Patient safety has always been at the heart of the movement to improve quality in health care. More than 30 years ago, the Harvard Medical Practice Study helped kick off the quality movement by demonstrating that many, if not most, instances of harm in hospitals were caused by system failures. Quality improvement methods and tools are designed to address these system failures. IHI’s founders started the organization to build, teach, and apply these methods.
I believe we are at an inflection point in the history of improving patient safety. Changing payment models, the uncertainty surrounding health reform, and the ever-increasing scrutiny of the modern digital age demand fresh thinking to ensure harm-free care. At IHI’s National Forum in December 2016, I proposed six patient safety “resolutions” for the new year — to sustain the great strides already made and to begin a conversation about new frontiers for patient safety:
- Focus on what goes right as well as learning from what goes wrong
- Move to greater proactivity
- Create systems for learning from learning
- Be humble – build trust and transparency
- Co-produce safety with patients and families
- Recognize that safety is more than the absence of physical harm; it is also the pursuit of dignity and equity
Numbers one and two come from some innovative thinking by Erik Hollnagel, Robert Wears, and Jeffrey Braithwaite. Their white paper, From Safety-I to Safety II, argues that we can expand our thinking about patient safety by moving from creating environments in which as few things as possible go wrong, to creating ones in which as many things as possible go right. This shift necessarily entails a more proactive management of safety — with a continuous focus on anticipating developments and events. My friend and colleague Carol Haraden calls this “getting to the thickness of the ice.” Carol argues that we spend time too much time measuring the times people fall through the ice, when we should be spending time monitoring the thickness of the ice.
The new IHI White Paper, A Framework for Safe, Reliable, and Effective Care, provides an in depth description of my third safety resolution. A systems-approach to ensuring and improving safety builds on the successes of individual projects by linking them within a larger framework that leverages crucial and interdependent elements such as culture, leadership, psychology, and continuous learning. Only through a comprehensive, systems-focused view of safety will be able to sustain and further the improvements made in individual improvement efforts.
My fourth resolution is about trust. Building and maintaining trust is essential to our professional relationships with colleagues, and to the healing relationships between patients and providers. Fear, blame, and liability do nothing to build trust. Trust is built through humility, and through that crucial manifestation of humility — transparency. We won’t improve safety if we fail to be completely open and transparent with ourselves, with our colleagues, and with our patients.
Resolution number five stems from all the inspiring work over the years to make health care more patient- and family-centered. Emerging from this work is the now prevalent understanding that improving our health systems requires more than just focusing on the needs of patients and families — it requires engaging them directly to co-design care. This is as true for patient safety as any other dimension of quality care.
And the sixth resolution is one I’ve been thinking a lot about over the past few years. We need to move from our traditional, narrow definition of harm, to a much broader definition. Now that we know how to reduce and even eliminate harms that some once thought inevitable — ventilator pneumonias, central line infections — we need to devote our efforts to eliminating harms we’ve yet to focus on explicitly. Harms caused by indignities and inequities in health care are just as preventable, and just as unacceptable, as wrong-site surgeries and medication errors. We’re beginning to understand more about how psychological trauma and racism affect physical health. Ensuring patient safety means guaranteeing a patient’s right to a free-from-harm care experience, which includes treating them equitably and with dignity.
We’ve made great progress in improving safety over the past 30 years. But patients are still being harmed. I think ensuring that we fulfill our very first promise to patients — do no harm — requires a reboot.
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.
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