1. Review the 17 recommendations and tactics to advance patient safety presented in the Institute for Healthcare Improvement (IHI) Safer Together: A National Action Plan to Advance Patient Safety, a report that harnesses the knowledge and insights of the National Steering Committee for Patient Safety members.
2. Identify a senior sponsor and core team charged with deploying the Self-Assessment Tool, a companion resource to the National Action Plan, to evaluate your organisation’s current state across each of the four foundational areas, prioritised as essential to create total systems safety.
3. Establish and enact strategies, tactics, and measurement and improvement plans to meaningfully fortify and sustain your organisation’s performance in each of the four foundational areas by leveraging the Implementation Resource Guide, a companion resource to the National Action Plan.

Culture, Leadership, and Governance

1. Ensure safety is a demonstrated core value.

2. Assess capabilities and commit resources to advance safety.

3. Widely share information about safety to promote transparency.

4. Implement competency-based governance and leadership.

Patient and family engagement

5. Establish competencies for all healthcare professionals for the engagement of patients, families, and care partners.

6. Engage patients, families, and care partners in the co-production of care.

7. Include patients, families, and care partners in leadership, governance, and safety and improvement efforts.

8. Ensure equitable engagement for all patients, families, and care partners.

9. Promote a culture of trust and respect for patients, families, and care partners.

Workforce safety

10. Implement a systems approach to workforce safety.

11. Assume accountability for physical and psychological safety and a healthy work environment that fosters the joy of the health care workforce.

12. Develop, resource, and execute on priority programmes that equitably foster workforce safety.

Learning system

13. Facilitate both intra- and inter-organisational learning.

14. Accelerate the development of the best possible safety learning networks.

15. Initiate and develop systems to facilitate interprofessional education and training on safety.

16. Develop shared goals for safety across the continuum of care.

17. Expedite industry-wide coordination, collaboration, and cooperation on safety.

• to foster connections and support networking across the Alliance
• to surface key issues that are top of mind to Alliance leaders
• to support capacity around personal, organisational, and industry leadership
• to promote discussion and activities that foster and advance courageous, creative, collaborative leadership across the network
• to inform and advance the direction of engagement, collaboration, and collective action opportunities across the Alliance network.

• describes the framework's two foundational domains, culture and the learning system, outlining what is involved with each and how they interact
• provides definitions and implementation strategies for nine interrelated components (leadership, psychological safety, accountability, teamwork and communication, negotiation, transparency, reliability, improvement and measurement and continuous learning)
• discusses engagement of patients and their families, the core of the framework, the engine that drives the focus of the work to create safe, reliable, and effective care.

Healthcare organisations and systems may use the framework as a roadmap to guide them in applying the principles, and as a diagnostic tool to assess their work to date.

Although initially focused on the acute care setting, the framework has evolved to be more broadly applicable in any setting, in acute care, ambulatory care, home care, long-term care and in the community.

• improvement capability
• patient safety
• quality, cost and value
• The Triple Aim
• leadership.

At the end of this activity, you will be able to:

• List three principles of reliable systems.
• Explain how the Central Florida Zoo uses these three principles in protecting staff from venomous snakes.
• Discuss how the zoo’s safety system can be applied to health care.

• Reasons why providers don’t always communicate with patients after adverse events.
• Why patient access to information is changing the dynamics of medical error.