By Jay Kumar
After several years of focusing on smaller improvements to eliminate preventable patient deaths, the Patient Safety Movement Foundation (PSMF) is thinking big. The group recently announced a new goal of zero preventable deaths by 2030, but with a new approach to bring about systemic change.
In an interview this week, PSMF CEO David B. Mayer, MD, and chief clinical officer Donna Prosser, DNP, RN, NE-BC, FACHE, BCPA, detailed how the group is expanding its efforts and preaching the gospel of high reliability.
Since the publication of the Institute of Medicine’s report To Err Is Human in 1999 IOM report, the healthcare industry has been working really hard to improve quality and safety, said Prosser. Patient Safety Movement was founded in 2012 with the goal of eliminating preventable patient deaths by 2020. While it fell short of that goal, the group says its hospital and health system partners saved 366,353 lives during 2012-2020 by improving processes. Still, there is much more to be done.
Instead of focusing on improvements in certain patient safety areas, the PSMF is taking its cues from the aviation and nuclear industries, which have embraced the concept of high reliability to build a foundation of safety.
“We’ve learned a lot from high-reliability organizations,” Prosser noted, adding that the expense required to carry out the organizational changes required has made high reliability previously unattainable for many smaller hospitals.
“We want to be able to help organizations in any way we can to remove the barriers to high reliability,” said Prosser.
Organizations that have done well with high reliability have the money to hire consultants, but many aren’t able to do so. The PSMF has been providing free resources such as videos, webinars, and articles, as well as its Actionable Patient Safety Solutions (APSS) blueprints, which are best-practice summaries to help organizations improve performance on various topics such as healthcare-associated infections and medication safety. As part of its new effort, the PSMF is going to offer free coaching to organizations that commit to high reliability and share their progress with PSMF. Prosser said she will oversee all coaching, with a fellowship program expected to start in the next year.
“We have a vast network of volunteers and content matter experts across the globe,” said Mayer.
The PSMF is in the process now of collecting baseline data, tracking serious safety events and near misses. Mayer said the group is in talks with Press Ganey to incorporate its Serious Safety Event Rate methodology into PSMF efforts.
For immediate goals, Prosser said the PSMF wants to get at least 50% of reporting hospitals in its network to commit to high reliability, which includes creating a person-centered culture of safety; implementing a holistic, continuous improvement framework; and sticking to an effective model for sustainment. Previously, the group was working with the heads of departments like Infection Prevention, but for this new initiative, the C-suite has to get involved, she added.
“We’re really focused on those medium and small hospitals that really want to do this work, but don’t have the time or resources,” Mayer said.
Impatient with slow progress
Mayer noted that many esteemed figures such as Lucian Leape and Don Berwick have championed the cause of high reliability and error prevention, but “we still haven’t done the critical things that are necessary,” such as ensuring the proper training and resources are available.
Medical malpractice and a lack of transparency has been a major problem, he said. The Communication and Optimal Resolution (CANDOR) toolkit developed by the Agency for Healthcare Research and Quality has provided open and honest ways for healthcare institutions to respond to adverse events.
But ultimately, change hasn’t occurred quickly enough. “We’re just tired of seeing slow progress,” said Mayer.
As the U.S. prepares for a new presidential administration to take over in January, Mayer is hopeful that patient safety efforts will be prioritized on a federal level. In 2016, then-President Barack Obama asked Vice President (and current President-elect) Joe Biden to lead the “Cancer Moonshot” effort to cure cancer in 10 years. The effort only lasted a year before Trump administration budget cuts slashed the research effort considerably.
“I’m confident the president-elect will re-engage the Cancer Moonshot,” Mayer said, adding that lobbying is already underway to encourage the incoming administration to do a “Patient Safety Moonshot” as well.
“We need a national Patient Safety Authority,” he said. “It’s going to take a lot of things to come together, but we’ve got to think big.”
The problems with patient and healthcare worker safety were evident before the pandemic, especially in OSHA worker injury rates, which are higher for healthcare than any other industry, said Mayer.
“The pandemic has exposed so many of these gaps,” he said, adding that once we provide the safest environment for caregivers, they can provide the best care for patients.
“ We’ve seen an increase in all kinds of patient safety issues because of the pandemic,” Prosser noted. “You can’t have patient safety without healthcare worker safety.”
The stress of working conditions during COVID-19 has also had a serious impact on caregivers, especially nurses. Not only are current nurses leaving the profession, the media coverage of overloaded hospitals and overburdened healthcare workers may make it difficult to attract new nurses. “I’m afraid we’ve taken out a generation of nurses,” Mayer said.
Although things look bleak right now, Prosser sees a silver lining.
“We need to focus back on the basics. This isn’t about the pandemic, this is about rebuilding our broken healthcare system,” she said. “This is actually a blessing in disguise for our system. If we can have that high-reliability mindset, we can learn from past mistakes.”
Jay Kumar is editor-in-chief of PSQH.