The Joint Commission
Over at Paul Levy's blog, Running a Hospital, an enlightening, frank discussion of the accrediting organization's role in patient safety and quality improvement. It includes an excerpt from a Boston Globe article that consists of a memo from the CEO of another hospital, Mass. General, to that hospital's staff in response to recent Joint Commission findings, and another of the commenters notes how, even though these proposed "duh" solutions seem so obvious, they're actually quite difficult to implement, and often require culture change.
I agree, and this isn't just nihilism or whining. For example, just because everyone supposedly knows that they're supposed to wash their hands between each patient encounter, it's not going to happen immediately, and the hospital has to play an active role in making it easier for staff to remember and providing more convenient, usable handwashing facilities.