UP FRONT

How Massachusetts can lead the way on patient safety

The Betsy Lehman Center for Patient Safety has convened a first-of-its-kind consortium to coordinate a sustained, multi-stakeholder effort to improve safety and quality in all settings where health care is delivered throughout the state. The purpose of the Massachusetts Healthcare Safety and Quality Consortium, a group of nearly 20 organizations, is to accelerate improvement in a state recognized for high-quality health care and international patient safety leadership. Beginning next month, the Consortium will leverage that expertise to develop a statewide framework and actionable plans to address safety as a persistent, systemic challenge throughout health care, in all settings and specialties.


A two-part study released earlier this month by the Betsy Lehman Center provides evidence of the need to boost efforts to improve health care delivery. Despite more than 20 years of dedicated work on patient safety, tens of thousands of patients continue to be harmed by medical errors in the Commonwealth each year. Using data available from the state’s Center for Health Information and Analysis and an established methodology for measuring error nationally, the Betsy Lehman Center study shows nearly 62,000 instances of preventable harm in one year—a number that does not include medication or diagnostic errors. 

Briefing
Event on June 10, 2019 at the Betsy Lehman Center

The second study asked Massachusetts residents if they had a recent experience with medical error. In-depth interviews with more than one quarter of the respondents who answered “yes” revealed long-lasting effects on patients’ physical and emotional health. The study also shows that some patients and families who have experienced medical harm continue to distrust providers and avoid health care services for many years. 

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As a state, we have a very strong track record of working together to overcome difficult health care challenges, and we are grateful to have the participation of so many individuals and organizations with the knowledge and commitment to help Massachusetts take an unprecedented step forward on safety.

Barbara Fain

Barbara Fain, Executive Director of the Betsy Lehman Center, acknowledges that much has been learned about factors contributing to medical errors and gains in safety have been made over the past two decades. 

Yet the Center’s research findings bring a sense of urgency to prioritizing safety throughout the health care system. “Massachusetts faces the same patient safety challenges that persist throughout the country,” says Fain. “As a state, we have a very strong track record of working together to overcome difficult health care challenges, and we are grateful to have the participation of so many individuals and organizations with the knowledge and commitment to help Massachusetts take an unprecedented step forward on safety”

Pat Noga, R.N., Ph.D., Massachusetts Health & Hospital Association (MHA)’s Vice President for Clinical Affairs, agrees: “Over the last several years, Massachusetts hospitals have made notable advances on patient safety, harm prevention and delivering high-quality care. Despite this progress, there is still more to do to improve care provided in hospitals and other healthcare settings. MHA and our members welcome the opportunity to continue to accelerate our work in these areas through the new Healthcare Safety and Quality Consortium.”

The Consortium includes provider organizations, professional societies, health plans, research and advocacy groups, state health care agencies, and patients, who are seen as integral partners in improving health care delivery in Massachusetts. 

The Massachusetts Medical Society President Maryanne C. Bombaugh, M.D., says MMS is “grateful for the opportunity to bring the perspective of physicians and our patients to these important discussions and plans for action. A collaboration that includes our partners from across the health care continuum mirrors the Medical Society's assertion that team-based health care, with the patient in the center, as the most important partner on that team, will lead to optimal patient safety and improved outcomes."

Consortium aligns with National Steering Committee

The Consortium’s work will dovetail with the efforts of the nascent National Steering Committee for Patient Safety. Established in 2018 and co-led by the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ), the Committee is comprised of stakeholders representing the broad constituency invested in improving health care and is charged with developing a national framework for reducing harm. 

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A collaboration that includes our partners from across the health care continuum mirrors the Medical Society's assertion that team-based health care, with the patient in the center, as the most important partner on that team, will lead to optimal patient safety and improved outcomes.

Maryanne C. Bombaugh, M.D.

Tejal Gandhi, MD, Chief Clinical and Safety Officer at IHI, co-chairs the National Steering Committee with Jeffrey Brady, MD, Director of the Center for Quality Improvement and Patient Safety at AHRQ. Underscoring that patient safety is an important public health issue, Gandhi says the future work of the Massachusetts Consortium will be helpful in strengthening “our coordinated response to patient safety issues at the state level.”

Begin with a roadmap

The Consortium is charged with developing a “Roadmap to Patient Safety,” a systematic approach to guide and energize future improvement efforts, with an emphasis on increased uptake of established best practices. The Roadmap will be structured around four interconnected pillars of patient safety: transparency, leadership and culture, learning health systems, and support for patients and the health care workforce.

Kim Hollon, CEO of Signature Healthcare, Brockton, notes an ongoing need to equip hospital and health care leaders with education and training in safety system process improvement. “Senior leadership has to see patient safety and quality as the most important strategic initiative of the organization,” says Hollon. “They have to speak it, talk it” as well as learn how to implement learnings from other high-reliability industries in their organizations.

Implementing current tools and strategies more effectively will be key to success. Evan Benjamin, M.D., Chief Medical Officer at Ariadne Labs, notes, “Improving patient safety is never about one intervention. It’s really about creating a culture that integrates numerous practices across an organization.” He adds, the Lehman Center’s research “highlights the opportunities we have to improve patient safety. Our call really needs to be, ‘What are we doing right for the patients?’”

Massachusetts Healthcare Safety and Quality Consortium

  • Ariadne Labs
  • Blue Cross Blue Shield of MA
  • Center for Health Information and Analysis
  • Coverys
  • CRICO: The Risk Management Foundation of the Harvard Medical Institutions
  • Health Policy Commission
  • Healthcentric Advisors
  • MA Alliance for Communication and Resolution Following Medical Injury
  • MA Association of Ambulatory Surgical Centers
  • MA Coalition for the Prevention of Medical Errors 
  • MA Health Quality Partners
  • MA Senior Care Association
  • MA Health and Hospital Association
  • MA Medical Society
  • MA Office of the Attorney General
  • MA Senior Care Association
  • Organization of Nurse Leaders
  • Quality & Patient Safety Division, MA Board of Registration in Medicine
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Email us your feedback and comments: patientsafetybeat@state.ma.us