Global action on patient safety: report by the Director-General

EXECUTIVE BOARD EB148/6 148th session 6 January 2021 Provisional agenda item 5 Global action on patient safety Report by the Director-General 1. Patient safety is fundamental to the provision of health care in all settings. However, avoidable adverse events, errors and risks associated with health care remain major challenges for patient safety globally. They contribute significantly to the burden of harm due to unsafe care. Available evidence suggests that hospitalizations in low- and middle-income countries lead to 134 million adverse events annually, contributing to 2.6 million deaths.1 Estimates indicate that in high-income countries, about 1 in 10 patients is harmed while receiving hospital care.2 2. The current pandemic of coronavirus disease (COVID-19) has further exposed the vulnerability of health systems, whether in high- or low-resource settings, in coping with increased demand while ensuring the safety and quality of services delivered. Patient safety issues such as personal protection, health worker safety, medication safety and patient engagement have become key areas of the COVID-19 response globally. Patient safety interventions must be urgently implemented in order to respond effectively to this global public health emergency of unprecedented scale. Such interventions are also needed to improve preparedness to respond to such challenges in the future. 3. The Seventy-second World Health Assembly in 2019 adopted resolution WHA72.6 on global action on patient safety. It urged Member States – and, where applicable, regional economic integration organizations – inter alia, to recognize patient safety as a health priority in health sector policies and programmes in order to achieve universal health coverage. 4. The Health Assembly also requested the Director-General to formulate a global patient safety action plan in consultation with Member States and all relevant stakeholders, including in the private sector, for submission to the Seventy-fourth World Health Assembly in 2021 through the Executive Board at its 148th session. 1 National Academies of Sciences, Engineering, and Medicine. Crossing the global quality chasm: improving health care worldwide. Washington (DC): The National Academies Press; 2018 (https://www.nap.edu/catalog/25152/crossing-the- global-quality-chasm-improving-health-care-worldwide, accessed 18 October 2020). 2 Slawomirski L, Auraaen A, Klazinga NS. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Paris: OECD; 2017 (https://www.oecd-ilibrary.org/docserver/5a9858cd- en.pdf?expires=1593688230&id=id&accname=guest&checksum=B1730733897FC2DC01D171C38D4218F2, accessed 18 October 2020). EB148/6 2 PROCESS 5. The WHO Secretariat, guided by the WHO Patient Safety Envoy, has developed a draft global patient safety action plan, supported by Organization-wide consultations with relevant technical programmes and departments within the WHO system. 6. A WHO global expert consultation on “A Decade of Patient Safety: formulating a draft global patient safety action plan 2021–2030” was held in Geneva from 24 to 26 February 2020 to discuss its proposed scope and strategic direction. More than 120 experts – from 44 Member States, international professional organizations, patient associations and intergovernmental organizations – participated in the consultation and provided consensus recommendations on 12 patient safety thematic action areas. Key inputs were also received from experts and stakeholders from 140 countries through the WHO Global Patient Safety Network. A drafting and review task force was constituted to take forward the recommendations from these consultations and to undertake a critical review of the draft action plan. 7. The Secretariat developed a first draft of the global patient safety action plan 2021–2030, which was made available online for global public consultation on the WHO website. The updated draft of the action plan was further discussed with Member States through regional committees, consultations and technical briefings between September and December 2020. 8. Feedback, comments and technical input from Member States and from the outcome of the public consultation were reviewed and addressed by the drafting and review task force. This process enabled a revised draft of the action plan to be prepared.1 PURPOSE 9. The purpose of the action plan is to provide strategic direction for all stakeholders for eliminating avoidable harm in health care and improving patient safety in different practice domains through policy actions on safety and quality of health services, as well as for implementation of recommendations at the point of care. The action plan provides a framework for countries to develop their respective national action plans on patient safety, as well to align existing strategic instruments for improving patient safety in all clinical and health-related programmes. 10. The action plan is expected to lead to concrete actions over the decade 2021 to 2030. The following six guiding principles establish an underpinning set of values to guide the development and implementation of the action plan: (a) engage patients and families as partners in safe care; (b) achieve results through collaborative working; (c) analyse data to generate learning; (d) translate evidence into measurable improvement; 1 Draft global patient safety action plan 2021–2030 (https://www.who.int/teams/integrated-health-services/patient- safety/policy/global-patient-safety-action-plan, accessed 6 January 2021). EB148/6 3 (e) base policies and action on the nature of the care setting; and (f) use both scientific expertise and patient experience to improve. VISION, MISSION AND GOAL 11. The draft action plan has been developed on the basis of a vision of a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere. 12. The mission of the draft action plan is to drive forward policies and actions, based on science, system design and partnerships, to eliminate all sources of avoidable risk and harm to patients and health workers. 13. The draft action plan has set an ultimate goal of achieving the maximum possible reduction in avoidable harm due to unsafe health care globally. 14. The vision, mission and goal of the action plan will be achieved through seven strategic objectives and through targeted strategies and actions for key stakeholders (see Fig. 1 for an overview). Fig 1. Overview of the global patient safety action plan 2021–2030 EB148/6 4 FRAMEWORK FOR ACTION 15. The draft action plan provides a list of suggested actions for governments, non-State actors, international organizations, intergovernmental organizations, the WHO Secretariat and, most importantly, for health care facilities. These actions have been grouped under the following seven strategic objectives (SOs). SO1: Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere SO2: Build high reliability health systems and health organizations that protect patients daily from harm SO3: Assure the safety of every clinical process SO4: Engage and empower patients and families to help and support the journey to safer health care SO5: Inspire, educate, skill and protect every health worker to contribute to the design and delivery of safe care systems SO6: Ensure a constant flow of information and knowledge to drive mitigation of risk, a reduction in levels of avoidable harm and improvements in the safety of care SO7: Develop and sustain multisectoral and multinational synergy, solidarity and partnerships to improve patient safety and quality of care 16. These strategic objectives serve to unify the work of policy-makers, the endeavours of health care leaders and managers, and the care provided by doctors, nurses and other health professionals. They should provide a test of everything from everyday clinical work to major strategic decisions about the design of health care systems. They should also provide a simple public accountability framework. They are articulated in such a way that it is entirely permissible within their scope to formulate programmes of action that fit with local needs and priorities and that are shaped by the specific context. 17. The framework of action is further elucidated through 35 strategies, five under each of the strategic objectives, to create a seven by five matrix. Each strategy has been further translated into suggested actions for four sets of partners: governments, health care facilities, stakeholders and the WHO Secretariat. The strategies corresponding to the seven objectives are described below. SO1: Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere Strategy 1.1: Develop a comprehensive patient safety policy, strategy, institutional framework and implementation plan for the country’s health system and all its components as a key priority in working towards universal health coverage. Strategy 1.2: Mobilize and allocate adequate resources for patient safety implementation throughout every level of the health care system. Strategy 1.3: Use selective legislation to facilitate the delivery of safe patient care and the protection of patients and health workers from avoidable harm. EB148/6 5 Strategy 1.4: Align health care regulatory, inspectorial and accreditation activities with the goal of improving performance on patient safety. Strategy 1.5: Create maximum awareness of World Patient Safety Day and Global Patient Safety Challenges, as a way of maintaining a high public and political profile for patient safety. SO2: Build high reliability health systems and health organizations that protect patients daily from harm Strategy 2.1: Develop and sustain a culture of openness and transparency that promotes learning, not blame and retribution, within each organization providing patient care. Strategy 2.2: Develop and operate effectively a good governance framework within each component of the health care system. Strategy 2.3: Develop clinical and managerial leadership capacity and capability at all levels to ensure a strong and visible focus on eliminating avoidable harm in health care. Strategy 2.4: Bring a strong human factors/ergonomics perspective and input to strengthening the resilience of health organizations and clinical practices. Strategy 2.5: Incorporate patient safety elements within the context of emergencies, disease outbreaks and settings of extreme adversity SO3: Assure the safety of every clinical process Strategy 3.1: Identify all risk-prone clinical procedures and mitigate their risks, taking account of national and local priorities. Strategy 3.2: Implement a programme to transform the safety of medication management and use based on the third WHO Global Patient Safety Challenge: Medication Without Harm. Strategy 3.3: Put in place rigorous and evidence-based measures for infection prevention and control, to minimize the occurrence of health care-associated infections and antimicrobial resistance. Strategy 3.4: Assure the safety of medical devices, medicines, blood and blood products, vaccines and other medical products. Strategy 3.5: Assure the safety of patients in all settings, including in mental health settings and care homes with focus on primary care and transitions of care. SO4: Engage and empower patients and families to help and support the journey to safer health care Strategy 4.1: Engage patients, families and civil society organizations in co-development of policies, plans, strategies, programmes and guidelines to make health care safer. Strategy 4.2: Learn from the experience of patients and families exposed to unsafe care to improve understanding of the nature of harm and foster the development of more effective solutions. EB148/6 6 Strategy 4.3: Build the capacity of patient advocates and champions in patient safety. Strategy 4.4: Establish the principle and practice of openness and transparency throughout health care, including through patient safety incident disclosure to patients and families. Strategy 4.5: Provide information and education to patients and families for their involvement in self-care, and empower them for shared decision-making. SO5: Inspire, educate, skill and protect health workers to contribute to the design and delivery of safe care systems Strategy 5.1: Incorporate patient safety within health professional undergraduate and postgraduate education curricula and continuing professional development with emphasis on inter-professional learning. Strategy 5.2: Identify and establish collaborations with centres of excellence in patient safety education and training. Strategy 5.3: Ensure that patient safety core competencies are part of regulatory requirements for health professionals. Strategy 5.4: Link commitment to patient safety with appraisal systems for health care professionals and managers. Strategy 5.5: Design care settings, environments and practices to provide safe working conditions for all staff. SO6: Ensure a constant flow of information and knowledge to drive the mitigation of risk, a reduction in levels of avoidable harm, and improvements in the safety of care Strategy 6.1: Establish or strengthen patient safety incident reporting and learning systems. Strategy 6.2: Create a patient safety information system based on all sources of data related to risks and harm inherent in the delivery of health care and integrated with existing health management information systems. Strategy 6.3: Establish, synergize and scale up patient safety surveillance systems to ascertain the magnitude and causes of harm in health care. Strategy 6.4: Develop active and funded patient safety research programmes, especially translational research. Strategy 6.5: Develop and implement digital solutions to improve the safety of health care. EB148/6 7 SO7: Develop and sustain multisectoral and multinational synergy, solidarity and partnerships to improve patient safety and quality of care Strategy 7.1: Fully engage all stakeholders that have the potential to have a positive impact on patient safety. Strategy 7.2: Promote a common understanding and shared commitment among all stakeholders to successfully deliver the global patient safety action plan. Strategy 7.3: Establish networks and convene consultative meetings to foster collaboration and partnerships in patient safety. Strategy 7.4: Promote cross-geographical and multisectoral initiatives to advance action on patient safety. Strategy 7.5: Work closely with technical programmes to ensure alignment in patient safety action. IMPLEMENTATION OF THE ACTION PLAN 18. The draft global patient safety action plan has been developed with full recognition that countries are at different stages in their efforts to reduce patient harm in health care and to strengthen their national health systems. Their health care contexts also vary greatly. Therefore, it is recommended that Member States should assess and analyse their situation to identify areas of progress which can be strengthened, as well as policy opportunities and practice gaps. 19. Upstream policy interventions in areas such as regulation, accreditation, leadership, safety culture, and public reporting can be driving forces for patient safety improvement. These interventions should be complemented by downstream patient safety improvement interventions in areas such as capacity building, reporting and learning systems, teamwork and communication, and patient engagement, as well as solutions to high-risk clinical care processes. 20. WHO, governmental and nongovernmental organizations can shape and accelerate patient safety implementation in countries through advocacy, coordination, normative guidance and technical support. Cohesive and complementary action by all stakeholders is essential. Fig. 2 illustrates the ecosystem for implementation of the global patient safety action plan. EB148/6 8 Fig. 2. The ecosystem for implementation of the global patient safety action plan 21. The key milestones in implementing the action plan at the national and subnational levels are as follows: • conduct a landscape assessment of major safety risks and barriers to improvement in patient safety; • secure strong commitment from political and organizational leadership; • establish a sustainable mechanism for implementation of patient safety policies, strategies and plans within the context of existing national health plans, and safety and quality policies; • align with national context and priorities, taking account of the health care context within the country; • decide upon and design the model of change for implementation. 22. Global patient safety targets have been proposed for measuring progress on implementation of the action plan, each linked to one of the strategic objectives, which could be used to track progress and trends. Governments, international organizations, and health care facilities should adapt these targets, taking into consideration the local context, priority, baseline, and capacity. 23. WHO will establish a formal mechanism for reporting on these indicators at the global, regional and national levels to ascertain the overall progress made, and provide feedback to the national and subnational implementation teams. EB148/6 9 ACTION BY THE EXECUTIVE BOARD 24. The Executive Board is invited to consider the following draft decision. The Executive Board, having considered the report on global action on patient safety,1 decided to recommend to the Seventy-fourth World Health Assembly the adoption of the following draft decision: The Seventy-fourth World Health Assembly, having considered the report on global action on patient safety decided: (1) to adopt the global patient safety action plan 2021–2030; and (2) to request the Director-General to report back on progress in the implementation of the action plan to the Health Assembly in 2023 and thereafter every biennium until 2031. = = = 1 Document EB148/6.