FIVE QUESTIONS

Safety leaders aim to hasten and sustain change with National Steering Committee

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Jeffrey Brady, M.D., M.P.H.

Rear Admiral Jeffrey Brady, M.D., M.P.H., is a member of the senior leadership team at the Agency for Healthcare Research and Quality (AHRQ), where he has worked since 2006. Prior to becoming Director of AHRQ’s Center for Quality Improvement and Patient Safety in 2014, he led the agency’s Patient Safety Research Program and, earlier, the team that reports annually to Congress on the status of health care quality in the United States. Dr. Brady has also served as a medical officer and clinical reviewer for the Food and Drug Administration, medical epidemiologist for the Department of Defense, and primary care physician in the U.S. Navy.

The Betsy Lehman Center: You serve with Dr. Tejal Gandhi as co-chair of the National Steering Committee for Patient Safety. Please update us about the early stages of the Committee’s work.

Dr. Brady: The National Steering Committee for Patient Safety was formed last year to bring greater collaboration and coordination to patient safety work across the United States. This is something that was called for in the landmark report, To Err Is Human: Building a Safer Health System, released by the Institute of Medicine (now the National Academy of Medicine) nearly 20 years ago. AHRQ and many others have made progress on making health care safer as a result of several collaborative efforts since then, but there is still a long way to go.

AHRQ and many others have made progress on making health care safer as a result of several collaborative efforts, but there is still a long way to go.

The Steering Committee is a public-private partnership that represents a broad range of stakeholders. We want to build on the good work and results that have been achieved to date. One of our first steps was to bring this group together and decide where to focus our efforts in order to make the biggest impact. We formed subcommittees to dive into four broad and intersecting areas of health care: culture, leadership, and governance; patient and family engagement; workforce safety; and learning health systems. These are the foundational areas that the committee determined are prerequisites if we are going to see sustained improvement on more specific goals. That’s especially true when we consider the challenge of addressing the full list of threats to patient safety such as healthcare-associated infections, adverse drug events, diagnostic errors and others.

For the past year, these four subcommittees have been meeting regularly to review the literature, assess the field for best practices, and develop recommendations and actions that organizations and people can take to advance patient safety. Although each of these areas has its own distinct challenges, we feel it is important to note that they are also interdependent. For example, it’s impossible to develop a strong workforce safety program without the culture and leadership to support it. 

The Betsy Lehman Center: The National Steering Committee has been charged with creating a “national action plan.” Can you describe what kinds of actions the Committee is considering? 

Dr. Brady: Because the subcommittees are still at work, I can’t really get into the specifics of the National Action Plan, which we hope to release in early 2020. However, I think it is fair to say that the recommendations will be broad-based. In the plan, we will endeavor to represent important lessons the field has learned about the value of bold changes such as bringing patients and families in as true partners and co-designers of care. Other recommendations may be more specifically related to best practices. We believe there will also be a place for policy recommendations and the recognition of emerging areas, such as diagnostic safety, that still need more research in order to inform future improvements that will benefit patients.

The Betsy Lehman Center: What do you say to people who believe that health care is already as safe as it can be, that we’re not likely to make further progress on patient safety, even with a coordinated response?

Dr. Brady: I think we’ve actually seen that some of the greatest progress we’ve made over the past 20 years has happened as a result of collaborative and coordinated work. For example, AHRQ, the Centers for Medicare and Medicaid Services, and other partners have helped to reduce hospital-acquired conditions, or HACs, such as adverse drug events and injuries from falls. These strides helped to avoid 350,000 HACs, prevent an estimated 8,000 deaths and save $2.9 billion between 2014 and 2016Furthermore, the Institute for Healthcare Improvement’s 100,000 Lives Campaign coordinated a 3,000-hospital effort that is estimated to have contributed to the prevention of 122,000 needless deaths. 

There is no question that making health care safer is difficult to accomplish on a national scale, but we believe the National Steering Committee will help us focus on the most actionable items and avoid duplication and redundancy. We know that health care is not as safe as it can be. We know that we can do better together.

There is value in sharing national- and state-level learning, which can accelerate and increase the efficiency of our collective efforts to keep patients safe.

The Betsy Lehman Center: Earlier this month the Betsy Lehman Center published research about the experience of medical harm in Massachusetts. Do you see parallels or differences between our experience in Massachusetts and in the country as a whole?

Dr. Brady: We’ve seen the benefits of addressing patient safety at multiple levels—from the national to the state and local level, where care is actually delivered. As you know, the Betsy Lehman Center’s recent research found nearly 62,000 preventable medical errors that cost more than $617 million in a single year, and in-depth interviews with patients and families revealed a great deal more about the impact of errors, which took a huge physical and emotional toll. Unfortunately, similar harms are continuing across the country, but there is value in sharing national- and state-level learning, which can accelerate and increase the efficiency of our collective efforts to keep patients safe. 

The Betsy Lehman Center: In a press release announcing formation of the National Steering Committee, you were quoted as saying that you “believe strongly that a new era of patient safety is within reach.” What are the characteristics of that new era? 

Dr. Brady: Health care is certainly changing, and while we are most familiar with what can go wrong in hospitals, I do see a growing awareness that preventable harm associated with health care can happen anywhere, as the Betsy Lehman Center’s report notes. So, I see a move toward more work in outpatient and community settings, like pharmacies, and in patients’ homes. I also hope that we’ll see a greater awareness on the part of patients and the public that health care is a high-risk industry, and they have a role to play in keeping themselves safe and improving the system. An effective National Action Plan for Patient Safety should bolster ongoing research and improvement activities that are guiding the pathway to safer, higher value care.

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