It is obvious we do not have best practices in place. Actually, there is no such thing as the best practice, only the better practice. Swensen et al.  at the Mayo Clinic have some suggestions. They say that developing highly reliable care for patients requires changesin some traditional beliefs of medical practice, an evolutiontoward a “system” of healthcare, the disciplined applicationof scientific principles, modifications in the way all futureproviders are trained, and a fundamental understanding by leadershipthat quality must become a business strategy and core work,not an expense or regulatory requirement. Quality at Mayo isdefined as a composite of outcomes, safety, and service. With continuous innovation, we can reinvent quality to meet and exceed the criteria above.