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Practice paper

Safer Together: A national action plan to advance patient safety

P. Jeffrey Brady, Tejal K. Gandhi, Patricia A. Mcgaffigan, Adam Novak and Sam R. Watson
Management in Healthcare: A Peer-Reviewed Journal, 6 (2), 155-168 (2021)
https://doi.org/10.69554/WZYM5292

Abstract

Healthcare leaders have a duty to ensure that their organisations are safe for those receiving care and for those providing it. Despite the efforts of many organisations across the United States, progress in patient safety improvement remains limited. Lack of a unifying strategy and challenges with coordination have limited substantial improvements in patient safety. In response, the Institute for Healthcare Improvement convened a group of national organisations that formed the National Steering Committee (NSC) for Patient Safety. The NSC’s charter was to develop ‘Safer Together: A National Action Plan to Advance Patient Safety’ (Safer Together). Guided by core principles, Safer Together focuses on four foundational and interdependent areas: culture, leadership and governance; patient and family engagement; workforce safety and the learning system. Safer Together provided 17 recommendations and related tactics across each of the four foundational areas. The recommendations are supported by an organisational Self-Assessment Tool and an Implementation Resource Guide. The Safer Together action plan highlights important interdependencies among the foundational areas and the coordination and collaboration that are necessary to drive safety improvement, as well as the importance of ensuring equity in all four foundational areas. Patient and healthcare worker safety should garner more attention as the US healthcare system continues to shift from fee-for-service to valuebased payment. As a result, organisations that maintain safety as a core value will be better situated to respond to the changing reimbursement landscape. Leadership must establish safety as a core value of the organisation, then leverage their influence to foster and sustain the implementation of the foundational areas and the recommendations. Organisations that devote resources towards ensuring safety are better positioned to improve value because of less harm to both patients and staff. The following sections of this paper describe in more detail the foundational areas outlined in Safer Together, provide practical examples of what success looks like and underscore the role of the healthcare leader as a structural linchpin.

Keywords: patient safety; leadership; culture; workforce safety; learning systems; patient and family engagement

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Author's Biography

P. Jeffrey Brady Jeffrey Brady MD, MPH, has served as the Director of AHRQ’s Center for Quality Improvement and Patient Safety since 2014. He is as a member of AHRQ’s Senior Leadership Team and manages a part of the Agency that conducts several AHRQ programmes, including patient safety research, prevention of healthcare- associated infections and others focused on improving health-care quality for patients. Dr. Brady led the AHRQ Patient Safety Research Program from 2009 to 2014, and in a prior position, he led the team that produces the National Healthcare Quality and Disparities Report, an annual report to Congress on the status of health-care quality in the United States. Before moving to AHRQ in 2006, Dr. Brady served as a medical officer for the Food and Drug Administration’s Office of Vaccines. Additionally, he has held positions as a medical epidemiologist for the Department of Defense and as a primary care physician aboard the U.S.S. Coronado while serving in the U.S. Navy. Rear Admiral Brady retired from active duty in the Commissioned Corps of the U.S. Public Health Service in 2019. He attended the Medical College of Georgia, completed internship training in internal medicine at the Naval Medical Center, San Diego, California, and earned a master’s degree in public health from the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland. Dr. Brady completed the Navy’s general preventive medicine residency, also at USUHS, and is board certified in public health and general preventive medicine.

Tejal K. Gandhi Tejal Gandhi MD, MPH, CPPS, is the Chief Safety and Transformation Officer at Press Ganey. In this role, Dr. Gandhi is responsible for advancing the Zero Harm movement, Brady: 301-427-1322 Gandhi: 800-232-8032 improving patient and workforce safety and developing innovative health-care transformation strategies. In addition, Dr. Gandhi leads the Press Ganey Equity Partnership to advance equity in health care. Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programmes focusing on improving patient and workforce safety. Prior to this, Dr. Gandhi was President and Chief Executive Officer of the National Patient Safety Foundation (NPSF) from 2013 to 2017. In 2019, Dr. Gandhi was elected as a member of the National Academy of Medicine. She is a recipient of the John M. Eisenberg Patient Safety and Quality Award, conferred in recognition of her contributions to understanding the epidemiology of medical errors in the outpatient setting and for developing prevention strategies. Dr. Gandhi has also been named as one of the ‘100 Most Influential People in Healthcare’, ‘Top 25 Women in Healthcare’ and ‘50 Most Influential Clinical Executives’ by Modern Healthcare. An internist by training, Dr. Gandhi previously served as Executive Director of Quality and Safety at Brigham and Women’s Hospital and as Chief Quality and Safety Officer at Partners Healthcare.

Patricia A. Mcgaffigan Patricia McGaffigan is Vice President at the Institute for Healthcare Improvement where she is IHI’s senior sponsor for the National Steering Committee for Patient Safety, and President of the Certification Board for Professionals in Patient Safety. She is the former Chief Operating Officer and Senior Vice President of Safety Programs at the National Patient Safety Foundation. Patricia is a Certified Professional in Patient Safety (CPPS), a graduate of the AHA-NPSF Patient Safety Leadership Fellowship Program and is a member of the Joint Commission National Patient Safety Committee, the Joint Commission Journal on Quality and Patient Safety Editorial Advisory Board and the Advisory Committee of the Coalition to Improve Diagnosis. Patricia serves as a Board Member of the Massachusetts Coalition for the Prevention of Medical Errors and on Planetree’s Person-Centered Certification Committee. Patricia represents IHI on numerous committees, taskforces and professional panels and is a frequent speaker at national and regional conferences. A recipient of the Lifetime Member Award from the American Association of Critical Care Nurses, Patricia received her BS in Nursing from Boston College and her MS in Nursing from Boston University.

Adam Novak MA, CPPS, is Director of Safety Initiatives at the Michigan Health & Hospital Association (MHA) Keystone Center. He manages all aspects of the MHA Keystone Center Patient Safety Organisation and oversees the development and deployment of patient safety culture–improvement efforts across all departmental projects under the umbrella of high reliability. Adam led the design and launch of the MHA Keystone Center Speak-Up! Award, a proven tool to promote culture and reduce costs and harm in healthcare. He also spearheads the MHA workforce safety collaborative, maternal health hypertension and diagnostic error reduction efforts. Adam currently serves as an editorial review board member for the peer reviewed journals Patient Safety and Journal of Healthcare Risk Management. Previously, Adam coordinated the implementation of the MHA Keystone Center patient and family engagement and pain management programmes. He also coordinated efforts for the CUSP 4 MVP-VAP, an AHRQ initiative to implement evidence-based best practices to prevent ventilator-associated pneumonia in 38 U.S. states, Puerto Rico and Saudi Arabia. Prior to joining the MHA, he worked with the Ingham County Health Department in Lansing, Michigan, on Community Health Assessment, Emergency Preparedness and Nurse–Family Partnership programmes. Adam earned his BA in communication with a specialisation in public relations and his MA in health & risk communication from Michigan State University. He is also a TeamSTEPPS Master Trainer, Just Culture Champion and holds the CPPS credential.

Sam R. Watson MSA, MT(ASCP), CPPS, is Senior Vice President of Field Engagement for the MHA. In this role, Watson leads member services and develops strategic relationships with stakeholders to further the mission of the MHA. Additionally, Watson provides executive leadership for the education division and the MHA Keystone Center. Watson has been recognised as one of the ‘50 Experts Leading the Field of Patient Safety’ by Becker’s Hospital Review, a leading health-care publication. Over the years, Watson has led numerous efforts to build collaborative relationships across multiple entities in Michigan and beyond, most recently, co-leading the creation of Superior Health Quality Alliance, an eight-organisation consortium that addresses quality and safety through federally funded contracts. Prior to being named Senior Vice President of Field Engagement, Watson led the MHA Keystone Center in its efforts to improve patient safety and quality, including federally funded Hospital Engagement Networks, Hospital Improvement Innovation Networks and many statewide quality initiatives, with focus areas such as surgery, obstetrics, hospital-associated infections, emergency departments, sepsis, falls, pressure ulcers, venous thromboembolism and care transitions. Watson currently serves on several professional organisations and committees, including the boards of directors for IHI, Christian Life Services–Holland Home, Spectrum Health West Michigan and the Michigan Homecare and Hospice Association.

Citation

Brady, P. Jeffrey, Gandhi, Tejal K., Mcgaffigan, Patricia A., Novak, Adam and Watson, Sam R. (2021, December 1). Safer Together: A national action plan to advance patient safety. In the Management in Healthcare: A Peer-Reviewed Journal, Volume 6, Issue 2. https://doi.org/10.69554/WZYM5292.

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cover image, Management in Healthcare: A Peer-Reviewed Journal
Management in Healthcare: A Peer-Reviewed Journal
Volume 6 / Issue 2
© Henry Stewart
Publications LLP

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