Learning from Every Patient
A Newsletter for Frontline Healthcare Team Members and Quality Improvement Professionals
Real cases. Practical improvements. Stronger voices at the bedside.
From HB Healthcare Safety® and Influence Ignited!
Edited by Jeanne M. Huddleston, MD, MS
Q1 2026 Trivia Question Winner is....
We do a random drawing on the first day of each quarter. Prize: $100 gift card. How do you get your name in that perverbial hat? There is a trivia question in each newsletter. Respond to the email with your response. Right or wrong, your name is added to the list of readers eligible for the drawing.
Thank you to everyone who submitted a response to the trivia questions. Congratulations to Tracy M. Abrams, DNP, MSN, RN, Chief Nursing Officer, Kaiser Permanente San Diego! And the answers to the questions were:
Dr Manning's word creation for not enough palliative care = palliopenia
Name of the week for that release = National Patient Safety Awareness Week
The HB in HB Healthcare Safety = Honey Badger
This was a short quarter for submissions since it was a new idea. The next drawing will be on Wednesday, July 1. First opportunity to respond to a trivia question is below!
Is Mortality Review Dead? Not Quite...
Summary from last week's Newsletter
BLUF: Mortality review is NOT dead. But it certainly fails to meet its intended goals when the review process is not tightly integrated within a learning system.
Mortality review is dead when case reviews are performed in isolation. While mortality review may be a stated component of a quality strategy, yet seemingly disconnected from everything around it. The reviews happen → data accumulates. A seemingly impenetrable wall between the database and proactive targeted improvement activity.
Mortality review is alive and well when case reviews are tightly and intentionally integrated into core quality work -- aligned with what the organization's strategic and operational plans. All systems have inputs and outputs. Those who make meaningful improvements based on mortality reviews recognize that this is just input. Without a corresponding 'output,' it is merely an exercise in labor-intensive data collection. Meaningful mortality reviews have corresponding outputs: integration with other metrics and analyses, prioritization, meeting cadence with senior leadership, accountability for adhering to the organization's strategic objectives, and an operational plan to address the most common process failures.
I am not prepared to watch the concept of a Mortality Review System disappear into binders and spreadsheets.
New QI Operating System (QI-OS) Course
Education, Training, & Coaching
BLUF: Behind every QI project are patients and healthcare team members who need us to finish. But if up to 90% of QI projects fail to sustain their results, we will have to approach the process differently.
My theory... I don't think we have been taught how. Now, before you argue with me, hear me out. Many of us have QI training. In my personal experience, this was a lot about the guiding theories and the tools to apply to solve a given type of problem. Some of us were even lucky enough to get facilitation and/or project management training. That is all necessary, but not sufficient.
None of that training taught me how to manage the following:
- Surgeons refusing to have a conversation, let alone participate in a multidisciplinary effort
- Clinical assistants and nurses pointing fingers at each other, with a degree of animosity that makes process mapping impossible to even begin
-The team refusing to consider any alternative solutions, other than the one they described in the first meeting before the problem statement was drafted
- Leadership setting a completely unrealistic timeline.
The tools we learned about won't cut it. Imagine trying to do a fishbone diagram or process mapping in any of the above scenarios!
Yet there is another scenario I have experienced much more often: the disconnect between leadership's vision/intent and frontline team members' reality. Sometimes the difference between these two perspectives feels like it is miles apart. Neither the executive sponsors nor the stakeholders is wrong. There is no ill intent. Both parties want the same thing... better patient outcomes. But the gap between them is filled with a mix of skepticism, hierarchy, history, fear, culture, distrust, and a lack of confidence that "another project" will yield anything lasting.
There was one time I waded into a mess like this and tried to do a brainstorming session. Needless to say, it was not a very productive meeting, and more than 50% of the group never came to another meeting. I decided to "own it". I decided I could do better. There was a huge gap in my knowledge that needed filling. I could not be part of lasting improvement unless I became more effective at bridging that divide.
I spent the next several years reading, studying, taking courses, and experimenting. I recently cataloged all of the wins and losses through the years. A pattern emerged. There was a set of steps I took each time the team succeeded, and when I didn't... well, that's where the perverbial bumps and bruises came from. As an engineer, those steps translated into how I "operated" in the messy middle. It is more than "doing stuff" and using tools... it is interpreting the tea leaves, deeply knowing the cultural history, studying the social implications and relationships, listening and integrating viewpoints, translating perspectives, aligning opposite perspectives, rectifying communication styles... plus dozens of other skills all BEFORE using a standard QI tool. To me, it is a QI Operating System (QI-OS) that is culturally and socially aware of the historical and current context and environment.
You all may have picked up these skills in your training or life experiences. I missed those lessons when taking my QI courses -- I have been known to skip a few classes now and then. But I needed to organize it so I could reproduce the steps I took with successful project teams. This exercise helped me process my career and life experiences over the last 30 years. I turned it into a live virtual course to share the real stories and life lessons from wading into the Messy Middle and creating meaningful, lasting improvement. I hope these stories inspire you to persist for our patients and frontline care team members. I hope the lessons help you succeed.
Register for the QI Operating System (QI-OS) Course:
Click Here: The skills no one taught you.
Learn More About the Course
Bonuses for enrolling in the full inaugural course (5 weeks at 1 hour per week) before Monday (4/6) at 11:59 pm:
1) Live Messy Middle "Hot Seat" Coaching Call with Dr. Huddleston - Bring your project and work through the issues in your own messy middle live;
2) “SBAER Mastery” Master Class — Get an exclusive 45-minute live capstone small group coaching session with Dr. Huddleston (week 5) plus a personalized SBAER template review. Helps you immediately turn course learnings into a powerful communication tool for your next QI project; and
3) DISC + 6 Working Geniuses Deep-Dive Bundle — Receive a private 30-minute interpretation call with Dr. Huddleston to braid your DISC profile (Ramsey style) and Working Genius results into your personal QI-OS action plan.
Quarterly Newsletter Trivia Question
Reply to the newsletter trivia question email for a single entry into our drawing for a $100 gift card. Correct or incorrect answer doesn’t matter — you will be included. Each newsletter has a different trivia question and you can reply once per newsletter. Names go into the drawing through the end of the quarter. The winner will be notified by email and the answer published in the following newsletter.
Trivia Question for the Week of April 1, 2026
In what century will you find the first reference to the Easter Bunny?
We'll add your name to the drawing twice if you can tell us the Country from which it originated!
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Remember that behind every QI project are patients and healthcare team members who need us to finish.
About this Newsletter
Learning From Every Patient is a case-based patient safety and quality newsletter for frontline clinicians and healthcare quality improvement professionals who want to stop preventable harm. Each issue features rotating content, including real cases, expert commentary, a short “Loved One Lens” reflection, a brief look at “what worked” in successful improvement efforts, tips and tricks for quality improvement and patient safety projects, and quick scans of relevant new evidence. Published by HB Healthcare Safety, SBC, and powered by Influence Ignited!, the newsletter is edited by Jeanne M. Huddleston, MD, MS, and is designed to turn everyday stories and process defects into practical, actionable lessons you can use on your next shift.
Editor: Jeanne M Huddleston, MD, MS
Founder, Influence Ignited, LLC
Co-Founder, HB Healthcare Safety, SBC
Professor of Medicine, Mayo Clinic College of Medicine
huddleston@hbhealthcaresafety.org
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Influence Ignited LLC | Newsletter link: influence-ignited.kit.com/profile/posts
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