Groups   |   Careers   |   Sign In   |   Join Now
Search our Site
President's Corner
Blog Home All Blogs
The President’s Corner is a monthly column presenting the insights and reflections of the president and chief executive officer of the National Patient Safety Foundation. Readers wishing to post comments need to register and sign in to the website before posting a comment.

 

Search all posts for:   

 

Top tags: leadership  culture  diagnostic error  patient safety  patients  public health  transparency  AHRQ  ambulatory  Health IT  IOM  workforce safety  2016 NPSF Congress  board certification  collaboration  communication  communication and resolution  CRP  diagnosis  education  emotional harm  families  flu  health communication  health literacy  IHI  measurement  medical education  medication  networking 

Into the Future with IHI, Together for Safer Care

Posted By Administration, Yesterday
Updated: Monday, April 24, 2017

As NPSF celebrates its 20th anniversary, we prepare for the next chapter of advances in patient safety
with the Institute for Healthcare Improvement.



By Tejal K. Gandhi, MD, MPH, CPPS

 

Tejal K. Gandhi

NPSF was founded in 1997, so this year marks our 20th as a leading voice for patient safety. It is not unusual while observing such a milestone to take time to reflect on where we’ve been and where we are headed.


Health care, and the patient safety field, have changed considerably over the past 20 years. At the beginning, NPSF was all about raising awareness, because people were not talking about preventable harm in health care back then. The first NPSF Patient Safety Congress was held in 2001 with the theme being, appropriately, “Let’s Talk.”


Since then, we have kept talking—and working—with many individuals and organizations committed to making health care safer. Among them have been government agencies, private foundations, professional societies, researchers, patients and patient advocates, industry, health care leaders, and frontline staff. NPSF has long held the position that everyone has a role to play in making health care safer. When we ask people about the Foundation’s place in the patient safety field, it is not unusual to hear the words “big tent,” an indication that NPSF has always been keen to invite those with diverse experiences and perspectives to share them in the interest of advancing our shared mission.

 

A notable change over the years has been a broadening of the definitions we use for patient safety. Initially, medical errors got the most attention and they were closely defined as adverse events or errors of omission or commission. More recently, patient safety has become the operative ambition for broad, organizational culture change and “systems of safety” that can prevent a wide range of harms, including those that are born of disrespect, poor communication, and insensitivity.

Back to top

 

We’ve also seen wide acceptance of the fact that faulty systems, not bad people, are the cause of preventable harm in health care. Improving systems is an ongoing effort, because new therapies and technologies are introduced every day. Vigilance is required to avoid unintended consequences of any new tool.


   

Another advance has been the growing emphasis on the importance of joy, meaning, and workforce safety as a precondition to patient safety. We can never truly ensure the safety of patients if those who are caring for them are at risk of injury or emotional or psychological harm from disrespect or bullying.


Perhaps most significant, patient safety is now recognized as a unique discipline in health care, with more than 1600 health professionals recognized as Certified Professionals in Patient Safety.

Topping the agenda for our 20th year has been a push to address patient safety as a public health issue and to focus on culture and leadership as the foundation for safe care. These are challenging efforts, and we are living in challenging times for health care. Continued progress requires bold moves, innovation, and collaboration.


This is why, in this year of celebration, NPSF and the Institute for Healthcare Improvement (IHI) have chosen to merge. NPSF has provided critical thought leadership with the aim of establishing safety as a core value in health care, and IHI has demonstrated an ability to influence large-scale, global change.


Together, officially as of May 1, we believe our combined knowledge, skills, and resources will be more effective in helping leaders and frontline clinicians meet all of today’s challenges and, together, we intend to develop some fresh approaches to focus and energize the patient safety agenda.


We want to ensure that safety is a central part of every organization’s improvement strategy today, and that the safety of patients and the health care workforce becomes a core value of health care systems around the world.


I will have the privilege of leading the safety programs at IHI, and I hope you will stay engaged with us as we move the mission forward.

What do you think has been the biggest advance in patient safety over the past 20 years? What advances do you hope to see in the near future? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Back to top

Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


This post has not been tagged.

Share |
PermalinkComments (1)
 

A Bold Move and a Call to Action

Posted By Administration, Monday, March 13, 2017
Updated: Friday, March 10, 2017

NPSF and the Institute for Healthcare Improvement are joining forces
in an effort to accelerate progress in patient safety.



By Tejal K. Gandhi, MD, MPH, CPPS

 

Tejal K. Gandhi

As many of you know, today marks the first business day of Patient Safety Awareness Week. This important week is a highlight of our United for Patient Safety Campaign and serves as dedicated time for raising awareness about patient safety among health professionals and the public.

With this in mind, today seems especially fitting to share the exciting news that NPSF and the Institute for Healthcare Improvement (IHI), are joining forces in an effort to accelerate progress in patient safety. The merger of our two organizations, which will be effective May 1, reflects a shared belief that patient safety is a public health issue and in need of a fresh and more robust approach. This bold move also reflects a strong commitment on the part of both organizations to making patient and workforce safety a core value in our health care institutions.

NPSF is also pleased to announce that IHI is among more than two dozen organizations that have endorsed the NPSF Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response, which released on our website today.

 

As we know, there is ample evidence to suggest that preventable harm in health care is a leading cause of death in the United States. In the Call to Action, NPSF calls on health care leaders and policymakers to initiate a coordinated public health response to improve patient safety and drive the collective work needed to ensure that patients and those who care for them are free from preventable harm.

Back to top

 

Building on successful efforts to reduce health care associated infections and taking advantage of critical lessons learned, the Call to Action provides a new public health framework to guide collective efforts. The six-part framework, which was developed with significant insight and perspectives from the NPSF Board of Advisors and Board of Directors as well as senior officials at the US Centers for Disease Control and Prevention, identifies effective, replicable interventions that can be implemented across the health care system. It begins with defining the problem and setting national goals and involves improving coordination of activities across sectors and stakeholders.


In our current political climate, leadership at the federal level may be uncertain. But that doesn’t mean others cannot or should not take on a roll in playing a part. As a first step, organizations can demonstrate their commitment to advancing patient safety by supporting the Call to Action.

 

We at NPSF look forward to working more closely with IHI as well as our many other endorsers to advance the components of the Call to Action in the coming year. I hope you will review our framework, share it with your peers, and get involved with us in creating solutions.

Do you believe patient safety is a public health issue? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Back to top

Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  IHI  public health 

Share |
PermalinkComments (0)
 

Swinging the Patient Safety Pendulum to Primary Care

Posted By Administration, Friday, February 10, 2017

Patient safety efforts in outpatient settings have been quietly advancing.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

This week, NPSF announced a project we are undertaking in collaboration with CRICO, the Risk Management Foundation of the Harvard Medical Institutions, to identify best practices for managing referrals using electronic health records (EHRs).

 

Breakdowns in referral management are common and can result in missed or delayed diagnoses and other lapses in patient safety. Closing the loop on referrals is vitally important to achieving correct and timely diagnosis and treatment, and research suggests that EHRs have the potential to close these loops. Through this collaboration, we hope to outline best practices.

I mention this project as an example of how patient safety in outpatient settings has been quietly advancing. As noted in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, we need more research, tools, processes, and structures specifically for ambulatory settings, where most health care is delivered.

Take primary care, for example. A recent review of studies published from 1980 to 2014 finds that patient safety incidents are relatively common in primary care, with roughly 2 to 3 incidents per 100 consultations. Of these, an estimated 4% result in harm, with the most severe cases of harm commonly associated with diagnostic or prescribing errors.

Back to top

Although considerable research is still needed into the causes of safety lapses in outpatient settings, we are also beginning to see resources developed that can help health care providers improve. In December, the Agency for Healthcare Research and Quality (AHRQ) began releasing resources as part of the Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. This project is modeled on a similar guide for the hospital setting. Led by MedStar Health Research Institute, the guide for the primary care setting provides resources in four main areas:

  1. Teach-Back: a technique for clearly communicating medical information to patients and families.
  2. Be Prepared to Be Engaged: a toolkit for patients and families to use that helps them get ready for medical encounters.
  3. Medication Management: a toolkit to help engage patients and caregivers in helping maintain accurate medication lists.
  4. Warm Handoff: a practice wherein transfer of care from one clinician to another is done with the participation of the patient and family.

As AHRQ notes, patient engagement has been shown to contribute to improved safety and quality. NPSF has long advocated that patient and family engagement at all levels of the health care system is a vital component of safe care. What works best in a hospital setting can be very different than what works in primary care, however, and the challenges are different. These new materials from AHRQ are a terrific resource for those working in primary care, and they can help frame an incremental approach to improvement.

Back to top

 

 
   

Another development comes from the World Health Organization (WHO). I had the privilege of serving as a reviewer last year on the WHO Technical Series on Safer Primary Care. Consisting of nine separate monographs on topics such as patient engagement, human factors, and transitions of care, this series delves into the scope and nature of harm in primary care settings.

Among its goals, the WHO project seeks to raise awareness among health professionals about the potential for safety lapses in primary care and to provide information about how to design and deliver safer care in that setting.


Raising awareness is a necessary first step in any improvement journey. The availability of these new resources is an encouraging sign that the patient safety pendulum is at last swinging to outpatient care.

What are your thoughts about improving the safety of primary care? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Back to top

 

Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


This post has not been tagged.

Share |
PermalinkComments (0)
 

Time to Step on the Accelerator

Posted By Administration, Wednesday, January 11, 2017

With recent gains in patient safety, let’s make sure we maintain focus.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

It snowed heavily in the Boston area this past weekend, resulting in challenging conditions for travelers. I watched one car try to make it up a hill during the worst part of the storm. Of course, driving in snow is hazardous, so we tend to slow down. But as the driver of that car discovered, slowing down can cause you to slip backward. Getting up a hill in difficult conditions requires that we maintain the right amount of momentum.

That’s what we are seeing in the patient safety field as well. As the field marks notable progress, now is the time to accelerate.

In December, the Agency for Healthcare Research and Quality (AHRQ) released the National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015. The agency estimates a 21% decline in hospital-acquired conditions (HACs)—such as pressure ulcers, adverse drug events, falls, and surgical site infections—since 2010. In real numbers, that amounts to 3.1 million fewer HACs than would have occurred had the 2010 rate remained unchanged. Moreover, AHRQ estimates that 125,000 fewer patients died as a result, and some $28 billion in health care costs was saved.

Back to top

 

But most important, the agency acknowledges, as we all must, that we are nowhere near done when it comes to patient safety. AHRQ estimates that in 2015 there were 115 HACs per 1,000 discharges. That is a lot of patients who still experienced preventable harm. Moreover, the definition of harm is broadening now to include both physical and psychological harm, which makes the opportunities for improvement even greater.

 

Furthermore, we must acknowledge how much care is delivered outside of hospitals, and how little we know about ambulatory safety. Improving the safety of care across the continuum is one of the recommendations made in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. It is encouraging that entities like AHRQ and the World Health Organization are turning some attention to primary care. I will be writing more about those efforts in a future column.

The HAC reduction effort detailed in the AHRQ Scorecard was largely fueled by programs and rules made at the federal level, including Medicare payment penalties and the Partnership for Patients initiative introduced as part of the Affordable Care Act. Today, there is much uncertainty about the future of the health care system and the federal government’s role. At NPSF, we remain hopeful that the commitment to better quality and safety will remain, particularly as it has been shown to be fiscally beneficial.

Back to top

 

In writing the preface to Free from Harm, Drs. Don Berwick and Kaveh Shojania, chairs of the expert panel that informed the report, note, “Today we must not let the many competing priorities in health care divert our attention from the important goal of preventing harm to patients. On the contrary—we need to keep our eyes on the road and step on the accelerator.”

As the New Year begins, that is what the National Patient Safety Foundation intends to do. We have a busy year ahead, and I hope you will join us however you are able.

What are your patient safety priorities for 2017? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Back to top

 

Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  patient safety 

Share |
PermalinkComments (0)
 

Five Notable Developments in Patient Safety in 2016

Posted By Administration, Tuesday, December 20, 2016

Progess was made in 2016, but there is much work to do in the patient safety field.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

Just about a year ago, the National Patient Safety Foundation released Free from Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human, a report offering eight recommendations for elevating national focus on patient safety. These recommendations continued to reverberate within the field in 2016, and guided my picks for five notable developments in patient safety this year.

  1. Developing a culture of safety (Recommendation 1): One of the chief messages of the Free from Harm report is that without a culture of safety, it is difficult for any organization to advance patient safety and sustain improvements. The report defines a culture of safety as one in which “health care professionals and leaders are held accountable for unprofessional conduct yet not punished for human mistakes; errors are identified and mitigated before they harm patients; and strong feedback loops enable frontline staff to learn from previous errors and alter care processes to prevent recurrences.”

    NPSF is currently collaborating with the American College of Healthcare Executives on a resource to help leaders create a culture of safety in their organizations. But perhaps most notable this year is the number of other organizations also working on this issue. The American Nurses Association addressed safety culture and leadership in monthly installments of resources this year, and a culture of safety was the theme of National Nurses Week. Meanwhile, the number of research studies and articles addressing the importance of culture is on the rise.

  2. Recognizing the need for improved safety metrics (Recommendation 3): In May, BMJ published a paper suggesting that medical errors are the third-leading cause of death in the U.S. The paper received wide attention, including some counter-arguments that the methodology was flawed. Ultimately, however, this article should spark broad agreement that there is a great need for improvements in the way we measure patient safety. Right now, too many of our methods are retrospective, reporting is inconsistent, and metrics are not uniformly used and analyzed. This year we began to see that the true toll of preventable harm in health care will only be known once we establish consistent and robust metrics in all settings.

    Back to top

     

     

  3. Adding to our knowledge about ambulatory safety (Recommendation 5): Free from Harm points out that, while most of the patient safety work done thus far has been done in acute care hospitals, the vast amount of health care delivered in the U.S. happens in the outpatient arena. For example, the Office of the Inspector General released a report this year estimating that 29 percent of Medicare recipients experience an adverse event or temporary harm while in a rehabilitation setting, with almost half of them deemed preventable.

       
       Some of Dr. Gandhi's picks for notable developments
    in patient safety this year reflect recommendations of
    the NPSF report, Free from Harm.
       
    We have so much to learn about risks and strategies to prevent harm in ambulatory or other settings. One notable development this year has been increased research in this topic. Most recently, AHRQ issued a technical brief that combined interviews with key informants as well as a literature review. The brief identifies medication safety, diagnosis, transitions, referrals, and testing as important ambulatory care safety topics. Communications, health IT, teaming, patient engagement, organizational approaches, and safety culture are flagged as the most important areas in which to seek improvement.

    This is not just a U.S. concern, however, and it is encouraging to see the World Health Organization convene experts to develop ways to “bridge knowledge gaps” in primary care.

  4. Increasing emphasis on workforce safety (Recommendation 6): NPSF considers the physical, psychological, and emotional safety of clinicians and staff to be a precondition to patient safety. This year we have seen growing recognition that burnout is a huge issue for the health care workforce, with more than half of physicians reporting at least one symptom of burnout. This has a direct impact on patient safety, as we know that clinicians experiencing burnout are not only more likely to make an error, but also less likely to take the steps necessary to engage patients, families, and the health care team.

    In encouraging signs, the American Medical Association, the National Academy of Medicine, and other entities are beginning to take a hard look at solutions. There is now wide acknowledgment that we need to look beyond the toll on individuals and begin addressing burnout as a system-wide issue and even as a quality measure.

    Related to this, fatigue can be a significant contributor to burnout. This year, the Accreditation Council for Graduate Medical Education has been exploring changes to duty hour limits, despite the evidence that fatigued residents are more likely to make errors that harm patients or themselves. NPSF and others are opposed to any change and, instead, argue for improving handoffs and communication.

  5. Partnering with patients and families (Recommendation 7): Communication and resolution programs (CRPs) promote open communication after an adverse event is discovered, comprehensive analysis of the event, implementation of improvement initiatives, emotional support for patients and providers, and appropriate resolution. In 2016, we saw progress in the number of organizations putting CRPs into practice.

    In April, NPSF offered a complimentary webinar on this topic in partnership with the Collaborative for Accountability and Improvement. The following month, the NPSF Patient Safety Congress featured an all-day immersion workshop on implementing CRPs.

    Also this year, the Agency for Healthcare Research and Quality released the CANDOR Toolkit, designed to help expand use of an AHRQ-developed process called Communication and Optimal Resolution, or CANDOR. This program gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.

If you have not had a chance to read the Free from Harm report, I encourage you to do so. These developments show that the issues discussed in the report remain vital to patient safety and are sure to be important as we move in to 2017.

What are your thoughts on the top developments in patient safety this year? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Back to top

 

Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  culture  Health IT  leadership  workforce safety 

Share |
PermalinkComments (0)
 
Page 1 of 7
1  |  2  |  3  |  4  |  5  |  6  |  7
more Calendar

5/11/2017
NPSF Webcast: Improving Patient Safety in Primary Care: Strategies to Engage Patients and Families

Copyright ©2017 National Patient Safety Foundation. All Rights Reserved.
Membership Software  ::  Legal