2026 Impact - T54 - One Team, 1 Approach: Scaling PSI Reduction Across 11 Hospitals - On Demand
In fiscal year 2023, only two of Memorial Hermann's 11 hospitals ranked in the top decile of the Vizient Quality and Accountability (Q&A) ranking, with three falling below the 50th percentile. Memorial Hermann restructured quality governance, forming four management guidance teams (MGTs) aligned to Vizient domains. The Patient Safety Indicator (PSI) MGT, led by quad leadership with Master Black Belt support, applied a systems-thinking methodology, benchmarked best practices already succeeding at individual facilities, validated effectiveness with analytics, developed standardized tool kits adaptable to facility differences, and coordinated systemwide deployment. Results include a 37.5% Vizient PSI composite observed-to-expected improvement and eight hospitals in the Vizient Q&A top quartile — including three in the top decile and zero below the 50th percentile.
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 how a systems-thinking governance model with quad leadership can accelerate quality improvement across a multihospital health system.
• Discuss the benchmark, validate, standardize, adapt, coordinate, scale methodology to identify best practices, developing adaptable tool kits and achieving full systemwide deployment within one fiscal year.
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
Tiffany Potter, DNP, RN, CPHQ, CLSSBB, Associate Vice President, System Quality, Safety, and Clinical Effectiveness, Memorial Hermann Health System, Houston, TX
Mary Carrillo, MSN, MBA, RN, NE-BC, FABC, Vice President, Chief Nursing Officer, Memorial Hermann Southeast Hospital, Houston, TX
Bela Patel, MD, Regional CMO, Memorial Hermann Health System, Houston, TX
Maria Milo, Lean Six Sigma Master Black Belt, Memorial Hermann - Memorial City Hospital, Houston, TX
Lance Ferguson, Vice President, Operations, Memorial Hermann-Texas Medical Center, Houston, TX

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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