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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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Time to Recognize and Honor Patients

Posted By Administration, Thursday, February 18, 2016

Patient Safety Awareness Week aims to engage health consumers in greater understanding of what we mean when we talk about patient safety.


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Anyone working in health care is likely to be aware of some of the many recognition weeks that take place throughout the year. From National CRNA Week (in January) to National Radiologic Technology Week (in November), the health care industry sets aside time to recognize the specialized efforts, skills, and dedication of its workforce.


Likewise, disease-specific weeks and months abound, from American Heart Month (February) to Diabetic Eye Disease Month (November), with the goals of informing the public of risks and prevention.


Patient Safety Awareness Week, which NPSF has led in March every year since 2002, is a bit different from the rest. It does not honor a specific area of the health care workforce, and it does not target a single issue. Instead, this recognition week challenges all health professionals and workers to put the focus on patients and families and on the need to create the safest health care delivery environment possible.


Like the disease-specific weeks and months, however, Patient Safety Awareness Week does aim to engage health consumers in greater understanding of the problem and what we mean when we talk about patient safety.


This year, in the wake of the recent NPSF report calling for a public health approach to improve patient safety, NPSF has initiated an ongoing campaign. The United for Patient Safety campaign seeks to highlight and reinforce the fact that everyone has a role to play in keeping patients safe and free from harm. Patient Safety Awareness Week, March 13-19, will be observed as a highlight of the campaign, through the message that “every day is patient safety day.”


Among the activities we have planned for the week is a webcast with distinguished speakers from the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, and NPSF. We anticipate a thought-provoking discussion about how we can apply the theories and principles of public health to accelerate progress in patient safety.


According to the CDC Foundation, “Injury prevention and detection are key components of public health. . . . Overall, public health is concerned with protecting the health of entire populations.” Even the healthiest among us is likely to be a patient one day, meaning the entire population has a stake in the safety of the health care system and the need to prevent harm.


Public health practice relies on research into the causes of disease and injury and application of broad programs to address them. Speaking last year about the Future of Public Health, Dr. Tom Frieden, director of the CDC, noted that, “The involvement of many parts of society, including government agencies, health organizations, nongovernmental organizations, clinicians, the private sector, and communities, is increasingly important for success” in public health efforts.


The same is true when it comes to patient safety; we need everyone to be involved.


What can you do? To begin, visit where you can honor a loved one affected by medical error, download educational materials, or share your plans for observing Patient Safety Awareness Week in your organization or community.


Join us March 17 at 1:00 PM Eastern Time for a complimentary webcast, Patient Safety Is a Public Health Issue. Registration is open to all. 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.

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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:  patient safety  patients  public health 

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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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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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