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eight dimensions of care, distilled from years of patient interviews—underlay almost all the deliberations and recommendations of Crossing the Quality Chasm. These eight dimensions formed the basis for the STEEEP principles that still undergird our quality measurement framework.

      More than two decades later, where do we stand? In some ways, patient engagement has been one of the big successes in patient safety and quality. The patient voice is increasingly prevalent throughout much of the health care system. We have patient and family advisory boards, family‐centered rounds, patient‐activated rapid response, shared decision‐making, and medical error disclosure programs. Crucially, we have patient surveys as a measure on which health care providers are assessed. Patient‐reported outcome measures are also now a part of many treatment programs.

      Yet in many ways, patients have yet to be fully integrated as functional members of their own health care teams. System‐wide transparency and centralized, patient‐centered safety reporting systems, fundamental components of patient engagement, remain largely unfulfilled goals. Health equity is finally being recognized as a threat to safety and quality, but strategies to address it are only beginning to evolve. Effective ways of involving patients in the essential outpatient functions of diagnosis and medication safety are still being worked out. Two bright spots are the Institute for Healthcare Improvement’s Safer Together national action plan and the World Health Organization’s Global Patient Safety Action Plan, both of which propose to achieve these and other aims by creating broad learning systems with patient partnership at all levels. If we want to improve, this is the future of health care.

      Social Determinants of Health

Sivashanker and Gandhi (2020) cite the inequities in the US health care system that continue to foster systemic racism, including race, sex, language, socioeconomic class, and other biases (Feeley and Torres, 2020). Race, social determinants of health, and other disparities limit access to care as measured by the STEEEP model, particularly timeliness, equity, effectiveness, and patient‐centeredness. Okoroh, Uribe, and Weingart (2017) completed a methodological review that found racial/ethnic disparities in adverse events to be mixed, although there was extensive evidence of disparities in the process and outcomes of health care. Because many studies did not report key variables, they found poor stratification of outcomes by race or ethnicity and recommend that future studies examine variations in the quality of care at hospitals and specific geographic locations.

A Way Ahead: Drivers for the Future

      In 2018, the IHI convened the first National Steering Committee (NSC) representing 27 professional organizations committed to improving patient safety and quality, who “refuse to accept preventable harm” (NSC, 2020a), a commitment built over the past 20 years. The result is the report Safer Together: A National Action Plan to Advance Patient Safety (http://www.ihi.org/SafetyActionPlan). The groundbreaking report is accompanied by a Self‐Assessment Tool (NSC, 2020b) to get started and an Implementation Resource Guide (NSC, 2020c). The report includes measurement guidance on evaluating structures and processes specific to the recommendations.

      The report recognizes progress and innovations in patient safety, yet preventable harm remains pervasive. It also recognizes the progress in working together interprofessionally, noting that the steering committee represents all health professions, with even more diversity represented among the four subcommittees; nurses were represented in all aspects, which also represents the commitment to the need to ensure safety for all health care workers. Interdependently working together will be the key to successful implementation.

The work was guided by the common vision that “working together to insure health is safe, reliable and free from harm.” Seven core principles formed the basis of the report (Textbox 1.5).

Like the 2021 WHO global report, Safer Together calls for a shift from safety as a reactive, piecemeal set of activities to a proactive, system‐wide safety plan to provide care that is safe, reliable, and free from harm. Total system safety is interdependent, collaborative, and coordinated, recognizing that the numbers of harm events are startling, but that each represents someone’s family member. The committee used a broader definition of preventable harm, including physical, psychological, emotional, moral, economic, and societal harm to patients and the workforce (Ottosen et al., 2018). Patient harm and workforce harm were treated independently; each has causes and effect, but both impact quality and safety.

Textbox 1.5 Seven Core Principles That Guided Safer Together: A National Action Plan to Advance Patient Safety

      1 Work together to drive greater urgency to prevent harm to patients and those who care for them in all settings across the care continuum.

      2 Strengthen the foundation for eliminating harm by ensuring that leaders actively promote a culture of safety, the spread of learning systems, patient and family engagement, and workforce safety.

      3 Partner with patients, families, and care partners and commit to open, honest, and respectful communication to create safe, person‐centered health care.

      4 Coordinate and collaborate to achieve large‐scale, sustainable improvement in safety.

      5 Transparently share successes and failures within and across organizations and industries to promote learning and improve outcomes for all.

      6 Advance health equity so that everyone has the safest care, and no one is disadvantaged due to demographic characteristics or social determinants.

      7 Support policies and regulations that will improve patient safety.

      Source: Institute for Healthcare Improvement, 2020.

Figure 1.3 National Action Plan for Patient Safety: four foundational themes.

      Source: Institute for Healthcare Improvement, 2020.

The action plan (Figure 1.3) is organized into four major themes: Culture, Leadership, and Governance; Patient and Family Engagement; Workforce Safety; and Learning Systems (Table 1.1). Seventeen recommendations accompany the four interdependent foundational themes to create total systems safety; no theme stands alone—improvement in one will reflect improvement in another.

      Three further cross‐cutting themes relate to each theme and specify how each should be enacted:

       Person‐centered care.

       Care across the continuum.

       Relationship between patient safety and health equity.

      Systemic biases in health care show concentrated harm to certain populations specific to race, ethnicity, sex, gender, age, and socioeconomics. All organizations are urged to apply the recommendations as the way forward to eliminate patient harm.

Education: The Bridge to Quality

The 2003 IOM report citing health professions education as the bridge to quality (IOM, 2003) ignited significant transformation across all areas of health professions education to prepare graduates in the knowledge, skills, and attitudes (KSA) for six competencies that would enable health care system improvement (Murray et al., 2020). The goal of the competencies is to enable health professionals to deliver patient‐centered care, work as part of interdisciplinary teams, practice evidence‐based

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