Redefining patient safety in 2017 — 6 thoughts from IHI CEO Derek Feeley

Even though much progress was made in terms of patient safety in 2016, there is still much more work to be done in 2017 and beyond, according to Derek Feeley, president and CEO of the Institute for Healthcare Improvement.

"Let's recognize the progress that we've made…but there's absolutely no room for complacency," he said during a Dec. 6 keynote speech at the IHI National Forum on Quality Improvement in Health Care in Orlando, Fla.

In fact, he cited the 2016 study that indicates medical errors are one of the leading causes of death in the U.S. as a clear example that more work is necessary to prevent patient harm.

Mr. Feeley urged healthcare executives to change the patient safety paradigm as part of their New Year's resolutions for 2017, and laid out six ways to do so.

1. Think about how to make as many things as possible go right, as well as how to minimize the number of things that go wrong. Learning from mistakes is important, but it is not sufficient to rely on hindsight alone. "We don't have to fail in order to learn," Mr. Feeley said. He encouraged provider organizations to learn from and build on successes instead of solely focusing on correcting failures.

2. Change from reactive to proactive. Mr. Feeley used a lake ice analogy to illustrate his point. "We're spending too much time measuring the number of people who fall through the ice — we should be monitoring the thickness of the ice," he said. In addition to asking themselves if care was safe yesterday, leaders should also ask themselves if their hospitals' care was safe today and if it will be safe tomorrow.

3. Think about patient safety systems, not only patient safety projects. While there will always be room for safety improvement projects, some safety issues cannot be solved by singular projects, according to Mr. Feeley. Additionally, focusing on one safety problem at a time allows others to crop up. Instead, hospitals should create feedback loops so every improvement project builds on the other, until safety is viewed through a system lens instead of an individual project lens. "My proposal is that we invest in safety systems rather than safety whack-a-mole," he said.

4. Move from fear, blame and liability to humility, trust and transparency. Provider organizations need to have a culture in place that encourages reporting of adverse events and near misses and protects those who report them. Stealing a concept from a flight crew, Mr. Feeley said, "A mistake is not always a failure, but not reporting one could be."

5. Make patient safety an inclusive initiative. "The people who are most invested in patient safety are the patients themselves," Mr. Feeley said, and healthcare in the U.S. needs to make it easier for patients to participate in their own care and safety. He referenced an initiative from the Canadian Patient Safety Institute called #AskListenTalk, encouraging patients to ask questions about their care and safety, and said such initiatives should be imported to the U.S.

6. Broaden the definition of harm. While infections and wrong-site surgeries are clear examples of patient harm, Mr. Feeley proposed expanding the definition of harm to include lack of humanity and dignity. For instance, when providers fail to introduce themselves to a patient, it can make the patient feel helpless and less than human. "No one should ever feel like just a…body in a hospital bed," Mr. Feeley said. "Absence of dignity is harm."

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