Fostering a culture that empowers staff to speak up when concerned about the quality or safety of patient care is both an ethically1 and economically2 responsible endeavor. The Michigan Health & Hospital Association (MHA) Keystone Center has implemented the Speak-Up! Award program that acknowledges frontline health care staff for voicing their concerns and making care safer. The objective of this effort was to advance patient safety in Keystone Center member organizations through widespread, measurable culture improvement. After extensive data collection and analysis, there was a discernable improvement in culture survey results across a 2-year period coinciding with the launch and sustainment of the award program. Furthermore, in an effort to demonstrate the power of speaking up among staff, the Keystone Center applied a cost-savings framework to the types of harm avoided. Results from the cost-savings analysis suggest that each instance of speaking up by staff saves patients, families, and health care organizations an average of more than $13,000. Keystone Center Speak-Up! Award nominations were submitted through an electronic form that collects open, closed, and Likert-type question responses, producing a data array on type and severity of harm prevented, as well as the difficulty and magnitude of the decision to speak up. All data were then coded by harm type and subsequently applied to a tailored version of the cost-savings estimation framework used in the Great Lakes Partnership for Patients Hospital Improvement and Innovation Network. Safety culture was measured through the use of a survey instrument called the Safety, Communication, Operational Reliability, and Engagement (SCORE) instrument. The Keystone Center Speak-Up! Award program received 416 nominations across the 2-year study period, of which 62% (n = 258) were coded as a specific harm type. Adverse drug events (n = 153), imaging errors (n = 42), and specimen errors (n = 27) were the most common harm types prevented by speaking up. After applying the cost-savings framework to these data, it is estimated that for every instance of speaking up, approximately $13,000 in total expenses were avoided, which is in line with the findings from a report on the economic impact of medical errors sponsored by the Society of Actuaries.3 Furthermore, culture survey results improved by 6% between 2015 and 2017, coinciding with the Keystone Center Speak-Up! Award program. The Keystone Center Speak-Up! Award has proven to be a valuable tool in recognizing staff awareness and willingness to raise concerns about quality and safety in health care. Data analysis from this program presents evidence that fostering a psychologically safe culture of speaking up yields fiscal and humanistic returns, both of which are crucial to sustainable, meaningful progress in safety and quality. However, further research is required to adequately gauge the degree to which safety culture improvement is proportional to cost savings.

This article describes the interventions that sustained low central line-associated bloodstream infection (CLABSI) rates in the Michigan Keystone ICU Project. This analysis included data from March 2004 to December 2013 for 121 intensive care units (ICUs) in 73 hospitals. The Keystone Project was a cohort collaborative with an improvement team in each ICU. During the sustainability period, teams integrated the intervention into staff orientation, collected and submitted monthly data, and reported infection rates to leaders. The annual mean rate of BSIs dropped from 2.5 infections/1000 catheter-days in 2004 to 0.76 in 2013. A subset analysis found nearly double the percentage of ICUs with a mean rate of <1 infection/1000 catheter-days in 2013 compared with baseline. Active involvement of hospital leaders and the Keystone Center as well as ongoing monitoring and feedback of performance were important in sustaining results. These findings suggest that large-scale improvement projects can be sustained, establishing a new normal for care.

On our current trajectory, severe disruptions to national and regional food systems are highly likely to happen - the main question is when. This report, commissioned by the UN DESA as a strategic input to SD21 and the Rio discussions, focuses on vital areas and offers a collection of up to date information on the current and likely trends for our global Food and Agriculture systems.With contributions from more than 70 global agri-food leaders in the business, policy, green, and social arenas, the report exposes unforeseen areas of consensus. By opening the silos of partisan thinking to invite reasoned discussion, it also exposes areas of disagreement and lays out a key set of specific high impact areas where smart decisions will make the most difference for sustainable and resilient food and agriculture systems.

AbstractThe La Plata River Basin in South America, whose waters are shared by Argentina, Bolivia, Brazil, Paraguay and Uruguay, provides important lessons from the long history of negotiations over its shared water and other natural resources. In particular, innovative resource management practices developed over time have led to the relative harmony in which the riparian countries coexist. In this article, we analyze negotiation techniques within the La Plata River Basin by examining in detail the processes leading to the two seminal agreements – the 1969 Treaty of La Plata Basin and the 1979 Itaipú-Corpus Agreement. Based upon our analysis of the complex and often contradictory relationships between the riparian states, we evaluate the outcomes of both treaties from the standpoint of cooperation in the region and sustainable development. In doing so, we extend the relevance of the analysis to other basins with similar issues of regional management. The article extends the basin cooperation, through negotiation, to include trade agreements and development via project partnerships that draw in regional and global actors, including non-governmental organizations, environmental lobbies in foreign countries, and multinational development banks. The above actors are relevant for many parts of the world in today's era of globalization.

The purposes of this research were to determine (a) the longitudinal effects of parent involvement on tenth grade students’ learning, as measured by their grade point average, (b) whether the same pattern of influences exist for boys and girls, and (c) whether the same pattern of influences exist for students from different ethnic groups. A series of structural equation models were derived from theory and previous research and were tested on a national sample of students. Results suggest that parent involvement has a large and significant effect on students’ grade point average in tenth grade. The pattern of influences of the variables in the model were indistinguishable for boys and girls, suggesting that the same model of influences holds across gender. There were differences in the constructs in the model and in their effects across ethnic groups, however. Nevertheless, parent involvement continued to have important effects for all groups. Thus interventions designed to increase involvement, if successful, should result in increases in learning for all groups.