Some 85 percent of people in the United States had an encounter with a health professional in the past year, according to the Centers for Disease Control and Prevention.
Most patients will never experience unintended medical harm, but health care can be high risk, and technological and treatment advances continually create new opportunities for safety lapses. While the field has made considerable progress in advancing targeted patient safety initiatives, preventable harm is far too common — and improvement is difficult to sustain.
The combined factors of universal “patienthood” and the potential risk of harm are the reasons why IHI has been advocating for a relaunch of the patient safety agenda and, specifically, the need to address patient safety within a public health framework.
A public health framework begins with defining the problem and setting national goals. It requires collaboration across a variety of stakeholder groups to identify causes of harm and interventions that work; educate and train those in positions to enact improvements; measure and monitor success; and inform the community.
Last month, IHI took steps toward creating this framework by convening the newly formed National Steering Committee for Patient Safety, made of up representatives of the health care policy, regulatory, and advocacy communities. Their charge is to create a national action plan to address preventable medical harm. The Committee is noteworthy for the broad spectrum of organizations represented and the depth of the knowledge and experience the members bring to this task.
Here are three key things to know about this work:
Why do we need a National Steering Committee for Patient Safety? We’ve seen real progress in patient safety, but it has been too slow and fragmented. Success in one organization or with one initiative has not translated seamlessly across organizations or settings. At IHI, we feel that there needs to be a much more coordinated response to achieve total systems safety — patient safety that is systematic and uniformly applied across all health settings. Having a broad body focus on setting goals is a key part of that coordination. The national action plan that will lay out those goals as a first step.
What will the national action plan focus on? At our recent meeting, the Committee used a set of criteria to determine areas of focus. We began by defining foundational elements that crosscut other goals and are the essential ingredients to any safety initiative, for example, safety culture. I think of these as the fertile soil that allows safety initiatives to blossom. Other criteria included identifying areas or goals that would benefit from a collaborative approach, are measurable (in terms of structure, process, or outcomes), offer significant opportunity for improvement, and for which evidence-based solutions already exist.
There have been numerous collaborative efforts around patient safety in the past, and many have been very successful. Most of those efforts were around specific projects — for example, reducing readmissions, reducing infections. By focusing on foundational concepts, we hope that this effort will be able to accelerate progress beyond any specific issue to impact all safety work.
As a result, the National Steering Committee identified four main targets of focus:
- Culture and leadership: As outlined in recent work, leadership and culture are strongly intertwined. Leadership commitment is essential to a culture of safety, and a culture of safety is essential to the success and sustainability of safety initiatives.
- Patient and family engagement: Mounting evidence suggests that putting patients and their family members at the center of care as full members of the care team can improve quality and safety, and new tools and resources are available to help in these efforts.
- Workforce safety: At IHI, we firmly believe that the physical and psychological safety of the workforce is a precondition to patient safety.
- Learning systems: Patient safety work can best be advanced when organizations have a systematic means of reflecting on the quality of their work and sharing that information while also having mechanisms in place to proactively improve and continuously learn.
What challenges need to be overcome to succeed in this effort? The initial meeting of the National Steering Committee was energizing, because the members were focused and committed to this work. Challenges ahead include implementing the action plan by encouraging broad collaboration throughout the health care system.
My hope is that those working in health care — and all of the “patients in waiting” out there — will resist the feeling that, because we’ve been working on safety for 20 years, we’ve got it solved. Yes, there have been significant advances, but we need to make sure people know that the burning platform of patient safety has not been extinguished — it’s still burning.
Tejal K. Gandhi, MD, MPH, CPPS, is IHI’s Chief Clinical and Safety Officer.
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