Approved by the Board of Governors Dec. 5, 2022.
Statement of the Issue
Providing safe, high-quality patient care always has been a focus of healthcare executives. However, the Institute of Medicine’s landmark report, To Err Is Human, Building a Safer Health System, issued in November 1999, was a clear indication that efforts needed to be intensified. The report laid out a comprehensive strategy by which government, healthcare providers, consumers and the industry as a whole could reduce preventable medical errors. Since the original IOM report, organizations such as the Agency for Healthcare Research and Quality, the Institute for Healthcare Improvement and The Joint Commission have focused on developing and promulgating best practices to improve patient safety, and the IOM released in 2001 its report Crossing the Quality Chasm: A New Health Care System for the 21st Century, which defines the six domains of quality: safety, efficiency, equity, timeliness, effectiveness and patient-centeredness. Particularly visible have been IHI’s 100,000 Lives campaign, followed by its Five Million Lives campaign. These efforts appear to have made a difference; in 2022, a study published in the Journal of the American Medical Association showed that from 2010–2019, in-hospital adverse events decreased between 18% and 41%.
Additional tools and evidence-based resources have become available, as well. Leading a Culture of Safety: A Blueprint for Success, developed by the American College of Healthcare Executives in partnership with IHI’s Lucien Leape Institute, can help leaders create and sustain a culture of providing high-quality and safe care in their organizations. Safer Together: A National Plan to Advance Patient Safety, an action plan developed by ACHE and members of the National Steering Committee for Patient Safety, can help health systems in efforts to eliminate preventable medical harm.
The IOM report To Err Is Human: Building a Safer Health System notes on Page 2 that the majority of medical errors do not result from individual recklessness or incompetency. The report concluded that errors are commonly caused by “faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them. … Thus, mistakes can best be prevented by designing the health system at all levels to make it safer—to make it harder for people to do something wrong and easier for them to do it right.”
Awareness of the prevalence of patient safety and quality issues has contributed to greater scrutiny from regulators, purchasers and the public. Whether in the form of consumer assessments (e.g., CAHPS) or various publicly available quality indicators, expectations for transparency are increasing. Both government and private payers also have begun to align payment and quality/patient safety by adopting pay-for-performance systems for certain hospital-acquired conditions and readmissions, and zero payment policies for “never events”—serious reportable events, such as wrong-site surgery, that never should occur.
Policy Position
Improving quality and eliminating errors requires executive leadership and the board to guide an organizational culture dedicated to improvement, focusing resources on the structures, processes and monitoring systems that will ensure patients receive the care they need while minimizing the risk of harm. While specific components of a patient safety and quality strategy will vary by organization, ACHE believes healthcare executives should lead a comprehensive approach to ensuring patient safety and quality, including:
- Equipping the board with tools and information to provide appropriate oversight of the patient safety/quality strategy.
The board of a healthcare organization has the responsibility of overseeing progress toward achieving organization-wide goals for patient safety and quality. The establishment and review of improvement goals and safety/quality indicators should be regular components of the board’s agenda. - Involving the entire executive leadership team in the patient safety and quality strategy.
The CEO, together with the other members of the senior leadership team, should establish and monitor an executable vision and strategy for setting and achieving patient safety and quality goals. That strategy should include clear metrics to determine progress and guide necessary adjustments. - Engaging the medical staff and the entire care team as meaningful partners in the development and implementation of the patient safety and quality strategy.
The patient safety and quality strategy, implementation plan and metrics should be developed with meaningful involvement of all clinical staff in a manner that effectively and efficiently uses their time and expertise. - Developing processes to include the voice of patients and families, and applying their input in leadership committees and in the equitable design and improvement of care processes.
Creating a patient-centered culture has been shown to improve outcomes and patient satisfaction while reducing errors and costs. Healthcare executives should design reliable methods to collect and use patient and family input and optimize engagement in their care. - Creating and sustaining a culture of safety.
Every healthcare executive should prioritize enhancing the safety of patients and the workforce. Small-scale, incremental improvements are not enough. The AHRQ defines a culture of safety as one “in which healthcare professionals are held accountable for unprofessional conduct, yet not punished for human mistakes, errors are identified and mitigated before harm occurs, and systems are in place to enable staff to learn from errors and near-misses and prevent recurrence.” This work requires a sustained focus on safety not just as a strategic priority or key improvement initiative, but as a core value that is fully embedded throughout the organization and industry. - Developing a culture of sustainable improvement that includes an organization-wide commitment to continuous learning.
Investment in human capital is critical for growing the capacity necessary for executing patient safety and quality initiatives and establishing a culture of improvement. Ongoing education should involve change leadership knowledge as well as specific techniques for identifying, implementing, monitoring and sustaining improvement opportunities. - Rigorously seeking out and applying best practices.
Well-defined, evidence-based practices, such as those promulgated by the AHRQ, are replicable across healthcare organizations and have been shown to lead to improved outcomes. The use of such established best practices should be a key component of an organization’s patient safety and quality strategy. - Providing open communication and demonstrating a commitment to transparency.
Achieving ongoing, sustained learning and improvement in patient safety and quality requires a commitment to frequent and open assessment of data by all relevant participants within a healthcare organization. In addition, the reporting of results and meeting public and stakeholder expectations for transparency—especially those of patients—should be incorporated as part of the patient safety and quality strategy. - Adopting information systems that support the patient safety and quality strategy.
Information systems play an important role in structuring processes so that appropriate decisions and actions occur. The patient safety and quality strategy should include the adoption of information systems demonstrated to facilitate improved outcomes, such as computerized physician order entry, with clinical decision support, while also ensuring strategies to mitigate unintended consequences of technology. - Encouraging organizational involvement in voluntary collaboratives.
Participation in voluntary collaboratives among providers and other interested parties can provide a valuable forum for comparing data, sharing best practices, stimulating improvement efforts and increasing transparency. To the extent that a relevant collaborative exists for an area served by a healthcare organization, active participation is encouraged. - Focusing on workforce safety as a precondition of patient safety and quality.
The basic precondition of a safe workplace is protection of the physical and psychological safety of the workforce. To create a safe and supportive work environment, healthcare organizations must become effective, high-reliability organizations, characterized by continuous learning, improvement, teamwork and transparency. Knowing that their well-being is a priority enables the workforce to be meaningfully engaged in their work, to be more satisfied, to be less likely to experience burnout, and to deliver more effective and safer care.
Improving patient safety and quality involves aligned leadership by the board and CEO based on an executable strategy cascading throughout the organization and applied across the entire continuum of care. The leadership actions recommended by ACHE in this policy statement represent core building blocks for such a patient safety and quality strategy.
Policy created: November 2008
Last reaffirmed: Last revised: December 2022