Advancing Patient Safety Together

What follows is an interview with Jeffrey Brady, MD, MPH, director of the Agency for Healthcare Research and Quality (AHRQ)'s Center for Quality Improvement and Patient Safety, who also served as the co-chair of the National Steering Committee for Patient Safety.

Who makes up the National Steering Committee for Patient Safety (NSC) and how was it formed?

The NSC is made up of 27 influential federal agencies, safety organizations and experts, and patient and family advocates, brought together by the Institute for Healthcare Improvement, a global leader in health and healthcare improvement worldwide. Several Coalition to Improve Diagnosis members were represented.

The Steering Committee came together in 2018 to form a first-of-its-kind coalition with a shared aim to bring a renewed focus to the persistent problem of patient harm. Some members had observed a sense of complacency in the field and that other priorities were pushing patient safety to the back burner. For the Steering Committee, this prompted an urgent need to re-energize and better coordinate efforts to improve patient safety, build upon accomplishments, and move to accelerate the pace of learning.

What is the National Action Plan and how did it come about?

The NSC built the Safer Together: A National Action Plan to Advance Patient Safety Implementation Resource Guide to focus on four foundational areas, which were deliberately chosen because of their essential relevance for ensuring safety across the continuum of care:

  • Culture, Leadership, and Governance reflect the imperative for leaders, governance bodies, and policymakers to demonstrate and foster deeply held professional commitments to safety as a core value and promote the development of cultures of safety.
  • Patient and Family Engagement focus on the spread of authentic patient and family engagement—in particular, the practice of co-designing and co-producing care with patients, families, and care partners to ensure their meaningful partnership in all aspects of care design, delivery, and operations.
  • Workforce Safety specifies the commitment to the safety and fortification of the healthcare workforce as a necessary precondition to advancing patient safety.
  • Learning Systems address the establishment of networked and continuous learning for improvement.

“For the NSC, releasing the Plan feels a bit like the end of a long journey, but it really is just the beginning,” explained Dr. Brady. “We want to engage every stakeholder, and, whether it's a small practice, a hospital, a health system, an association or government agency, almost every stakeholder working in health care can find helpful information in this Plan and discover recommendations they can actively work on. We hope the National Action Plan sparks the beginning of the next phase of patient safety improvement.”

Why did AHRQ become involved in the National Action Plan?

“AHRQ, as the Federal Government’s lead patient safety agency, has a history of experience and expertise in the four essential areas that emerged from the Steering Committee’s discussion:

AHRQ believes that patient safety culture—that is, fostering a healthcare environment in which all participants believe and work in ways that prioritize patients’ wellbeing—is a critical first step to making care safer. Resources, including the AHRQ Surveys of Patient Safety Culture, enable healthcare organizations to assess how staff perceive various aspects of safety culture.

By conducting research and providing training, tools, and data for the field to use, AHRQ supports the development of learning health systems, or health systems that systematically learn about and improve care. In a learning health system, internal data and experience are systematically integrated with external evidence. When organizations establish successful learning systems, patients benefit from a “virtuous cycle” of constant learning that leads to better—and safer—care.

Fostering better patient and family engagement has long been a theme integral to numerous AHRQ initiatives. Encouraging communication among providers, patients, and families, and engaging patients in all aspects of care improvement activities, can reveal important opportunities that otherwise may be missed.

Often intertwined with safety culture, clinicians’ physical and emotional well-being are major issues in their own right. It is difficult to imagine safe care being delivered by clinicians who themselves do not feel safe. Since 2001, AHRQ has been funding research on clinicians’ working conditions to understand what causes burnout and explore interventions to combat it.

AHRQ also acknowledges the need to remain vigilant and continues to address specific targets that can threaten safety,” said Dr. Brady. “All the familiar concerns, from medication safety to pressure injuries, and healthcare-associated infections remain important. Continuous learning, on both foundational and specialized topics, should drive future efforts to improve safety.”

How can other Coalition members become involved in the work of the Action Plan and contribute to the mission?

Coalition members can respond to the national call to action, in which the NSC invites all healthcare leaders and organizations to stand with us and take decisive action to advance the recommendations outlined in the Plan.

“The active engagement of all stakeholders who make up the healthcare system, including policymakers, governance bodies, professional advocacy groups, and clinicians, is critical to the successful implementation of the Action Plan,” said Dr. Brady.

Two supplementary materials offer further guidance to contribute to the mission:

  1. The Self-Assessment Tool which helps leaders and organizations determine where to start on their respective safety work, set goals for progress, and track progress over time.
  2. The Implementation Resource Guide which details tactics and supporting resources for identifying relevant actions based on the self-assessment tool and implementing the National Action Plan recommendations.

The Plan is envisioned to be especially helpful to organizational leaders, who play a critical role in establishing, maintaining, and promoting a culture of safety, the spread of learning systems, patient and family engagement, and workforce safety.

“The Action Plan helps direct attention to these interdependent areas, which have substantial, wide-ranging influence on many aspects of patient safety,” said Tejal K. Gandhi, MD, MPH, CPPS, NSC Co-Chair, IHI Senior Fellow, and Chief Safety and Transformation Officer at Press Ganey. “Accelerating improvement in each of these areas will mutually support improvement in others and create the fertile soil that allows broader safety initiatives to take root and be cultivated.”

How has participation in the Coalition to Improve Diagnosis impacted your work?

“The mission and activities of the Coalition to Improve Diagnosis are well-aligned and mutually supportive of the vision of the NSC that guided the development of the Safer Together: A National Action Plan to Advance Patient Safety to ensure that health care is safe, reliable, and free from harm,” said Dr. Brady. “It is difficult to pursue that vision without correct and timely diagnoses, and the Coalition’s focus on this critically important aspect of health care is entirely consistent with the NSC’s core principles and the kind of productive collaboration that is necessary to accomplish meaningful improvements that benefit patients.”

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