the relationships and differing roles between people and technology," says Clapper. "Technology is a wonderful thing; barcode scanning, for example, saves tremendous time and helps ensure we're using the right medicines and doing the right procedures at the right time."

Technology does help solve problems. "We fix a flaw within a system and that element is solved," he says, emphasizing that the human element must also change. "People are the part of the equation who care, who can use critical thinking skills and solve a problem before it happens," says Clapper.

Some current estimates have the number of accidental deaths each year in U.S. hospitals hovering just below 100,000, a number that can, should and must fall rapidly. Already, some health care organizations are seeing 50% to even 80% improvements just from focusing on a changed-behavior approach.

Take a deep dive on pain management   As part of the West Coast Region's Pain Well-Managed Collaborative, the group began by making maximum use of the wealth of knowledge already in the hands, heads and hearts of VHA affiliates such as the Florida-based Baptist Leadership Group. During the two-day kickoff workshop, Katie Owens, director of performance improvement and research, and April Fairey, nurse consultant, delivered an in-depth overview of lessons learned that provided optimum HCAHPS strategies. Titled "Impacting Performance by Leveraging Data, Tactics and Behaviors," the presentation combined a high-level review with practical deep-dive experience to show how the Group created a customized pain management plan ideally suited to its unique needs. Beginning with the basic background and purpose of HCAHPS and its fast-growing impact on hospital systems nationwide, the four-hour program addressed topics ranging from best practice sharing and coaching on tools and tactics to creating a learning experience adapted to each organization's needs and effectively communicating goals and results.