Dr. Tejal Gandhi is President and Chief Executive of the National Patient Safety Foundation (NPSF), an IHI faculty member, and patient safety thought leader. She has contributed to a number of IHI programs, including the Patient Safety Executive Development program. In this interview with IHI Content Development Manager Jo Ann Endo, Dr. Gandhi talks about the history and future of patient safety.
How has patient safety evolved over the years?
Fifteen years ago, when the Institute of Medicine published To Err Is Human, the focus of the patient safety movement was on convincing both providers and patients that we had a safety problem. We focused on the “burning platform” – an estimated 98,000 every year dying of medical errors – and the need to make care safer. Now, we’ve evolved to where I think most people understand that patient safety is a real issue. We now focus more on implementation science and how to implement the best practices that we know exist.
Something that hasn’t changed much is that we’re still talking about how to create a culture of safety. We’ve made progress, but some of the biggest areas for improvement are still around culture and leadership. Culture comes from the top, so you need leadership engagement because safety won’t be a priority if leadership isn’t fully committed to it.
What do you see as the future of patient safety?
Culture change – The future of safety will involve culture change, but culture change takes time. We’re doing much more education around safety in medical and nursing schools. The generation of docs and nurses out there now learned about safety as part of their training, whereas folks like me never heard of it when we were in training.
Engaging the frontline – The future of safety will also involve teaching more people on the front lines about patient safety concepts and improvement methods. The changes we always talk about in safety need to happen at the front lines. In the future, we’ll see more people working on safety together as opposed to it being just the responsibility of the patient safety team.
Health IT – Health Information Technology is changing the way we deliver health care. We need to think about how to optimize it to improve patient safety and minimize some of the potential harms.
At the National Patient Safety Foundation, we also see issues like patient engagement, transparency, and workforce safety as essential for the future of safety. If we don’t make progress on these issues, it will be much harder to achieve better safety for patients.
Do you think one particular person or team in a hospital should be the patient safety experts? It sounds like you think there needs to be a wider range of health care professionals with patient safety competence.
I think you need both. You need a core group of people with safety expertise. One of the reasons NPSF has been promoting certification in patient safety is because we believe every organization should have someone who really understands how to apply those core patient safety concepts and knowledge. But you also need to have an environment in which everybody can identify patient safety issues, report them, and think proactively about solutions.
This also comes back to my earlier point about leadership. You’re never going to get all the frontline staff engaged if they don’t believe they’re part of a culture that provides psychological safety. They need to know their organization will support them when they raise patient safety issues.
With more attention in recent years on the need to improve care across the continuum, what are the implications for patient safety?
Safety is foundational for providing the best care across the continuum; so many safety issues pertain to transitions of care. Much of the focus has been on hospital readmissions, but just think about all the transitions between various settings – from rehab to home, or nursing home to emergency room, or hospital to home health.
There are also challenges for someone, for example, who sees a family care doctor and a specialist and they also get dialysis. Is all of that care coordinated?
We are also starting to learn more about the types of adverse events that occur in primary care, nursing home, and surgical center settings. We’re not going to achieve better population health if we don’t address medication errors, incorrect or delayed diagnosis, infections, and falls in these care settings. Safety is a huge issue across the continuum of care, and it really hasn’t gotten the attention it deserves.
What will bring more of that attention?
I’m hoping some of the new reimbursement models will make a difference because the incentives will be much greater to invest in improving handoffs, transitions, and better care throughout the continuum. Malpractice insurers are starting to become involved because of an increasing number of malpractice claims from cases occurring in the outpatient setting. I hope the pressure from the insurers will lead to more [safety] investments outside the hospital settings.
For a long time, I felt that we shouldn’t have to make the financial case for safety; making care safe for patients is just the right thing to do. But I’ve learned that you also have to make the financial case, in addition to the clinical and ethical case for safety. I hate to think that financial pressure is what gets us going, but financial drivers can be helpful.