IHI rolls out new National Action Plan for patient safety

By Jay Kumar

With the goal of eliminating preventable medical harm, a new National Action Plan was released today by the Institute for Healthcare Improvement’s (IHI) National Steering Committee for Patient Safety (NSC).

The plan is designed to provide health systems with advice and directions based on evidence-based practices, case studies, interventions, and new innovations. The report, Safer Together: A National Action Plan to Advance Patient Safety, was put together with the input of 27 federal agencies, safety organizations and experts, and patient and family advocates.

“The plan shows how leaders can move from measurement to action,” said NSC Co-Chair Jeffrey Brady, MD, MPH, who directs the Center for Quality Improvement and Patient Safety at the U.S. Agency for Healthcare Research and Quality, during a IHI-hosted press call.

One goal of the plan is to create an “anti-silo effect,” he noted. “We know that no single person or organization alone can guarantee patient safety. Working together is a must.”

The plan focuses on four areas: Culture, leadership and governance, workforce safety, and learning systems. To help organizations act on the recommendations in these areas, the plan includes a 41-page report with implementation tactics, case examples, tools, and resources. These are available online, including a downloadable self-assessment tool and an implementation resource guide.

Workforce safety is a major focus in the report because of the inherent risks in the healthcare profession, said Mary Beth Kingston, PhD, RN, NEA-BC, chief nursing officer at Advocate Aurora Health, who co-chaired the NSC subcommittee on workforce safety. “Healthcare has one of the highest rates of illness and workplace injuries of any industry,” she said. “Psychological and emotional injuries can also occur.”

Medical errors can also lead to emotional trauma for caregivers, and there is also moral distress, which arises from situations when policies or procedures prevent caregivers from doing what they think is right, Kingston added. Organizations must create a culture of safety that promotes psychological well-being, she said.

In addition, “the risk of exposure to infectious disease is not new to healthcare,” she said. But “it has been tremendously magnified by COVID-19.”

Patient and family engagement has come a long way, but there’s more to be done, said Helen Haskell, MA, founder of Mothers Against Medical Error, who worked on the National Action Plan. “Patient safety, for all its years of trying, hasn’t progressed the way it should have,” she said. “Progress in patient engagement has been one of the bright spots,” but we can do better.

The pandemic has made it difficult for organizations to keep patients and families engaged in their care, Haskell noted. “Healthcare organizations responded to the pandemic by unilaterally keeping patients and families apart,” she said.

The new action plan provides tools to help healthcare organizations achieve these patient engagement goals and “help take this to the next level,” Haskell added.

Tejal K. Gandhi, MD, MPH, CPPS, IHI senior fellow and chief safety and improvement officer, Press Ganey Associates, said the report includes different timelines for its recommendations, some that can be done in the short term and others that will take years to accomplish.

“The report is certainly geared mainly to leaders across all the sectors of healthcare,” said Gandhi, co-chair of the NSC.  “It’s meant for leaders to take stock of what they’re doing.”

Work on the report began in 2018 and was completed in January 2020, prior to the COVID-19 pandemic reaching the U.S., Gandhi said. The recommendations were re-evaluated during the pandemic, but everything remained relevant, she added.

Releasing the action plan in the midst of a pandemic creates more will to achieve the recommendations it sets out, said Kedar Mate, MD, president and CEO of the IHI. “There’s been a tremendous wealth of new ideas,” he said. “Execution on ideas is harder. Can we maintain the energy and focus like we know we must?”