Committing to Continuous Patient Safety Learning: Recommendations and Case Examples

Why It Matters

Last fall, the National Steering Committee for Patient Safety (NSC), convened by the Institute for Healthcare Improvement (IHI), released Safer Together: A National Action Plan to Advance Patient Safety. The NSC report draws from evidence-based practices, widely known and effective interventions, exemplar case examples, and newer innovations.

The National Action Plan prioritizes four foundational — and interdependent areas — to advance a total systems approach to patient safety:

• Culture, Leadership, and Governance
• Patient and Family Engagement
• Workforce Safety
• Learning System

The following excerpt (adapted from Implementation Resource Guide: A National Action Plan to Advance Patient Safety) focuses on establishing a learning system.

What is a Learning System?

A learning health system integrates internal and external information, including safety data, best practices, and patient and employee feedback while leveraging technology to generate change ideas, test those changes, and either implement or amend the changes as necessary to improve the safety of both patients and employees. Key characteristics of a learning health system include a pioneering spirit, leadership engagement and commitment to learning and improvement, inclusion of patients and frontline employees in the learning and improvement process, a culture that supports transparency and process change to improve safety, and active engagement in a regional or national learning system if one is available.

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To develop a total systems approach to advance patient safety, health care organizations and other stakeholders across the care continuum must implement reliable learning systems. To do this, the National Action Plan makes the following recommendations:

• Facilitate both intra- and inter-organizational learning. All health care organizations must take steps to become collaborative learning organizations by using high-reliability principles, ensuring robust learning feedback loops, and engaging with established local, regional, state, or national learning systems.
• Accelerate the development of the best possible safety learning networks. Leaders of existing safety learning networks must engage in the development of a network of networks to identify and increase adoption of best practices so that, working together, all can become the most effective learning networks possible.
• Initiate and develop systems to facilitate interprofessional education and training on safety. Academic institutions, professional educators, and leading patient safety and quality organizations must collaborate to better understand how to improve safety education and training for clinical and administrative staff. These organizations must identify and share openly all best practices on the creation, dissemination, and assessment of safety education and training methods and materials.
• Develop shared goals for safety across the continuum of care. Leaders of health care organizations, employers, and policymakers must collaborate with leaders of safety learning networks to adopt national-level goals to eliminate specific types of harm across the continuum of care, ultimately advancing the development and dissemination of methodologies and processes to improve safety.
• Expedite industry-wide coordination, collaboration, and cooperation on safety. Modelling leaders in civil aviation, health care leaders representing all stakeholders must actively develop a public-private partnership to use the power of data sharing and cooperative learning to identify and solve the most urgent and emerging patient safety problems.

Follow the Learning System Track: IHI Patient Safety Congress

Consider this selection of case examples to support your learning system development and implementation efforts:

• Children’s Hospitals’ Solutions for Patient Safety Network — With an international network of more than 140 participating children’s hospitals, the Solutions for Patient Safety (SPS) Network is built on “the fundamental belief that by sharing successes and failures transparently and learning from one another, children’s hospitals can achieve their goals more effectively and quickly than working alone.” Participating hospitals agree not to compete on safety or to use safety data for competitive purposes. In addition, participating hospitals are asked to follow an “all teach, all learn” philosophy to share and learn from others and work on developing a culture of safety in their organizations. Looking at results in the SPS Network, “in 2017, SPS reported a 9 percent to 71 percent reduction in eight harm conditions by an initial cohort of 33 hospitals. SPS estimates that more than 9,000 children have been spared harm since 2012, with $148.5 million in health care spending avoided.”
• Partnership for Patients — The Centers for Medicare & Medicaid Services (CMS) implemented the Partnership for Patients (PfP) model in 2011, one of the first models tested using section 1115A of the Social Security Act. The PfP was a quality improvement network designed to reduce preventable hospital-acquired conditions (HACs) by supporting more than 3,700 acute care hospitals to achieve more than a 40 percent reduction in HACs and a 20 percent reduction in readmissions. While patients and private and federal partners worked to align policy and action toward the goal, government contractors called Hospital Engagement Networks (HENs) provided direct technical assistance to acute care hospitals in implementing evidence-based best practices of high-performing health care systems. Representing the next phase in the evolution of highly coordinated patient safety efforts, the HENs integrated with the Quality Improvement Network–Quality Improvement Organization (QIN–QIO) program in 2016 to maximize the strengths of the QIO program while continuing to expand national reductions in patient harm and 30-day readmissions. Built on the collective momentum of the HENs and QIOs, CMS elected to refer to the contractors awarded as Hospital Improvement Innovation Networks (HIINs). CMS, through the 16 HIINs, further instilled best practices in harm reduction in more than 4,000 US acute care hospitals. The HIINs regularly engaged with hospitals, providers, and the broader caregiver community to implement evidence-based practices in harm reduction to improve care quality for Medicare beneficiaries.
• Learning Healthcare System Networks Project — PCORnet awarded funding in 2017 to Peter Margolis, MD, at Cincinnati Children’s Hospital Medical Center (CCHMC) and the Learning Healthcare System Networks Project (previously called the People-Centered Communities). Work is underway to develop four pilots based on CCHMC’s successful learning network model that supports the design, development, and implementation of learning and data networks. The project will provide funding and technical assistance for pilot patient-powered research networks to plan and implement programs that pursue the Learning Healthcare System model as a central strategy. It will also help create a collaborative learning community designed to assist networks interested in
• Institute of Nuclear Power Operations — The Institute of Nuclear Power Operations (INPO) was established in 1979 by nuclear facilities in the US following a serious accident at the Three Mile Island nuclear power plant. INPO identifies generic safety problems and precursors by reviewing and analyzing nuclear power plant operating experiences and communicates this information to its members to help reduce the possibility of similar occurrences at other plants. INPO also conducts evaluations of nuclear power plant operations to aid in identifying areas in which improvements can be made.
• Aviation Safety Information Analysis and Sharing — To ensure civil aviation safety, the Aviation Safety Information Analysis and Sharing (ASIAS) program works closely with the Commercial Aviation Safety Team and the General Aviation Joint Steering Committee to monitor known risks, evaluate the effectiveness of deployed mitigations, and detect emerging risks. ASIAS brings together government agencies, aviation stakeholder organizations, aircraft manufacturers, and dozens of airlines and corporate operators. It also connects approximately 185 data and information sources across government and industry, including voluntarily provided safety data. Once analyzed, “the aggregated data helps to proactively identify safety trends and assess the impact of changes in the aviation operating environment.”

For more details and additional case examples, download the Safer Together: A National Action Plan to Advance Patient Safety, Self-Assessment Tool, and Implementation Resource Guide.