The COVID-19 pandemic created countless challenges for healthcare providers, but some silver-linings-minded leaders believe the health crisis also accelerated innovation in quality and safety. In a March/April 2021 Healthcare Executive column, Richard Brant, MD, CPHQ, medical director for quality and patient safety at West Virginia University Medicine Children’s Hospital, expressed his belief that the heightened activity catalyzed by the pandemic will ultimately help organizations move along the journey to zero harm.

ACHE joins with members of the National Steering Committee for Patient Safety to announce the release of a National Action Plan to provide health systems with renewed momentum and clearer direction for eliminating preventable medical harm. Safer Together: A National Action Plan to Advance Patient Safety draws from evidence-based practices, widely known and effective interventions, exemplar case examples, and newer innovations. The plan is the work of 27 influential federal agencies, safety organizations and experts, and patient and family advocates, first brought together in 2018 by the Institute for Healthcare Improvement.

The ultimate goal for healthcare providers is zero avoidable harm to patients, families and the workforce. To achieve and maintain this goal long term, you have to learn how to walk before you can run. Leading a Culture of Safety: A Blueprint for Success helps leaders break down priorities and focus on fine-tuning a few pillars of change at a time. The evolving road to patient safety requires a plan for longevity and transparency. By thoroughly committing to prioritizing action steps around one or two domains, leaders can reassess progress six months later before advancing to the next layer of improvement.

Leading for safety is a daunting challenge that requires strength and courage. Committed leaders lead with intent. They set the purpose and direction within their organizations—they lead for zero harm. Committed leaders do not allow for delays or excuses. Instead, they are ready to strategically face areas of improvement, and are eager to assess and sustain a culture of safety. In the healthcare industry, with lives on the line, every step to reduce medical error must be taken with purpose and direction.

The statistics on patient deaths due to medical error are alarming. Even still, these statistics don’t take into account serious temporary or permanent physical and psychological harm caused by medical error, nor do they include harm to the healthcare workforce. Medical errors impact caregivers greatly, from concern for their patients and job, to possible isolation, depression and self-harm. The feeling of desolation after an incident is typically worse in organizations that lack supportive systems.

Don Berwick, IHI president emeritus and senior fellow, has characterized our current healthcare system as "repair shops" where we rise to the challenge of fixing and correcting the damage for what’s broken. Often work gets accomplished without deeply understanding and addressing the underlying causes and determinants of the problem.

We’ve all heard of Six Sigma. It’s familiar terminology to any healthcare leader focused on quality improvement. Surely, however, there are some of you out there who know only that it is a methodological tool used to recognize variability, prevent error and manage change. How, exactly, does it work? Will understanding it better help you to do a better job? No doubt.

Inaccurate or delayed diagnoses are the most common, most catastrophic and most costly of serious medical errors. The National Academy of Medicine believes improving the diagnostic process is not only possible, but also represents a moral, professional and public health imperative. An inaccurate or delayed diagnosis can result in inappropriate treatment, worsen underlying conditions and cause serious harm.

As leaders, we represent more than the roles we play. We belong to a profession centered on an important calling: to care for those who put their trust in us and to model the values for which we stand. We work tirelessly to advance health for our patients and communities, and each day we recommit to the safety imperative. We’ve worked together through initiatives and innovations to reduce preventable harm in our institutions. Even as we celebrate these achievements, we recognize that continual assessment and improvement are key to making further inroads.

Improving safety has been a top priority at healthcare organizations across the country for the last two decades, but preventable harm is still an issue. To help tackle this problem, the Institute for Healthcare Improvement-convened National Steering Committee for Patient Safety released Safer Together: A National Action Plan to Advance Patient Safety earlier this fall.