Putting the Patient in Patient Safety

Outcomes still matter. They really do.

Amidst all the talk about making care more accessible and convenient and making care more affordable and valuable, making care safer often gets lost drowned out in the conversation.  

So, it’s nice to hear that someone is still thinking about patient safety because the healthcare industry in the U.S. is still accidently killing thousands of patients a year.  

That someone last week was the Institute for Healthcare Improvement, which released a 41-page report called Safer Together: A National Action Plan to Advance Patient Safety. You can download the IHI’s plan here to celebrate World Patient Safety Day on Sept. 17. 

The report is the work product of the IHI-convened National Steering Committee for Patient Safety, a group of representatives from 27 national organizations “committed to advancing patient safety.”

The NSC organizations include the American College of Healthcare Executives, the American Hospital Association, the American Nurses Association, the Joint Commission, Mothers Against Medical Error, the Agency for Healthcare Research and Quality, American Society of Health-System Pharmacists and the Betsy Lehman Center for Patient Safety. 

(Now, unless I missed it, I didn’t see the American Medical Association or any state medical societies on the list. I’m sure there’s an interesting back story there, but I’ll leave it to my 35-year-old self to find out what excuse the AMA and state medical societies have for not participating.  I’m sure it’s a good one.)

The steering committee said this report is different from all other previous reports calling for action on patient safety because “it was created based on the NSC’ members’ unified determination to refuse to accept preventable harm and their eagerness to act.” Or, to put it another way, past patient safety calls to action didn’t work because industry stakeholders weren’t unified, accepted some level of preventable harm and weren’t champing at the bit to do something about it. 

To me, that’s the most refreshing aspect of this new report. The people responsible for not accidentally killing patients are collectively pointing the finger at themselves for not taking patient safety as seriously as they should, and they’re promising to do something about it now. 

The report goes on to detail 17 recommendations in four domains to put the IHI’s plan into action.  Most of the recommendations are the usual create-a-cultural-of-safety stuff. But, what I think makes this plan different than most is the goal of making patients and patients’ families partners to make care safer. 

Who among us hasn’t said or at least thought that it was a good thing they were in their (mom’s, dad’s, wife’s, husband’s, son’s, daughter’s, etc.) hospital room or physician’s office or something terrible was going to happen. 

One of the report’s four domains is “patient and family engagement,” and the recommendations in the domain, verbatim, are:  

• “Establish competencies for all health care professionals for the engagement of patients, families, and care partners”
• “Engage patients, families, and care partners in the co-production of care”
• “Include patients, families, and care partners in leadership, governance, and safety and improvement efforts”
• “Ensure equitable engagement for all patients, families, and care partners”
• “Promote a culture of trust and respect for patients, families, and care partners”

I’m not much for the Oxford commas, but I’m all for taking patients and their families seriously. Patients and their families know when something is wrong. They know what medications they’re on. They know that they just took the same diagnostic laboratory test at another hospital or physician’s office.

It’s no different from businesses in any other industry taking their customers seriously. Healthcare is a business, and patients are the customers.  

If the signers to the report’s declarations do what they say they’re going to do, this plan may actually have a chance of working because patients will be part of the patient safety equation. 

If not, we’ll be writing about this report on its 20-year anniversary, saying we’ve made progress but we have a long way to go to make care safer. Let’s not do that again. 

Thanks for reading.

Stay home. Stay safe. Stay alive. 

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