Recommendations from the Subcommittee to Inform the National Action Alliance to Advance Patient and Workforce Safety

We stand for a healthcare delivery system that is free from preventable harm, inspires continuous improvement in the delivery of care across the continuum, and promotes a culture of safety in an environment that is healing for all.

Our aims are intended to ensure that all healthcare systems strengthen their foundations in patient and workforce safety through assessing and addressing the four foundational areas outlined in the National Action Plan to Advance Patient Safety (culture, leadership, and governance; patient and family engagement; workforce safety; and creation of learning health systems). 

Principles:

• Policymakers should evaluate all future health policy choices, including the impact of funding decisions, through a lens of patient safety.
• Efforts to address patient and workforce safety must include a focus on targeting health inequities and eliminating disparities. 
• The human connection between patients (with their families/caregivers) and healthcare providers is the fulcrum of person centered, safe care.
• Policies aimed at improving patient safety must be based on evidence-based practices and acknowledge and reflect patients' social risk factors. 

Overarching Aim:  Every healthcare system and supporting organization in the United States will commit to operationalizing the foundational elements of the National Action Plan to assure safer care everywhere for all.

• Healthcare systems will complete a baseline self-assessment by December 2024.
• Healthcare systems will ensure the voices of patients, families/caregivers, and employees are at the core of their safety strategy by reviewing the self-assessment and identifying areas of potential improvement.
  • Healthcare systems will develop a safety plan that empowers the voice of patients and families by 2024.
    • Safety plans will include provisions for patient access to submit safety concerns, inclusion in event review, key input on the development of safety initiatives, implementation of communications and resolutions programs.
    • Organizations will include relevant structure, process and outcome measures.
  • Implementation of robust safety measurement systems including solicitation of patient and employee concerns by 2025 and documented improvements by December 2026.  Example metrics include:
    • Increase in the percentage of claims identified in reporting systems within 48 hours of an event.
    • Improvement in speaking up scores (psychological safety).
  • Implementation of robust communication and resolution programs with reported event feedback provisions by 2026.

Engineering Safe Practices Aim:  Through partnership with technology vendors, FDA, ONC, and other relevant partners, the HHS Action Alliance will drive measurable changes in healthcare technology to increase the proportion of devices and software that incorporate “safety by design” features that make it easy to follow the safer practices and hard to follow less safe practices.

• HHS will convene human factors engineers, safety science experts, bedside clinicians, and technology leaders to identify 5 key actions that stakeholders (including patients and families) agree will facilitate engagement between stakeholders (care delivery organizations, regulators, and vendors including software developers, medical device developers, pharma, etc) for optimized safety design of new/future high-frequency + high-risk healthcare technology to optimize safety by design by December 2024.
  • We will measure both adoption and impact of above metrics throughout 2025 and beyond.
• HHS will work with industry partners to create safety standards, evaluation protocols, and certification processes for devices, software, AI applications, and other technology tools that balance the support for rapid-cycle innovation with the need to build-in safety by design beginning January 2025.

Learning Capacity Aim:  We aim to develop a healthcare safety focused Learning Network (LN) with a vision and aim to provide reliable safety for patients and staff. This LN will use design and co-production methods, which have been shown to be successful, including those focused on safety (e.g., Solutions for Patient Safety).  The LN will have a decentralized leadership and a centralized infrastructure to continuously learn and transparently track and report on improvement progress while minimizing reporting burden by patients and staff.

• Working with industry and federal partners, including independent regulatory agencies, we will create the continuous monitoring and reporting systems that will enable rapid-cycle improvement in patient and workforce safety resulting in:
  • Transparent sharing of process and safety outcome data on a near real-time basis to enable continuous improvement.
  • A new, scalable bundle of safe practices across the care continuum and phasing out of numerous current, misused, misrepresentative, and misaligned measures.
  • Building adequate quality improvement science capability across all LN participants.
  • In addition to a focus on process reliability, the LN will transparently learn and share on all aspects of the National Action Plan including governance and leadership and inclusive engagement with patients and families.
• Working with a cross-section of the nation’s healthcare systems willing to serve as change leaders who agree to transparently document and share promising practices for implementation of safety practices and strategies to overcome barriers to adoption.
  • Demonstrated 50% improvement in patient and workforce safety among hospitals/health systems actively participating in the LN within 24 months (December 2026).
• Progression of the LN will be measured and assessed based on:
  • Progress against goal of 50% reduction in harm.
  • Active data sharing and participation by LN participants.
  • Participant retention and growth.
  • Maturation of LN annually using an adapted maturity model rubric (Lannon et. al, 2020).

Education and Training Aim:  We aim to establish a set of safe practice competencies that can be used in the education of healthcare safety leaders. Basic competencies can be developed for clinicians, healthcare administrators, and partners (e.g., developers, manufacturers, pharma) who are involved in safety management activities.

• We will develop a set of safety science competencies that can be used in education and continuing education training programs by July 2024.
• DHHS will work with professional societies and educational accrediting bodies to adopt and report on demonstrated competencies by the end of December 2025.

Research Recommendation:  We recommend establishing and funding a cross-agency research agenda on high-priority safety gaps to address policy, payment, and practice knowledge needs that will support the National Action Alliance.