Why It Matters
"Now is the time to move to collective, common action. [The National Action Plan] gives us an overall direction and specific recommendations that, if enacted broadly, will transform the safety of care for patients and providers."
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Use the National Action Plan to Create the “New Normal” for Patient and Workforce Safety

By Kedar Mate | Friday, September 25, 2020
Use the National Action Plan to Create the New Normal for Patient and Workforce SafetyPhoto by Drew Beamer | Unsplash

The following is adapted from remarks given by Kedar Mate, MD, IHI President and CEO, during a virtual news conference on Monday Sept 14, 2020, to announce the release of Safer Together: A National Action Plan to Advance Patient Safety.

The publication of the National Action Plan is, I believe, a turning point in our pursuit of truly safe health care.

It’s been 20 years since To Err Is Human: Building a Safer Health System documented the full scope of the safety problems in health care. Now is the time to build on two decades of learning and progress. Now is the time to move to collective, common action. This plan gives us an overall direction and specific recommendations that, if enacted broadly, will transform the safety of care for patients and providers.

We, of course, can’t ignore that this plan is being released amid unprecedented challenges in health care. The COVID-19 pandemic has revealed or resurfaced a whole host of current and potential risks to patients and the workforce. Health systems are creating a “new normal” in care every day. Implementing the recommendations laid out in the National Action Plan can help us build safety into the very foundations of the new normal rather than adding it on as a feature.

Particularly important, I think, are the plan’s emphasis on leadership and workforce safety. Leadership is always crucial in the middle of a crisis, but it’s just as important when moving out of one. If we don’t heed the countless lessons we’ve all learned this year, we will waste the extraordinary courage, commitment, and creativity that health care has demonstrated during the pandemic. It’s incumbent on us — the leaders of the safety movement in health care — to honor that courage, commitment, and creativity by hardwiring all that we’ve learned into the systems we steward. We can’t let this moment pass by without real and lasting change.

One aspect of this plan that I am personally passionate about, and that I will commit IHI’s resources and energy to, is the safety of the health care workforce. The plan makes clear that workforce safety can’t be an add-on or an afterthought. Workforce safety is a prerequisite for safe and effective patient care. Health care’s most precious resource is its people.

Working in health care has always been fraught with risks to physical and psychological safety even before COVID-19. We must now leverage the urgency of this moment to once and for all rid our systems of all types of harm, and give members of our workforce the safety and support they need to fulfill their calling as healers.

I am proud that IHI has been a leader in the safety movement throughout its history, and that, under the leadership of Tejal Gandhi, Patricia McGaffigan and others on IHI’s safety team and many supporting staff, IHI had the honor of convening the National Steering Committee. Co-chairs Tejal Gandhi and Jeff Brady were key to maintaining the collaborative process, enabling individuals from 27 member organizations, plus experts in the four foundational areas, to set their sights on an ambitious body of work in order to offer new direction for the safety movement as a whole. I’m grateful to Helen Haskell, President of Mothers Against Medical Error, and the many patient and family leaders who helped build and co-develop this plan. It is because of their deep and meaningful contributions that this plan is focused on what truly matters to patients. 

IHI will continue to support this indispensable work through the National Steering Committee, through the activities and output from our Lucian Leape Institute, and throughout our daily efforts to improve safety for everyone who interacts with the health care system.

IHI will use its voice and influence to improve safety by calling on everyone in health care to use this plan, to heed its recommendations, and to work together toward our shared goal of a health system free from harm.

Kedar Mate, MD, is IHI President and CEO.

Editor’s note: Along with Safer Together: A National Action Plan to Advance Patient Safety, download the National Action Plan Self-Assessment Tool and Implementation Resource Guide.

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