National Action Plan Seeks to Renew Momentum on Patient Safety
The National Steering Committee for Patient Safety (NSC) has released a National Action Plan intended to provide health systems with renewed momentum and clearer direction for eliminating preventable medical harm.
Convened by the nonprofit Institute for Healthcare Improvement, the NSC’s effort is called “Safer Together: A National Action Plan to Advance Patient Safety” and draws from evidence-based practices, widely known and effective interventions, exemplar case examples, and newer innovations. The plan is the work of 27 federal agencies, safety organizations and experts, and patient and family advocates, first brought together in 2018 by IHI.
“The way in which diverse groups and patient advocates who are interested in patient safety came together to forge the National Action Plan is unprecedented, and it underscores the necessity to work together to create the safest health care possible,” said NSC Co-Chair Jeffrey Brady, M.D., M.P.H., who directs the Center for Quality Improvement and Patient Safety at the U.S. Agency for Healthcare Research and Quality, in a statement. “Over the past 20 years, the field has amassed a tremendous body of knowledge to improve healthcare safety. What’s been missing is the use of this knowledge for more coordinated action. That’s what we want to rectify.”
Although development of the National Action Plan was initiated prior to the onset of the COVID-19 pandemic, the core principles and recommendations are relevant to the crisis, IHI notes. In addition, COVID-19 has exposed the health consequences of inequities that have persisted for decades across health and healthcare. The National Action Plan highlights advancing health equity as a core principle of its recommendations and compiles resources to help health systems address and eliminate inequities at the point of care and in the community.
The insights and recommendations in the National Action Plan center on four foundational areas deliberately chosen because of their widespread impact on safety across the continuum of care: Culture, Leadership, and Governance; Patient and Family Engagement; Workforce Safety; and Learning Systems. The National Action Plan offers 17 recommendations, under those four categories:
Culture, Leadership, and Governance
1. Ensure safety is a demonstrated core value.
2. Assess capabilities and commit resources to advance safety.
3. Widely share information about safety to promote transparency.
4. Implement competency-based governance and leadership.
Patient and Family Engagement
5. Establish competencies for all health care professionals for the engagement of patients, families, and care partners.
6. Engage patients, families, and care partners in the co-production of care.
7. Include patients, families, and care partners in leadership, governance, and safety and improvement efforts.
8. Ensure equitable engagement for all patients, families, and care partners.
9. Promote a culture of trust and respect for patients, families, and care partners.
Workforce Safety
10. Implement a systems approach to workforce safety.
11. Assume accountability for physical and psychological safety and a healthy work environment that fosters the joy of the health care workforce.
12. Develop, resource, and execute on priority programs that equitably foster workforce safety.
Learning System
13. Facilitate both intra- and inter-organizational learning.
14. Accelerate the development of the best possible safety learning networks.
15. Initiate and develop systems to facilitate interprofessional education and training on safety.
16. Develop shared goals for safety across the continuum of care.
17. Expedite industry-wide coordination, collaboration, and cooperation on safety.
A Self-Assessment Tool assists leaders and organizations in deciding where to start on their respective work and is designed to allow organizations to track progress over time. An Implementation Resource Guide details tactics and supporting resources for implementing and measuring the National Action Plan recommendations.
One foundational area, Workforce Safety, is the focus of this year’s World Patient Safety Day, organized by the World Health Organization and taking place Sept. 17. The theme recognizes the risks to health and safety which front-line caregivers and workers have faced while taking care of patients before and during the COVID-19 pandemic.
