Everyone Plays a Role In Total Systems Healthcare Safety
The Institute for Healthcare Improvement’s (IHI) To Err Is Human (2000) and Crossing the Quality Chasm (2001) reports gave great momentum to patient safety programs and influenced regulations and standards. And yet, “unacceptably high rates of preventable harm….for both patients and the workforce,” remain, the IHI stated. Now, an IHI-led consortium called the National Steering Committee for Patient Safety (NSC) aims to galvanize national collaboration to decrease preventable harm in healthcare.
The NSC’s new National Action Plan to Advance Patient Safety urges total systems safety that involves everyone. It recognizes that areas across the healthcare continuum must accelerate and sustain improvements to prevent harm. After all, we’re all patients and stakeholders in our healthcare system.
Members of the movement
An “all hands” approach to making healthcare safe, reliable, and free from harm is reflected in the consortium’s 27 charter members, which include:
- Healthcare organizations and systems
- Patients, families, and care partners
- Professional societies
- Safety and quality organizations
- Regulatory and accreditation bodies
- Federal agencies
According to the NSC, thousands of fragmented safety initiatives are in place in individual organizations or collaborations across the country and the world. And many have made progress in reducing harm. Yet, collectively, our healthcare system still fails a percentage of patients, families, and healthcare workers.
The NSC created its plan with the recognition that healthcare organizations are at different points in their progress toward creating safer care, and with the understanding that its recommendations would have to apply across different settings, specializations, and populations served.
Most significantly, the plan gives actionable recommendations, clear direction and tactics, and measurement strategies for healthcare organizations striving for the safer delivery of care. The consortium deployed subject-matter experts to establish the recommendations and delivered three downloadable resources: a summary report, a self-assessment tool, and an implementation guide. The NSC has stated, however, that it won’t engage in policy development or provide a finite list of measures.
Guiding principles to partner and share data
The NSC’s vision and principles start with the premise that every participant in healthcare must contribute to ensuring that healthcare is safe and reliable, and speak up when issues or inequities are seen. Its charter member organizations committed to eight core principles, urging others to adopt them as well. They are:
- Work together to drive greater urgency to prevent harm to patients and those who care for them in all settings across the care continuum.
- Strengthen the foundation for eliminating harm by ensuring that leaders actively promote a culture of safety, the spread of learning systems, patient and family engagement, and workforce safety.
- Partner with patients, families, and care partners and commit to open, honest, and respectful communication to create safe, person-centered health care.
- Coordinate and collaborate to achieve large-scale sustainable improvement in safety.
- Transparently share successes and failures within and across organizations and industries to promote learning and improve outcomes for all.
- Advance health equity so that everyone has the safest care, and no one is disadvantaged due to demographic characteristics or social determinants.
- Support policies and regulations that will improve patient safety.
- Advance the National Action Plan to Advance Patient Safety.
Healthcare governance, risk, and compliance’s role
Ensuring that our healthcare workforce is supported is essential to establishing total systems safety. Without the same support, respect, resources, and attention given to patients’ safety, providers and personnel can’t fulfill their potential and/or are “more likely to fail to follow safe practices, not work well in teams, and make errors,” according to the IHI.
What will it take, on a practical level, to advance healthcare safety and quality efforts? Increasingly, it means more commitment to collaboration not only within any organization but with individuals and entities like those represented in the NSC’s volunteer consortium.
Healthcare governance, risk, and compliance (GRC) professionals—whether their job is to focus on credentialing, privileging, governance support, quality, or risk and compliance—are uniquely positioned to support providers and administrators in three areas that the NSC prioritized (the other area being Patient and Family Engagement):
- Culture, Leadership, and Governance
- Workforce Safety
- Learning System
GRC professionals help move the needle on safer care and the reduction of harm in the following concrete ways:
Identifying documenting, and mitigating regulatory compliance risks.
How organizations track and manage issues and investigations is a unique process. However, ensuring that activity enterprise-wide, by all participants, is coordinated, risk-based, and handled according to compliance and regulatory guidelines is universal. Compliance, risk, and quality professionals define and assign responsibilities for each action to mitigate issues. They monitor results in real-time to ensure proper management, reporting, and resolution.
Collecting, analyzing, and reporting data on incidents and near misses.
Incident management is a potentially powerful improvement tool, but it can’t succeed without participation at all levels. To make it successful, all parties—administration/management, clinicians, staff, and patients—must have access to event reporting tools and training on how it works. It’s incumbent on provider data management professionals to develop a robust program that encourages everyone to report incidents, near-misses, and errors in a blame-free environment, and to learn from the events toward the goals of greater patient safety and quality.
Driving safety and quality through meaningful provider evaluations.
Practitioner performance evaluations must evolve along with safety intervention programs, such as the NSC’s, that aim to reduce harm. Whether a negative outcome becomes public or not, GRC professionals can guide administrations in reassuring all parties that there are ongoing processes in place to evaluate provider and hospital performance every day. In addition, they can point to focused review processes used to evaluate any patient care and safety issue that occurs. The goal of constant vigilance to defend against possible human errors and to always improve patient safety must not eclipse the need to truly focus on provider support, improvement, and retention.
Providing compliance and other guidance.
GRC professionals educate and train administrators, providers, and support staff on accreditation and regulatory issues, and interpret standards and regulations. Specifically, they offer expertise and technical assistance, consultation, and training to associates and service colleagues regarding laws, statutes, rules, regulations, and standards related to performance improvement and patient safety. Further, they analyze data for trends and recommend to hospital leaders corrective action and foster a just culture for reporting variances.
Ensuring policies and procedures are updated to reflect modern methods of shared accountability for healthcare safety.
A large percentage of provider data management professionals’ jobs is ensuring compliance with regulations, accreditors, bylaws, and P&Ps. They facilitate the committees that affect safety and quality—such as the MEC, Quality/Peer Review, Performance Improvement, and departmental committees. As such, they can inform and influence physician leaders to consider and adopt total systems safety.
The NSC has begun the new, national movement to reduce preventable harm in healthcare. What will be your contribution to the new total systems approach to safety?
About Joni Orand
Joni Orand has worked in the healthcare industry for twenty eight years’, in both managed care and hospital environments, working with providers and staff gaining unparalleled experience in all aspects of provider management and quality improvement initiatives. She holds a degree in Corporate Communications, with minors in Interpersonal Communication and International Studies in Communications. Joni is a certified trainer, speaker and coach, and is known for helping, educating, and supporting clients as they develop quality improvement plans. Currently working as a Senior Solution Consultant for symplr, Joni speaks as a Subject Matter Expert at industry events.