The Institute for Healthcare Improvement along with nearly 30 federal and private stakeholders on Monday released a comprehensive plan for the industry to improve patient safety.
The 41-page plan is part of the ongoing work by IHI's National Steering Committee for Patient Safety, which was formed in May 2018 over concerns that progress on patient safety has slowed in recent years due to a siloed approach and renewed attention on a national scale was needed. The committee involves 27 organizations including CMS, the Agency for Healthcare Research and Quality and the Joint Commission, which collaborated over 18 months to assemble the plan.
"We don't tend to work together (on patient safety) in a coordinated and collaborative way and it often results in the front lines getting recommendations and advice coming at them in many different directions," said Dr. Tejal Gandhi, co-chair of the committee and IHI senior fellow. "We believe if we all work together and are synergistic, rather than uncoordinated, we can go further faster."
The action plan has 17 recommendations for healthcare organizations based on four topic areas the committee deemed essential to improve patient safety: culture, leadership and governance; patient and family engagement; workforce safety; and learning system.
The recommendations are based on peer-reviewed literature, best practices or advice from experts in the field. An example of one of the recommendations is making leadership accountable for physical and psychological safety of the workforce. The report then lists several tactics to achieve this such as by integrating workforce safety in job descriptions for management roles.
The recommendations in the action plan were completed in January, before the COVID-19 pandemic rocked the healthcare industry in March, but committee members insist they are still relevant.
"As the pandemic has evolved we have been impressed by how the plan is as relevant for addressing the new challenges from COVID as it is for long-standing patient safety problems," said Dr. Jeffrey Brady, co-chair of the committee and director of the Center for Quality Improvement and Patient Safety at AHRQ.
COVID-19 brought more attention to physical and psychosocial safety of the healthcare workforce, the importance of engaging with patients and families and the value of strong leadership, all of which the action plan dives into, added Dr. Kader Mate, CEO of IHI.
"There is almost no question that COVID creates more will for many of these recommendations in the action plan," Mate said, adding it's a matter of staying focused on these issues long after the pandemic is over.
The plan also has a guide to help organizations implement the recommendations as well as a self-assessment tool to help leaders understand where to start on the action plan.
IHI is calling on the 27 committee members to spread the word about the action plan to healthcare organizations. Gandhi said the plan was created for leaders of all kinds of healthcare organizations.
There isn't a concrete timeline for when IHI expects to see progress on the recommendations, but Gandhi said the committee will reach out to organizations using the plan and regularly meet to gauge progress. "We don't want this to be a report that sits on a shelf," she said.
The action plan is available for free to download on IHI's website.
