Guiding Principles

1. The focus is on the smallest elements of safe patient care because they are defined by standards and are either present or not-present. Both safe and unsafe care can result in good patient outcomes, but it is more likely with safe patient care. Essential to consistently good patient outcomes is safety at all points of patient care, and in every process, action, and step supporting that point. Here, we refer to the processes, actions, and steps that support care as “elements”. In One Standard, the goal is to improve the outcome, quality, and efficiency of every care process. This is done by making the goal at points of patient care and in the supporting elements to meet safety standards, which makes every violation of the elements of care correctable.

Improving patient outcomes will require changes. One Standard links all change to supporting safety in the elements of care, consistent with healthcare standards. If the focus was on improving poor outcomes, as it usually is, changes might seem random and detached from outcomes for providers. There are correctable elements in some, but not all, cases that result in poor outcomes. Additionally, some cases that result in good outcomes also have correctable elements. Some breaches in healthcare standards are very hazardous and must be corrected even if they have never been associated with a poor outcome at a site, for example reusing needles or syringes. Often, higher surgical volumes are necessary to make evident the results of unsafe care. Here, we focus on two absolute requirements for safety at points of patient care: there must be 1) actions and 2) equipment, medication, and supply preparedness that meet healthcare standards at every step of patient care . If any of the two requirements are not met, then this is a violation of safe patient care and needs correction.

2. Unbiased measurements identify goals, areas of correction, and document progress. Elements of safe patient care are absolute and measurable. At this level there is no partial credit - an element is either present or not present, an action was either done or not done, an item that is required by healthcare standards to be ready and available at a point of care, is either there or not there. Measurements are objective and define the goals for the elements and at points of care. In One Standard, these clearly defined goals are intended to be understood by everyone at the beginning of the system strengthening process. It does not allow for goals to be debated before being adopted, and thus improvements are not delayed. In One Standard, there are measurements of action and preparedness elements at points of care, which are grouped into categories. Preparedness categories include anesthetic monitoring equipment, adult airway equipment, medication in the operating room, and pediatric monitoring equipment in the PACU. The elements in each categories that meet safety standards are counted, then divided by the total number of elements in that category. A percent score is thereby calculated, which shows the category’s compliance with standards and represent safe patient care. The percent score places everyone at the same starting point, allows trends to be followed and improvements to be verified. This score can also be used to compare safe patient care across a system, a country, or globally.

3. Sustainability requires a commitment to safety. Safe patient care is sustainable only when there is a facility-wide commitment to this as a primary goal. With this common mindset, management maintains an environment of safety, create protocols that enhance processes, and provides oversite that prevents human errors. This mindset, supported by the actions of management, provides staff with the essential tools that they need to do their job and an environment that supports safe care, and prevents pressure on staff to provide unsafe care or to give in to unsafe practices.

4. This method limits improvements to three targets at a time and builds infrastructure. One Standard presents a nine-step plan that can fix and advance care. In this method, three points in healthcare that are linked to the highest patient risk of harm are fixed first. This saves the most lives upfront and improves infrastructure and efficiency. When one target reaches healthcare standards, another is identified and fixed using the same process. This method does not fix everything at once, but creates early successes that affirm the process and fuel futher improvements. One Standard begins with perioperative care.

5. Tools support standardization and sustainability. Various tools in One Standard support achieving and maintaining actions and preparedness that are to standards.

6. There are four requirements for safe patient care.

1. Preparedness of equipment, medication, and supplies at points of care

2. Actions (core and specialized) at points of care

3. Patient preparedness

4. Facility and leadership support and infrastructure

The essential requirements and One Standard (OS) tools that can be used to achieve and maintain the requirements are listed below:

I. Item Preparedness: Equipment, medications, and supply requirements as defined by standards. Equipment and supplies must meet the One Standard- Needed qualities in equipment and monitors.

a. Defined, clear, and in writing (Anesthesia Ready, OS checklists)

b. Understood and completed by health workers with oversite (OS visual checklists)

c. For patient care:

1. Basic

a. All item that are needed should be at the site

2. That includes any amount of critical care. This includes all patient care in a hospital.

a. All items that are needed for care should be at the point of care

i. Standardized: type, amount, and location (One Standard visual checklists). This will increase safety and efficiency, enforce a level of consistency and quality, and eliminate guesswork

ii. Available/Ready: Clean, working, and checked before each patient contact

b. All Item that may be needed for care should be able to be at the point of care in 1-2 minutes (ie: emergency: airway carts (adult/pediatric), medications, defibrillator, etc.)

i. Standardized

ii. Available/Ready: Clean, working, checked, and ready for use

At assigned frequency (every Friday, last day of month, etc.)

Task is assigned to staff, with accountability and oversight

iii. Either in a designated area or signed out

iv. Secure behind a metal or plastic lock and always accessible

v. Protocol to request and get items to point of care that is practiced

II. Action requirements

a. Core action requirements of all health workers

b. Understand and complete job duties that are defined and achievable (printed)

i. Accountability

ii. Professional communication skills

iii. Duty to speak up is something is unsafe or abnormal

iv. Duty to request needed items

c. Core actions requirements of all providers:

i. Standardized documentation of care (forms, orders, vital signs, events: what/when, charting, etc.)

ii. Standardized communications (hand-off reports, requesting help during a crisis)

iii. Standardized performance of basic patient care tasks

Measuring vital signs, events if abnormal, performing all types of assessments (breathing/lung ventilation, etc.), declaring a crisis, equipment care and security, ordering items, etc.)

d. Specific actions required of all provider groups

i. Follow standards of care and protocols

ii. Have and maintain the minimal skillsets necessary to do their job

III. Patient preparedness: Optimized, instructed, and following surgical infection prevention protocols

Facility and Leadership: Provide policy, procedures, protocols, and oversite. Maintain an environment of safety with accountability. Provide the tools for everyone to do their job and the mechanism to maintain preparedness