A national push involving more than two dozen organizations is seeking to ramp up patient safety efforts.
A coalition of 27 organizations convened by the Institute for Healthcare Improvement has launched an initiative to improve coordination of patient safety work nationwide.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The new initiative is detailed in an "action plan" published on Sept. 14. The document was crafted by the National Steering Committee for Patient Safety, which was formed in May 2018. There were 27 organizations represented on the steering committee from the following groups: healthcare organizations and healthcare systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies.
The action plan has four focal points and 17 recommendations.
1. Culture, leadership, and governance
The action plan calls on healthcare leaders, governance bodies, and policymakers to demonstrate a commitment to safety as a core value and to foster cultures of safety. There are four recommendations related to culture, leadership, and governance.
- Healthcare leaders and governance bodies must demonstrate that safety is a top priority and part of their organization's mission and values. Organizational cultures should embrace trust and transparency, ensure physical and psychological safety for healthcare workers, and promote joy in work.
- Healthcare leaders and governance bodies must regularly assess capabilities and devote resources to promote safety at the personal and organizational level. Assessments should include the core competencies of every employee in the organization.
- Healthcare leaders and governance bodies must encourage sharing of information about safety such as near misses and harm incidents. This transparency should include timely sharing of information across organizations as well as with patients, families, and care partners.
- The quality and patient safety competencies of healthcare leaders and governance bodies should be assessed during onboarding and throughout their tenure. These competencies include knowledge, skills, and characteristics needed to promote patient safety.
2. Patient and family engagement
The action plan calls for propagation of effective patient and family engagement. Specifically, healthcare organizations should include patients, families, and care partners in the design and delivery of care. There are five recommendations related to patient and family engagement.
- Healthcare organizations should set competencies for all healthcare workers to engage patients, families, and care partners. All healthcare workers should be capable of forming equitable and effective partnerships with patients, families, and care partners.
- Healthcare leaders and workers must enlist patients, families, and care partners in the design and delivery of care.
- Patients, families, and care partners should be included in leadership and governance of safety and improvement initiatives.
- In their engagement efforts, healthcare leaders should actively and equitably work with patients, families, care partners, and community organizations.
- Healthcare leaders must ensure that all healthcare workers are respectful and transparent in their interactions with patients, families, care partners, and each other.
3. Workforce safety
The action plan says patient safety and workforce safety are linked closely. To boost workforce safety, healthcare organizations should take a unified and total-systems approach. There are three recommendations related to workforce safety.
- In a systems approach to workforce safety, all healthcare organizations should have comprehensive workforce safety programs. A systems approach includes leadership and engagement, safety management systems, risk reduction, and performance analytics.
- Healthcare organizations should hold themselves accountable for the physical and psychological safety of healthcare workers as well joy in the workplace.
- Healthcare leaders should create and implement programs to prevent healthcare worker injuries.
4. Learning system
The action plan calls on healthcare organizations to foster networked and continuous learning such as promoting the sharing of information and improvement efforts. There are five recommendations related to a learning system.
- Learning should be promoted inside and between healthcare organizations. Methods to achieve collaborative learning include using high-reliability principles as well as creating local, regional, state, and national learning systems.
- Promote safety learning networks and adoption of best practices.
- Improve safety education and training for all healthcare workers.
- Healthcare leaders should develop shared goals for safety in all healthcare settings and disseminate these goals widely.
- Promote coordination, collaboration, and cooperation on safety across the healthcare sector. "Modelling leaders in civil aviation, healthcare leaders representing all stakeholders must actively develop a public-private partnership to use the power of data sharing and cooperative learning to identify and solve the most urgent and emerging patient safety problems," the action plan says.
Call to action
During a press conference yesterday, the co-chairs of the National Steering Committee for Patient Safety urged healthcare organizations to redouble their patient safety efforts.
Coordinated work is required to re-energize patient safety improvement and accelerate change, said Tejal Ghandi, MD, MPH, senior fellow at the Institute for Healthcare Improvement.
"In the United States, there are many organizations that work on patient safety—multiple federal agencies, hospitals and health systems, accreditation groups, associations, foundations, patient advocacy groups—the list goes on and on. But we don't tend to work together in a coordinated and collaborative way, which often results in the frontline getting recommendations and advice coming at them from many different directions. We believe that if we all work together and are synergistic rather than uncoordinated, we can go further faster," she said.
Even the safest healthcare organizations in the country can benefit from following the action plan's recommendations, said Jeffrey Brady, MD, MPH, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality.
"In these high-performing organizations, delivering care is a team effort and safety is a shared value. When it comes to safety, no one sits on the sidelines. People who work in these organizations also trust that their own safety is important to leadership. Clinicians feel safe, and they work with patients and families to keep them safe. That is the kind of care that we want for ourselves and our families, but we all know that many obstacles stand in the way. Even the best organizations in the country struggle with these barriers, and they know the job of ensuring safety is never done."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Two decades after publication of the landmark report To Err Is Human: Building a Safer Health System, patient safety remains a vexing challenge in healthcare.
A new national "action plan" calls for greater coordination and cooperation between organizations that are working on patient safety.
The action plan has four focal points and 17 recommendations.