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Patient Safety’s Missed Opportunities

By Derek Feeley | Friday, June 9, 2017
Line of Sight

Many people have been asking me about the reasons behind the recent merger of IHI and NPSF. I tell them this is not just a coming together of two organizations. It is a merger of shared mission, purpose, and unwavering commitment to patient safety. In many ways, I see it as the next step in the patient safety reboot I’ve been talking about since IHI’s Forum last December.

Both IHI and NPSF have been restless for improvement. In 2015, NPSF published a report called Free from Harm. It acknowledges that we’ve made a lot of progress, but there’s still much to do.

Together, we’re exploring how to get the breakthrough level of performance in patient safety that we owe to patients and families everywhere. Our previous endeavors got us to a level of safety that is undoubtedly better than 20 years ago, when the patient safety movement started to gather momentum. But our current way of working will only get us the results we currently have, and that’s not good enough. Every patient should be able to expect the safest care every time. And we’re not there yet.

Reach Beyond Isolated Examples of Excellence

Safety work is still often a collection of well-meaning projects. But safety has to be a system property.

We need a more methodical approach — like the set of strategic, clinical, and operational components in the Framework for Safe, Reliable, and Effective Care developed by IHI and Safe & Reliable Healthcare. There is both a cultural aspect to this approach and what we call a “learning system.” The learning system analyzes strengths and weaknesses, identifies opportunities for improvement, and requires data transparency and innovation.

My IHI colleague, Carol Haraden, uses a metaphor when she talks about health care’s current approach to patient safety: it’s like measuring the number of people who fall through the ice. In the future, Carol says, we should be measuring the thickness of the ice. In other words, we need to move from only measuring incidents that have already happened to monitoring risk with real-time data. Using data to learn from the past is still important. But we must also analyze today's data and look at what's in front of us to understand the risks and threats to patients right now.

Approach Safety from the Patient’s Perspective

No one is more invested in patient safety than the patient. And yet, to date, they have been a largely untapped resource to improve safety. We need to make it easier to hear what patients and families have to say about creating a safe environment.

We haven’t done enough of the kind of things that I’ve seen in Canada, for example, where they’ve created a conversation about safety. Patients can say, “Here’s what I’m worried about as I’m going into hospital.” Clinicians can say, “Here are some things you can do that might reduce your worries about that.” Patients, families, and clinicians exchange ideas in anticipation of a possible hospitalization, rather than as a reaction to incidents of harm.

We’ve only just begun to scratch the surface of what might be possible if we collaborate with patients and families to co-produce safety. To go further, we need to invite patients and families into the design of care, and listen to their voices. We also need to meet them where they are in their homes and communities. We have yet to develop strong programs to improve patient safety in the home.

Prioritize Workforce Safety and Joy in Work

Another way to move forward will be to expand the conventional thinking about safety, including harms to the health care workforce.

There’s a strong parallel between NPSF’s work to include harm to the provider as part of the definition of safety, and IHI’s work on increasing providers’ joy in work and reducing burnout. The challenge for us as a new, combined organization is to put those two things together.

In IHI’s Joy in Work framework, one of the first priorities is making sure staff feel safe. Staff need to be physically safe and feel psychologically safe to do things like identify errors and question the status quo. Some of the other drivers of joy in work — asking what matters to staff members and identifying the “pebbles in people’s shoes,” for example — can help create both a safety culture and an environment that lessens the likelihood of both physical and emotional harm to staff.

Remember Why Safety Is Important

Every instance of harm has a human cost, but it also comes with a financial cost. Data from large surveys of hospital systems in the US indicate that if a patient gets an infection while in our care, the average cost to the health care system is around four times what it would be if there was no infection.

Some of the new payment models — including bundled payments and capitation — offer financial incentives to prevent harm, but I don’t know whether to be saddened or heartened by this arrangement. I understand the need to build a business case, but health care leaders should be pursuing safety regardless of whether it helps the bottom line.

Nevertheless, the safety community will welcome people who are motivated by the business case. (In fact, an upcoming NPSF-IHI report will build the business case further.) But I hope all leaders remember that ensuring patients and staff are safe is the job of the health care leader, regardless of the business case. This understanding will drive us toward the next horizon for patient safety more than financial incentives ever will.

The mantra of “first, do no harm” is at the very heart of a caring profession. So, let’s bring on the business case, and at the same time, let’s do the right thing because it’s the right thing to do.

Editor’s note: Look for more from IHI President and CEO Derek Feeley (@derekfeeleyIHI) on leadership, innovation, and improvement in health care in the “Line of Sight” series on the IHI blog.

 

You may also be interested in:

IHI White Paper - A Framework for Safe, Reliable, and Effective Care

Six Resolutions to Reboot Patient Safety

Using Retrospective Data Alone Will Not Make Care Safer

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