National Patient Safety BoardNational Patient Safety Board Logo

COVID-19 demonstrated a pressing need to improve safety in our health system. Prior to the pandemic, preventable medical error caused an estimated 250,000 deaths a year in the U.S., ranking as the 3rd leading cause of death. Despite earlier disclosures of this tragedy, we have not made significant progress over the past 20 years.

Previous efforts to improve processes and change behavior at healthcare’s frontline have been decentralized and have not been successful. The primary reason is that these improvements do not have one federal agency to independently determine why the adverse events are occurring and create solutions to prevent recurrence.

Meanwhile, other industries have seen dramatic improvements in safety. Transportation, for instance, benefits from having that single federal agency with a clear, defined, and focused mission—the National Transportation Safety Board (NTSB). The NTSB studies the accidents, mishaps, and close calls with the greatest potential for harm. The NTSB’s interdisciplinary teams then propose solutions and corrective actions to prevent future injury. The vast majority of NTSB solutions have become standard practice and widely adopted, producing exceptional levels of safety and saving lives.

A proposed federal independent agency, the National Patient Safety Board (NPSB), would model the NTSB within health care. The NPSB would 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.

In early 2021, a growing coalition of leading healthcare organizations and experts began to advance and call for the creation of the NPSB.  For more information, please visit

We invite you to Get On Board with us today. 

Like the NTSB, the NPSB will save lives.


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