NIH Clinical Center Patient Safety and Clinical Quality Improvements

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 recent years. 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.


  • 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
  • Established Surgeon in Chief role

Patient Safety and Quality of Care Improvements

  • Launched new patient safety event reporting system = Safety Tracking and Reporting System (STARS)
  • 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
  • Posted patient safety/quality and employee safety metrics on the Clinical Center website
  • Implemented the Urgent Transport process
  • Established Off-Hours Triage protocol
  • Developed a Massive Transfusion protocol
  • Established the Pediatric Anesthesiology Critical Care Unit
  • Charged the ICU Trigger Team to review unplanned admissions to the ICU
  • Launched the SuperSTARS program to recognize high quality service and good catches
  • Added training on developing a culture for high reliability

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
  • Published Patient Safety newsletter in collaboration with the Deputy Director for Intramural Research
  • Launched CEO Town Hall meetings
  • Established SuperSTARS awards to recognize high quality service and “good catches”


  • 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
  • All aseptic facilities producing sterile products used in Clinical Center protocols now adhere to U.S. Pharmacopeia (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
  • Deployed an anonymous Hotline for concerns regarding safety issues
  • Established a “sterility lab” in the Department of Laboratory Medicine

Patient Experience

  • Established a Hospice Unit


  • 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 became operational in late 2017; Trailer 2 became operational in early 2018)
  • Repaired the NCI Division of Cancer Treatment and Diagnosis/Biopharmaceutical Development Program and the Leidos Radiopharmacy

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This page last updated on 06/24/2019

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