the system supported the workers; glove consumption and costs dropped 15 percent as “stashes” disappeared. The unit believes it has already gained ground on the Centers for Disease Control and Prevention’s goal of improved compliance as hand hygiene compliance has risen.32

Special thanks to the following individuals for their advice and comments on this project: Judene Bartley, Paul Batalden, Donald Berwick, David Blumenthal, Mark Brulin, Mark Chassin, Richard Croteau, Edward Dunn, Karen Feinstein, Robert Galvin, Doris Hanna, Brent James, Molly Joel Coye, Lucian Leape, Tammy Lundstrom, Thomas Massero, Julie Mohr, Thomas Nolan, Elisabeth Paté-Cornell, Paul Schyve, Ethel Seljevold, Kimberly Thompson, Mark Van Kooy, Cindy Wallace, and Jonathan Wilwerding.


1. Committee on Quality of Health Care in America. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. Pp. 41–42.

2. For a discussion of HFMEA/FMEA and HACCP, see McDonough J. 2002. Proactive Hazard Analysis and Health Care Policy. New York: Milbank Fund and ECRI.

3. Nolan T. 1996. The Improvement Guide. New York: Jossey Bass.

4. Blumenthal D, Kilo C. 1998. A report card on Continuous Quality Improvement. Milbank Quarterly 76(4): 625–648.

5. See [accessed March 27, 2003].

6. Welch J. 2001. Jack: Straight from the Gut. New York: Warner Business Books.

7. Chassin M. 1998. Is health care ready for Six Sigma quality? Milbank Quarterly 76(4):565–591.

8. Military Procedure MIL-P-1629. 1949 (November 9). Procedures for Performing a Failure Mode, Effects and Criticality Analysis.

9. Marx, D, Slonim A. 2003. Assessing Patient Safety Risk Before the Injury Occurs: An Introduction to Socio-Technical Probabilistic Risk Modeling in Healthcare. Qual Saf Health Care 12(Suppl2):ii33–ii38.

10. Green L, Crouch E. 1997. Probabilistic risk assessment: Lessons from four case studies. Annals of the New York Academy of Sciences 837:387–396.

11. Op. cit., p. 10.

12. See McDonough, op. cit., for detailed references.

13. Personal communication, Dr. Mark Van Kooy, M.D., Virtua Health Master Black Belt, March 26, 2003.

14. Ackoff R. 1994. The Democratic Corporation. New York: Oxford University Press. Pp. 18–21.

15. Batalden PB, Mohr JJ. 1997. Building knowledge of health care as a system. Quality Management in Health Care 5(3):1–12.

16. Personal Communication, Dr. Brent James, March 3, 2003.

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