The Institute for Healthcare Improvement’s (IHI) National Steering Committee for Patient Safety (NSC) recently released its national action plan, aimed at helping healthcare organizations reduce preventable medical harm.1
Safer Together: A National Action Plan to Advance Patient Safety includes evidence-based practices, case studies, and recommended interventions. The report was the result of work by federal agencies, safety organizations and experts, and patient and family advocates. It includes four areas: culture, leadership and governance, workforce safety, and learning systems. There are implementation tactics, case examples, tools, and resources. This action plan is intended to return focus to patient safety and medical errors, says Patrick Horine, MHA, who served on the IHI NSC that wrote this report. The Institute of Medicine’s 1999 report, To Err is Human: Building a Safer Health System, brought attention to patient safety.2
Patient safety is more of a constant focus than it was before the IOM report, Horine says, but it has plateaued as a priority for healthcare organizations.
“We’ve done more on the preventable issues, but eradicating patient harm has not happened. Keeping this to the forefront of the mindset of leadership was a key issue for us,” says Horine, chief executive officer at DNV GL Healthcare in Milford, OH, which offers hospital accreditation. “We brought together so many different parties because we wanted to look at this from all perspectives, which includes patient safety and healthcare worker safety.”
The protection of healthcare workers was a key component of the plan, even though most of it was developed before the COVID-19 pandemic.
“This is something that DNV GL is going to be asking hospitals about more in the future. It goes well beyond patient/staff ratios. This is really about the psychological and physical impacts, what it is doing to contribute to patient outcomes as well as the well-being of staff,” Horine says. “I never would have foreseen the psychological impact that COVID has had on healthcare workers. Patients are dying, and [clinicians are] doing everything they can for them, to no avail. That has a real impact.”
The IHI report also focuses on the involvement of the hospital or health system board. “What level of involvement do we have at the board level? They might get summaries and highlights at the board level, but how aware are they of safety and quality issues? What do they need to be committing more resources to?” Horine asks. “That level of understanding and participation from the board level is a primary concern.”
- Institute for Healthcare Improvement. Safer Together: A National Action Plan to Advance Patient Safety. http://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx
- 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.