Skip to main content

NIH Clinical Center Patient Safety and Clinical Quality Improvements 2016-2017

Through the hard work of clinical leadership and staff at the NIH Clinical Center and NIH Institutes and Centers, we have made significant advancements to foster and support the highest quality of patient safety and research support. While not a comprehensive list, the following provides key improvements made in 2016-2017. Toward our continuous improvement effort, additional improvements in all of these areas are planned or underway and will be added as they are completed. These improvements bolster the NIH Clinical Center's extensive activities in patient safety and clinical quality.

Leadership Structure and Reporting Relationships

  • Established a new hospital board with Dr. Laura Forese, Executive Vice President and Chief Operating Officer of New York-Presbyterian, as Chair
  • Hired its first ever CEO, Dr. James Gilman, with a mandate to guide performance and to focus on setting a high bar for patient safety and quality of care
  • Realigned the Clinical Center leadership structure
  • Clinical Directors now report directly to their Institute and Center Directors
  • Hired new Chief of Pharmacy

Patient Safety and Quality of Care Improvements

  • Daily patient safety huddle
  • Executive Walk-Rounds
  • Systems-based Morbidity and Mortality Rounds open to all NIH Clinical Center staff
  • Using Failure Mode and Effects Analysis to identify patient safety and clinical research risks prospectively
  • Patient falls improvement initiative
  • ENT Surgery program enhancements
  • Renovation of MRI facilities
  • Newly hired medical oncology service hospitalists
  • Bolstered staffing in the Clinical Center pharmacy with 44 new hires

Staff Engagement

  • Established the Clinical Center Engagement Working Group, and held several town hall-style meetings and ~70 focus group sessions with ~620 staff
  • Established a new Patient Safety, Clinical Practice and Quality Committee that includes front-line Licensed Independent Practitioners and patient care staff, and reports to the Clinical Center CEO and the Medical Executive Committee

Compliance and Reporting

  • Created the Office of Research Support and Compliance to ensure that research conducted across all NIH Institutes and Centers, whether in or outside of the Clinical Center, adheres to the highest regulatory, professional, and ethical standards
  • Posted patient safety/quality PDF Icon and employee safety metrics PDF Icon on the Clinical Center website
  • Replaced the Occurrence Reporting System with the Safety Tracking and Event Reporting System
  • All aseptic facilities producing sterile products used in Clinical Center protocols now adhere to USP standards
  • Initiated an independent Quality Improvement Assessment to identify possible systemic challenges, assess compliance, and identify improvement strategies
  • Retrained all NIH intramural researchers and research staff to ensure full awareness and compliance with event reporting requirements
  • Added training on developing a culture for high reliability
  • Deployed an anonymous Hotline for concerns regarding safety issues


  • Constructed an interim intravenous admixture unit (I-IVAU), which opened in April 2017 and meets strict USP 797 industry standards
  • Renovated the Clinical Center PET Radiopharmacy to serve all NIH's clinical research needs
  • Improved the facilities, equipment, and standard operating procedures for the NCI Surgery Branch Cell Processing Laboratory, which reopened in June 2016
  • Purchased two modular GMP manufacturing facilities (Trailer 1: operational in late 2017; Trailer 2: operational in early 2018)
  • Repaired the NCI Division of Cancer Treatment and Diagnosis/Biopharmaceutical Development Program (completed March 2017) and the Leidos Radiopharmacy (completed August 2016)

NOTE: PDF documents require the free Adobe Reader.

This page last updated on 07/19/2018

You are now leaving the NIH Clinical Center website.

This external link is provided for your convenience to offer additional information. The NIH Clinical Center is not responsible for the availability, content or accuracy of this external site.

The NIH Clinical Center does not endorse, authorize or guarantee the sponsors, information, products or services described or offered at this external site. You will be subject to the destination site’s privacy policy if you follow this link.

More information about the NIH Clinical Center Privacy and Disclaimer policy is available at