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In a recent New England Journal of Medicine commentary, leaders from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services stated, “the fact that the [COVID-19] pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure.”
One can think of health care as a house. And right now — as we continue to deal with a sometimes-deadly virus that has at times felt like a series of 100-year storms — our house is looking battered. The pandemic has disrupted nearly every aspect of health care and patient safety, with setbacks in healthcare-associated infections, patient falls and pressure ulcers, and staff ratings of safety culture.
My clarion call to health care leaders who have been weathering these tempests is to take the time now — while the skies are looking a little clearer in some communities — to identify and fix the cracks in the foundation as your core recovery work. Without refortification, progress in safety will be limited as our attention moves to our next burning platform, and sustainability of progress will remain elusive.
Whether you’ve been steady at the wheel or need to regroup, you can fortify the foundations of safe, person-centered, and equitable care by using Safer Together: A National Action Plan to Advance Patient Safety as your guide. Use it to build on the gains we’ve made in safety to date, address recent setbacks and new challenges, and strengthen the resilience of our systems across four foundational and interdependent areas. Prioritized as essential to create total systems safety, these include culture, leadership, and governance; patient and family engagement; workforce safety; and the learning system.
The Role of Leaders
Leaders can review the National Action Plan recommendations, conduct an organizational self-assessment using the companion tool, and tap into numerous implementation resources. To support a strong safety culture, for example, follow these recommendations:
- Ensure safety is a demonstrated core value.
- Assess capabilities and commit resources to advance safety.
- Widely share information about safety to promote transparency.
- Implement competency-based governance and leadership.
An additional resource that is referenced in the National Action Plan is Leading a Culture of Safety: A Blueprint for Success. The Blueprint was developed through the work of the American College of Healthcare Executives and IHI and has been well-received by health care leaders. The Blueprint provides clear actions for organizational leaders to take in developing strong cultures of safety.
Protect and Support the Workforce
COVID-19 has exacerbated harms to the workforce through illness, injuries, burnout, staffing shortages, and inequities. As we enter the third year of the pandemic, leaders must commit to physical, psychological, and emotional safety and wellness, and full and equitable support of workers.
- Multiple surveys indicate that workers are leaving their jobs for a range of reasons, including unresolved and worsening issues related to the culture and health of work environments, insufficient staffing and increasing workloads, lack of flexibility, and burnout. Growing numbers of temporary workers are being employed across all aspects of health care, and the safety of patients and the workforce must be at the forefront of how we adapt care and staffing models; select, onboard, and deploy staff; and support the optimization of team performance across a blended workforce.
- Implement a systems approach to workforce safety. This workforce safety recommendation encourages all health care organizations to have comprehensive workforce safety programs in place. These programs incorporate leadership education on the impact of harm and the moral and business case for workforce safety, ensure a clear workforce safety strategy, and facilitate a coordinated approach to patient and workforce safety. Comprehensive workforce safety programs also encourage systematic use of risk analytics across jobs and tasks to collect and analyze data on harm, including musculoskeletal injury, trips and falls, exposure to infectious and chemical pathogens, and violence.
- Develop, resource, and execute on priority programs that equitably foster and promote workforce safety. Adopt measures to assess physical and psychological safety, well-being, and joy in work, including measures of safety culture, turnover and absentee rates, likelihood to recommend the organization, and intention to leave. To align with the recommendations of the National Action Plan, the Agency for Healthcare Research and Quality (AHRQ) recently introduced Workplace Safety Supplemental Items to accompany their Hospital Survey on Patient Safety (SOPS) Culture. These items will help leaders capture and act upon both patient and workforce safety insights.
Embed Equity Into Safety and Quality Work
Unsafe conditions result from unwanted variation in systems. Inequities — which represent a particularly insidious type of unwanted variation — are inextricably linked to patient and workforce safety and harm. The National Action Plan includes the advancement of health equity as one of its core principles. Leaders must develop, resource, and execute programs that equitably foster and promote patient and workforce safety. Here are some concrete examples of how leaders can engrain equity into safety and quality:
- Conduct an equity inventory. Learn what the workforce understands, believes, and experiences with respect to equity, including gaps in our workforce, work environment, psychological safety, and our ways of working.
- Integrate sociodemographic data into patient and workforce safety reporting systems and analysis of harm. While we may, for example, know what harms are occurring, a deeper understanding of who is experiencing harm can establish priorities and chart the course for future improvements.
- Apply an equity lens to your Root Cause Analysis + Action (RCA2). Analyze contributing factors to harm at multiple levels, including the interpersonal (explicit bias), human behavioral (implicit bias), institutional (policies and practices), and structural (societal determinants of health) levels.
- Proactively apply an equity lens when redesigning and expanding care models. For example, as health care expanded the use of telehealth during the pandemic, it has become clear that many patients do not have reliable and adequate internet access. If patients can only access the internet through a public Wi-Fi location, they may not have privacy to engage in a telehealth interaction fully and comfortably. The IHI white paper Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care offers a useful framework to guide organizations in providing safe, equitable, person-centered telemedicine across six elements, including access, privacy, diagnostic accuracy, communication, psychological and emotional safety, and human factors and system design.
The impact of the COVID-19 pandemic continues to be felt throughout our health care systems. While some may yearn for the “normalcy” of our pre-pandemic safety state, that status quo was never good enough for eliminating preventable harm for patients, families, and the health care workforce. If we continue to address safety through a “slice-and-dice” project approach without shifting the weight and force of our actions to the essential, load-bearing, and foundational requirements for achieving and sustaining safety, the conversations we’ve been having for decades will continue to be repeated, and progress, once more, will be lost in the face of future challenges and crises.
Patricia A. McGaffigan, RN, MS, CPPS, is an Institute for Healthcare Improvement Vice President and President, Certification Board for Professionals in Patient Safety.
You may also be interested in:
IHI Patient Safety Congress (in-person or virtually from May 16–18, 2022)
Conversation and Action Guide to Support Staff Well-Being and Joy in Work During and After the COVID-19 Pandemic
IHI Framework for Achieving Health Equity: A Guide for Health Care Organizations