Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA). The goal is to build a social movement so that all care with older adults is age-friendly. Specifically, it aims to reach older adults in 2,600 places of care by June 30, 2023.

IHI recognizes clinical care settings that are working towards reliable practice of evidence-based interventions for all older adults in their care known as the 4Ms (4Ms: What Matters, Medications, Mentation, Mobility). Learn more about the 4Ms in the Age-Friendly Health Systems Guide to Using the 4Ms in the Care of Older Adults in Hospitals and Ambulatory Care Practices.

IHI recognizes care locations at two milestones on their Age-Friendly Health System journey:

• Level 1: An Age-Friendly Health System Participant has completed a 4Ms Care Description to outline how it will assess, document, and act on all 4Ms at its care setting. At first, their 4Ms Care Description might represent a plan that they will test and work towards reliably performing. 4Ms Care Description fillable PDF forms for submission can be found on the Recognition page (see above).
• Level 2: An Age-Friendly Health System — Committed to Care Excellence is working toward reliable practice of the 4Ms. They have achieved level 1 and have submitted at least three months of counts of the number of older adults that have received care that included all 4Ms. Counts of older adults reached can be submitted with the bottom portion of the 4Ms Care Description form that was submitted for level 1 recognition.

Age-Friendly Health System recognitions are made at the facility level including hospitals, practices, nursing homes and convenient care clinics.

First, learn the 4Ms Framework by reviewing the Age-Friendly Health System Guide to Using the 4Ms in the Care of Older Adults. For additional guidance from experts and peer health systems, you can sign up to join an Action Community or receive asynchronous virtual support. 

Building on what you already have in practice, use the 4Ms Care Description worksheet to outline how you will close the gap and reliably practice all 4Ms. Share your 4Ms Care Description with IHI through this electronic form.

IHI will recognize care locations as Participants (Level 1) for submitting a completed 4Ms Care Description. You will receive an email from AFHS@ihi.org within 3 weeks celebrating you as an Age-Friendly Health System Participant. 

The email might indicate the need to make updates to your 4Ms Care Description to bring it into alignment with the Guide to Using the 4Ms in the Care of Older Adults. You can email updates to your 4Ms Care Description to AFHS@ihi.org. If no updates are needed, you will be invited to begin working toward Committed to Care Excellence (Level 2) Recognition by submitting counts of the number of older adults receiving 4Ms care for 3 months. 

There is no cost associated with Age-Friendly Health Systems Recognition. Thanks to generous support from The John A. Hartford Foundation, IHI offers implementation support and recognition at no cost to health systems. ​

When your organization is recognized, you will receive a toolkit for celebrating your efforts within your organization and community. The toolkit includes a "badge" that you can add to your email signature and slides or print and display. It also includes templates and best practices for communicating your achievement via press releases and on social media. IHI will list the name of your care location on the Age-Friendly Health Systems Recognition web page. IHI and The John A. Hartford Foundation may also celebrate recognized care locations in press releases, on social media, and in other settings.  

Submissions are reviewed and responses are emailed from AFHS@ihi.org throughout the month. You should receive an email with information about your recognition status within three weeks. Email AFHS@ihi.org for questions.

You do not need to take additional action to sustain your original recognition. Instead, focus on improving the reliability and spread of the 4Ms within your health system.

We encourage recognized care locations to continue their Age-Friendly Health Systems journey in the following ways:

• ​If you are a Participant, make edits to your 4Ms Care Description to align with the Guide to Using the 4Ms in the Care of Older Adults (if the need was indicated in your Participant email from AFHS@ihi.org) and measure the number of older adults that are receiving care that includes all 4Ms in your care setting. Submit at least 3 months counts to be recognized as Committed to Care Excellence. 
• Scale-up Age-Friendly care in your setting by bringing the 4Ms to additional facilities and achieving recognition in those locations.

In the face of continued unacceptably high rates of harm, the Institute for Healthcare Improvement convened the National Steering Committee for Patient Safety (NSC) in May 2018 to encourage greater coordination of collective patient safety efforts. Organizations were purposefully selected for their demonstrated commitment to accelerating the improvement of safety, reducing harm, and working with others to spread best practices.

Membership in the NSC is voluntary and includes leaders from 27 organizations representing health care organizations and health care systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies.

Together, members developed a vision statement and core principles to guide the work of the NSC and the creation of the National Action Plan to Advance Patient Safety to address areas of need and advance collective progress toward establishing total systems safety.

National Steering Committee Co-Chairs

• Craig Umscheid, Agency for Healthcare Research and Quality
• Patricia McGaffigan, Institute for Healthcare Improvement

National Steering Committee Leadership

• Erin Grace, Agency for Healthcare Research and Quality
• Tejal Gandhi, Press Ganey

National Steering Committee Members

• Paul Abramowitz, American Society of Health-System Pharmacists
• David Bartholomew, American College of Healthcare Executives
• Robyn Begley, American Hospital Association / American Organization for Nursing Leadership
• Jeff Brady, Highmark Health
• Gerard Cox, VA National Center for Patient Safety, Veterans Health Administration (VA)
• Missy Danforth, Leapfrog Group
• Shannon Davila, ECRI
• Chris DeRienzo, American Hospital Association (AHA)
• Susan Edgman-Levitan, Massachusetts General Hospital, IHI Lucian Leape Institute
• Rollin J. (Terry) Fairbanks, MedStar Health
• Andrew Furman, Executive Quality and Safety Consultant
• Amy Gibson, American Board of Medical Specialties
• Thomas Granatir
• Danielle Harris, US Food and Drug Administration
• Helen Haskell, Mothers Against Medical Error
• Martin Hatlie, Project Patient Care
• Rita Jew, Institute for Safe Medication Practices
• Gary Kaplan, IHI Lucian Leape Institute
• Steve Littlejohn, Patient Family Representative
• Helen Macfie, IHI Faculty and Executive Consultant, Healthcare Performance Improvement
• Tilithia McBride, Federation of American Hospitals
• Troy McCann, DNV
• Rosha McCoy, Association of American Medical Colleges
• Stephanie Mercado, National Association for Healthcare Quality
• Elizabeth Mort, CMO, The Joint Commission
• Stephen Muething, Children’s Hospitals' Solutions for Patient Safety
• Mallika Mundkur, US Food and Drug Administration
• Minda G. Nieblas, Occupational Safety and Health Administration
• Jade Perdue-Puli, Agency for Healthcare Research and Quality
• Cheryl Peterson, American Nurses Association / Nursing Alliance for Quality Care
• Anne Marie Pizzi, DNV
• Susan Reinhard, AARP
• Suz Schrandt, Chief Patient Advocate
• Michelle Schreiber, Centers for Medicare and Medicaid Services
• Daisy Smith, American College of Physicians
• Arjun Srinivasan, US Centers for Disease Control and Prevention
• Marijin VanOort, American College of Healthcare Executives
• Ron Wyatt, Society to Improve Diagnosis in Medicine
• Edward Yackel, Executive Director, Veterans Health Administration (VHA) National Center for Patient Safety

People around the globe observe Patient Safety Awareness Week in creative ways — see the examples below.

Centrastate Medical Center, New Jersey: Displayed banners at the main hospital entrances. The team also created trivia activities to test staff knowledge of patient safety, with opportunities for staff to be entered into drawings for gift cards. They ended the week with a complimentary ice cream treat for staff.

Community Medical Center, Montana: Planned a safety display highlighting the five patient incident posters displayed on the organization's website. They were displayed with safety behaviors used in the institution and a list of Safety Champions for the past year. The team also provided a suggestion box for ways to make the hospital safer, and had a room occupied by "Miss Mayhem," with a prize for a person who identified all of the safety issues in the room. Staff signed a huge Pledge Poster as they entered the display. The poster was rotated among departments as a reminder to staff about patient safety.

Deaconess Health System, Illinois: Planned several activities, including a bulletin board competition through which departments could show their "patient safety destination" (hand washing, fall reduction, etc.). They also gave "Speak Up" awards, chosen through peer nominations and awarded to staff who speak up to advocate and keep their patients' safe. A life-sized cut-out of their patient safety mascot, Safety Sam, conveyed patient safety messages throughout the week. The team planned to share the results of the competitions and the creative efforts at the organization's Safety Ambassador Committee meeting, Patient Safety Committee, Leadership Meeting, and on the hospital's internal webpage.

Dell Seton Medical Center, Texas: In collaboration with UT Austin Dell Medical School, hosted a series of interactive talks from local experts to highlight safety culture. Among the topics were health equity, patient experience, wellness, costs of care, and an interprofessional happy hour.

Kootenai Health, Idaho: Recognized staff that were involved in a "Good Catch" with Swedish Fish and Goldfish prizes. The team also hosted a viewing party for the IHI free Virtual Learning Hour and a screening of a patient safety documentary, and held a Safety Fair and poster contest. To promote the event, images of staff and quotes from staff and patients were placed on cafe tables.

Livingston Hospital and Healthcare Services, Kentucky: Convened a team to view the Patient Safety Awareness Week free webcast and created word-search puzzles with health care quality and safety words and phrases.

Maui Memorial Medical Center, Hawaii: Their team incorporated storytelling in an interactive presentation to staff.

Memorial Sloan Kettering, New York: The Division of Quality & Safety presented “Patient Safety Lightning Rounds” during Patient Safety Awareness Week. This fast-paced, interactive series of roundtable discussions was led by subject matter experts on institutional safety initiatives, and open to all staff.

Minnesota Alliance for Patient Safety (MAPS), Minnesota: The organization’s belief is that sharing stories and experiences helps all stakeholders understand the impact of preventable errors and unexpected experiences in the delivery of care. The organization invited members to create patient story galleries in their facilities using the innovative storyboards MAPS co-created with five patient partners to illustrate their challenging health care journeys.

Olympic Medical Center, Washington: Convened staff to listen to the free IHI PSAW webinar, and offered information via posters in the cafeteria and emails to highlight PSAW and the hospital’s safety initiatives. They also released a special edition of their “Safety Minute — Guardians of Safety” video focused on Patient Safety Awareness Week.

Residential Home Health and Hospice, Michigan: One staff member wrote an article on safety for the organization’s website.

Scott Air Force Base, Illinois: Medical staff organized a patient safety poster contest during Patient Safety Awareness Week.

Seattle Children's Hospital, Washington: Hosted a full week of activities. On Monday, senior leaders thanked staff for their commitment to safety and handed out swag/stickers at the front entrances of our hospital. On Tuesday they held Quality and Safety Poster Walkarounds (highlighting staff quality and safety improvement work) and provided a booth for patients and families to learn more about what patient safety means for them. On Wednesday the team held a screening of the documentary, “To Err Is Human.” Thursday was the annual Safety Coach/Safety Leader Celebratory Luncheon, and a second screening of the documentary was held on Friday. The organization featured personal statement posters and a large poster for folks to pledge their commitment to safety.

South County Health, Rhode Island: This organization put a special focus on education about patient identification.

Southwest General, Ohio: This organization sent daily emails to staff with safety tips.

St. Christopher Hospital for Children, Pennsylvania: Scheduled handwashing demonstrations that show what’s missed and activities to boost patient engagement.

Tufts Medical Center and The Floating Hospital for Children, Massachusetts: Patient Safety Awareness Week coincided with the Safety Culture Survey at these organizations. Patients and staff members took the IHI PSAW pledge and signed a “Safety Starts with Me” poster, which was displayed in the hospital's main atrium. In addition, Quality Improvement and Patient Safety staff members offered information to increase patient safety awareness and encourage reporting of safety events as part of the “Quantros/Good Catch” initiative, and held educational sessions open for staff on process mapping and fishbone diagram.

Altababa Advanced Health Solutions, Khartoum: The organization held an event for all health care providers to learn about patient safety, best practices, high-reliability practices, and examples of patient safety practices.

Do Not Harm, Armenia: This health care-related NGO based in Yerevan created a series of videos about patient safety to be shared on their website and on social media.

Frenchay Brain Injury Unit, England: The organization held a series of themed awareness days to demonstrate what the organization does to keep patients safe. Themes included clinical observations, falls prevention, swallowing awareness, sepsis/DVT prevention, and infection control.

Guam Regional Medical City, Guam: Held a themed event for each day of Patient Safety Awareness Week, from poster presentations on fall prevention to a "room of horrors" and awards for "Good Catch" submissions. ​

King Fahad Hospital Hofuf, Saudi Ministry of Health, Saudi Arabia: Quality and Patient Safety staff publicly shared stories​​ and lessons learned from five incidents reported during the second quarter via their reporting system. The incidents ranged from inappropriate patient identification to medication errors. The incidents were analyzed by the Quality and Patient Safety Team and the relevant departments to prevent recurrence. By making them public, they hoped others could learn and benefit.​

Mafarq Hospital, Abu Dhabi: Teams conducted a collage competition with the theme “Why Safety Matters to You.” They also held a Quality and Patient Safety Symposium and offered quizzes and games for staff.

Red de Salud UC CHRISTUS, Chile: Marked its sixth Patient Safety Awareness Week with activities like leadership rounds, challenging teams to develop ideas about patient safety and share them on a public whiteboard and a photography competition, "Safety in Images." The staff contributed to an annual patient safety survey and held an International Conference of Patient Safety and Quality. Activities were aimed at engaging clinical and not clinical staff alike.

Rotunda Hospital, Ireland: This stand-alone maternity hospital held a series of initiatives aimed at staff and patients to promote patient safety. They included a display of patient safety projects that have made a real impact on patient care, and a patient information booth informing patients of what the hospital does to keep them safe and advising them of what they can do to help staff to keep them safe. The finale was short presentations from multidisciplinary staff comprising patient safety themes.

Saudi Patient Safety Center, Saudi Arabia: Activities included Twitter posts discussing patient safety initiatives such as medication safety, reporting, measuring safety culture, patient empowerment, and innovation. Collaborating hospitals were asked to highlight national initiatives in patient safety.

Tabba Heart Institute Karachi, Pakistan: The organization conducted a culture of safety survey during Patient Safety Awareness Week, and presented a webinar and a discussion on patient feedback.

US Naval Hospital Yokosuka, Japan: Numerous activities included a “room of horrors” for staff to identify safety risks; an ice cream social for staff to ask and answer patient safety questions; and a “Good Catch” award ceremony for the night staff.

Diagnostic Excellence
March 14, 2024

• Watch the recorded webinar

Incorporating CPPS™ Certification into Academic Curriculum
March 16, 2023

• Watch the recorded webinar
   

Partnering with Patients to Improve Diagnostic Safety
March 15, 2023

• Watch the recorded webinar

Back to Our Purpose: The Reboot of Safety
March 14, 2023

• Watch the recorded webinar
   

Sensemaking in Times of Uncertainty: Essential for Safety
March 16, 2022

• Watch the recorded webinar
   

Workplace Violence: Protecting the Health Care Workforce
March 16, 2021

• Listen to the recording
• Download the slides

Raise awareness for Patient Safety Awareness Week at your organization with these suggested resources.

Publications

• Safer Together: A National Action Plan to Advance Patient Safety
• Optimizing a Business Case for Safe Health Care: An Integrated Approach to Safety and Finance
• Leading a Culture of Safety: A Blueprint for Success offers strategies and tactics for leaders at every level to create and sustain a safety culture
• IHI White Paper: A Framework for Safe, Reliable, Effective Care
• Read the latest patient safety Insights from IHI

Tools

• IHI's Patient Safety Essentials Toolkit
• Learn how to conduct Root Cause Analyses and Actions using the tool, RCA²: Improving Root Cause Analyses and Actions to Prevent Harm

Training and Educational Opportunities​

• Become a Certified Professional in Patient Safety
• IHI Open School Patient Safety Curriculum

• Visit The Conversation Project website for tools and resources to help you have conversations with loved ones facing complex medical conditions or end-of-life care decisions
• Download the Ask Me 3 resources, which can help you think about what questions to ask your health providers

This IHI Lucian Leape Institute report describes three use cases for generative artificial intelligence (genAI) applications in clinical care, including a detailed review of benefits and potential risks for patient safety; recommendations and mitigation strategies; an appraisal of the impact of genAI on the patient safety field; and considerations for key groups.

This IHI White Paper describes a framework to guide health care organizations in their efforts to provide safe, equitable, person-centered telemedicine. The framework includes six elements to consider: access, privacy, diagnostic accuracy, communication, psychological and emotional safety, and human factors and system design.

The white paper, Framework for Effective Board Governance of Health System Quality, 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.​

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. The resulting report, Americans' Experiences with Medical Errors and Views on Patient Safety, provides a detailed report of the survey findings, including that 21 percent of adults reported having personally experienced a medical error. 

ACHE and the IHI Lucian Leape Institute collaborated with leaders of progressive health care organizations and globally renowned experts in leadership, safety, and culture to develop this resource, Leading a Culture of Safety: A Blueprint for Success. 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.

Shining a Light: Safer Health Care Through Transparency makes the case that true transparency will result in improved outcomes, fewer medical errors, more satisfied patients, and lowered costs of care. This report offers recommendations for greater transparency between clinicians and patients, among clinicians within an organization, between organizations, and between organizations and the public.

The report, Safety Is Personal: Partnering with Patients and Families for the Safest Care, 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.

The report, Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care, details how workplace safety is inextricably linked to patient safety, highlighting common vulnerabilities in health care organizations, the costs of inaction, attributes of a healthy and safe workplace, and recommendations for actions.

Too often, care integration — the planned, thoughtful design of the care process for the benefit and protection of the patient — is lacking. This report, Order from Chaos: Accelerating Care Integration, 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, the culmination of three Lucian Leape Institute roundtable discussions, makes key recommendations for reforming medical education in order to improve patient safety. 

Risks to Patient Safety When Medical Errors Are Criminalized (March 30, 2023)

RaDonda Vaught Sentencing (May 13, 2022)

Salzburg Statement on Moving Measurement into Action
In September 2019, the IHI Lucian Leape Institute, in collaboration with Salzburg Global Seminars, led an expert panel's work on developing global principles for measuring patient safety which resulted in eight recommendations for standard methods of measuring, understanding, and improving the safety of patients across the care continuum.

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.

The members of the IHI Lucian Leape Institute represent national thought leaders with a common interest in patient safety.

Gary S. Kaplan, MD, FACMPE    
Chair, IHI Lucian Leape Institute
Senior Vice President, Common Spirit Health

Donald M. Berwick, MD, MPP   
President Emeritus and Senior Fellow, Institute for Healthcare Improvement

Joseph R. Betancourt, MD, MPH
President, The Commonwealth Fund

Susan Edgman-Levitan, PA   
Executive Director, John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital, Division of General Internal Medicine 
Co-Chair, Mass General Brigham Patient Experience Leaders Committee 
IHI Senior Fellow 
Harvard Medical School

Gregg S. Meyer, MD, MSc, CPPS   
Professor of Medicine, Massachusetts General Hospital and Harvard Medical School

Julianne M. Morath, RN, MS, CPPS   
Leadership Quality Advisor and Coach
Board President Elect, Collaborative for Accountability and Improvement, University of Washington

Susan Sheridan, MIM, MBA, DHL  
Founding Member, Patients for Patient Safety (PFPS) US
Director of Patient Engagement Emeritus, Society to Improve Diagnosis in Medicine

Hardeep Singh, MD, MPH
Professor of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston

Charleen Tachibana, DNP, RN  
Former Hospital Administrator, Chief Nursing Officer, SVP and Chief Quality, Safety, and Patient Experience Officer, Virginia Mason Franciscan Health

Charles Vincent, PhD, MPhil   
Professor of Psychology, University of Oxford   
Emeritus Professor of Clinical Safety Research, Imperial College, London

Sylvia Trent-Adams, PhD, RN, FAAN 
IHI Board Liaison, IHI Lucian Leape Institute
President, University of North Texas Health Science Center

Carolyn M. Clancy, MD, Assistant Deputy Under Secretary for Health for Quality, Safety and Value, Veterans Health Administration, US Department of Veterans Affairs

Amy C. Edmondson, PhD, AM, Novartis Professor of Leadership and Management, Harvard Business School

Lucian L. Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health

Paul O’Neill, 72nd Secretary of the US Treasury