At the White House’s Tuesday morning forum, speakers from the private and public sectors said issues around patient and workforce safety are finding new buy-in from those at the top.
The Biden administration met World Patient Safety Day with a blitz of new programs, panel discussions and commitments from government agencies as well as healthcare industry organizations all focused on reducing harm within healthcare.At the top of that list is the formation of a cross-agency, public-private National Action Alliance for Patient and Workforce Safety.Headed by the Agency for Healthcare Research and Quality (AHRQ), the initiative is planning to develop and release a National Healthcare Safety Dashboard to display nationwide progress against preventable patient and workforce harm. The dashboard will reflect all settings of care but will begin with hospitals.Meanwhile, the Centers for Disease Control and Prevention will be releasing new guidance for hospitals focused on cutting down diagnostic testing errors, as well as working with the Centers for Medicare & Medicaid Services (CMS) on new measures surrounding sepsis, the White House said.CMS further plans to incorporate patient safety into its public reporting and quality programs with an ultimate goal of cutting down payments for services that lead to harm. It will also put together a patient-reported safety measure.Elsewhere across the government are Safety Culture Commitments for the Veterans Health Administration around patient fall prevention and data system modernization, slated for 2025, and the National Institute for Occupational Safety and Health’s renewed commitment toward providing workplace violence prevention training to provider and degree programs.Outside of the government came concurrent safety commitments from nearly two dozen healthcare organizations highlighted by the administration.The Association of American Medical Colleges, for instance, said it would release a revised set of educational competencies focused on patient safety and quality improvement.The Ambulatory Surgery Center Association said it would partner with the Ambulatory Surgery Center Quality Collaboration to disseminate a new quality measurement tool across over 6,300 Medicare-certified surgery centers.And 16 of the country’s largest health systems—including names like CommonSpirit Health, Ascension, Novant Health, Trinity Health and Sanford Health—said they would take actions “that support providing safe care and zero preventable harm for all,” the administration said. About 1 in 4 Medicare patients experience an adverse event during their hospitalization, and more than 2 in 5 of those events could have been prevented, per data from the Office of Inspector General.The commitments and a related discussion forum held in the White House Tuesday morning “demonstrate the Biden-Harris Administration’s commitment to healthcare safety,” the administration said.They also reflect recommendations from Council of Advisors on Science and Technology, which this time last year advised the administration to, among other steps, partner with stakeholders and promote adoption of evidence-based harm reduction practices.Health systems share systematic strategies to reduce harm, build culture At the White House’s Tuesday morning forum, speakers from the private and public sectors said these issues are becoming priorities across the industry and finding new buy-in from those at the top. “The recognition that there is a crisis in American healthcare and that we can’t sit back has been accepted,” AHRQ Director Robert Otto Valdez said during a session. “And more importantly, healthcare executives also realized from a business perspective, providing high-quality care is in the best interest of not only their bottom line, but also their communities. In this world where we have a labor shortage, creating a culture of safety and innovation [with] continuous improvement and empowerment of all employees is really a selling point for finding people who want to work in your organization.”One series of conversations tapped leaders from Cincinnati Children’s Hospital, MedStar Health and Prisma Health to share firsthand how healthcare providers can take systematic approaches to prioritizing preventable harm within their organizations.Stephen Muething, M.D., chief quality officer at Cincinnati Children’s, recalled the formation of Solution for Patient Safety, a national network of roughly 150 children’s hospitals that share quality data and best practices to reduce patient harm.Children’s hospitals in Ohio, where a state-level iteration of network was formed 15 years ago, “saw that no other industry had made significant safety improvements by working independently,” he said. “It only came through cooperation across the industry, so we decided to stop competing on safety and start working together to eliminate serious harm.”The network’s transparent approach—member hospitals’ performances are updated monthly and shared online for anyone to see—has led to 28,000 less children being seriously harmed and $600 million in costs being driven out of the broader healthcare system, Muething said.Pamela Wendel, director of family relations at Cincinnati Children’s, noted the involvement of patient families in committees focused on reducing harm. The organization asks “specific questions about what is keeping people from participating or speaking up,” she said, and ensures that the involvement continues after a patient safety event has occurred “so we’re able to go past the hypothetical and really look at what was it that could have made a difference for that child.”Rollin Fairbanks, M.D., senior vice president and chief quality and safety officer at MedStar Health, also questioned healthcare’s resistance to outside influence.A safety engineer turned doctor, he said he was “shocked and dismayed” to find that “all of the safety science that was being applied in other industries was unknown to healthcare.” Rather than taking a proactive, evidence-based approach, “we were waiting until a patient’s injured and then trying to figure out what happened—and even then, we weren’t using good approaches.”One component of those poor post-event approaches was a culture of shame toward clinicians involved in the error. Fairbanks was joined by Andrea Geraci, clinical lead nurse practitioner at MedStar, who recounted an incident when she was suspended for what was eventually determined to be a glucometer malfunction.“After the event happened, all I could think about was the patient,” she said. “All I could think about was that I harmed someone and they could have possibly died because of something I did, so for days I didn’t eat, I didn’t sleep, I was just crying. … I felt I didn’t have the support. They disciplined me, suspended me … and then we moved on.”Geraci said she went from “loving my life to just hating my career,” and noted that fellow nurses stopped interacting with her when they’d seen she had fallen out of favor with management. She also recalled that colleagues told her “all the time” that they wouldn’t report incidents after seeing how she was treated.MedStar later did a systems-based event review and special simulation that exonerated Geraci and in doing so realized the damage her event had on workplace culture, Fairbanks said. The system created a video that featured Geraci to help other employees and “every single unit-level manager in our organization understand” the need for a comprehensive review and letting it run its course.Marcus Schabacker, M.D., CEO of healthcare safety nonprofit ECRI, who was leading the discussion, warned attendees that scenarios like Geraci’s happen “every single day in our hospitals and our practices, in our surgery centers. And we just need to move on from that, from that culture, and create that emotional and psychological safety for our staff and our patients.”But creating cultural changes and safer outcomes is no easy feat for organizations entrenched in their ways. At Prisma Health, Jonathan Gleason, M.D., vice president and chief medical officer, said the system made “a pretty radical” decision to completely redesign its clinical operating model in response to pandemic-era declines in patient safety. To do so, Gleason took a page out of other industries where high-performing companies will take “an intense focus, even obsession, on how the work at the front line is designed,” he continued. He and the system created a “holistic, simplified, branded set of workflows” within a singular playbook that defines how employees interact with each other and patients “and how all of that is supported seamlessly with technology throughout specific times of the day.”Since launching in October 2022, the overhaul has led to a 30% reduction in serious safety events and a 40% increase in event reporting, with anonymous reports falling from more than 50% of those submitted to 13%. Internal safety culture surveying is now 20 percentage points over the national average, he continued, while turnover and length of stay both decreased.“So we’ve gotten more efficient,” he said. “That has resulted in improved financial performance, which is so important for the largest Medicaid provider in South Carolina. … It is better business to be truly an operating company, where there’s an obsession with the design of the work even at the front line.” The other core components of that approach are transparency and cultural buy-in, Gleason and Acute Care Chief Medical Officer Greta Harper, M.D., explained.Harper—who had been with the organization for nearly 35 years and noted that the redesign “was very different than anything we [had] ever experienced or attempted to do in the past—noted that Gleason “shared a very clear vision for this new operating system and the plan as well. And along the way, he brought leaders up … in terms of what we could expect and then also, very importantly, how we could help inform, build and then … implement our new clinical operating system utilizing the playbook.”That new operating system also extended past leaders and into the workforce, the pair said. Prisma worked to make various data points available to executives and front-line staff alike in real time so that “everyone is an owner,” Gleason said. More broadly, it didn’t place any failings in quality on the workforce but gave everyone a stake in improving the collective.“Healthcare workers are pretty awesome people … that care deeply about their patients,” Gleason said. “They have missed birthday parties and holidays to gain the skills to take care of patients—they’re really not fundamentally the problem.“We as executives at the company, we say that. We say, ‘Not only is the system the problem, it is my problem and with your help we will fix it.’ That rings true to people who work in healthcare, and it’s also comforting to them, right? It gives them a sense of hope, and so they’re sort of automatically on board.”
