Tejal Gandhi, M.D., M.P.H., has been a leader in patient and workforce safety for more than 20 years. With experience as an internist, researcher, teacher and hospital executive, Dr. Gandhi became President and CEO of the National Patient Safety Foundation in 2013 and Chief Clinical and Safety Officer at the Institute for Healthcare Improvement when NPSF merged with IHI in 2017. Since early 2020, she has been Chief Safety and Transformation Officer at Press Ganey. She also co-chairs the National Steering Committee for Patient Safety convened by IHI. Dr. Gandhi talked with Patient Safety Beat following publication of her essay, “Don’t Go to the Hospital Alone: Ensuring Safe, Highly Reliable Patient Visitation,” in the Joint Commission Journal on Quality and Patient Safety in January.
Betsy Lehman Center: Visitation policies were necessarily restrictive in the earliest waves of COVID-19 but the resulting isolation caused harm on all sides. As the Omicron surge recedes, is it time for hospitals, nursing homes and others to reset their policies? What do you recommend?
Dr. Gandhi: Before the pandemic, we encouraged organizations to welcome visitors to inpatient settings 24/7. Clearly COVID-19 disrupted that work. Now it’s time to refocus on patient and family engagement in general and to find ways to include visitors while keeping everyone safe. We have concentrated our attention on the risks of visitation and lost sight of the benefits. I’d like to see organizations take a broader perspective and think comprehensively about visitation, considering both the pros and cons.With COVID, infection control protocols mean that accepting visitors adds work, but we often underestimate the value of having family at the bedside. They help by providing a safety net — communicating with the patient, making sure patients understand what’s happening, adding another set of eyes. I think we tend to skew to the negative versus the positive. Disruptive visitors and workplace violence are important issues, but they can and should be addressed. When we close our facilities to visitors because we fear a few individuals, many are harmed.
The reasons why we prioritized patient and family engagement before the pandemic haven’t gone away. As we learn to live with COVID as an endemic virus — our “new normal” — we should return to that vision and figure out how to do it safely. In my recent article, I recommend using high reliability principles, which first and foremost say to make sure you’re committed to a vision. Then bring in the right people to be part of the conversation, including patients and families.
We can also begin to collect data about the effect of visitors on safety. In our review process around falls, for example, we can ask, “Was a visitor present or not?” and begin to understand those differences. On the workforce side, many organizations are doing pulse surveys, where they’re trying to understand the experiences of our workforce. We can use pulse surveys to evaluate visitation, too.
Betsy Lehman Center: Over the past two years, efforts to incorporate input from patients and families took a backseat to the immediate needs of health care organizations. How can we more reliably embed patient and family engagement in patient care?
Dr. Gandhi: We define high reliability as “performing consistently as intended over time.” We want to do that with patient and family engagement and recognize that high reliability is the method or the how-to. It’s important to emphasize that patient and family engagement is central to patient safety. It’s essential, not just “nice to have.” Patients and families are essential members of the team.
Patient engagement is one of the four foundational areas in the National Steering Committee’s Action Plan to Advance Patient Safety. It’s also prominent in the World Health Organization’s Global Patient Safety Action Plan and the Massachusetts Roadmap to Healthcare Safety.
As a foundation for advancing patient safety, patient and family engagement is something we must hardwire into healthcare, and there are many strategies for doing that, including thinking about levels of engagement. There’s the frontline, where you’re working one-on-one with patients and families on things like shared decision-making, informed consent, disclosure, visitation, and making sure those things are all happening reliably. At the next level, we also need to include patients and families in quality improvement efforts and root cause analyses, patient-and-family advisory councils and have them serve on boards.
At the country-wide level, patients served on the steering committee for the National Action Plan, and this should be the case for all national groups. The influence of the high-level, national groups can be felt all the way down to the frontline, through all the structures and processes that occur at hospitals and clinics.
Betsy Lehman Center: You noted in your essay that the pandemic applied a stress test to our health care system, with mixed results. How should the patient safety community respond at this point? Where do you think we should go from here?
Dr. Gandhi: When I was at IHI, we convened the National Steering Committee for Patient Safety because we thought the movement was losing momentum. We felt the need to re-energize our efforts to improve safety. And then the pandemic hit. Over these past two years, we have seen organizations work incredibly hard to deal with COVID and safely take care of patients. But we’ve also seen certain safety outcomes worsen. Press Ganey and the Centers for Disease Control and Prevention have reported increased rates of falls, central-line infections, and pressure injuries. Our national safety culture data for 2020 and early indications for 2021 show worsening trends.
Three years ago, we recognized a need to re-energize patient safety; we need to do that now even more. Everyone’s been working under terrible stress, organizations are exhausted, and we’ve lost ground on some core safety measures. Safety culture is considered a leading indicator, so the fact that it’s gotten worsen over the last couple of years means we need to do something pretty major to turn it around. The National Steering Committee, together with some federal agencies, has been talking about speaking with a collective voice about the need to re-energize and where to go from here.
We’ll continue to focus on culture, patient engagement, workforce safety and the learning system as the core components of the National Action Plan. Everything in the Plan is still incredibly relevant; the foundational elements of patient safety aren’t going to change. But we do need to figure out how to implement and embed those elements so they will withstand stress. We want safety to be so hardwired that it can be maintained in difficult times. That’s the goal.