National Patient Safety Authority

Harm to patients and healthcare workers across the continuum of care can be dramatically reduced using the power of available technologies deployed in other complex, high risk industries. They include advanced analytics, Artificial Intelligence (AI), and Machine Learning to mine large, existing data sets to anticipate and avoid harm through automated corrective action. The unsatisfactory progress on reducing preventable medical errors, and the deaths resulting from a pandemic for which we were disturbingly unprepared, underline the critical need for a new and bold safety strategy—one that prevents harm before it occurs and responds vigorously when a crisis emerges.

Through a Full Court Press effort with its Board Members and content experts, JHF and PRHI propose a National Patient Safety Authority (NPSA), using the well-established and successful National Transportation Safety Board (NTSB) as a model. The NTSB is structured as an independent agency that investigates accidents and proposes recommendations and solutions to prevent the adverse events from re-occurring. The NTSB’s solutions often rely on autonomous safety technologies, such as airbags, autonomous slack adjusters, anti-collision equipment, autopilot features, fail-safe thrust reversers, automatic shutoff valves, and autonomous internal inspections and correction devices for pipelines.

The NPSA, like the NTSB, would guarantee a data-driven, non-punitive, collaborative approach to protecting patients and providers. The NPSA would exist as an independent agency at the federal level and interface with HHS agencies (e.g., CMS, ONC, AHRQ, CDC, FDA, NIH, and ONC) similar to how the NTSB interfaces with the Department of Transportation (DOT) and its Federal Aviation Administration (FAA). At its core, the NPSA would mine big data from EHRs to monitor and anticipate medical errors with AI and Machine Learning technology, investigate major safety events with NTSB-like “Go Teams,” and create recommendations, including autonomous solutions, to prevent medical errors. While saving lives, an NPSA would reduce the cost of care (related to litigation, waste, and inefficiency) and alleviate worker burnout by centralizing data collection, enabling autonomous safety measurement, real-time safety monitoring, prediction, and corrective action.

It is time to extend fail-safe technologies to health care, where people can then seek medical care without the threat of unanticipated and preventable adverse events. The key ingredients exist. Our nation’s $30 billion federal investment in Electronic Health Records (EHRs) has unlocked healthcare data and AI technology is available to convert the data into intelligence. Automation is also turning appropriate actions over to the computer to create safe and assured operations and team with providers and patients, accomplishing human-specified goals and decisions with trust.

The nation has the capability to detect the conditions that precede error, to identify critical risk factors, and to act in time to reduce pain and suffering. Does it have the political will?

If you are interested in joining the effort to advance the NPSA, please contact us at info@jhf.org.

Download a summary of the proposed National Patient Safety Authority here.

PRACTICE TRANSFORMATION 

The Pittsburgh Regional Health Initiative (PRHI) offers an array of support services related to organizational development and healthcare transformation focused on consistent application of a structured approach to quality improvement. Our comprehensive services and highly-skilled team of professionals brings a broad spectrum of relevant experience, reflective of years of on-the-ground practice and learning about what it takes to implement, spread, and sustain practice improvement. Helping providers shift from focusing on acute health episodes to long-term patient engagement has wide-ranging benefits.

PRHI uses multiple approaches to learning and engaging activation for self-care, including collaborative conversation techniques and behavioral health activation tools. Workshops are structured in a way that promotes discussion, practice, reflection, and experiences toward the ideals of patient collaboration and activation with their providers. Onsite training is augmented by virtual discussions and online community engagement. PRHI’s coaching strategy involves real-time, point-of-care observation, feedback, and demonstration.

We are committed to patient-centered care and have learned firsthand the positive impact that patient-centered, efficient, and evidence-based care delivery can have on patient outcomes and experience. This knowledge has also helped us to know the challenges that come with implementing and sustaining this type of delivery when faced with a fragmented healthcare system, inadequate volume-based reimbursement structures, and an ever changing healthcare policy landscape rife with uncertainty.

To support organizational teams in navigating these challenges, we tailor our approach to the needs of healthcare organizations with a focus on building the internal capacity for an organization to develop its people and its adaptive reserve for continuous improvement. We provide relevant classroom training and skill development, supported by in-person and virtual coaching to develop structured and sustainable quality improvement efforts across all levels of the organization. Current projects include:

  • Coaching and training partnership with a county public health department as they redesign their clinical programs
  • Quality Improvement capacity building with 16 primary care practices in an AHRQ funded partnership with the Department of Family and Community at the Penn State College of Medicine
  • Technical assistance to prepare clinicians for value‐based payment initiatives, greater information sharing with patients and other providers, and ongoing practice improvement activities through a subcontracting role as part of the NRHI High-Value Care Support and Alignment Network, a CMMI grantee, to lead its “Transforming Clinical Practice Initiative”
  • Training and coaching in conjunction with Allegheny Health Choices, Inc. for Conference of Allegheny Providers mental health and substance use disorder provider organizations to develop the internal ability of behavioral health organizations to track and act upon common metrics across a network of agencies
  • Coaching and training partnership with HealthVisions Delmarva for practice transformation with 360 clinical providers
Contact: Jennifer Condel, SCT(ASCP)MT
412-594-2589