The Institute of Medicine and others have stressed the urgency of transforming hospitals into places where each patient receives the best quality care, every single time. Hospital leaders agree that they need to change their systems and processes in order to achieve substantial increases in reliability, and leadership is the most important ingredient in increasing the reliability of an organization. This book presents concepts and tools that a growing number of hospitals are using to help achieve their safety, quality, and efficiency goals. The author includes numerous case studies to demonstrate successes and failure of concepts and tools discussed in the book.