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areas of health care delivery were impacted, as noted in Textbox 1.6. Staines et al. (2020), however, point out that competencies built over the past decade to advance quality and safety are key ways to maintain quality safe care during COVID. Still, nursing homes were particularly vulnerable, in part because of the nature of the work. It may yet prove that lessons learned can leave lasting improvements in care (Scopetti et al., 2020). Many developments are being measured, such as: What is the impact of increasing use of telehealth on patient care quality and safety? What will be the lasting impact of the multiple stressors on the workforce? How will systems adapt as COVID‐19 abates to apply lessons learned? Like the past 20 years, the next 20 will be equally impactful as all join in making patient care safe, reliable and free from harm.

Textbox 1.6 Quality and Safety during the COVID‐19 Pandemic

      Contributed by

      Eric Wolak, DNP, MHA, RN, NEA‐BC

      Chief Operating Officer and Chief Nurse Officer

      Chatham Hospital | UNC Health System

      The Coronavirus (COVID‐19) pandemic placed a huge strain on health care professionals. As health care leaders during this unprecedented time, it was imperative to leverage and maximize key core leadership competencies, Communication and Relationship Management (American Organization for Nursing Leadership [AONL], 2021). The pandemic created dramatic changes in clinical practice making good communication and interpersonal relationships imperative as data were ever evolving and changing. Other competencies key to operations are the Quality and Safety Education for Nurses’ (QSEN) competencies, especially Safety and Quality Improvement (QSEN, 2020), which could only be successfully maintained in an environment of constant communication among and across multiple disciplines and through multiple media.

      Safety

      Due to the novelty of COVID‐19 and its abrupt appearance across the world, the unknowns in managing these patients and in adequately protecting our health care workforce led to an abundance of caution. To protect supplies of personal protective equipment (PPE), hospitals around the world created COVID containment units, where staff would fully don PPE and enter a contained space where care was provided without doffing between patients, just one example of ensuring safe care for patients and staff. Multiple stakeholders were engaged in creating a COVID unit where all staff can be assured of their own health safety, arrange layout and workflows, and manage PPE equipment—for example, infection prevention, physicians, pharmacy, respiratory therapy, phlebotomy, patient transport, environmental services, nutrition food services, and supply chain management. To ensure input from all roles was equally provided, nurse leaders of COVID units facilitated good communication, fostering strong relationships among stakeholders (AONL, 2021). Such behaviors are core to a culture of safety.

      Quality Improvement

      Using the experiential learning method of Plan‐Do‐Study‐Act (PDSA), small tests of change became a part of daily work in COVID units (QSEN, 2020). Continuous flow of information on managing COVID patients and evolving workflows, as well as ongoing quality improvement, became imperative. At one hospital, the COVID step‐down care unit was eliminated so that COVID patients were in either intensive care (ICU) or an acute care unit. Constant data monitoring revealed that rapid responses within 48 hours for patients with COVID increased when patients transferred from the COVID ICU to acute care because of increasing oxygen care needs, necessitating transfer back to the COVID ICU due to oxygen requirements, and then returning to COVID acute care within 24 hours. To maximize bed utilization and staffing, leaders and staff from the two units collaborated to create guidelines for increased oxygen care on the acute care unit, an example of collaboration on care standards and clear expectations on how and when to escalate care. After implementation and several rounds of PDSA, the frequency of rapid responses and escalation in care from COVID acute care to COVID ICU decreased by more than 50%. This PDSA work and outcomes were a result of frequent communication and strong relationship management among front‐line staff and leaders.

      Core competencies are easily ignored during moments with high stakes, frequent practice changes, and multiple decision points, but it is exactly during such moments where core competencies, as highlighted by QSEN (2020), are needed the most.

      Sources: American Organization for Nursing Leadership, 2021, AONL Nurse Leader Competencies; Quality and Safety Education for Nurses 2020, QSEN Competencies.

      A Call to Action: It Is Time for a “Moonshot”

Patient safety and quality are now familiar terms, given the work of many outstanding health care leaders over the past 20 years. The work is not finished. Ricciardi (2021) looks ahead from 2020 to 2030, with goals for implementing evidence and developing tools and strategies to help health systems and front‐line health care workers deliver safe, high‐quality, high‐value, accessible health care that is equitable and affordable, as first called for in the IOM 2001 report. This will require the commitment and passion of all health care workers to develop methodologies, new knowledge and initiatives, and system‐wide capacity intended to improve quality and safety across the continuum of care. How will each of us answer this and the aims in the 2020 Safer Together National Safety Plan? David Mayer, MD and CEO of the Patient Safety Movement Foundation, set an ambitious agenda in asking for a “Moonshot” to achieve the goals set 20 years ago and updated in subsequent reports (Textbox 1.7). No one can do it alone, patient safety truly is a team sport, but working together we can “shoot for the stars,” to keep every patient and every worker safe if all of us make the commitment.

Textbox 1.7 Creating Urgency in Addressing Patient and Health Worker Safety

      Contributed by

      David Mayer, MD

      CEO Patient Safety Movement Foundation

      Executive Director, Medstar Institute for Quality and Safety

      In 2016 a British Medical Journal article authored by Martin Makary (Makary and Daniel, 2016) estimated that 251,000 patients die in hospitals each year due to medical errors, making it the third leading cause of annual deaths in the United States behind cancer and heart disease. That number is staggering… a quarter of a million people in the United States receiving treatment for an illness or having routine preventative healthcare services die because of experiencing a medical error during their care each and every year. Parents, children, and spouses who should be home with their families for the holidays—there is now an empty chair at the once festive dinner table.

      Making an error is a human condition. All of us, including health care workers, make mistakes every day. We go into medicine to heal, not harm, patients, but when we make a mistake our weak health care systems and processes fail to catch and trap our errors. Because of these safety gaps, many of our errors end up reaching our patients, causing preventable medical harm or death.

      When patients are unintentionally harmed, there is little transparency in health care when it comes to clinical outcomes or open and honest conversations with patients and families after preventable medical harm occurs. Death certificates remain silent when it comes to mortality caused by medical error. While the first catastrophic life‐changing preventable harm occurrence to a patient is unintentional, the second harm we inflict on our patients and their families is very intentional, well resourced, and well calculated. The second intentional harm occurs because many hospitals today still hide preventable serious harm and death events by blocking patients and families from gaining access to medical records, not returning phone calls made to hospital leadership seeking answers to their questions,

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