What I Wish I Had Known
A Chief Safety Officer reflects on 25 years as a healthcare safety leader
By Dr. Tejal Gandhi
In the late ’90s, I entered the healthcare workforce as an internist at Brigham and Women’s Hospital. I was called to medicine, like so many of my peers, by a desire to help people, to heal them. And throughout my career, I’ve had the extraordinary opportunity to learn from and work alongside some of the brightest minds in the industry, at Brigham and Women’s and Partners Healthcare as a safety and quality leader, through my work at the helm of the National Patient Safety Foundation and as a leader at the Institute for Healthcare Improvement (IHI), and in my role as Chief Safety and Transformation Officer at Press Ganey.
For as long as I can remember, I’ve been passionate about the mission of creating safe, highly reliable environments—for our patients and our workforce. As an executive sponsor of Press Ganey’s Equity Partnership, co-chair of the National Steering Committee (NSC) for Patient Safety, and coauthor of “Safer Together: A National Action Plan to Advance Patient Safety,” the relentless pursuit of zero harm is a core principle that guides my every action in healthcare. I have focused on building high reliability through system and process design, as well as resilient, engaged teams and a culture of safety. It’s a complex puzzle, but when these pieces fit together, we can truly elevate healthcare, and the Human Experience, for everyone.
So much has changed since I first donned the white coat. A growing emphasis on patient- and family-centered care. A focus on human factors, science, and process redesign. Emerging technologies like electronic health records, telehealth, and artificial intelligence, which are, collectively, changing healthcare as we know it.
Safety in healthcare has undergone nothing short of a revolution. Having spent years navigating these complexities, I’ve learned a few things—often the hard way—that I would impart to my younger self, who created the safety program at Brigham and Women’s many years ago. Today, as we enter a new era of healthcare, I hope these lessons can provide guidance and support to the next generation of leaders who are tackling the ongoing challenges of building a safer healthcare system.
1. We have to address emotional harm, too
Healthcare leaders must treat emotional harm with the same rigor and urgency as physical harm. Compared to physical harm, emotional harm can be harder to quantify, but it happens when patients or employees feel unsupported, unheard, or disrespected. Patients subjected to emotional harm may feel anxious, lose trust in their providers, and disengage from care, leading to poorer health outcomes. For staff, emotional harm can translate into lower engagement, burnout, and even turnover—all of which compromise safety.
2. Patients’ perceptions of safety shape their experience
Press Ganey data shows a clear link between safety and patient experience (PX). Hospitals with high safety perceptions from patients see a direct correlation with PX measures: According to a new data analysis out of Press Ganey, 84% of patients who feel safe are likely to recommend the facility, compared to only 34% who don’t.
Making harm visible across the organization, conducting daily safety huddles, and setting a goal of zero harm all have a huge role to play in impacting safety. But it’s not just how safe people are that matters. They also have to feel safe, and observe safety behaviors in nurses and physicians. Patients are astute observers. Even things like washing hands upon entering a room, having coordinated teams, and involving patients in discussions about their care plans all impact patients’ perceptions of safety, and they’re all important for the delivery of safe care.
Put simply: When patients feel safe, their experience improves. We should, therefore, be routinely asking patients about their safety experiences to identify concerns and address them.
3. Care is only truly safe if it’s also equitable
Inequity is a form of harm in healthcare. But diversity, equity, and inclusion (DEI) efforts often get siloed, instead of prioritized as a core value across the organization. This can lead to a mismatch between an organization’s stated values and its actual practices around DEI. Inequities contribute to all kinds of harm, and we need to embed the equity lens into all of our work on safety, quality, and patient experience. For example, a 2023 study from Press Ganey’s Patient Safety Organization (PSO) identified racial bias in harm classification data for falls and maternal/perinatal death or disability. While safety event data existed, it was more complete for white patients than those of other races/ethnicities. This kind of unequal reporting on patient harm across races and other demographic signifiers makes it harder to analyze events and identify trends and causes.
Data shows that by breaking down the silos and embedding DEI within the very DNA of an organization, we drive higher performance and achieve positive results. As safety people, we need to be mindful of DEI in everything we do, and work together to reduce harm for everyone.
4. Workforce safety is a precondition of patient safety
Healthcare is a high-risk industry. A safe environment fosters a highly engaged workforce, and a highly engaged workforce keeps people safe.
One in five employees still doesn’t feel safe in their workplace. In addition, reported assaults against nursing personnel rose sharply in 2023, jumping 5% to 2.71 incidents per 100 staff, according to Press Ganey’s National Database of Nursing Quality Indicators (NDNQI). While this is cause for concern, we have to remember that increased reporting could be a contributing factor, since the heightened focus on workforce violence prevention in recent years can lead to more incidents being documented by healthcare employees themselves.
Leaders need to commit the same intensity of effort and methodologies to workforce safety as they do patient safety, because the former is a precondition of the latter.
5. Safety culture and employee engagement are mutually reinforcing
A strong safety culture is critical to driving employee engagement and performance—and vice versa. When employees’ perceptions of safety culture are high (4.00 or above out of 5.00), employee engagement ranks in the 98th percentile. Conversely, when those perceptions are low (below 4.00), engagement plummets to the 2nd percentile. This data underscores the virtuous cycle between patient safety and the engagement of the healthcare workforce. Prioritizing open communication and mutual respect creates a culture of psychological safety, which, in turn, promotes teamwork and empowers employees to speak up for safety without fear of retaliation or retribution. Given these connections, safety culture surveys should be integrated with engagement surveys, and lead to a coordinated response on actions to improve. This will help focus on cross-cutting interventions that will improve both safety culture and engagement.
6. Bring together people, process, and technology to fortify the system and strengthen the skills of people in the system
While a skilled workforce is fundamental to patient safety, a comprehensive strategy requires more. Having robust, reliable processes in place and leveraging cutting-edge technology can minimize human error. It can also take some of the pressure off clinicians so they can do their jobs better, more compassionately, and more efficiently. Furthermore, we need to give our people the skills and behaviors to help them more effectively provide safe care, embedded in high reliability principles. Taking an integrated, three-pronged approach—one that focuses on people, processes, and technology—helps us develop robust safety interventions and strengthens our overall safety infrastructure. For example, Press Ganey strategic consultants partnered with Community Health Systems (CHS) to create a unified safety and high reliability framework across the organization (as outlined in NEJM Catalyst). By first establishing safety as a core value, standardizing safety measures, developing consistency among leaders, and understanding the human- and system-based causes of harm, they were able to reduce serious safety events and advance on the journey to zero harm.
By adopting a holistic approach that connects people, processes, and technology, organizations can, effectively, implement high reliability organizing (HRO) principles. HRO is often viewed as a safety-focused framework. But at its core, it’s a systems-based approach that sets the stage for excellence across the board. HRO principles—i.e., deference to expertise, reluctance to simplify, sensitivity to operations, commitment to resilience, and preoccupation with failure—aren’t just about preventing mistakes. They’re the foundation for achieving excellence across the board, from safety and quality to patient experience to employee engagement and financial performance.
In other words, think of HRO as a chassis for organization-wide improvement—a strong, adaptable platform upon which safety, quality, experience, and every other key aspect of healthcare can flourish.
7. Safety is the foundation of healthcare. It’s a baseline expectation for patients as well as all of our colleagues on the front lines. It undergirds patient and employee experience, financial performance, and, ultimately, high-quality care and optimal outcomes.
But the healthcare landscape is constantly shifting. Technologies emerge, expectations keep rising, and new challenges mean that we, as safety leaders, have to be agile and willing to adapt. What will the next three decades bring? Only time will tell, but hopefully we can embed these lessons learned into our work today and in the future. I look forward to continuing along this journey with you, as we progress toward our shared mission of keeping people safe and striving for zero harm.
Tejal Gandhi, MPH, CPPS, is Chief Safety and Transformation Officer at Press Ganey. She is responsible for improving patient and workforce safety, and developing innovative healthcare transformation strategies. She leads the Zero Harm movement and helps healthcare organizations recognize inequity as a type of harm for both patients and the workforce. Dr. Gandhi also leads the Press Ganey Equity Partnership, a collaborative initiative dedicated to addressing healthcare disparities and the impact of racial inequities on patients and caregivers. Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programs focused on improving patient and workforce safety.