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National Quality Forum updates Safe Practices for 2009

Leadership attitudes and actions keys to adopting Practices correctly

Explaining how the National Quality Forum (NQF) came to update its Safe Practices for 2009, Charles Denham, MD, founder and chair of the Texas Medical Institute of Technology and cochair of the NQF Safe Practices committee, recalled an anecdote told by Jeanette Ives-Erickson, CNE, at Massachusetts General Hospital in Boston.

“When an event occurs in which a nurse is involved with harming a patient, she pulls him or her aside and asks, ‘Did you harm this patient on purpose?’ and if he or she answers no, she answers, ‘Then this is my fault— errors stem from system flaws, and I’m responsible for creating safe systems,’ ” said Denham as part of his presentation at the IHI’s 20th annual National Forum on Quality Improvement in Health Care in December.

This example of leadership taking responsibility for a system failure exemplifies a basic change that has started and must continue within healthcare if the U.S. system as a whole wants to move away from its current state of chaos, said Denham.

A larger focus on leadership has been added to the NQF’s Safe Practice update for 2009, which is on track to be published early this year. The best hospitals are realizing that their performance outcomes are directly reflective of the values they have in place, Denham said.

“The breakthroughs of the next decade in healthcare performance improvement won’t be through technology or a new drug,” said Denham. “It will be social entrepreneurship, leveraging what we have.”

Since 2003, the NQF has published its Safe Practices to help prevent errors that could result in patient harm. The 2009 edition will modify and add new practices to the original 30, bringing the total number to 34.

These practices fall into the following existing areas:

  • Creation of a culture of patient safety
  • Informed consent and disclosure
  • Work force
  • Information management and continuity of care
  • Medication management
  • Healthcare-associated infections
  • Condition- or site-specific practices

Leadership’s role of increased importance

The first area, related to building a culture of safety, now breaks out what were considered practice elements in 2006 into their own safe practices, a move showing the importance of the culture of safety.

“The new safe practices will have a whole new leadership focus,” said Denham. “The measurement of their values and behaviors will be core.”

Central to an organization accomplishing any of the Safe Practices is the need to compare the organization’s core values with current practices, Denham said. If the two do not align, there’s a clear weakness present that will ultimately make patients less safe and result in rising costs.

“Good leaders have the courage to look at their [organization’s] core values and ask if the rhetoric matches reality,” Denham said. “People are the real drivers of economics, and they drive patient-centered care.” If staff members think their leaders do not fully believe in the organization’s core values, it will be reflected in the quality of care delivered, he added.

Leaders look to patient safety officers for help

As leaders become more aware of the relationship between patient safety and the revenue a facility generates, Denham said he thinks patient safety officers will soon be seen as “chief revenue presentation officers.” As he describes in his article “CEOs: Meet Your New Revenue Preservation Officer…Your PSO!” in the Journal of Patient Safety, the next era of healthcare will be that of “no outcome, no income,” instead of the past era’s mantra of “no margin, no mission.”

Nothing illustrates this better than CMS’ no-pay conditions, which went into effect in October 2008. Patient safety and quality improvement staff members in hospitals are becoming responsible for ensuring that patients do not develop any of the healthcare-acquired conditions for which CMS will not pay. Hospital leaders are looking to these staff members for guidance in how to receive full reimbursement, said Denham.

Medication management

Another new practice included in the 2009 Safe Practices concerns medication management; specifically, the expanded role pharmacists should play in ensuring medication safety.

Safe Practice 18 now outlines a new leadership role for pharmacists, giving them the authority to ask to be included in leadership discussions concerning medication-related performance improvement and quality measures.

“The objective was to look at the pharmacy as being core to a successful medication safety program,” said Hayley Burgess, PharmD, BCPP, director of medication use and safety at HCA, who copresented with Denham. “Pharmacists should have an active role on the administrative team.”

Aligning quality standards

The 2009 Safe Practices take into account many other existing quality standards, measures, and campaigns in an attempt to standardize the data hospitals need to collect and the initiatives they need to take on, said Denham.

The NQF’s Safe Practices align where possible with the following groups:

  • CMS
  • The Agency for Healthcare Research and Quality
  • The Joint Commission (formerly JCAHO)
  • The Leapfrog Group
  • The IHI


The NQF embarked on its National Priorities Partnership in November 2008 to show how important the development of a national set of core priorities and goals is for U.S. healthcare as a whole. So far, more than 25 healthcare groups have signed on to be a part of the National Priorities Partnership.

Editor’s note: Visit to find out more about the NQF’s 2009 Safe Practices. Visit to find out more about the National Priorities Partnership.