EXECUTIVE SUMMARY

The Institute for Healthcare Improvement (IHI) has released Safer Together: A National Action Plan to Advance Patient Safety, a roadmap for progress that includes tools that organizations across the healthcare continuum can use to assess their own approach to safety, and target areas in need of improvement.

  • Experts involved in this effort say what has been missing in previous safety initiatives is collaboration. The IHI plan is designed to address this gap.
  • The plan is built on four foundational areas developers contend all must be addressed to advance safety: leadership and culture, patient and family engagement, workforce safety, and the learning system.
  • Plan developers note ensuring the well-being and safety of the healthcare workforce is essential in all efforts to improve patient safety.
  • The IHI plan was released with two accompanying documents, an implementation guide and a self-assessment tool that organizations across the healthcare continuum can use to find areas in need in improvement within their own groups or systems.

Ever since the Institute of Medicine released To Err is Human: Building a Safer Health System (1999), which shined a harsh spotlight on the issue of errors that occur in the course of delivering healthcare, there has been a continuing focus on patient safety.1 Since the report was published, dozens of organizations have launched initiatives around this issue, and the topic frequently headlines national meetings of healthcare providers and administrators.

However, experts suggest what has been missing from this movement is a guiding hand leading all these disparate efforts in the same direction, with everyone working synergistically toward improvement in a way that does not waste precious time, effort, and resources.

To address this problem, the National Steering Committee for Patient Safety (NSC) has been working for two years on a framework that its members believe will facilitate the kind of collaboration that so many patient safety experts contend has been lacking. Convened by the Institute for Healthcare Improvement (IHI), the NSC represents 27 patient safety agencies, organizations, and experts that have been working to develop a common roadmap that leaders can use to highlight where their own operations are lacking, and establish improvement plans to address gaps.

Act with Urgency

The result of this work is Safer Together: A National Action Plan to Advance Patient Safety, a robust call for transformation that provides evidence-based practices, interventions, specific examples, and expert input to show organizations precisely how they can jump-start their own paths to improvement.2 When revealing the plan during a media briefing on Sept. 14, Tejal Gandhi, MD, MPH, CPPS, the NSC co-chair, IHI senior fellow, and the chief safety and transformation officer at Press Ganey, offered her perspective on precisely why all the efforts toward patient safety to date have not delivered the kind of results many had envisioned.

“There are so many organizations that work on patient safety, which is great — multiple federal agencies, hospitals and health systems, accrediting associations, foundations, and patient advocacy groups — but we don’t have to work together in a coordinated and collaborative way,” she said. “It 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.”

IHI released its plan with two accompanying documents, an implementation guide and a self-assessment tool.2 Gandhi said all these materials focus on what the NSC participants consider to be foundational areas in patient safety:

  • Leadership and culture;
  • Patient and family engagement;
  • Workforce safety;
  • The learning system.

“The COVID-19 pandemic has reinforced the urgent need for collaboration and a greater focus on all of these foundational areas to reduce the many kinds of harm that are occurring,” Gandhi said. “You see in a pandemic physical and emotional harm to patients and the workforce across the continuum. Inequity is contributing to these harms.”

The NSC believes focusing on these four foundational areas will advance the work that patient safety advocates are conducting during the COVID-19 pandemic. “The national action plan, implementation guide, and self-assessment include recommendations, strategies, and tactics in each of these four foundational areas. We believe these tools will engage all stakeholders, driving urgency to move this work forward,” Gandhi said.

Confront Barriers

Jeffrey Brady, MD, MPH, the other NSC co-chair and the director of the Center for Quality Improvement and Patient Safety at the Agency for Health Research and Quality (AHRQ), acknowledged that ensuring patient safety is hardly a simple task.

“It requires robust systems that engineer safety and care. That can help [prevent] pitfalls like medication errors, pressure ulcers, falls, infections, and many other threats that we all know can harm patients,” he said.

Brady added that while work on the plan began before the COVID-19 pandemic, the NSC participants have been impressed by how relevant the plan is for addressing many of the challenges that have arisen. He also noted that high-performing organizations understand delivering care is a team effort, and that safety needs to be a shared value.

“When it comes to safety, no one sits on the sidelines. People who work in these organizations trust that their own safety is important to leadership,” he said. “Clinicians feel safe, and they work with patients and families to keep them safe.”

However, Brady noted many obstacles stand in the way of providing safe care — even the best healthcare organizations in the country struggle with these barriers. He added organizations that have made good progress regarding patient safety can benefit from the IHI plan.

For instance, concerning “leadership and culture,” Brady said many organizations use tools that help measure safety culture. In the IHI plan, there is guidance on how leaders can move from measuring to acting, which actually will improve their safety culture and support safer care.

Further, Brady noted it is difficult for anyone to focus on the safety of others when they do not feel safe. “The pandemic has highlighted the need to take care of those who are on the frontlines every day, standing ready to take care of us when we get sick,” he said. The IHI plan includes tips on how to effectively partner with patients and families, and keep patients at the center of care.

The action plan also highlights the importance of putting learning systems in place so healthcare workers understand what is happening and why.

“The key here is sharing information about best practices, both within and across organizations, with timely, relevant data and useful information that can guide action and improve safety,” Brady shared.

Brady stressed the four foundational areas are interdependent and prerequisites for ensuring patient safety. “I think of this aspect as a kind of anti-silo effect that we hope the plan will achieve,” he said. “This feature also aligns well with systems-based perspectives, and it involves key parts of the system and how they need to fit and work together for safety.”

The emphasis on collaboration is highlighted in the plan, and for good reason, according to Brady. “We know that no single person in an organization alone can guarantee patient safety,” he noted. “Raising our level of cooperation is a must.”

Brady, who has pledged to put the IHI plan to use at AHRQ, cautioned there is a tendency toward the technical in healthcare, which is insufficient. “For example, in medication safety errors ... a provider order entry [system] that is computerized is a known safe practice that works, but it has to exist in a culture that is mindful about safety,” he observed.

All the elements have to work together, and that is one of the reasons why safety is so complex. “You can’t always focus on just one thing and expect change,” Brady added.

Link Patient, Worker Safety

Mary Beth Kingston, PhD, RN, NEA-BC, chief nursing officer at Advocate Aurora Health in Milwaukee, served as the NSC’s subcommittee lead for workforce safety, a subject of increasing importance to healthcare workers. She noted the action plan puts that issue front and center.

“Ensuring the well-being and safety of the healthcare workforce is absolutely essential in any and all efforts to improve patient safety,” she said during the Sept. 14 press briefing.

Kingston noted healthcare has one of the highest rates of illnesses and work-related injuries among many industries, including those considered to be of high risk (e.g., mining, construction, and agriculture).

Regarding physical harm, Kingston explained musculoskeletal injuries, such as back and shoulder damage, are common, particularly among healthcare workers involved with moving patients. Trips, falls, workplace violence, and exposure to infectious disease also are important concerns related to physical harm that affect healthcare workers. Kingston also stressed psychological and emotional injuries also are prevalent among the healthcare workforce.

“When we have an error that occurs with a patient, obviously our first concern is outcomes with that patient. [But] we also have to think about the trauma that the physician or the nurse, for example, might experience when they make an error that results in that harm,” she said. “Another example is the stress that occurs when the healthcare team member ... is somehow constrained from doing what they believe is right. We call that moral distress.”

The pandemic has shined a spotlight on both the physical and psychological harms that can affect healthcare workers, but Kingston stressed these types of injuries are not new. As an example, she pointed to the risk of exposure to infectious disease. “We can think back to some high-profile events like HIV, AIDS, and Ebola,” she said. “This actually is an issue that we face every day in healthcare. Attention to infection prevention is a cornerstone of safe patient care and a safe workplace; however, this has been tremendously magnified by the COVID-19 experience.”

The mental health and well-being of healthcare workers has been an ongoing concern, too. During the COVID-19 pandemic, fatigue, stress, and moral distress have made problems worse. Kingston said it is essential for organizations to create a safety culture that supports psychological safety.

“In organizations that do this well, the healthcare team feels safe and comfortable speaking out and questioning if a decision is made, and [if] something just doesn’t feel right to them,” she said. “When this culture is lacking, it causes tremendous stress and harm to the healthcare team. There also can be unsafe practices that occur that are really never brought to the forefront.”

Kingston acknowledged some progress has been made in the safety arena, but she noted much work remains to ensure workplace safety is embraced as a core value and a responsibility of leaders across every healthcare setting.

“We know that patient safety and workforce safety are linked,” she said. “[The IHI plan] highlights that it is possible to achieve sweeping improvement by advancing workforce and patient safety together under the same improvement umbrella.”

Heed Lessons

Kedar Mate, MD, president and chief executive officer of IHI, expressed his belief that the publication of the action plan will be a turning point in the pursuit of truly safe care.

“Now is the time to build on two decades of learning and progress, and to move to collective and common action,” he said during the Sept. 14 press briefing. “The National Action Plan gives us exactly what we need: An overall direction and specific recommendations that, if enacted broadly, will transform the safety of care for patients and for providers.”

In particular is the plan’s emphasis on leadership and workforce safety. “Leadership is always crucial in the middle of a crisis, but it is just as important in moving out of a crisis,” Mate said. “If we don’t heed the countless lessons we have all learned this year, I feel we will waste the extraordinary courage, commitment, and creativity that healthcare has demonstrated during the pandemic.”

Mate promised to marshal IHI’s energies and resources toward the safety of the healthcare workforce.

“The plan makes clear that workforce safety cannot be an add-on or an afterthought, but is in fact a prerequisite for safe and effective patient care,” he stressed. “Working in healthcare has always been fraught with risks to physical and psychological safety. We have to leverage the urgency of this moment to once-and-for-all rid our systems of all types of harm, and give our workforces the safety and supports they need to fulfill their calling as healers.”

Work Together

Ana Pujols McKee, MD, executive vice president and chief medical officer of The Joint Commission, did not speak at the media briefing, although she is a member of the NSC and participated in developing the action plan. She tells ED Management she was most involved in the development of recommendations on governance, an area where she sees much room for improvement.

“More emphasis needs to be given to the importance of instituting accountable governance practices,” she explains.

McKee says the IHI plan is in broad alignment with the efforts and goals of her accrediting organization. “The Joint Commission has been promoting the foundations of becoming a highly reliable organization to our accredited healthcare organizations. Specifically, we focus on developing leadership, safety culture, and robust process improvement,” she says. “Joint Commission surveyors have already incorporated these principles while they work with our accredited healthcare organizations. The National Action Plan to Advance Patient Safety is confirmation of most of these same principles.”

While the Emergency Nurses Association (ENA) was not part of the work team that developed the IHI, its leadership applauds the effort.

“The plan calls out the need to move away from a piecemeal intervention process, which has been the standard approach, to more of a true total-system approach,” says Mike Hastings, MSN, RN, CEN, president of ENA. “[We] will take a look at the report to see how we can internalize this from an association [standpoint] as well as determine how we should disseminate the information to our members.”

Hastings tells ED Management he was pleased to see the plan’s focus on workplace safety, and how the plan addresses both the physical environment as well as the psychological safety of healthcare providers. “The key throughout the report is that there must be a systematic approach, which is definitely needed when you are talking about workplace safety,” he observes. “Everyone must work together to address the root causes of workplace violence, and then figure out systems to mitigate the issues in order to keep the staff safe.”

Hastings adds that ENA looks forward to collaborating with other associations and healthcare organizations to help address these needs, similar to the way ENA and the American College of Emergency Physicians partnered in the launch of the No Silence on ED Violence campaign to raise awareness about the prevalence of workplace violence in the ED.

REFERENCES

  1. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
  2. Institute for Healthcare Improvement. Safer Together: A National Action Plan to Advance Patient Safety.