 Hello, I'm Marty Hatley, President and CEO of Project Patient Care. I'm a patient safety advocate and serve on the Board of Directors of the Patient Safety Movement Foundation. I'm also a World Health Organization, Patients for Patient Safety Champion, and serve on the steering committee of the Patients for Patient Safety Network. It's my pleasure today to introduce Dr. Jeff Brady, who is the Director of HRQ Center for Quality Improvement and Patient Safety. He's served in that role since 2014. Prior to that, he led the HRQ Patient Safety Research Program, and prior to that, he led the agency's work on producing the National Health Care Quality and Disparities Report. So a long and distinguished history, on top of earlier service to the country as a physician and epidemiologist in the military. He's now on the HRQ senior leadership team that oversees patient safety research, the PSO program, and the Health Care Associated Infections Prevention Program of HRQ. Jeff, HRQ is the leading research engine in the world on patient safety, and your agency has been prolific in evidence-based tool development and identification of best practices. In your view, what's driving patient safety now, and will you speak to Safer Together, the National Action Plan for Patient Safety that HRQ published last year on World Patient Safety Day? Well, thank you, Marty, and thanks to the Patient Safety Movement Foundation for your work to promote patient safety. There's a lot happening in patient safety, and we can all appreciate that many more things still need to happen. The COVID pandemic has served as a real-life stress test for health care, and it's called attention to some of the weaknesses in our systems. But thankfully, in other cases, we've also seen the value of resiliency and the benefits of well-designed system-based care. The concept of high reliability organizations has also been a positive influence on safety, and organizations embracing these principles are successfully overcoming some very substantial threats to safe care. These are very personal to all of us. Patients and their families expect safe care, and clinicians want to provide care that's safe. Clinicians also need to know that their own safety is a priority. I want to be sure to acknowledge the hard work that so many are doing to keep patients and healthcare workers safe. We most often see progress when that shared purpose and our hard work and dedication draw on what the field has learned from research and the effective use of data to understand safety threats. It's tempting to oversimplify and underestimate threats to safety. We know that, unfortunately, healthcare can harm patients in many different ways, whether it's harm to a mother or newborn during childbirth or an avoidable harm from a fall, medication error, healthcare-associated infection, diagnostic error, or one of several other types of events. The full array of safety threats is not always straightforward. We can be faced with confusing mixes of patient, clinician, organizational, and other features all interacting in complex ways. As healthcare evolves, so can the risks and hazards. Safe healthcare organizations understand this challenge, and they provide the resources and capabilities to monitor for adverse events and outcomes and to respond confidently with well-designed safety changes that will help prevent harm. Before the pandemic, the Institute for Healthcare Improvement convened a U.S.-based committee to develop a national action plan for patient safety. It was my privilege to co-chair the steering committee with my colleague, Dr. Tejal Gandhi. We were joined by many experts from more than 30 organizations who contributed their collective wisdom to developing the national action plan that we released last fall. The plan emphasizes the importance of foundational factors that must be in place for safe care. Those factors are culture leadership and governance, patient and family engagement, learning systems to better understand patient safety and guide improvements, and the safety of the healthcare workforce. We have come to appreciate that these factors are prerequisites for safety since they are common elements that enable almost all improvement efforts. The plan has 17 recommendations based on these foundational factors with the intent of moving from concepts to capabilities by establishing strong systems that will support the implementation of safe practices for better care, such as those we summarize in the AHRQ Evidence Synthesis series Making Healthcare Safer. The combined effects of foundational factors and proven safe practices can have profoundly positive effects on safety. Working together in several dimensions is essential for progress. We see the value of effective teamwork among clinical teams, patients, and their families. It's also important for leaders in healthcare to support the work of clinicians and their organizations with robust learning systems that harness a wide range of data and novel analytic capabilities to guide this critical work. Finally, we must improve our ability to learn together and share the lessons that research, practice, and implementation science teach us. Collectively, we've seen that when we do this well across organizational and other boundaries, it can have profoundly positive effects that keep patients safe. Safety is central to our mission at AHRQ, and I'd like to take this opportunity to thank everyone who's working to keep patients and healthcare workers safe. Thanks, Jeff, and thanks for everything you and your colleagues at AHRQ do to inform the field, equip us with tools, drive change, and prevent harm to patients and families. Paul Tang is an answering professor in the Clinical Excellence Research Center at Stanford University and an internist at the Palo Alto Medical Foundation. He has over 25 years of executive leadership experience in health information technology within medical groups, health systems, and corporate settings. He has directed innovation and technology teams in provider organizations, academic institutions, corporate research organizations, and the product development sphere. Dr. Tang is an elected member of the National Academy of Medicine and has served on numerous study committees there, including a patient safety committee he chaired that published two reports, patient safety and new standard for care, and key capabilities of an electronic health record system. He's a member of the Health and Medical Division Committee of the National Academies of Science Engineering Medicine, and he's the co-chair of the Federal Health Information Technology Policy Committee from 2009 to 2017. Dr. Tang, you're an editor on a recent National Academy of Sciences peer review report on strategies to improve patient safety. That report analyzed progress since the first IOM call to action on patient safety in 1999 and the passage of the Patient Safety Quality Improvement Act of 2005. That law created the national infrastructure for patient safety organizations to use data to drive improvement in the United States, and it raised a lot of hopes and expectations for big leaps forward in preventing harm. Paul, in your view, how are we doing so far, and what are the opportunities you see going forward? Well, thanks, Marty. I want to start out by thanking this wonderful coalition that's championing this important cause because I think we're at a tipping point. I think we have a glass half full opportunity. So you think of it in 1999, the publication of the Institute of Medicines to Eric's Human Report raised the public's, and frankly, the healthcare workers' level awareness of patient safety imperative. But the reason we're all here at this summit today, 20 years later, is really, I don't think any of us are satisfied with the progress we've made today. We often hold the aviation industry as an exemplar of high safety and high reliability, and there are many reasons for that. One is they have very visible and transparent failures, but also from a learning point of view, aviation safety relies on standardized mandatory electronic data collection systems, and they have a robust, legally protected analysis and recommendation process. That helps them continually improve and makes flying safer every year. Now, at the time the IOM report was issued, we did not have that in healthcare. We didn't have a data infrastructure. We didn't have legal reporting protections, and frankly, we didn't have incentives to report patient safety incidents. So in 2005, Congress fixed one of those barriers in their Patient Safety and Quality Improvement Act, PSQIA, and this law created patient safety organizations and a network of patient safety databases that had the legal protection so individuals and organizations could report patient safety incidents without fear of legal viability. Now, these actions are necessary but not sufficient for us to catch up with the aviation industry. So what have we accomplished with that? Well, not much yet, and in order to understand why, we need to understand the infrastructure that was present in 2005. So in 2005, only 4% of U.S. physicians even had an electronic health record system in the EHR. Maybe about 10% of hospitals did. So even if we took advantage of the new legal protections and could gather data, it was all on paper, so we really couldn't conveniently aggregate it and analyze it. So enter HITECH. HITECH was a provision in the stimulus bill of 2009 that provided financial centers for healthcare organizations to adopt EHRs. And as a result of HITECH, U.S. went from basically the bottom of the OCD community using EHRs to really being at the top. One, because of the penetrance of EHRs, maybe 95% of us use EHRs at this point and the comprehensive functionality we have in these systems. So all of this because of the law, HITECH, which is part of the stimulus bill. Now the reason I think this is so germane to today's discussion is because our adoption of EHRs has dramatically improved the feasibility of capturing and analyzing data related to patient safety. So it reduces the burden of collecting data. In theory, it improves the consistency and the standards with which we collect these data so that we can aggregate them and analyze them. We now have much better AI of artificial intelligence to glean the important insights from this aggregate data. But maybe what excites me the most is because nearly all of us use EHRs, the lessons that we get out of that analysis of the aggregate data, we can actually deploy to the front line caregivers. We can deploy those to the clinicians so they can make better decisions and make fewer errors. That's fundamentally different. It's a fundamentally different value proposition than was available in 2005. So it doesn't matter what you could learn from aggregate data analysis if you can't deploy that analysis where it's used. So I think fundamentally compared to 1999 or 2005 and PSQIA was passed, this changes everything. I think we now have the capabilities to make care safer, but we need the coalition the willing like the people who are watching this summit in order to convert these possibilities into reality. But I think, again, we stand at the tipping point. If we choose to act, I think this class is half full. We just need the will to do it. So thanks again to the organizers of this for giving us the impetus to take new steps to make things better. Paul, I'm sober by the challenges we still face, but encouraged by the increased capabilities you mentioned. Thank you for your work, your thoughtful comments today, and for underscoring that this is a matter of will at this point, not capability. Irina Papieva is with the World Health Organization, Patient Safety Flagship, which is the name of the secretariat managing the new Global Patient Safety Action Plan 2021 to 2030. She's a physician and has a master's in public health. Dr. Papieva in 2019 by resolution, the World Health Assembly established September 17th as World Patient Safety Day and called for every nation to implement a list of proven strategies to improve patient safety. And this year, World Health Organization followed up with a powerful new Global Patient Safety Action Plan to advance improvement between now and 2030. What can you tell us about the action plan and how WHO will be working to see it implemented? So thank you very much, dear Marty and Patient Safety Movement Foundation for this opportunity to share one of the biggest achievements by the Global Patient Safety Community to date. Indeed, the benefits of having a strategic and coordinated approach to patient safety addressing the common causes so far and the approaches to preventing it have been recognized by policymakers, political and health leaders worldwide. And in recent years, this global advocacy around patient safety has culminated in the adoption of the resolution that you just mentioned by the World Health Assembly in 2019 called Global Action on Patient Safety. The resolution, apart from establishing World Patient Safety Day to be observed each year on 17 September, arched member states and all stakeholders to recognize patient safety as health priority and address that in health sector policies, strategies and programs highlighting its importance within the overall context of universal health coverage. The World Health Assembly also requested in the same resolution WHO to develop a Global Patient Safety Action Plan, which was done in the subsequent two years and then it culminated in its adoption by the World Health Assembly in May 2021 with a subsequent formal launch in the months of August. The Global Patient Safety Action Plan strives to eliminate the avoidable harm in healthcare with the vision of a world in which no one is harmed in healthcare and every patient receives safe and respectful care every time, every day. Our ultimate goal is to achieve maximum possible reduction in avoidable harm due to unsafe healthcare globally. The Global Action Plan provides a strategic framework for action through seven strategic objectives and is further elucidated through 35 strategies, five under each of the strategic objectives. Considering that patient safety is everybody's business and requires active participation of many key partners, each strategy has been further operationalized into suggested actions for the four key categories of partners that are governments, healthcare facilities and services, stakeholders and WHO secretaries. The action plan hasn't set a numerical reduction goal, acknowledging that there is no reliable estimation of the extent of avoidable harm in most of the countries. Thus, all countries are encouraged to implement their baseline estimates of safety-related performance and set their national targets to monitor implementation progress of the Global Action Plan. The plan proposes a set of indicators to support countries in monitoring and reporting progress and it contains set of course and advanced indicators and global targets that are aligned with the strategic objectives. Progress on the implementation of the Global Patient Safety Action Plan should be reported to the World Health Assembly every two years starting 2023 until 2031. We fully recognize that countries are at different stages in their efforts to reduce preventable harm and to strengthen their national health systems. Therefore, there is no single policy strategic approach or intervention that can be inversely applied in all healthcare settings. That is why we strongly encourage countries to adopt implementation approach to their national context. What is also important to highlight that this Global Plan was developed through health systems strengthening plans, taking into consideration the multidimensional nature of patient safety and the need for truly collaborative efforts to achieve actionable, measurable and sustainable improvements. So we call all member states and our partners to align implementation approach with a national health agenda within broader health systems strengthening and universal health coverage context. It also harmonized this implementation approach in relation to the existing organizational structures, governance mechanisms, management processes, as well as local expertise. WU2 Secretariat also has a set of very specific actions to implement in coming decades and I would like to reaffirm our strong commitment to continue cooperating with our countries and with partners by providing high level advocacy, strategic leadership and technical guidance in the implementation process of the Global Patient Safety Action Plan. Thank you very much. Thank you to all the panelists for your thoughtful comments today and for joining us on World Patient Safety Day 2021. This has been a patient safety movement foundation Unite for Safe Care event. We're very excited that you were part of it. You've given us a lot to think about and a lot to do and we're grateful.