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IHS Re-Commits to Strengthening Patient Safety

by Lt. Cmdr. Michelle Livingston, Nurse Consultant, Patient Safety – Division of Patient Safety and Clinical Risk Management, Office of Quality

Patient safety is a priority of the Indian Health Service and is included in the IHS 2023 Agency Work Plan, which outlines critical priorities that will guide agency improvements over the next year. It is a vital element intricately woven into all processes that come together in the delivery of health care to our patients. Over the past several years, health care systems across the globe, including the IHS, have seen increased challenges related to the COVID-19 pandemic. IHS employees have faced these challenges head on and continue to do tremendous work in the service of our patients. As we move forward, the IHS re-commits to strengthening patient safety and enhancing critical oversight in our agency.

The Office of Quality is collaborating with key stakeholders on strengthening patient safety agency-wide. The next step in our commitment to patient safety is to develop a unified, system-wide, patient safety program that provides oversight to our facilities and areas with standardized policies, processes, tools, and training that increase safety for both our patients and our workforce.

The Total System Safety Strategy was recently developed by our agency patient safety subject matter experts, in collaboration with IHS national combined councils, IHS Chief Medical Officer Dr. Loretta Christensen, and IHS area directors. The strategy provides the roadmap to strengthen patient safety enterprise-wide, and identifies the aim, goals, and objectives of the agency patient safety program. The TSS Strategy aligns with the HHS Patient Safety initiative, The National Healthcare System Action Alliance to Advance Patient Safety Exit Disclaimer: You Are Leaving , and utilizes the most up to date resources and terminology in the patient safety field. The IHI Framework for Safe, Reliable and Effective Care Exit Disclaimer: You Are Leaving  and the 17 recommendations in four domains put forth by the National Action Plan to Advance Patient Safety Exit Disclaimer: You Are Leaving  were utilized as foundational documents in the strategy development.

A critical component to developing an overarching and unified patient safety program is an agency patient safety policy. Last fall, key stakeholders, to include patient and workforce safety experts, came together to develop the agency patient safety policy. This policy identifies the foundational elements required of all IHS patient safety programs, sets patient safety program standards, and provides mechanisms for patient safety oversight. We look forward to sharing and implementing this policy agency-wide once it reaches final approval.

Another step in our commitment to patient safety is the development of the agency adverse event reporting policy. This policy will provide a standardized risk consequence score system for adverse events and good catches, further define risk consequence scores that will require a root cause analysis, and provide standardized processes and tools to complete those activities. The policy also defines mechanisms of communication for events and good catches that reach a specified risk level, and provides mechanisms to share learning across the system related to those identified risks.

The next steps in further developing the agency patient safety program are to work with our facilities to conduct patient safety program assessments to collect data, identify trends, and to guide project prioritization. These efforts support the IHS’ enterprise risk management program and allow us to stratify and prioritize the management of identified risks.

For more information on the IHS Total System Safety Strategy, I encourage you to review our TSS Strategy fact sheet.

Lt. Cmdr. Michelle Livingston, Nurse Consultant, Patient Safety – Division of Patient Safety and Clinical Risk Management, Office of Quality

Lt. Cmdr. Michelle Livingston, MSN, RN, CNL, CIC, CCM, CPPS, is the nurse consultant, patient safety, in the IHS Office of Quality, Division of Patient Safety and Clinical Risk Management.