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National Action Plan to Advance Patient Safety


By Ana Pujols McKee, MD, Executive Vice President and Chief Medical Officer 

There is some exciting news to share in the patient safety and quality realm. The National Steering Committee for Patient Safety (NSC) – convened by the Institute for Healthcare Improvement (IHI) – recently released a National Action Plan to provide health systems with renewed momentum and clearer direction for eliminating preventable medical harm. 

I had the privilege of representing The Joint Commission as an NSC member. The Joint Commission, along with 26 influential federal agencies, safety organizations and experts, and patient and family advocates, worked diligently over the past few years to develop  “Safer Together: A National Action Plan to Advance Patient Safety.” 

The National Action Plan uses evidence-based practices, known effective interventions, case examples and new innovations to offer insights and recommendations centered around four foundational yet interdependent areas: 

  • culture, leadership and governance 
  • patient and family engagement 
  • workforce safety
  • learning systems 

The plan also provides implementation tools and resources, as well as two supplementary materials: 

  • The Self-Assessment Tool to assist leaders and organizations on where to start and how to track progress over time. 
  • The Implementation Resource Guide, which details ways to implement and track the National Action Plan’s recommendations. 

 Resiliency of Plan During COVID-19 

The COVID-19 pandemic has provided a unique opportunity to test the resiliency of the National Action Plan. It was our hope for the plan to be evergreen yet flexible to address new challenges as well as long-standing problems.  

While COVID-19 has changed many things, it has not changed the plan. In fact, it further supported the idea that the same important principles in everyday patient safety and quality apply during all types of situations, including a global pandemic.  

Workforce Safety  
COVID-19 has reinforced the critical need for workforce safety to reduce preventable harm in every health care settings, including long-term care and home care. The National Action Plan encourages organizations to: 

  • implement a systems approach to workforce safety 
  • assume responsibility for physical and psychological safety 
  • establish a healthy work environment that fosters the joy of health care workers
  • develop, resource and execute on priority programs that equitably foster workforce safety 

Health Bias and Inequities 
COVID-19, along with racial tensions across the nation this year, have shed much needed light on the racial bias and inequities that exist in health care. While COVID-19 data is still incomplete, early research shows that African Americans are dying at twice the expected rate based on their share of the population nationwide. In some states, they are dying at three to four times the expected rate. And, given the low access to testing in black communities and communities of color, it is possible these numbers are higher.  

The National Action Plan encourages organizations to ensure equitable engagement of all patients, families and care partners, as well as to promote a culture of trust and respect for all patients, families and care partners.  

While health care is complex – it is our duty to ensure patients receive safe and quality care. We hope that the National Action Plan will help catalyze patient safety work in the United States and further drive an urgency of patient safety. 

Ana Pujols McKee, MD, is the executive vice president and chief medical officer of The Joint Commission.