evidence‐based best practices.
Science of Improvement
Quality improvement (QI) is a critical component of ensuring quality care and achieving safety. QI requires assessing safety issues for prevalence; making comparisons across units, departments, and even organizations; and using benchmark data to make clinicians and leaders improve their own practices as well as the system (Dolansky et al., 2017; Niñerola, Sánchez‐Rebull, and Hernández‐Lara, 2020). Using principles and strategies from QI, the rate of medication errors occurring in a given setting provides measurements that can be compared with a peer unit or industry benchmark. These processes also identify areas for root cause analysis to determine why errors occur in critical activities such as medication administration, to change the system by preventing or lessening the possibility of errors occurring. It is critical that all health professionals know how to assess scientific evidence to determine what constitutes good care, identify gaps between good care and care delivered in their setting, and implement actions to close gaps (McNab et al., 2020). Niñerola et al. (2020) used Six Sigma as another form of QI to eliminate waste, improve supply chains, and improve wait times. While the QI process might seem straightforward, successfully changing, monitoring the change, and adapting or sustaining a change are challenging.
Workforce: Impact of the Work Environment
Health care workers are affected by the quality of care in the systems in which they work, experiencing loss of morale and lower satisfaction when they are not able to provide best care. Health care is value based; professionals pledge, first, to do no harm. Quality is an essential value. Professionals take pride in doing the right thing, but quality is more than will; it is a mindset of inquiry and the capacity to use appropriate tools to improve the systems in which we work. QI intersects all areas of health care, from economic issues to the moral basis undergirding quality for doing our best. It builds on health professionals’ shared values, moral commitment, and mindful presence to do work well (Dempsey and Assi, 2018). Health professionals have the motivation and ability to improve systems if they have the necessary education and training and work in organizations where they are supported (Janes et al., 2021).
Brooks Carthon et al. (2019) examined the role of the work environment on patient safety. The influence of human factors, the interrelationship between people, technology, and the environment in which they work, affects how they complete their work. Human factors consider the ability or inability to perform exacting tasks while attending to multiple tasks at once. The attention from organizational leaders to human factors includes managing workload fluctuations, seeking strategies to minimize interruptions in work, and attending to communication and care coordination across disciplines (Roussel, 2019). Nurses manage care coordination, employ checklists, and ensure safe handoffs between providers and settings (Bowles et al., 2019). Nurses are challenged with multitasking, distractions, fatigue, task fixation that limits environmental scanning, and hierarchy and authority gradients, staffing, and interpersonal relationships, all of which contribute to fatigue and emotional exhaustion, which challenge the ability to provide good care (Tawfik et al., 2019).
Psychological safety is critical for organizational learning. New graduate nurses in particular need to feel psychologically safe as they transition into professional nursing practice. Understanding new graduate registered nurses’ experiences of psychological safety can guide leaders and others to create work environments that foster psychological safety and organizational learning (Zhao, Ahmed, and Faraz, 2020). Psychological safety is an emerging area of study in patient safety that has been particularly evident in the 2020–21 COVID‐19 pandemic, as so much of health care shifted priorities leaving many feeling vulnerable. The pandemic reinforced the connection of psychological safety to inclusive leadership and healthy worker relationships. Team members who feel psychologically safe are comfortable sharing innovative ideas, providing feedback and speaking up about problems—without fear of repercussions.
Consumer Engagement
Consumers have helped motivate changes in health care. Patients and families who experienced adverse events help push reform in how health care systems identify, investigate, report, and share information related to errors. Patients and families who experience health care mistakes leverage their influence to prevent similar events happening to others. Numerous nonprofit organizations have been created in response to adverse events focusing attention on particular care delivery issues as well as broader issues. Many patients or their family members now serve on hospital boards or consumer panels, share their stories in learning situations, participate in health care research, and join improvement efforts in all areas of health care. Helen Haskell provides insight into the role of patients and families in patient safety in Textbox 1.4.
Many organizations now include a Patient and Family Advisory Council (PFAC; Hatlie et al., 2020). Active engagement of patients and families, especially those who have experienced preventable harm, helps co‐create organizational alignment with quality and safety goals and improve the care experience. Street et al. (2020) found that providers who were dismissive of patient and family involvement missed opportunities for clear communication that prevented errors and delays in treatment. Patients and families, in fact, often “saved the day” by catching close calls.
It is well established that patients and families should be active members of their health care team and participate in shared decision‐making. Neves et al. (2020) examined the impact of sharing electronic health records (EHRs) with patients on the six quality domains in the STEEEP model (i.e., safety, timeliness, effectiveness, efficiency, equity, and patient‐centeredness). Most frequent was effectiveness, the least were timeliness and equity, and patient‐centeredness was inconsistent (i.e., satisfaction, participation, self‐efficacy, empowerment, or health literacy); overall, sharing the EHR yielded a positive effect.
Textbox 1.4 Patient Engagement: Key to Healthcare Improvement
Contributed by
Helen Haskell, MA
President, Mothers Against Medical Error and Consumers Advancing Patient Safety
Co‐chair, WHO Patients for Patient Safety Advisory Group
Co‐chair, Patient Engagement, WHO Global Patient Safety Action Plan
National Steering Committee, Institute for Healthcare Improvement, National Action Plan on Patient Safety
Though people do not always recognize it, patient engagement lies at the heart of the modern patient safety movement. Stories of patient harm in the 1990s were the impetus for the early Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, and the patient stories on the opening pages of To Err Is Human were one of the main reasons that report resonated so profoundly with the public. Patient activism—the Picker Institute’s eight dimensions of care, distilled from years of patient interviews—underlay almost all the deliberations and recommendations of Crossing the Quality Chasm. These eight dimensions formed the basis for the STEEEP principles that still undergird our quality measurement framework.
More than two decades later, where do we stand? In some ways, patient engagement has been one of the big successes in patient safety and quality. The patient voice is increasingly prevalent throughout much of the health care system. We have patient and family advisory boards, family‐centered rounds, patient‐activated rapid response, shared decision‐making, and medical error disclosure programs. Crucially, we have patient surveys as a measure on which health care providers are assessed. Patient‐reported
