Knowledge to Practice observes Patient Safety Awareness Week 2020


Mark Chassin, MD, FACP, MPP, MPH, president and CEO, The Joint Commission, was a member of the IOM’s Committee on Quality of Health Care in America, which wrote To Err is Human: Building a Safer Health System in 1999. In November 2019, Dr. Chassin reflected on the accomplishments of the past 20 years and emphasized the importance of the leaders of healthcare organizations to commit to “zero harm” in these 2 ways:

Creating an organizational culture of safety

Leaders of healthcare systems and hospitals are encouraged to create a culture in which (1) all staff feel empowered to speak up and raise concerns and safety and quality of care and (2) all staff are held accountable for 100% adherence to safety protocols and best practices.

In observance of Patient Safety Awareness Week, K2P spoke to four professional leaders who play different roles in patient safety. Read our discussion with Nancy A. Myers, Ph.D., Vice President of the American Hospital Association Center for Health Innovation.

We spoke to Nancy A. Myers, Ph.D., Vice President - Leadership and System Innovation at the American Hospital Association Center for Health Innovation. She brings to her current position her broad and deep leadership experience in health system redesign and population health.

What have been the most notable improvements in patient safety in the 2 decades since the publication of To Err is Human and Crossing the Quality Chasm?

Since those landmark reports, hospitals and health systems have accelerated their work to better identify patient safety events and near misses, and have come together to identify leading practices to decrease those numbers. Over the past decade, hospitals and health systems significantly reduced the incidence of many hospital-acquired conditions (HACs) and healthcare-associated infections (HAIs), reduced avoidable readmissions, dramatically reduced early-elective deliveries, and improved outcomes for stroke and heart attack victims. Further, patients have reported more favorable experiences with their hospital. Patient perception of the care experience is critical to quality improvement efforts and a fundamental aspect of quality of care. Evidence shows that improving the patient experience and developing partnerships with patients are linked to improved health outcomes and better quality.

What are the largest challenges to health systems at this time? 

Hospitals and health systems face significant challenges in quality measurement, improvement and standards as they strive to advance and build on existing accomplishments and infrastructure.  For example, in 2019, hospitals reported on more than 80 quality measures to the Centers for Medicare and Medicaid Services (CMS) alone!  While continuing to measure the outcomes of care is critical to improving quality, there needs to be more integration across measures to streamline reporting and focus on those that are most meaningful to drive improvements.

What is the American Hospital Association (AHA)’s role? 

The AHA works on several levels to support hospitals and health systems in their delivery of high quality, safe care.  We act as a convener of hospitals to learn from the experts and each other; our collaborative learning networks have supported hospitals’ success to lower rates of patient safety events.  In addition, we offer Team Training to systems across the country, focused on bringing high-reliability methods to health care settings.  Finally, we provide input at the national level to policy-makers on how together we can better understand, measure, and improve the quality of care delivered to patients.

How does the focus on safety fit into the overall context of quality in healthcare? 

High-quality care includes both the increase of intended or expected outcomes of care and the decrease in unintended or unexpected outcomes.  The fundamental toolkit is the same for both, and includes using data to better understand performance, undertaking evidence-based care delivery redesign, focusing on building and supporting a culture that encourages transparency and innovation at the point of care, and always looking for the next opportunity to improve.