Could a National Patient Safety Board Be a Key to Fixing our National Strategy for Healthcare Safety? We Think So.

Our founding non-executive chair, Paul O’Neill, Sr., used to say that a lot of well-intentioned activity and all the right words do not equate with results. And, unfortunately, when it comes to safety in American healthcare, that’s the current state, 22 years after the Institute of Medicine's seminal call to address the epidemic of harm caused by preventable medical errors, To Err is Human.

There are countless patient safety-related activities occurring across the industry. Yet, progress was made against only a few types of healthcare-associated infections and other narrow types of harm prior to the pandemic. February 2022 releases from CMS and the CDC show that much of that progress has now been wiped away and indeed reversed. The gains were fragile and easily destabilized.

The question is … why?

Design Systems to Produce Desired Outcomes

The most powerful problem-solving techniques in the world – the only ones that work on a sustainable basis – are based on what is called “systems thinking.”

One adage of systems thinking is that current results are always the product of a system (or the interactions of various systems and subsystems), that are in fact “designed” and operated to produce exactly the results they are producing.

The fact that we still have hundreds of thousands of Americans dying each year due to healthcare-associated harm is not some inevitable state we have to shrug off and accept. It's the product of a bad design for making healthcare safe (or in this case, inadequate design).

If you want better results, change how the system works; improve how it’s designed and operated.

So what kind of design is needed?

A National Safety Improvement System

It turns out that to make any high-risk environment safe, there is a very powerful system for continuous detection of harm and risk, as well as corresponding action to learn and prevent future harm, deeply embedded into its very fabric.

Sadly, we lack that in healthcare.

We have hundreds of disparate government and private-sector entities and healthcare institutions themselves producing, requiring, or requesting reports -- analyzing information, inspecting, and grading.

Among them are only a few truly effective pieces and parts, and those that we do have are not connected together effectively.

There is no overall architecture for a national improvement system and, critically, no trusted authority at its center establishing expectations for what good looks like, and acting as a constant beacon of learning and truth and transparency and high standards based on the risks and harms that are actually occurring.

Today, we have models of what this overall architecture could look and act like.

Transportation, for example, has such a gravitational center helping to embed safety learning and improvement at a high standard across the country. This is the National Safety Transportation Board.

You see their investigators on the news as they hit the scene of a transport disaster, like a train derailment or the recent collapse of the Fern Hollow Bridge in Pittsburgh in January. The NTSB investigators expertly help to identify the cause of the incident, and issued highly credible, evidence-based, respected recommendations on what others with the same risk should do in order to prevent another such incident.

The NTSB not only investigates individual incidents. They look at industry practices and safety systems methodically and rigorously, helping to strengthen the improvement systems themselves through their gravitas and insight and, significantly, their use of transparency.

For example, over the years, the NTSB has effectively called for addressing the holes in key aviation safety learning systems, as well as highway and rail safety, to great effect. They aren’t regulators – they stand only for getting the objective truth and the best possible safety recommendations to industry and to the public.

And they don’t try to do it all themselves. Quite to the contrary, they collaborate with or deputize other agencies and partners who have “best in breed” capabilities or are best situated to handle particular levels of problems, while the NTSB makes sure that the most critical incidents and the safety of the system overall is being attended to and rigorously improved.

Here is an excerpt from the NTSB website:

"Safety recommendations address specific issues uncovered during investigations and specify actions to help prevent similar accidents from occurring in the future. These safety recommendations are the agency’s most important products because they alert government, industry, and the public to the critical changes that are needed to prevent transportation accidents and crashes, reduce injuries, and save lives.

We issue recommendations to the organizations best able to take corrective action, such as the US DOT and its modal administrations, the Coast Guard, other federal and state agencies, manufacturers, operators, labor unions, and industry and trade organizations."

Sounds like the kind of entity we might desperately need in healthcare, doesn’t it?

Value Capture Supports Creation of a National Patient Safety Board

We support the creation of a National Patient Safety Board, an independent federal agency (like the NTSB) to support agencies in monitoring and anticipating adverse events with artificial intelligence, conduct studies, create recommendations and solutions to prevent medical error, and leverage existing systems and bring key learnings into practice.

You can see a proposed design of a National Patient Safety Board here, including a potential enhanced focus on using Artificial Intelligence and some of the real-time universal harm measurement that is possible through electronic medical records, which would help healthcare providers understand and prevent individual cases and patterns of harm. Support is being gathered on Capitol Hill to encourage policymakers to create and fund such an entity.

We support the creation of a National Patient Safety Board because we know that the needle has barely moved in the decades since To Err is Human, and that the current national healthcare system is producing mediocre outcomes.

We know that our current multiple splintered, unconnected health safety systems are unable to produce the consistent high quality experiences patients deserve - not for lack of effort and intentions, but for sheer lack of a powerful national system for improvement in healthcare.

We know that a central trusted, deeply expert source whose only role is to get the truth out and make sure continuous improvement to prevent harm is happening effectively has been a powerful keystone for true national learning systems and measurable progress in other sectors.

With great leadership and determination, it can be the same in healthcare.

We can have consistently excellent health and medical care throughout the U.S., rather than isolated pockets of safe, high-quality care.

We hope you will support the creation of a National Patient Safety Board, and are eager for your thoughts.

Learn much more about the NPSB:


Up Next for Patient Safety podcast

Join the coalition of healthcare organizations, provider associations, businesses, nonprofit organizations, and consumer advocacy groups who are asking in unison for the creation of a National Patient Safety Board.

Value Capture is very proud to be a NPSB coalition member!

Learn more about Value Capture's mission, vision and values.

Learn more about  Value Capture's work for Patient Safety and Zero Harm.   

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