Health Leaders Urge Immediate Action on Patient and Workforce Safety

Representatives from the Institute for Healthcare Improvement (IHI), Centers for Medicare and Medicaid (CMS), Centers for Disease Control (CDC), and the Agency for Healthcare Research and Quality (AHRQ) – three member organizations of the IHI-convened National Steering Committee for Patient Safety (NSC) – discussed the importance of national level coordination to address patient and workforce safety across the continuum of care at the IHI Patient Safety Congress. The NSC pressed for immediate action to address safety from a total systems approach and implored leaders to adopt safety as a core value and foster collective action to uphold this value.

These recommendations are part of the Declaration to Advance Patient Safety, which was introduced during the opening keynote address at the IHI Patient Safety Congress taking place through May 18 in Dallas, Texas and online as a virtual experience. This annual gathering brings together hundreds of diverse stakeholders who are passionate about providing safer care for patients in all care settings.

An emerging body of evidence reveals that health care safety has declined significantly during the COVID-19 pandemic. In a recent article published in the New England Journal of Medicine, authors from the CMS and CDC noted substantial deterioration on multiple patient safety metrics since the beginning of the pandemic, despite decades of attention to complications of care. The pandemic has also magnified patient and workforce safety risks and harms and introduced new threats to an already fragile system.

As stated in the Safety Declaration, “The return to a pre-pandemic status quo state of safety is insufficient for ensuring safe, reliable, and equitable care for every person. Rather, our recovery trajectory requires long-term, intensive focus to create, rebuild, and sustain the foundations for safe care.”

Safer Together: A National Action Plan to Advance Patient Safety, developed in 2020 by the 27 organizations that comprise the NSC, provides concrete guidance for leaders to assess and fortify their systems approach to safety by driving improvement in four foundational areas: Culture, Leadership, and Governance; Patient and Family Engagement; Workforce Safety; and Learning System.

“There is a critical need for health care leaders to take urgent action to create, rebuild, and sustain the foundations for safe care to address longstanding challenges and troubling setbacks in patient and workforce safety during the pandemic,” said Patricia A. McGaffigan, RN, MS, CPPS, IHI Vice President. “The National Action Plan provides leaders with the tools to assess the current state of their organization’s foundational safety practices and offers actionable solutions for a clear path forward.”

To meaningfully reset and advance safe, reliable, and equitable care and to strengthen the resilience of systems, the National Steering Committee urges health care leaders to:

1. Review the recommendations and tactics of Safer Together: A National Action to Advance Patient Safety.
2. Identify a senior sponsor and core team charged with deploying the Self-Assessment Tool, a companion resource to the National Action Plan, to evaluate their organization’s current state across each of the foundational areas.
3. Establish and enact strategies, tactics, and measurement and improvement plans to meaningfully fortify and sustain their organization’s performance in each of the four foundational areas by leveraging the Implementation Resource Guide, a companion resource to the National Action Plan.

“The National Action Plan to Advance Patient Safety draws from the insightful work of many in the field, and the plan specifies important steps organizations can take to protect the safety of patients and those who care for them,” said Jeffrey Brady, MD, MPH; Co-Chair, IHI National Steering Committee, Highmark Health, Senior Vice President Enterprise Research and Innovation.

“Inequities are an important contributor to both patient and workforce harm, as has been reinforced by the pandemic. Throughout the National Action Plan, health equity is embedded into the recommendations across all the foundational areas due to this important linkage,” said Tejal Gandhi, MD, MPH, CPPS, Co-Chair, IHI National Steering Committee, Chief Safety and Transformation Officer, Press Ganey Associates LLC.

About the Institute for Healthcare Improvement (IHI)

The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization based in Boston, Massachusetts, USA. For 30 years, IHI has used improvement science to advance and sustain better outcomes in health and health systems across the world. IHI brings awareness of safety and quality to millions, catalyzes learning and the systematic improvement of care, develops solutions to previously intractable challenges, and mobilizes health systems, communities, regions, and nations to reduce harm and deaths. IHI collaborates with a growing community to spark bold, inventive ways to improve the health of individuals and populations. IHI generates optimism, harvests fresh ideas, and supports anyone, anywhere who wants to profoundly change health and health care for the better. Learn more at ihi.org.

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