Adopt 3-Part Commitment Model for Patient Safety

The Patient Safety Movement Foundation is seeking to reduce preventable patient deaths to zero by 2030.

The Patient Safety Movement Foundation has changed its commitment model for hospitals and other healthcare organizations to achieve zero preventable harm and deaths.

Despite making considerable progress over the past two decades since the publication of the landmark report To Err Is Human: Building a Safer Health System, patient safety remains a primary concern at U.S. healthcare organizations. Estimates of annual patient deaths due to medical errors range as high as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.

The Irvine, California-based Patient Safety Movement Foundation has shifted its focus away from preventing specific kinds of patient harm, says Donna Prosser, DNP, RN, chief clinical officer of the nonprofit group.

"We have revised our commitment model because in the prior eight years what we were asking healthcare organizations to do was to make a commitment to improving safety and reducing incidents of medical harm through certain populations. When I say populations, I mean reducing falls, reducing healthcare-acquired infections, reducing sepsis, and so on. So, we had asked healthcare organizations to make a commitment to improve specific focus areas," she says.

Now, the Patient Safety Movement Foundation has adopted a three-part commitment model.

1. Person-centered culture of safety

Healthcare organizations should commit to ensuring the safety of every person who enters their doors, Prosser says. "For every person who comes into a healthcare organization, everybody needs to have in the front of their minds the safety of every person. It could be a patient, a family member, a physician, any staff member, or a vendor representative—it could be anybody."

The coronavirus pandemic has illustrated the need for a person-centered culture of safety at healthcare organizations, she says. "One of the things we have learned from the COVID-19 pandemic is that we did not have adequate healthcare worker safety. We did not have the personal protective equipment to keep our healthcare workers safe. If we have learned anything from the pandemic, it is that you cannot have patient safety without healthcare worker safety."

2. Holistic and continuous improvement framework

Although hospitals and other healthcare organizations have made progress in working collaboratively, siloes persist, Prosser says. "Since the publication of To Err Is Human, we have learned a lot about continuous improvement. But we have done continuous improvement the same way we have always delivered care, and that is in siloes. The Joint Commission has been telling us for 30 years to get out of our siloes in healthcare. And it has gotten better—it has gotten a lot more collaborative over the years."

A more holistic and coordinated approach to patient safety is needed, she says.

"In a hospital, there can be 10 or 100 committees that are all doing continuous improvement work. There are committees, departments, even students that are doing continuous improvement work. Everybody picks and chooses what they want to do, so we end up with a patchwork quilt of improvement where the right hand does not know what the left hand is improving. This makes it difficult for the frontline workers, who are the recipients of continuous improvement projects."

Coordination is crucial, Prosser says. "We need to look at continuous improvement holistically and figure out how we can have one department, one committee, or one person overseeing the continuous improvement work that is happening in a hospital. One entity needs to know what is going on and plot it on a calendar, so you do not have multiple committees or departments competing for the same resources, and you do not have the frontline being bombarded by change."

3. Effective model for sustainment

Sustaining patient safety initiatives is a daunting challenge, she says.

"For any healthcare leader, the most difficult aspect of performance improvement is sustainment. Healthcare is a profession made of human beings taking care of human beings. There is ambiguity in healthcare. So, if we do not give clear direction to the frontline, they are going to make up their own rules. And they are usually going to revert to rules that are comfortable that they know. It is not intentional—it is just human nature."

To achieve sustainment in continuous improvement of patient safety, healthcare organizations need to have an effective education plan, Prosser says. "You need to reinforce change. You need to build change into existing annual competency reviews, so that you make sure people stay on track and know what to do. Your education program needs to be aligned with your continuous improvement framework."

There are several primary elements of an education plan related to patient safety initiatives, she says. "To sustain continuous improvement with an education program, it is all about onboarding, orientation, annual competency validation, continuing education, and leadership development. That is the continuum of education for any healthcare organization. You need to learn how to keep people accountable."

For example, Prosser says if a hospital does an improvement project for appropriately restraining patients and rolls it out to the frontline staff, the hospital also must insert the change into orientation, insert it into competency evaluation on an annual basis, insert it into the continuing education curriculum, and insert it into leadership development, so that leaders can learn how to measure the change and hold staff accountable.

In addition to education, healthcare organizations must account for the human factor to sustain change, she says. "You must study human factors. You must understand the ways human beings react and behave. You must anticipate what is going to happen when you make a change."

Related: Expert Reflects on New Patient Safety Action Plan: 'Healthcare Organization Leadership Is Integral'