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Beyond the Pandemic: Creating Total Systems Safety

Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD | August 30, 2023 
View more articles from the same authors.

The COVID-19 pandemic necessitated a shift in operations as healthcare delivery organizations and workers adjusted processes and workflows to accommodate the rise in cases across the country. To ease the burden on a strained system, organizations paused elective procedures, reduced in-person treatment across care settings, and reprioritized care to address the increased volume of critically ill patients and shortages in both staffing and equipment. On May 11, 2023, more than three years after the first cases were documented in the United States, the U.S. Department of Health and Human Services (HHS) declared the end of the federal COVID-19 public health emergency (PHE).

While responding to COVID-19 remains a public health priority, there is a renewed focus on patient safety to address systems issues that were brought to light or magnified during the pandemic. HHS Secretary Xavier Becerra has asked healthcare systems to recommit to patient safety through the National Action Alliance. Organizations can move forward and commit to reestablishing patient safety as their purpose through lessons learned during the pandemic.

Impact of the COVID-19 Pandemic on Healthcare

Decline in Performance on Safety Measures

Prior to the onset of the pandemic, there were notable improvements in performance on patient safety measures associated with healthcare-acquired conditions, such as central-line bloodstream infections and adverse drug events. Researchers and healthcare professionals attribute these pre-pandemic improvements to initiatives such as the implementation of patient safety bundles and taking a systems approach to analyzing and approaching patient safety like root-cause analyses.

Although processes were put in place to address patient safety challenges, many organizations that had achieved gains prior to the pandemic experienced setbacks during the pandemic. Studies show that an increase in healthcare-acquired infections, falls, and pressure ulcers has occurred since the pandemic’s onset. In its Declaration to Advance Patient Safety, the National Steering Committee for Patient Safety (NSC), led by the Institute for Healthcare Improvement (IHI) and AHRQ, underscores increases in central line bloodstream infections, ventilator-associated events, and catheter-associated urinary tract infections across hospitals. Similar increases were observed in falls and pressure ulcers at skilled nursing facilities and preventable 30-day hospital readmissions.1

Coupled with the decline in safety performance indicators, many healthcare workers noted an overall downward shift in the results of surveys of patient safety culture and items related to workplace culture of safety. The Pennsylvania Patient Safety Authority noted that reported safety events declined from 2019 to 2020, indicating that the pandemic had a negative impact on reporting. In a survey of critical care clinicians, a majority of respondents noted that they felt conditions were more hazardous during the pandemic, and 47% stated they observed more patient safety events within the intensive care unit than pre-pandemic. Across healthcare, surveys reveal workforce concern that healthcare workers are unable to provide safe care and are working in unsafe and unhealthy work environments.2

Factors Impacting Patient Safety

The decline in safety performance can be attributed to a number of factors. Many safety leaders argue that the disruptions caused by the pandemic exacerbated pre-existing symptoms of system vulnerabilities. Systems and processes were overly reliant on the healthcare workforce’s attention to maintaining safety. With an unprecedented surge of critically ill patients to care for and a shortage of personal protective equipment, long hours of care, and abnormally high death rates, safety protocols may have shifted as patient safety risks may have increased. Further concerns about financial vulnerabilities, staffing and supply chain shortages, and highlighted health inequities caused additional stress to the system and posed added challenges for healthcare leaders and executives who may have needed to prioritize which challenges to address first.

Pre-existing challenges of the healthcare workforce have been exacerbated during the past three years. In addition to severe staff shortages and the increased need to use agency and float staff across hospitals and healthcare units, healthcare workers have shared that they are experiencing higher levels of burnout and workplace violence. With the changes in environment, moral distress, and discomfort with clinical situations, many clinicians have shared a loss of psychological safety. Many experienced staff members have left the healthcare workforce, resulting in changes to established teams, team dynamics, and skill mix across healthcare, further posing safety challenges.

An additional factor that has impacted patient safety is the setbacks in patient and family engagement in their own care as well as the design and delivery of safe care. Patient and family engagement can improve the quality and safety of healthcare as patients and their care partners collaboratively work with their healthcare teams. Another way patient and family engagement can improve quality and safety is by engaging patient and family advisory councils in meaningful work. With the increase in COVID cases and the goal to reduce further spread, many healthcare facilities shifted policies and restricted access to care units and visitation policies with the unintended consequence of reducing the involvement of patients’ families and care partners in their ongoing care.

Positive Trends and Developments During the Pandemic

While the pandemic caused disruptions to the normal operations of healthcare organizations, it triggered innovations and the implementation of rapid-cycle learning collaboratives, as well as the introduction of new technologies to address gaps in healthcare access. As a part of the flexibilities permitted under the PHE, HHS facilitated the expansion of telehealth which helped to ease the burden of delayed care due to fear of spreading COVID. Many states have the ability to make these telehealth flexibilities permanent to allow continued access to care, given the benefits of coordinating care and reducing barriers to care access, like transportation. Other technologies such as remote patient monitoring were leveraged throughout the pandemic to provide ongoing care for COVID patients outside of the hospital setting.

The pandemic accelerated a shift from healthcare in the hospital toward healthcare in the home and the community. The movement toward more ambulatory care began prior to the pandemic as more outpatient procedures were offered and coordination and home healthcare options have been developed. The Centers for Medicare & Medicaid Services’ (CMS’) programs like the home and community-based services were developed before the pandemic as ways for beneficiaries to receive care outside of the hospital. CMS waivers for acute hospital care at home have been extended through 2024, fostering the interest and uptake of care at home that would normally be provided in inpatient acute care settings. While there were challenges in meeting the needs of home-based care, the demand for outpatient care has increased through the pandemic.

The pandemic highlighted pre-existing gaps in the system and processes that contribute to health inequities and spurred the growing recognition of health inequities as harms. Also brought to light was the importance of identifying needs related to social determinants of health to address related gaps. Initiatives such as the RISE to Health: National Coalition for Equity in Health Care bring together individuals and organizations to transform healthcare through coordinated and collective action.

Addressing the Setbacks with Total Systems Safety

In the post-pandemic space, healthcare organizations can address the setbacks experienced during the pandemic and regain lost ground using a whole systems approach that will result in improvement in both patient safety processes and outcomes. In 2018, prior to the onset of the pandemic, the IHI convened the NSC, an interdisciplinary workgroup of leading healthcare organizations, associations, patient and family activists, and federal agencies, including AHRQ, and chartered the NSC with developing an action plan to improve patient safety on a national level. Safer Together: A National Action Plan to Advance Patient Safety was released in fall 2020. The central concept of this plan is total systems safety, that is, applying principles systematically and uniformly across four foundational and interrelated areas that are critical for preventing harm and advancing safety. The NSC also developed supplemental resources, including the Self-Assessment Tool and an Implementation Resource Guide, to aid organizations in their implementation plans across the four foundational areas: (1) culture, leadership, and governance; (2) patient and family engagement; (3) workforce safety; and (4) learning systems, to build and sustain improvements in safety. Healthcare leaders across the country are rethinking and reinvesting in safety using the Self-Assessment tool and high reliability principles to make healthcare systems more impermeable to disruptions. These principles include ideas such as improving situational awareness, leveraging data and learning networks, and rebuilding a culture of safety, among many others.

Importantly, using a coordinated and comprehensive approach like the recommendations presented in the National Action Plan helps avoid a piecemeal and reactive response. Instead, healthcare leaders and staff can apply proactive and systemic approaches to provide safer care across the entire continuum of care. A key component of total systems safety is the shift toward a proactive strategy to anticipate, mitigate, and control upstream risks to prevent harm. The shift toward anticipation and coordination before an event occurs using data and input from stakeholders (such as frontline staff, human-centered design engineers, safety scientists, and patients) offers many opportunities to avoid harm completely.

Future Directions: Taking Safety Another Step Forward

As organizations level-set and recommit to safety, resources like the National Action Plan can help move performance in the right direction toward preventing harm to patients, as can engaging in the National Action Alliance to Advance Patient Safety. Additional resources, such as the National Plan for Health Workforce Well-Being by the Clinician Well-Being Collaborative, can further address workforce challenges. As the healthcare system recovers from the pandemic, preventing harm in a coordinated and intentional way will help the system become more resilient.


Patricia McGaffigan, MS, RN, CPPS
Vice President, Safety

President, Certification Board for Professionals in Patient Safety

Institute for Healthcare Improvement

Boston, MA

Cindy Manaoat Van, MHSA, CPPS
Senior Researcher

American Institutes for Research (AIR)

Arlington, VA

Sarah E. Mossburg, RN, PhD
Senior Researcher

American Institutes for Research (AIR)

Arlington, VA

  1. Taupin D, Anderson TS, Merchant EA, et al. Preventability of 30-Day Hospital Revisits Following Admission with COVID-19 at an Academic Medical Center. Jt Comm J Qual Patient Saf. 2021;47(11):696-703. doi:10.1016/j.jcjq.2021.08.011
  2. American Nurses Foundation. Pulse on the Nation’s Nurses Survey Series: 2022 Workplace Survey. Accessed June 16, 2023.
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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