2026 Impact - T42 - Beyond the OR: A Systemwide Approach to Procedural Safety - On Demand
In 2025, Stanford Health Care and the Stanford School of Medicine partnered to close a critical gap in procedural safety across the full continuum of procedural care, including both the operating room (OR) and non-OR settings. Policies, workflows and behaviors were fragmented and inconsistently applied across the OR, emergency department, ambulatory clinics and inpatient units, creating variation in how universal protocol (UP) was interpreted and executed. With strong physician and board sponsorship, a multidisciplinary team redesigned procedural safety end to end, aligning policy language, practical standard work and education, and enabling technology so UP expectations are clear, usable and consistently applied wherever procedures occur. The initiative produced statistically and clinically meaningful improvements, including reductions in procedure-related serious safety events and sustained gains in procedural safety compliance, demonstrating safer care regardless of setting.
Target Audience
- Dietitians
- Healthcare Quality Professionals
- Nurses
- Pharmacists
- Pharmacy Technicians
- Physicians
- Physician Associates
- Other Healthcare Professionals
Learning Objectives
At the conclusion of this activity, participants should be able to:
• Describe standardized time-out behaviors for independently performed procedures using defined pause cues and role expectations.
• Discuss using coaching-audit feedback to improve compliance with universal protocol and postprocedure debrief expectations across care settings.
Course summary
- 0.50 AAPA CMEVizient Inc. has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria.
- 0.50 ACPE Pharmacist
- 0.50 ACPE Pharmacy Technician
- 0.50 AMA PRA Category 1 Credit™
- 0.50 ANCC
- 0.50 CDR
- 0.50 CPHQ – Certified Professional Healthcare Quality
- 0.50 General CE - Attendance
- 0.05 IACET
Hurley W. Smith, MS, Director, Performance Improvement, Stanford Health Care, Palo Alto, CA
Ashley Peterson, MD, Associate Chief Quality Officer, Stanford Health Care, Palo Alto, CA

Interprofessional Continuing Education (IPCE)
Physician Associates (AAPA)
Vizient, Inc. is Jointly Accredited by the Joint Accreditation for Interprofessional Continuing Education and has been approved to offer Continuing Education Units (CEUs). CEUs are awarded for learning events that align with the ANSI/IACET Standard for Continuing Education and Training. IACET is recognized internationally as a standards development organization and accrediting body that promotes quality continuing education and training. Available Credit
- 0.50 AAPA CMEVizient Inc. has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria.
- 0.50 ACPE Pharmacist
- 0.50 ACPE Pharmacy Technician
- 0.50 AMA PRA Category 1 Credit™
- 0.50 ANCC
- 0.50 CDR
- 0.50 CPHQ – Certified Professional Healthcare Quality
- 0.50 General CE - Attendance
- 0.05 IACET
- If the Register/Take Course tab is displayed instead of the Obtain Credit tab, you must first login to proceed with the credit claim process.
Required Hardware/software
The Vizient CE Learner Portal is compatible with most modern web browsers (such as Firefox, Google Chrome, Microsoft Edge, Apple Safari) and can also be accessed with mobile devices.

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