Reports and Related Publications


Framework for Effective Board Governance of Health System Quality
A resource from the IHI Lucian Leape Institute

The IHI Lucian Leape Institute’s research scan on board governance of health system quality, evaluation of governance education in quality, and expert interviews made it clear that board members, and those who support them, desire a clear and consistent framework to guide governance of all dimensions of quality beyond safety, including identification of the core processes and necessary activities for effective governance of quality.

This white paper includes a Framework for Governance of Health System Quality, a Governance of Quality Assessment tool, and three Support Guides.​ These resources strive to reduce variation in and clarify trustee responsibilities for quality oversight, and also provide practical tools for trustees and the health system leaders who support them to govern quality in a way that will deliver better care to patients and communities.​

Americans' Experiences with Medical Errors and Views on Patient Safety

In 2017, the LLI collaborated with NORC at the University of Chicago to conduct a national survey of the general public's experience of harm in health care in the US. Among the findings, 21 percent of adults reported having personally experienced a medical error.

Leading a Culture of Safety: A Blueprint for Success
A resource from the American College of Healthcare Executives and the IHI Lucian Leape Institute

Whether an organization is just beginning the journey to a culture of safety or is working to sustain its safe culture, this resource can serve as a useful guide to direct efforts and evaluate an organization’s success along the journey to zero harm.

ACHE and the IHI Lucian Leape Institute collaborated with leaders of progressive healthcare organizations and globally renowned experts in leadership, safety, and culture to develop this resource.

Transforming Health Care: A Compendium of Reports from the NPSF Lucian Leape Institute

A guide for health care leaders in assessing where their organizations stand in the journey to safer care and what steps they can take to make greater progress

This compendium brings together the executive summaries, recommendations, and action checklists from five reports published by the Institute between 2010 and 2015. The series of reports has revealed how much the issues overlap and intersect. What has become particularly clear is the fact that strong leadership and a culture of safety are essential for lasting improvement in patient safety. We urge health care leaders to use the recommendations presented here to inform discussions, set work priorities, and make what may sometimes be difficult decisions that will help them make progress toward safer care.

Shining a Light: Safer Health Care Through Transparency

Report of the NPSF Lucian Leape Institute Roundtable on Transparency

Defining transparency as “the free flow of information that is open to the scrutiny of others,” this report offers sweeping recommendations to bring greater transparency in four domains: between clinicians and patients; among clinicians within an organization; between organizations; and between organizations and the public. It makes the case that true transparency will result in improved outcomes, fewer medical errors, more satisfied patients, and lowered costs of care.

Safety Is Personal: Partnering with Patients and Families for the Safest Care

Report of the NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety

This report is a call to action for health leaders, clinicians, and policy makers to take the necessary steps to ensure patient and family engagement at all levels of health care. It identifies specific action items for health leaders, clinicians, and policy makers to pursue in making patient and family engagement a core value in the provision of health care.

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care

Report of the NPSF Lucian Leape Institute Roundtable on Joy, Meaning, and Workforce Safety

This report details how workplace safety is inextricably linked to patient safety. It looks at the current state of health care as a workplace, highlights vulnerabilities common in health care organizations, discusses the costs of inaction, and outlines what a healthy and safe workplace would look like. The report concludes with seven recommendations for actions that organizations need to pursue to effect real change.

Order from Chaos: Accelerating Care Integration

Report of the NPSF Lucian Leape Institute Roundtable on Care Integration

Health care today presents a difficult challenge: as our ability to recognize and treat disease continues to grow, so too does the complexity of delivering those solutions to each patient and to populations. Too often, care integration–the planned, thoughtful design of the care process for the benefit and protection of the patient—is lacking. This report, the result of a Roundtable that brought together the insights of various stakeholder groups, addresses the issue of care integration with the aim of outlining the major barriers to effective integration and providing a framework for further consideration and action among stakeholders.

Unmet Needs: Teaching Physicians to Provide Safe Patient Care

Report of the NPSF Lucian Leape Institute Roundtable on Reforming Medical Education

Ten years after the Institute of Medicine’s landmark 1999 report To Err Is Human, the Lucian Leape Institute at the National Patient Safety Foundation released a white paper finding that US medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care. Unmet Needs is the culmination of three LLI roundtable discussions and makes key recommendations for reforming medical education in order to improve patient safety. The paper was the first in a series of such reports on issues that the Lucian Leape Institute has identified as top priorities in ongoing efforts to improve patient safety.

Related Publications

Transforming Concepts in Patient Safety: A Progress Report
Gandhi TK, Kaplan GS, Leape L, et al. Transforming concepts in patient safety: a progress report. BMJ Quality & Safety. Published Online First: July 17, 2018.
In this paper, IHI Lucian Leape Institute members assess progress and ongoing challenges in five areas of health care they had previously cited as critical to improving patient safety.

Beyond the Front Lines: Why Greater Openness Am​ong Clinicians Is Needed to Drive Improvement in Patient Safety
Gandhi T. Beyond the front lines: Why greater openness among clinicians is needed to drive improvement in patient safety. PSQH Magazine. 2015 November/December.
Drawing from the NPSF Lucian Leape Institute report on transparency, this article argues for greater transparency among clinicians, to facilitate learning and sharing best practices.

The ‘Must Do’ List: Certain Patient Safety Rules Should not Be Elective
Wachter R. The ‘Must Do’ List: Certain patient safety rules should not be elective. Health Affairs Blog. August 20, 2015.
Written on behalf of the NPSF Lucian Leape Institute members, this article proposes criteria for “must do” practices and argues that two practices — hand hygiene and influenza vaccination for health care workers — should currently qualify.

Improved Patient Safety with Value-Based Payment Models
Corrigan J, Wakeam E, Gandhi TK, and Leape LL. Improved patient safety with value-based payment models. Healthcare Financial Management Magazine. August 1, 2015.
For health systems in the process of transitioning to value-based payment programs, improving patient safety can be key to financial survival.

You Can't Understand Something You Hide: Transparency as a Path to Improve Patient Safety
Wachter R, Kaplan G, Gandhi T, Leape L. You can't understand something you hide: Transparency as a path to improve patient safety. Health Affairs Blog. June 22, 2015.
Evidence suggests that greater transparency can boost patient safety by promoting accountability, driving improvement in care, promoting trust, and facilitating patient choice.

Empowering Patients as Partners in Health Care
Edgman-Levitan S, Gandhi T. Empowering patients as partners in health care. Health Affairs Blog. July 24, 2014.
Evidence is mounting in support of patient engagement as a vital component of safe health care, but that is often easier said than done.

Shared Decision Making — The Pinnacle of Patient-Centered Care
Barry MJ, Edgman-Levitan S. Shared decision making — Pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780-781.
In this perspective piece, the authors assert there is a critical need in health care to educate patients about the essential role they play in decision making and give them effective tools to help them understand their options and the consequences of their decisions.

Transforming healthcare: A safety imperative
Leape L, Berwick D, Clancy C, Conway J, Gluck P, Guest J, Lawrence D, Morath J, O’Leary D, O’Neill P, Pinakiewicz D, Isaac T, for the Lucian Leape Institute at the National Patient Safety Foundation. Transforming healthcare: A safety imperative. Quality and Safety in Health Care. 2009;18:424-428.
This paper outlined measures deemed by the Institute members to be crucial to reforming and improving the safety of the health care system. It was featured in Quality and Safety in Health Care, a British Medical Journal publication, as the Editor’s Choice.