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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.


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Top tags: leadership  culture  diagnostic error  patient safety  patients  public health  transparency  AHRQ  ambulatory  Health IT  IOM  workforce safety  2016 NPSF Congress  2017 Patient Safety Congress  board certification  collaboration  communication  communication and resolution  CRP  diagnosis  education  emotional harm  families  flu  health communication  health literacy  IHI  measurement  medical education  medication 

Lessons Learned from the NPSF Patient Safety Congress

Posted By Administration, Thursday, May 14, 2015
Updated: Thursday, May 14, 2015

Leadership, Culture, and the Power of Patients Made a Strong Showing at the 2015 NPSF Congress.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

The National Patient Safety Foundation hosted the 17th Annual NPSF Patient Safety Congress last month in Austin, and it was wonderful to see so many health professionals gathered in one place to learn and share best practices about patient safety. We are so grateful to our enthusiastic attendees, our committed faculty and planning committee, our exhibitors, and of course, the supporting organizations that helped make the Congress such a success. It was particularly exciting to meet so many members of the NPSF membership programs, the American Society of Professionals in Patient Safety and the NPSF Stand Up for Patient Safety program, and get to hear from them in person.


One of the lessons I took from the meeting is how much the discussions about culture and leadership resonated with attendees. We weren’t mired in theory—our speakers focused on practical ways to help change culture—which, of course, requires strong leadership commitment. During our opening keynote session, Dr. Gary Kaplan, chief executive officer and chairman of Virginia Mason Health System, said that leaders—be they CEOs or unit managers—should aim to be “idea coaches.” They need to support their staff in working on ideas, encourage root cause thinking, be straightforward with feedback, and ask questions to spark creativity and critical thinking. As he noted, this kind of behavior can be a stretch for some who think that they, as the leader, need to solve all the problems.


Dr. Gerald Hickson, senior vice president for quality, safety, and risk prevention and assistant vice chancellor for health affairs at Vanderbilt University Medical Center, talked about the people, processes, and technology that are necessary to bring about culture change. Disrespect and disruptive behavior, even when rare, can be very damaging to an organization, and Vanderbilt uses a detailed and well-defined process for addressing such behavior when it occurs. Their tools and approach have shown real results, with improvements in hand hygiene compliance, improved adherence with clinical protocols, and reduced malpractice claims and expenses.


The bookend to this discussion was our closing keynote, by Dr. Allan Frankel, chief medical officer, Safe and Reliable Healthcare, and author of The Essential Guide for Patient Safety Officers. Dr. Frankel gave examples of organizations that are generative in their approach to patient safety—meaning safety and improvement are hardwired into their operations. He pointed out that professionalism, behavioral norms, psychological safety, and culture are measurable. “Cultures catapult from mediocrity into excellence when all the components come together,” he said.


Another top takeaway came from three speakers who began their work in patient safety as patients or family members of patients. Through their powerful stories, Kim Blanton, Chrissie Blackburn, and Beth Daley Ullem showed the many ways that health care organizations can better partner with patients. Their journeys from places of loss and fear to positions of influence show that some organizations are making real progress in patient engagement, and I know a lot of our attendees took these lessons to heart. (Read more about this topic on the P.S. blog.)


Last but not least, I came away from the meeting with a renewed appreciation for the value of networking. Many attendees told me how much they gain from talking face-to-face with others—be they peers in similar organizations or industry representatives discussing new and innovative tools. Some attendees made new friends and professional connections, while others caught up with colleagues they met at past NPSF Congresses. The strength of our connections and commitment to making health care safer truly brought this year’s Congress theme, United in Safety, to life.


Visit for more news about the annual meeting. If you attended the 2015 Congress, we’d love to hear your comments, either via the survey we sent, or comment below.

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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  leadership  networking  NPSF Congress  patients 

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Patient Safety: Required Learning for Physicians

Posted By Administration, Monday, April 13, 2015

Physicians should aspire to be leaders in patient safety knowledge and practice.


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Some of you may know about the recent firestorm over the American Board of Internal Medicine’s Maintenance of Certification (MOC) program. For those of you who don’t, here is a bit of background.


Prior to 2014, physicians who were board certified by ABIM could maintain that certification by successfully completing an exam once every 10 years. In January 2014, recognizing the need for a more continuous learning pattern, ABIM introduced an updated MOC program that would have required physicians to be assessed every two years in areas such as medical knowledge, practice assessment, and patient safety. (In full disclosure, the American Board of Medical Specialties [ABMS], of which ABIM is a member, made the NPSF Online Patient Safety Curriculum available to diplomates of their Member Boards to bring patient safety education to physicians participating in the ABMS MOC®.)


For those of us working in the patient safety field, such changes sounded sensible and warranted. In large numbers, however, physicians disagreed, even starting petitions against the new MOC requirements.


This issue is complicated, largely because physicians already face rigorous requirements. For example, continuing medical education credits are required to maintain state licensure, and health care organizations require physicians (and all staff) to complete mandatory education modules every year. Moreover, most physicians work in stressful environments where they battle the clock and burnout every day, so any time away from their practice is a difficult trade-off.


In February of this year, bowing to critics, ABIM announced it was “suspending the Practice Assessment, Patient Voice, and Patient Safety requirements” for MOC. Since then, ABIM has embarked on a “listening” campaign, and one of the ways they are collecting the opinions of their diplomates and others is through a website, Assessment 2020. I recently submitted the following comments on behalf of NPSF:


To the ABIM Assessment 2020 Team,


I write on behalf of the National Patient Safety Foundation to support the call for ongoing patient safety education for physicians. We understand the current, vocal criticism of the ABIM Maintenance of Certification requirements. However, we remain hopeful that the re-evaluation currently under review will result in meaningful standards for incorporating safety science and practice into the core medical knowledge that physicians are expected to demonstrate in order to achieve board certification.


Physicians commit to lifelong learning, and by its very definition, lifelong learning needs to incorporate new knowledge. No one would deny vast changes in medicine, clinical practice, and in our knowledge of how to improve quality and safety that have taken place over the past 20 years or so. For example:

  • The Institute of Medicine’s report on medical error, estimating that 98,000 people die preventable deaths each year
  • Research showing that patients receive the correct care only 55% of the time
  • Systems approaches to the design of care (e.g. human factors design, checklists)
  • The growing use of electronic health records to improve care

Today, being a good physician requires a lot more than being smart and technically skilled. Those of us who work in patient safety know how much the field is changing as new research is conducted and new practices adopted. In a 2010 report, the NPSF Lucian Leape Institute called for medical schools to address patient safety as a science encompassing key areas such as error causation and mitigation, human factors concepts, systems theory and analysis, and error disclosure and apology.


The American Association of Medical Colleges and the Accreditation Council for Graduate Medical Education (ACGME) have seen substantive changes in curricula over the years. The authors of a 2010 paper looking at medical education in the US and Canada found that “medical student education has undergone and continues to undergo substantive change…and has continued to evolve during the past decade.” Among the changes were the introduction of content addressing teamwork, patient safety, and the use of simulation.


Similarly, ACGME has developed the Clinical Learning Environment Review (CLER) program, which specifically addresses patient safety as one of its areas of focus. The goal of the CLER program, according to an ACGME brochure is “to improve how clinical sites engage resident and fellow physicians in learning to provide safe, high quality patient care.”


We strongly believe that ongoing education about patient safety is as important for established physicians as it is for physicians in training. In fact, established physicians should aspire to be leaders in patient safety knowledge and practice.


We believe that revamping board certification standards to incorporate the science of patient safety is an exercise that is long overdue. However, it is critical that patient safety is not incorporated as a rote set of requirements; instead patient safety must be incorporated in a way that is meaningful, practical, and useful to practicing physicians so they can improve the safety of practice and see the value.


We hope that ABIM and its diplomates will be able to move beyond the current acrimony and create plans for ongoing patient safety education that will ultimately benefit the patients our health system serves.


I have had the privilege of working alongside many skilled, caring, dedicated physicians who understand safety science and are helping to ensure that we deliver the safest care. We need to determine the best path forward to ensure that all physicians (trainees and established) have the skills to improve patient safety. I hope you, too, will visit the Assessment 2020 website and make your voice heard.


Do you believe that established physicians should be required to receive ongoing education in patient safety? Comment on this post below.


Tags:  board certification  education  physicians 

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Lessons Learned: Patient Safety Awareness Week 2015

Posted By Administration, Monday, March 16, 2015

When it comes to patient and family engagement, it's okay to start small. Just get started.


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


More than 1,000 organizations across the country joined with NPSF in observing Patient Safety Awareness Week, March 8-14, 2015. They held safety fairs for staff, provided resources to their patients and the public, wrote op-eds for their local papers, created games and videos, and dressed in purple.


We also had some 2,000 people tuned in to our special webcast, Patients and Families as Partners: United in Safety, with speakers from Children’s Mercy Hospital and Clinics. (If you were not able to listen in, you can view the presentation slides and download the audio replay.) Our speakers gave examples of how patients and family members share their voices in important areas. They serve as “faculty,” providing insights during nursing orientation, Grand Rounds, and lunch-and-learn sessions. Family members are included in rounds on the inpatient side, and also serve on committees, contributing to everything from medication safety goals to facility redesign.


Our speakers also talked about some of the lessons they have learned, and a few things struck me as particularly notable:

  1. Support of the executive leadership is essential. As our experts noted, the chief executive officer of Children’s Mercy was a supporter from the start, and the chief operating officer has been instrumental in helping the program thrive. Without executive support, patient and family engagement programs will be difficult to sustain.

  2. It’s okay to start small. You don’t need a fully formed program to begin to make a difference. If you are preparing patient education materials, for example, ask a patient or family member if the information makes sense to them. Look to resources you already have in place, such as the patient advocate, to identify patients and family members willing to share their experiences, opinions, and ideas—even on a single issue that might be the focus of a new initiative.

  3. Partnerships pay off. In discussing the Children’s Mercy experience, our speakers noted the organization’s participation in Solutions for Patient Safety, a group of children’s hospitals that became a federally funded hospital engagement network (HEN) under the Partnership for Patients initiative. Solutions for Patient Safety has grown from 8 participating organizations to 80, and recently reported a 70% reduction in serious safety events from 2009 to 2012. While patient and family engagement is certainly just one part of that success, shared learning among the organizations is likely a big contributing factor.

The NPSF Lucian Leape Institute report Safety Is Personal: Partnering with Patients for the Safest Care (2013) calls for patient and family engagement at all levels, not just in direct clinical care, and in many of its activities, Children’s Mercy is an exemplar. NPSF will continue the focus on patient and family engagement at the 17th Annual NPSF Patient Safety Congress with a Pre-Congress session and a breakout track devoted to this topic. I hope you will join us if you are able, as we continue to be United in Safety.


Tags:  families  leadership  partnership  patients 

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United in Safety: Strategies for Engagement

Posted By Admin, Friday, February 13, 2015
Updated: Friday, February 13, 2015

How do we make patient engagement more systematic in our health organizations?


By Tejal K. Gandhi, MD, MPH, CPPS


   Tejal K. Gandhi

Patient Safety Awareness Week, which this year is March 8-14, is one of the most exciting weeks of the year for the National Patient Safety Foundation because we hear from so many people across the country—and abroad—who are doing work to raise awareness in their organizations or communities about patient safety.


This year’s week is focusing on strategies to enhance patient and family engagement in health care. As documented in a 2014 NPSF Lucian Leape Institute report, research and practice have shown that patient and family engagement can contribute to safer care through improved outcomes, better patient experience of care, and better working experience for health professionals. Many organizations are making good progress in this area, yet our health care system has only begun to reap the benefits that can truly come from greater patient and family participation. Barriers to engagement remain high, most notably the time constraints on clinicians and the lack of formal, relevant training to teach clinicians how to interact more effectively with their patients.


Recently I was asked how we might go about making patient engagement more systematic in our health organizations. If the leadership is committed, there are things they can start on right away:

  1. Patient and family advisory councils (PFACs) have become more common, and many organizations have different levels of PFACs in action. NPSF recommends involving patients and families in quality improvement projects and in the development of patient education materials.
  2. Open visitation in hospitals is another key recommendation, and NPSF is a strong supporter of the Better Together campaign sponsored by the Institute for Patient and Family-Centered Care. Having families free to visit would encourage another recommendation: patient and family participation in in multidisciplinary rounds, to increase their understanding of the patient’s status and care plan, and to bring forth any questions or concerns.
  3. Enlist patients and families to serve as "faculty" to educate clinicians, staff, and students in the health professions about the experience of illness and perceptions of safe care.
  4. When something does go wrong, involve a patient or patient representative in root cause analysis to bring the patient voice to these discussions.

This is but a sampling of the recommendations in the report, Safety Is Personal: Partnering with Patients and Families for the Safest Care. I encourage you to review the report as well as the accompanying action plan checklist to get a better sense of this issue.


Like many areas of patient safety, when it comes to patient engagement, one person’s effort is important, yet everyone’s effort is essential. That sentiment is reflected in this year’s Patient Safety Awareness Week theme, United in Safety. I hope you’ll take a moment to explore the activities we have planned and set aside some time to recognize the week with NPSF.


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Transparency in Support of Patient Safety

Posted By Admin, Monday, January 19, 2015

Making transparency a reality in health care is far from simple. The new LLI report cites significant obstacles but presents a set of specific recommendations.


By Tejal K. Gandhi, MD, MPH, CPPS


   Tejal K. Gandhi

In a 2009 paper, the NPSF Lucian Leape Institute members called transparency “fundamental to the endeavor of achieving meaningful improvement in health care system safety” (Leape et al. 2009). This month, I am pleased to share news of a new report on the topic. Shining a Light: Safer Health Care Through Transparency argues for sharing of important information—particularly the kind of information that can influence quality and safety.


The report defines transparency as “the free, uninhibited flow of information that is open to the scrutiny of others.” To break it down in the simplest of terms: if a clinician causes harm to a patient, and no one else knows about it, how can we prevent others from causing—and suffering—the same harm?


Yet the report considers the application of greater transparency far beyond the doctor-patient relationship. To truly advance patient safety, transparency needs to occur in four domains both within and outside of organizations: between clinicians and patients; among clinicians within an organization; between health care organizations; and between health care organizations and the public. These domains are interdependent for, as the report states, “If the environment is not supportive of clinicians reporting and discussing their errors, it will be difficult for them to be open and honest with their patients, and unlikely that errors will be reported, analyzed, and shared within the organization or with other organizations.”


Of course, making transparency a reality in health care is far from simple. The report cites very significant obstacles—chief among them being that few health care organizations can claim the kind of safety culture that supports and expects transparency to be practiced at all levels. Other notable obstacles are a lack of reliable definitions, data, and standards for reporting on quality and safety; fear of potential negative effects on finances or reputation; and the objections of individuals who may be benefiting from the status quo.


These are not easy obstacles to overcome, but this report offers more than three dozen recommendations for how we can begin. Moreover, it includes case studies of how transparency is being put into practice—and how some are reaping the rewards.
This new report is the result of two Institute Roundtables—with participants representing every sector of health care—that reviewed the literature, discussed the barriers, heard success stories, and developed recommendations. I hope you will take the time to review the report, share it with your colleagues, and let us know what you think.


Members of the NPSF Lucian Leape Institute Roundtable on Transparency will discuss this new report in a webinar on February 12, 2015, from 12 noon to 1:00pm Eastern Time. Registration is free of charge. Register at:

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