EXECUTIVE SUMMARY

A coalition of more than 50 leading healthcare organizations is calling for the creation of a National Patient Safety Board. The board would be modeled after the National Transportation Safety Board.

  • The board’s goal would be to reduce medical errors and improve patient safety.
  • The board would be a federal agency but would not issue regulations.
  • Two decades of focus on medical errors have produced few significant improvements.

When an airplane crashes, whether a commercial airliner or a small private plane, federal investigators swoop in quickly to collect evidence so independent experts can determine what happened and how to prevent it from happening again.

That does not happen in the event of a medical error. Some healthcare leaders are proposing the creation of a federal patient safety board that would take a similar approach to improving safety in the healthcare system.

The Institute of Medicine’s groundbreaking report, To Err is Human, was published 20 years ago and spurred a vigorous effort to improve patient safety, but preventable medical errors still cause an estimated 250,000 deaths a year in the United States, making this problem the third-leading cause of death.

Well-intentioned efforts to improve processes and change behavior in the healthcare industry have been decentralized and resulted in minimal improvements, says Karen Wolk Feinstein, PhD, president and chief executive officer of the Pittsburgh Regional Health Initiative and Jewish Healthcare Foundation. The failure can be traced to the lack of a single federal agency that investigates healthcare errors and identifies ways to prevent them, she says.

Following the Lead of the NTSB

Feinstein is spearheading the creation of a proposed federal independent agency, the National Patient Safety Board (NPSB), modeled after the federal National Transportation Safety Board (NTSB) that investigates accidents involving airplanes, railways, motor vehicles, and other modes of transportation.

The NTSB is renowned for its thorough investigation of accidents, followed by an objective analysis that yields a report detailing how the accident occurred, what lessons might be learned from it, and sometimes specific recommendations for changing requirements within the industry.

Most NTSB recommendations become standard practice and are widely adopted, contributing to significant increases in transportation safety since its creation in 1967. The NTSB has issued more than 15,000 safety recommendations. “Because the NTSB has no formal authority to regulate the transportation industry, our effectiveness depends on our reputation for conducting thorough, accurate, and independent investigations and for producing timely, well-considered recommendations to enhance transportation safety,” the board reports.

The proposed NPSB would operate similarly with investigations, but also by monitoring and anticipating adverse events with artificial intelligence, studies, and recommendations to prevent medical error, Feinstein says.

A coalition of leading healthcare organizations and experts is calling for the creation of the NPSB.

Started with Lean Management

Feinstein was spurred to act on patient safety when she learned of the high error rates in medicine and the lack of a national structure to study and learn from them. She sought help from industry leaders who had addressed safety issues, starting with a local executive, Paul O’Neill, who ran the major aluminum producer Alcoa. The company was known for improving safety in its own organization and within the industry.

“He brought his solutions from industry, including Lean, quality improvement, and his perspective on leadership. We formed a regional health improvement collaborative called the Pittsburgh Regional Health Initiative,” Feinstein recalls. “We got a lot of support from the Bush and Obama administrations, but I realized that Lean quality improvement was not working to improve patient safety the way we wanted.”

The solution depended on trained coaches and champions to driving improvement. But every time those people were transferred from a unit or moved to another employer, the quality indicators reverted to baseline, she says.

The experience helped Feinstein see what does and does not work when improving safety. Over the years since 1994’s Error in Medicine by Lucian Leape, MD, and To Err is Human, the healthcare industry has talked a lot about improving patient safety without making significant strides forward.

“Every time there’s a leak in the dam, someone sticks a finger in. That’s where I think we’ve been for the last 20 years,” she says. “We try a lot of solutions that are, I hate to say it, the easy way out. Things like learning collaboratives that are so neutral they offend no one and are just a gathering of believers.”

More recently, Feinstein sensed a societal desire to improve patient safety as part of reforming the entire healthcare system, but she worried the industry might just try “a heavier dose of what didn’t work before. More of the same.”

True improvement would come only if there were an authority at the top of the entire healthcare system that is responsible for overseeing and determining ways to reduce medical errors, Feinstein concludes. This agency should be patterned after the existing NTSB that has proven the effectiveness of its approach.

“In healthcare — unlike aviation, nuclear, or any other complex, high-risk industry — there is no commitment at the highest level to acknowledge that we are incredibly dangerous,” she says.

The healthcare industry has made little progress in improving patient safety in the past two decades, Feinstein says, even though one of the most often-cited successes is the 68% reduction of central line infections in the 32 Pittsburgh hospitals in her own Pittsburgh Regional Healthcare Initiative. She was involved with that success and was proud of it at the time — in 2002.

“It’s now almost 2022 and I’m supposed to be excited about something we proved was possible in 2002 in conjunction with the CDC? Looking backward doesn’t help,” Feinstein says. “But I’m also tired of people bashing To Err is Human for not creating miracles. It’s not up to the people who did To Err is Human to fix things now; it’s up to every stakeholder in the healthcare community to make changes that will have real impact.”

With that idea in mind, Feinstein tried to think of a solution that would not involve regulation, shame, and blame because those approaches do not bring the best results in healthcare. She found the NTSB to be a good model that can work in healthcare.

“They study and they recommend solutions. Healthcare has more accidents than the NTSB could study, but we can start by picking out the biggest and most serious risks to patients,” she says. “We can look at the conditions that precede these errors, when are they occurring, what could we do to prevent them, and what technology do we have to make that prevention autonomous. We need to take the burden off the front line.”

One aspect of the NTSB is the way it embraces technology to prevent errors — something the healthcare industry should do more, Feinstein says. The NTSB also makes better use of data collected across the industry to identify potential safety issues and recommend changes.

Public Wants Improvements

The NPSB coalition includes more than 50 members. Organizations supporting the proposed NPSB include Cincinnati Children’s Hospital Medical Center, Dartmouth-Hitchcock, IHI Lucian Leape Institute, Institute for Healthcare Improvement, National Alliance of Healthcare Purchaser Coalitions, National Association for Healthcare Quality, National Quality Forum, The John A. Hartford Foundation, and The Leapfrog Group.

“Everyone in the industry acknowledges that there is so little trust of the medical community right now. People are saying, ‘Stop telling me you’re hiring a new head of equity and you should trust us. No, we want our friends to get out alive when they go in for outpatient surgery,’” Feinstein says. “Hiring a new head of equity and diversity doesn’t address why they don’t trust us.”

The creation of a NPSB will require the support of Congress and the American Health Association, Feinstein says. They can push for more data-sharing among healthcare organizations, which is vital to the proposed NPSB to anticipate medical errors and provide solutions rather than only responding after a patient has been harmed. Congressional action also would be necessary to create the federal agency.

“Everyone would agree that it’s time. The public is getting more and more cranky because of COVID and this lack of faith in our healthcare system, which creates even more mayhem in hospitals and practices,” Feinstein says. “It’s time to do something that assures everyone that our health system acts in the public interest.”

SOURCE

  • Karen Wolk Feinstein, PhD, President and CEO, Pittsburgh Regional Health Initiative and Jewish Healthcare Foundation, Pittsburgh. Phone: (412) 594-2555. Email: info@jhf.org.