Uma abordagem de sistemas totais para a segurança

Apesar do esforço substancial nos últimos 20 anos, danos evitáveis ​​na assistência médica continuam sendo uma grande preocupação nos Estados Unidos. Embora muitas práticas recomendadas eficazes e baseadas em evidências relacionadas à redução de danos tenham sido identificadas, elas raramente são compartilhadas nacionalmente e implementadas efetivamente em várias organizações.

Reduzir danos evitáveis ​​requer um esforço concertado, persistente e coordenado de todas as partes interessadas, e uma abordagem de sistemas totais para a segurança. A segurança total dos sistemas requer coordenação em muitos níveis, o que, por sua vez, necessita de colaboração robusta entre todas as partes interessadas.

Ao aproveitar o conhecimento e as percepções de agências federais influentes, organizações líderes em assistência médica, defensores de pacientes e familiares e especialistas respeitados do setor em um conjunto de recomendações práticas e eficazes, o Plano de Ação Nacional fornece uma direção clara para fazer avanços significativos em direção a cuidados mais seguros e redução de danos em todo o continuum de cuidados .

Ao planejar e investir juntos, mobilizar recursos juntos, aprender juntos e compartilhar lições aprendidas, podemos promover mudanças significativas e promover a meta de criar o atendimento de saúde mais seguro para os pacientes e aqueles que cuidam deles.

Mais seguros juntos: um plano de ação nacional para promover a segurança dos pacientes

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Mais seguros juntos: um plano de ação nacional para promover a segurança do paciente destaca os insights coletivos de 27 organizações líderes que compõem o National Steering Committee for Patient Safety, que estão unidas em seus esforços para alcançar cuidados verdadeiramente mais seguros e reduzir danos aos pacientes e àqueles que cuidam deles.

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O relatório reúne o conhecimento e as percepções dos membros do National Steering Committee for Patient Safety (NSC), incluindo agências federais influentes, importantes organizações de assistência médica, consultores de pacientes e familiares e especialistas respeitados do setor, em um conjunto de recomendações práticas e eficazes para promover a segurança do paciente.

O Plano de Ação Nacional se concentra em quatro áreas fundamentais e interdependentes, priorizadas como essenciais para criar a segurança total dos sistemas. As recomendações nessas quatro áreas se baseiam no corpo substancial de experiência, evidências e lições aprendidas que o NSC reuniu e testará e implementará em conjunto para permitir refinamentos futuros à medida que nossa compreensão, experiência e evidências evoluem ao longo do tempo.

Plano de Ação Nacional: 17 Recomendações para Promover a Segurança do Paciente

Cultura, Liderança e Governança

1. Garantir que a segurança seja um valor fundamental demonstrado.

2. Avaliar capacidades e comprometer recursos para promover a segurança.

3. Compartilhe amplamente informações sobre segurança para promover a transparência.

4. Implementar governança e liderança baseadas em competências.

Envolvimento do paciente e da família

5. Estabelecer competências para todos os profissionais de saúde para o envolvimento de pacientes, familiares e parceiros de cuidados.

6. Envolver pacientes, familiares e parceiros de cuidados na coprodução do cuidado.

7. Incluir pacientes, familiares e cuidadores nos esforços de liderança, governança, segurança e melhoria.

8. Garantir o envolvimento equitativo de todos os pacientes, familiares e parceiros de cuidados.

9. Promova uma cultura de confiança e respeito pelos pacientes, familiares e parceiros de cuidados.

Segurança da força de trabalho

10. Implementar uma abordagem sistêmica para a segurança da força de trabalho.

11. Assumir a responsabilidade pela segurança física e psicológica e por um ambiente de trabalho saudável que promova a alegria da força de trabalho da área da saúde.

12. Desenvolver, fornecer recursos e executar programas prioritários que promovam de forma equitativa a segurança da força de trabalho.

Sistema de Aprendizagem

13. Facilitar a aprendizagem intra e interorganizacional.

14. Acelerar o desenvolvimento das melhores redes possíveis de aprendizagem em segurança.

15. Iniciar e desenvolver sistemas para facilitar a educação e o treinamento interprofissional sobre segurança.

16. Desenvolver metas compartilhadas para segurança em todo o continuum de cuidados.

17. Acelerar a coordenação, colaboração e cooperação em segurança em todo o setor.

Ferramenta de autoavaliação

A Self-Assessment Tool, um recurso suplementar ao National Action Plan, auxilia líderes e organizações a decidir por onde começar. Saiba mais sobre a Self-Assessment Tool online .

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Guia de Recursos de Implementação

O Guia de Recursos de Implementação, um recurso suplementar ao Plano de Ação Nacional, detalha táticas específicas e recursos de apoio para implementar as recomendações do Plano de Ação Nacional.

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Declaração para promover a segurança do paciente

Em maio de 2022, o NSC emitiu a Declaração para Promover a Segurança do Paciente para instar os líderes de saúde em todo o espectro de cuidados a se comprometerem novamente a promover a segurança do paciente e da força de trabalho com uma abordagem sistêmica total, conforme apresentado no Plano de Ação Nacional.

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Celebrate Your Team's Dedication to Patient and Workforce Safety

Your moment to shine as a beacon of inspiration in health care improvement is here! The Institute for Healthcare Improvement (IHI) invites all hospitals committed to advancing quality and safety to participate in the IHI Safer Together Recognition Program. 

The IHI Safer Together Recognition Program acknowledges the achievements of hospitals that have made significant strides to improve patient and workforce safety by implementing proactive changes in systems and processes.

The Recognition program is grounded in IHI’s proven methodologies for quality and safety improvement and based on the principles outlined in the publication Safer Together: A National Action Plan to Advance Patient Safety, which focuses on four foundational areas:

• Culture, Leadership, and Governance
• Patient and Family Caregiver Engagement
• Workforce Safety and Well-Being
• Learning System

Why This Recognition Matters

The IHI Safer Together Recognition Program is built around a widely recognized framework for advancing safety. It offers tremendous value and opportunities to health care leadership, quality and safety improvement professionals, and individual hospitals.

Achieving this acknowledgment from IHI, a global leader in health care improvement, enhances a hospital’s reputation among peers, regulators, health care consumers, and the public. Recognition may also contribute to additional funding opportunities, higher workforce satisfaction, and better team performance.

Recognition provides a signal for patients/consumers and workers that their hospitals have attested to leadership commitment to safety and have structures and practices in place that are associated with high-performing organizations.

Recognition Program Details

To be considered for Recognition, a hospital must undergo rigorous and comprehensive self-assessment, ensuring that they have critically evaluated their safety practices.

Honoring evidence-based practices and driving real-world impact in safety management systems and safety culture, the IHI Safer Together Recognition Program awards hospitals for their continuous work to ensure that health care is safe and reliable as identified through a combination of quantitative and qualitative assessments.

• Online Team Self-Assessment Tool: Meet or exceed a specific threshold on the online Team Self-Assessment Tool for Safer Together: A National Action Plan to Advance Safety.
• IHI Safety Expert Panel Verification: Hospitals will receive verification by the IHI Safety Expert Panel, comprising nationally recognized patient and workforce safety experts.

Recognition Cycles

Recognition is awarded quarterly, for a duration of two years. The Recognition cycle timeframes are noted below.

Review and Recognition Process

To be considered for the IHI Safer Together Recognition Program, hospitals must follow the process described below.

1. No fewer than five (5) leaders must complete the online Team Self-Assessment Tool for Safer Together: A National Action Plan to Advance Safety. More than one of these leaders must be a C-suite leader (e.g., CMO, CNO, CFO, CEO).
2. Hospitals that meet or exceed a certain quantitative threshold on their online Team Self-Assessment Tool will receive an invitation via email to complete a Qualitative Verification Assessment. The Verification Assessment includes the upload of documents (e.g., policies) and attestations from the hospital’s senior leader or CEO, which verify the quantitative score received on the online Team Self-Assessment Tool.
3. IHI Safety Expert Panel reviews the assessments.
4. Hospitals receive email notification of the IHI Safety Expert Panel’s decision.
5. Hospitals awarded Recognition pay the Recognition fee of $5,000 per hospital.

Acknowledgment of intent to pay the Recognition fee must be received within 30 days of conditional Recognition notification email, and invoice paid within 30 days of invoice receipt, to claim Recognition status and receive the benefits listed below.

IHI is pleased to recognize health care organizations of all sizes and offers special pricing for the Recognition fee to the following organizational types (identification of organizational type occurs during Verification Assessment):

• Critical Access Hospitals
• Hospitals with 50 or fewer beds
• Members of America’s Essential Hospitals
• 501(c)(3) organizations with a defined operating budget of less than $5 million, serving community-based organizations
• Ministries of Health
• Faith-based health institutions

Recognition Benefits

Hospitals awarded IHI Safer Together Recognition receive*:

• Acknowledgment as a “Recognized Hospital” on IHI’s website and in marketing materials.
• The Official Badge of Recognition shared with hospitals for use in digital communications, including marketing and social media.
• 15% discount for staff to attend the IHI Patient Safety Congress (starting in 2026).

*Upon approval and invoice payment

Need Help or Have Questions?

Email our team at safertogether@ihi.org.

Recognition Cycles

Recognition is awarded quarterly, for a duration of two years. The Recognition cycle timeframes are noted below.

Recognition Benefits

Hospitals awarded IHI Safer Together Recognition receive*:

• Acknowledgment as a “Recognized Hospital” on IHI’s website and in marketing materials.
• The Official Badge of Recognition shared with hospitals for use in digital communications, including marketing and social media.
• 15% discount for staff to attend the IHI Patient Safety Congress (starting in 2026).

*Upon approval and invoice payment

Need Help or Have Questions?

Email our team at safertogether@ihi.org

Human factors is a discipline that seeks to optimize the relationship between technology, the environment, systems, and humans. In health care, it is an essential component for mitigating risks to both patients and the workforce.

The Certified Professional in Human Factors in Health Care (CPHFH) credential is earned by demonstrating a high level of proficiency in applying the core standards of human factors, systems thinking, and design to health care improvement.

Certification is awarded upon passing a comprehensive examination covering three key domains: Assess and Analyze, which involves evaluating and understanding human-system interactions to identify potential risks; Design, which focuses on designing and implementing systems and processes that enhance safety and efficiency; and Improve and Monitor, which entails continuously refining and overseeing systems to ensure ongoing safety and sustainable effectiveness.   

Health care professionals who are educated in human factors are empowered with valuable insights into the relationship between humans, patients, and the systems with which they interact.

Benefits of CPHFH Certification

• Health Care Leadership Confidence: Leadership is assured teams are capably skilled to effectively manage complex health care environments through a deep understanding of human-system interactions.
• Skills to Improve Team Performance: Certification affirms competence in applying human factors principles to streamline and optimize team interactions and workflows for more efficient and effective health care delivery.
• Enhanced Patient Safety: Health care professionals with human factors credentials use their knowledge to enhance patient outcomes, minimize errors, design safer systems, and reduce adverse events.
• Professional Recognition: This certification, fully accredited by the National Commission for Certifying Agencies (NCCA) and the Certification Board for Professionals in Patient Safety (CBPPS), validates specialized knowledge in human factors, distinguishing professionals as highly valued experts in creating user-centered and safer health care systems.
• Career Advancement: Human factors in health care certification opens doors to roles that require expertise in system improvement and human factors, positioning professionals for leadership and specialized positions within healthcare organizations. 

Why Certification Is Important

This professional certification program establishes core standards for the field of human factors in health care, benchmarks requirements necessary for health care professionals, and sets an expected proficiency level.

• For professionals, the CPHFH credential provides those working in human factors a means to demonstrate their proficiency and skill in the discipline.
• For organizations, requiring the CPHFH credential provides a way for employers to validate a potential candidate’s human factors knowledge and skill base, critical competencies for today’s health care challenges. 

Requirements for Certification

Candidates for the CPHFH credential are those who include human factors practices as an integral component of current or future professional responsibilities. Candidates must also possess academic and professional experience at one of the following levels:

• Diploma (e.g., associates, bachelors), plus 3 years of experience in Human Factors in Health Care Related Field over five years (either full time or part-time)

OR

• Master/Doctorate in Human Factors Related Field, plus 1 year of full-time experience or 2 years of part time experience in Human Factors in Health Care Related Field over five years

These candidates may include:

• Physicians, Nurses, and Pharmacists
• Patient Safety Professionals
• Quality, Improvement, and Risk Professionals
• Human Factors and Systems Engineering Professionals
• Health Care Executives
• Non-Clinical Health Care Professionals
• All other health care professionals with the requisite background

The Certification Board for Professionals in Patient Safety (CBPPS) randomly audits a limited number of applications per year to confirm eligibility requirements are met. If your application is selected for audit, please be prepared to provide documentation attesting to your education and experience.