True patient safety requires uniting diverse stakeholders

September 12, 2024

By Ikhlass Hassen, Vizient Sr. Clinical Manager, Clinical Solutions-Spend Management, Contracting Center of Excellence

With World Patient Safety Day just around the corner, it feels especially important to highlight some key - and startling - statistics.

According to the World Health Organization (WHO), an estimated 1 in 10 patients are harmed during healthcare interactions, with over 3 million deaths each year attributed to unsafe care. In low-to-middle-income countries, the impact is even more severe, with up to 4 in 100 people dying from unsafe care.

Remarkably, over 50% of this harm is preventable.

Thankfully, the Patient Safety Movement is working to unite diverse stakeholders to advance patient safety. Their mission is to spread actionable, evidence-based practices, integrate them into healthcare organizations and ensure data transparency by 2030.

Just last week, the organization brought together stakeholders from across the healthcare spectrum - including patients, clinicians, payers and policymakers - to tackle the complex challenges of patient safety at the 11th Annual World Patient Safety, Science & Technology Summit. The event featured a multidisciplinary group of experts from the WHO, Institute for Healthcare Improvement, Centers for Medicare & Medicaid Services, WebMD Health Corp, Agency for Healthcare Research and Quality, Black Valley Films, Office of Inspector General, American Society of Anesthesiologists, Emergency Care Research Institute, Global Engineered Device Supplier Association, international patient safety representatives and others.

Why it matters

In alignment with the President's Council of Advisors on Science and Technology (PCAST)report, the CMS Patient Safety Structural Measure (PSSM) is set to streamline how hospitals report on safety practices starting in 2025, aligning with fiscal year 2027.This new measure evaluates hospitals on their efforts to enhance safety culture and systems. The PSSM measure focuses on five core areas:

• Leadership commitment to reducing preventable harm
• Strategic planning and organizational policy
• Cultivating a safety culture and learning health systems
• Accountability and transparency
• Engaging patients and families

Hospitals will submit attestations on their adherence to these areas, earning scores from zero to five points based on their performance. Hospitals that skip reporting on the PSSM face Medicare payment reductions, making it essential to prioritize these safety practices.

Key takeaways

At the Patient Safety Movement Foundation summit, several insights from speakers and panelists provided thought-provoking perspectives on enhancing patient safety, emphasizing the need for diverse thought leadership across the continuum of care and in governance. A few of the insight and action items:

• Microfixing: Tackling even seemingly small problems with a determined mindset can lead to substantial improvements. Find your own microfixes and address issues that may seem challenging but are solvable. Envisioning a world where everyone embraces this approach could lead to significant advancements in patient safety over time.
• Common factors in patient safety incidents: Incidents often feel deeply personal and can be traumatizing, leading to guilt and shame. Many incidents remain unreported and unrecorded, and following an incident, the status quo is often maintained despite obvious problems.
• Essential components for driving effective change: Will (the determination and commitment to drive progress); ideas (innovative concepts and strategies to guide the change process); execution (the practical implementation of ideas to achieve tangible results).
• The human-organization-technology triad: There is a critical balance between human factors, organizational structures and technology. Experts noted a common disconnect between senior management and other team members and highlighted four elements of a positive safety culture that organizations can tackle, including:
• • An informed culture
  • A reporting culture
  • A learning culture
  • A just culture
  • A flexible culture
• Global Interprofessional Patient Safety Fellowship: The organization emphasizes the importance of bridging the global quality gap in healthcare. Visit PSMF to learn more about this program.
• The myth of "access to care": Simply increasing access to healthcare doesn't guarantee safety. In fact, more access can sometimes lead to higher rates of harm and mortality in hospitals. Even high-economic countries face challenges like long wait times for specialists. This highlights the need to tackle underlying systemic issues rather than just expanding access.
• Big data vs. small data: It's not about the sheer volume of data but its availability, accuracy and transparency. Organizations should focus on auditing a manageable number of records to derive meaningful insights rather than relying solely on large datasets. Many hospitals face challenges with complacency and lack of follow-through; establishing universal data standards could address these gaps and turn data into actionable improvements.
• Technology integration: Interoperability remains a critical safety issue. AI should support, not dominate, safety efforts. Human judgment is essential for effective detection and management of adverse events.
• Workforce well-being: The shifting age and experience levels in the workforce contribute to burnout. The well-being of healthcare professionals is crucial for patient safety. Factors like internalized stress, lack of respect and financial pressures - such as reduced federal reimbursements - lead to burnout, early retirements and disengagement. Effective support mechanisms like peer groups and acute counseling have proven successful. Building a culture of shared accountability and balancing flexible leadership approaches can help address these issues. After all, a workforce can be both adaptable and resilient.
• Proactive vs. reactive measures: A proactive safety strategy that focuses on preventing near misses instead of just reacting to failures is essential, and shifting from punitive approaches to learning from mistakes will enhance patient safety. Hospitals need to adopt risk calculation methods and integrate safety science into medical education alongside clinical training. Ensuring hospital staff mirrors the demographics of the population they serve also plays a crucial role in addressing health equity.
• Patient empowerment vs. powerlessness: Empowering patients and families through education about their rights and involving them in safety discussions - such as having a seat on advisory boards - can significantly improve safety. For instance, one hospital benefited from including patients in mortality meetings.

What we all need to remember

Enhancing patient safety requires a multifaceted approach that addresses systemic issues, supports the workforce, integrates technology effectively and returns power to patients and families. By focusing on collaboration with implementation, healthcare organizations can create a more resilient and effective safety culture.

Learn about Vizient's Safe and Reliable Healthcare solution, which partners with organizations to tackle quality, safety, and workplace challenges to reduce the chances of patient harm.