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Analysis

New Patient Safety Panel's 3-Pronged Strategy

By Christopher Cheney  
   June 28, 2018

The National Steering Committee for Patient Safety seeks to recast siloed approaches to safety, create measurable goals, and promote the total systems approach to safety.

A national coalition of healthcare organizations is seeking to jumpstart patient safety efforts.

The National Steering Committee for Patient Safety is tasked with crafting an action plan to reduce patient harm by early 2019 and generating measurable results within the next three years.

In 2016, Johns Hopkins safety experts reported that more than 250,000 deaths in the U.S. were linked to medical errors annually.

The new patient safety panel is striving to slash that mortality figure by breaking down safety siloes, creating measurable safety goals, and taking a systematic approach to improving safety.

Boston-based Institute for Healthcare Improvement (IHI) is the prime organizer of the steering committee. Twenty-four organizations are represented on the panel, including:

  • American Hospital Association
  • American Nurses Association
  • Centers for Disease Control and Prevention
  • Centers for Medicare & Medicaid Services
  • The Joint Commission
  • National Quality Forum
  • Occupational Safety and Health Administration
  • U.S. Food and Drug Administration

The scale and reach of the steering committee's membership bodes well, says Tejal Gandhi, MD, MPH, chief clinical and safety officer of IHI, and cochair of the steering committee.  

"We need to percolate everything we are doing to the local level. The organizations we have pulled together all have interconnections with the frontlines," says Gandhi.

The steering committee has three primary objectives.

1. Break down safety silos

The steering committee seeks to promote coordination and cooperation among healthcare organizations, Gandhi says.

"There are many organizations working on patient safety, ranging from hospitals to health systems, primary care practices, associations, foundations, and government agencies. But what has become apparent is that there are often different agendas," she says.

A siloed approach to safety is inefficient and limits progress, she says.

"You can have two or three organizations working on similar safety topics but doing it in different ways without coordinating. The risk is that at the frontline the messaging can become complicated. One organization can want you to do five things, and another organization can want you to do another five things," she says.

To increase cooperation, the steering committee is drawing on the public health model, Gandhi says.

"As we have tackled public health issues over the years, we have had national coordination for these issues, whether it has been smoking, seat belts, or another public health issue. That kind of approach was the impetus behind the National Steering Committee," she says.

2. Create unified and measurable safety goals

A top objective of the steering committee will be selecting strategies to strengthen the foundation of patient safety such as leadership, organizational culture, and patient engagement.

"The hope is we will be able to create a national action plan with three or four significant goals related to safety that can be measured," Gandhi says.

Setting metrics will be a challenge, she says. "There has been a lot of debate about how you measure patient safety and harm; so, getting several organizations to come to a consensus on what we are going to measure and what we are going to improve is a key piece."

The steering committee's goals likely will be measured on a case-by-case basis. "There are many metrics, but the ones we choose are likely to be a combination of structure, process, and outcome measures. We will work that through for every one of the areas we pick," Gandhi says.

Leadership and culture are tempting targets for improvement.

"Leadership needs to be fully engaged in patient safety and see it as a core value for their organization. They set that vision and goal for the entire organization," she says.

Culture also is crucial for safety.

"Culture is foundational in terms of creating a culture where people feel comfortable talking about errors; and they know if they do talk about errors, they won't be punished. That culture is critical in advancing efforts for patient safety," Gandhi says.

3. Promote a systematic approach to safety

The steering committee, which held its first meeting in May, is promoting the total systems approach to healthcare safety.

The total systems approach is comprehensive rather than piecemeal, Gandhi says.

"You might have a medication error issue and a falls issue, which are important issues to address; but if you focus on them one at a time, you may improve them without achieving success across the board," she says.

Components of the total systems approach include ensuring that leaders foster a safety culture; creating centralized oversight of patient safety; addressing safety across the entire continuum of care; and partnering with patients and families.

Engaging healthcare leaders is essential to promoting the total systems approach to patient safety, Gandhi says.

"The governance and leadership of health systems need to understand the total systems approach. We are working on leadership and culture with the American College of Healthcare Executives. We are working on a project to better educate boards about total systems safety," she says.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


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