In 1999, the Institute of Medicine Committee on Quality of Health Care in America published “To Err is Human: Building a Safer Health System” — an investigation into the prevalence of medical errors and the steps health systems could take to improve patient safety and care quality. As we approach the twenty-fifth anniversary of this landmark report, preventable medical harm remains a serious problem in health systems worldwide.
Today, nearly 1 in 4 hospitalized patients experience a harm event, 25% of which are preventable. The impacts of medical harm are vast, affecting not only patients and their families but also healthcare staff — from a clinician who struggles with guilt after making a medication error to a security guard who witnesses a preventable patient fall and is afraid to report it. Healthcare workers are experiencing unprecedented levels of emotional exhaustion and mental health challenges, driven by administrative overload, the moral injury associated with medical harm, inadequate peer support and the strain of inefficient technology and siloed data. Our healthcare workforce may also find themselves trapped behind a metaphorical “wall of silence” caused by being discouraged from speaking up about medical errors and safety incidents — all of which can contribute to a vicious cycle of harm.
In August, the Centers for Medicare & Medicaid Services (CMS) finalized the Patient Safety Structural Measure (PSSM), which sets forth a broad roadmap for the implementation of a culture of safety, learning, transparency and accountability within hospitals and health systems nationwide — enabling and encouraging significant progress towards safer care and improved support for healthcare workers.
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There is a need to bring joy, meaning and compassion back to the healthcare profession and foster transparency and learning around harm. Reducing preventable harm, alleviating emotional exhaustion and making it easier to report concerns will require a comprehensive, multi-pronged approach. The PSSM is critical to sparking this approach within health systems across the country.
PSSM formalizes the requirement for safety culture within health systems
The PSSM is designed to address patient safety by leveraging evidence-based practices to drive improvement. It includes five key domains: leadership commitment to preventing harm; strategic planning/organizational policy; creating a culture of safety and learning systems; accountability/transparency; and patient and family engagement. The PSSM also encourages the establishment of a just or fair and accountable culture.
With the final ruling published and attestations expected in October of this year, the PSSM is a significant step forward in addressing the core challenges impacting the healthcare industry. It will serve as a patient safety compass that encourages open communication, thorough incident reporting and data sharing. The PSSM provides a structured framework to guide health systems in establishing and upholding best practices that truly move the needle towards true north for patient safety. The measure will also guide health systems in normalizing compassionate honesty around patient safety.
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The role of connected data and incident reporting
Historically, thorough incident reporting and transparency around patient harm have been hindered by data silos and technology overload within health systems. While the healthcare industry generates massive amounts of data, the majority of this data is not accessible nor actionable. Managing data across all operations to enable a comprehensive understanding of existing challenges and target areas for improvement has been a persistent challenge impacting our ability to hardwire patient safety. Currently, roughly 86% of patient safety incidents occurring in healthcare organizations go unrecorded, in part due to the inefficient technology and the administrative burden involved in documenting these events.
Health systems that implement connected healthcare operations – the harnessing of actionable data, insightful analytics to break down silos and improve safety, accuracy and efficiency across the continuum of care – and AI-enabled risk reporting solutions, can unlock new data insights and cut down the time staff spends on incident documentation, encouraging comprehensive risk reporting and transparency around harm.
To further these efforts and increase alignment with the PSSM, healthcare organizations should adopt platforms that unlock actionable data while reducing administrative burden and improving the bottom line. Additionally, by working with a Patient Safety Organization, healthcare organizations can access more data insights from across participating hospitals and health systems. With the right software solutions and collaboration, healthcare organizations can hardwire compassion and safety into their daily processes and enable more effective peer support for everyone associated with a harm incident.
Approaches to peer support and empathetic communication
The finalization of the PSSM reflects an increasing nationwide commitment to restoring empathy, compassion and transparency to healthcare — changes that are sorely needed to support patients, families and healthcare workers struggling with the effects of medical harm. Implementing Communication and Optimal Resolution (CANDOR) is an immediate step that hospitals and health systems can take to make tangible improvements to their patient safety culture and peer support. The CANDOR toolkit provides hospitals and health systems with tools to respond to patient harm through rapid event reporting, immediate response, empathetic communication, peer support and resolution. Effective empathetic communication is a skill that can be learned, and CANDOR involves training healthcare staff in this skill so that they can communicate compassionately with patients and their families.
With the PSSM now mandating more transparent communication and approaches such as CANDOR, hospitals and health systems will have the tools and support they need to approach patient safety from a systematic and empathetic lens.
Bringing joy, meaning and compassion to healthcare organizations
The PSSM reinforces the critical role connected healthcare operations play in driving patient safety. It will have a profound impact on transforming the overall landscape – encouraging hospitals and health systems to establish a just culture around patient safety.
Healthcare workers enter their professions because they want to help people, but this passion can be compromised by data overload, inefficient technology and lack of transparency and peer support around medical harm. To remedy this, we need to find ways to empower the front line and remove barriers to them providing safer and compassionate patient care. Meaningful change takes time, but it’s worth it. By aligning their systems and processes with the five domains of the PSSM, healthcare organizations can improve care quality and safety and empower staff, enabling clinicians to practice at the top of their licenses — ultimately resulting in safer patients, a safer workforce and a safer organization.
Photo: kutubQ, Getty Images
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE is Vice President and Chief Risk Officer at Children’s National Medical Center in Washington, D.C. She has a Bachelor's of Science in Nursing from Georgetown University and is a graduate of the University of San Diego School of Law. Prior to coming to CNMC in 2008, Rebecca was a partner at Grace, Hollis, Lowe, Hanson and Schaeffer, a California law firm, where she practiced in the areas of malpractice defense, healthcare, and professional licensure law. She has published extensively in the area of nursing and the law, and is a frequent lecturer to healthcare providers. She was Editor in Chief of the Journal of Nursing Administration's Health Care Law, Ethics, and Regulation from 2002-2013. She also served as president of the American Society for Health Care Risk Management (ASHRM) in 2023.
Timothy McDonald, MD JD, is the Chief Patient Safety and Risk Officer for RLDatix and a Professor of Law at Loyola University – Chicago. Tim is a physician-attorney who has assisted more than 800 hospitals and health systems implement a culture of “normalized compassionate honesty” combined with “fair and accountable culture” transformation. His research has focused on conducting patient safety, Just Culture, and high reliability needs assessment/Gap Analysis for organizations along with assisting them in the principled approach to unexpected events with an emphasis on reporting of patient safety events, the use of simulation and human factors analysis, the provision of emotional first aid to affected health care team members and providing open and honest communication following harm events. This approach to unexpected events also includes a commitment to communicate and provide peer support within the health care team and to communicate with patients and families throughout the therapeutic relationship, especially after harm occurs. He has received numerous national and international Patient Safety awards including the American College of Medical Quality’s Founder’s Award, the Institute of Medicine – Chicago Patient Safety Award, and the Medically Induced Trauma Support Services [MITSS} Hope Award.
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