In the face of continued unacceptably high rates of harm, in May 2018 IHI convened the
National Steering Committee for Patient Safety (NSC) to create a national action plan to guide patient safety efforts across the United States in a more cohesive and coordinated fashion.
A Total Systems Approach to Advance Patient Safety:
Four Foundational Areas
Recognizing that there are many areas that need to change to accelerate and sustain improvement in patient safety, the NSC prioritized four foundational areas for developing a total systems approach to advance patient safety:
Culture, Leadership, and Governance: The imperative for leaders, governance bodies, and policymakers to demonstrate and foster our deeply held professional commitments to safety as a core value and promote the development of cultures of safety.
Patient and Family Engagement: The spread of authentic patient and family engagement; the practice of co-designing and co-producing care with patients, families, and care partners to ensure their meaningful partnership in all aspects of care design, delivery, and operations.
Workforce Safety: Ensuring the safety and resiliency of the organization and the workforce is a necessary precondition to advancing patient safety; we need to work toward a unified, total systems-based perspective and approach to eliminate harm to both patients and the workforce.
Learning System: Establishing networked and continuous learning; forging reliable learning systems within and across health care organizations at the local, regional, and national levels to encourage widespread sharing, learning, and improvement.
In developing the National Action Plan, NSC members convened subcommittees of subject matter experts to establish specific recommendations, tactics, and identify related resources for the four foundational areas as well as the associated measurement strategies. Recommendations were based on peer-reviewed published literature wherever possible, or best practices and expert opinion when no such evidence existed at the time of consideration.