Background

Despite the development and publication of effective and evidence-based strategies to enhance patient safety and reduce preventable harm in healthcare settings, there are gaps in the large-scale dissemination and implementation of these approaches. The National Patient Safety Goals (NPSG) program was developed by The Joint Commission, a healthcare accrediting body in the United States. The goals were developed as a response to the National Academy of Medicine (formerly the Institute of Medicine) report, “To Err is Human: Building a Safer Health System” which described the high prevalence of preventable medical errors in the United States. The NPSGs offer ways to develop proactive system-level processes of care to promote patient safety instead of focusing on reactive and punitive individual-level approaches.

Similar approaches to setting patient safety goals have been undertaken by other countries and organizations. For example, Healthcare Excellence Canada lays out The Canadian Quality and Patient Safety Framework for Health Services and its goals for safe care include monitoring, disclosing, and addressing patient safety incidents, patient harms, and avoidable deaths. The World Health Organization’s Global Patient Safety Action Plan is a framework that was adopted by the World Health Assembly in 2021 with the goal of enhancing patient safety worldwide. The Plan emphasizes actions at the policy and leadership level, in addition to steps at the point of care at health care facilities. It provides guidance to countries as they formulate their national action plans on patient safety and its recommendations are well-aligned with the NPSGs. Common features include enhancing patient and caregiver engagement, tracking and sharing safety data, increasing healthcare staff skills, promoting a culture of patient safety, and developing high-reliability healthcare systems.

Although successful patient safety interventions have been implemented widely in the United States over the past two decades, the COVID-19 pandemic uncovered and worsened significant gaps and inequities in healthcare. Health systems nationally had to focus on mitigating severe shortages in health care staffing, widening disparities in access to care, and the growing need for behavioral health services. As health systems address these critical issues, a renewed focus on national action plans for patient safety that address system level solutions is both timely and crucial.

Development

The first set of NPSGs was developed in 2002 and implemented the following year. The NPSG program aimed to provide a common improvement framework to enable organizations, especially those accredited by The Joint Commission, to focus on timely and crucial patient safety issues. Goals for each year are identified based on feedback from clinicians, healthcare organizations, insurers, and consumers. Using input from these partners and evidence from the literature, The Joint Commission identifies areas of priority and accompanying strategies to address these areas. Goals are updated annually based on data and feedback on their benefits, results, implementation, utility, and cost-effectiveness.

Scope

National Patient Safety Goals are developed in the context of specific settings, including ambulatory health care, hospitals, nursing care centers, assisted living facilities, surgical facilities, behavioral health, laboratories, and home care. There is substantial overlap of goals between settings, and they focus on a range of areas including accurate patient identification, medication and surgical safety, alarm safety, facilitating clinician communication, as well as preventing hospital-associated infections, falls, pressure ulcers, and inpatient suicide. A recent addition to NPSGs has been highlighting health care equity as a patient safety standard by identifying healthcare disparities in the population served by the healthcare organization and developing a written plan to improve health care equity.

Examples

An example of an NPSG in the ambulatory healthcare setting involves accurate identification of patients to ensure that errors in procedures and treatments are avoided. This check is implemented by utilizing at least two identifiers such as the patient’s name and date of birth before interventions. An NPSG in the hospital setting includes preventing surgical errors by ensuring that the right surgical procedure is conducted on the right patient at the correct location on the patient’s body. This safety standard is implemented by marking the accurate surgical site prior to the procedure and taking a pause before surgery to ensure no errors occur. A nursing care center goal includes preventing falls in patients and nursing home residents by identifying individuals at risk for falls, such as those taking medications that could result in weakness, dizziness, or sleepiness. The goal additionally includes taking steps to prevent falls in these high-risk individuals.

Implementation

The implementation of NPSGs is enhanced through proactive, coordinated, and systems-level approaches that are incorporated across healthcare systems and involve multidisciplinary and multisectoral partners. Healthcare organizations in the United States can improve patient safety by using the NPSGs to identify their priorities for data collection, select metrics to measure and track their performance, and create and implement systems-level quality improvement strategies to address them. The NPSGs are safety standards that hold hospital and healthcare workers accountable to best practices to keep patients safe and make maintaining these standards a prerequisite to accreditation. Failure of hospitals and healthcare organizations to maintain optimal performance on patient safety goals increases their risk of not obtaining or losing their accreditation from The Joint Commission.

NPSGs are the method through which The Joint Commission identifies the attainment of its standards and performance metrics during its accreditation surveys. During The Joint Commission’s on-site surveys, surveyors collect data on NPSGs at healthcare organizations, evaluate their implementation processes and outcomes, and provide feedback and guidance that can inform the organization’s approaches to improve patient safety. Surveys for reaccreditation are usually unannounced and occur approximately every three years. During the survey, compliance with NPSG-associated standards is assessed through a range of methods such as tracers that follow the experience of patients and other individuals through the health care system, surveys of organizational safety culture, and evaluating the competence and credentialing of medical staff. If lapses are observed, health care organizations are provided with requirements for improvement, survey reports, and accreditation decisions based on their performance. Accreditation decisions are made available to the public on the Quality Check® website.

An implementation resource that healthcare organizations can use to incorporate NPSGs into their daily work is Safer Together: A National Action Plan to Advance Patient Safety. The National Action Plan was collaboratively developed by 27 organizations in the U.S. that came together to form the National Steering Committee for Patient Safety, convened by the Institute for Healthcare Improvement in 2018. The Plan contains 17 recommendations to improve patient safety in the areas of developing a culture of patient safety, organizing governance and leadership to oversee and develop safety cultures, engaging patients and caregivers in co-designing and co-producing care, ensuring the safety of the healthcare workforce, and fostering a learning health system that shares its successes and challenges to enable continuous improvements in patient safety. Healthcare organizations can use the National Action Plan along with its companion Self-Assessment Tool and Implementation Resource Guide to analyze gaps, implement interventions, and track their performance and progress on NPSGs.

The National Action Alliance for Patient and Workforce Safety builds on core principles of Safer Together: A National Action Plan to Advance Patient Safety and is a public-private collaboration and learning community that aims to implement a systems approach to safety. Its goal is to disseminate and expedite the implementation of evidence-based approaches that span culture, leadership and governance, patient and family engagement, workforce safety, and the development of learning health systems.

Ulfat Shaikh, MD, MPH, FAAP
Associate Editor, AHRQ’s Patient Safety Network (PSNet)
Professor of Pediatrics and Director for Healthcare Quality
UC Davis Health