COVID-19 Continues to Expose the Urgent Need for a National Patient Safety Authority

We knew before COVID-19 that the U.S. health system poorly protected patients and workers. The number of preventable errors leading to death and injury has been horrifyingly stagnant for decades, and previous efforts to build quality engineering into every aspect of health care and establish a culture of safety at the frontline have not been successful. Then COVID-19 entered this mess and the results have been devastating but not unpredictable. The experience of COVID-19 is a patient safety experience, and the results indicate that our system is clearly missing something. If the United States is to rebuild its reputation as having one of the best health systems in the world, a dramatic response is needed. More and more of our nation's experts are beginning to see that solution as the formation of a National Patient Safety Authority.

There are many roadblocks to improving patient safety: EHRs that underperform; conflicting assessments of safety and quality; a "market-driven, efficiency-obsessed culture of hospital administration"; failures of leadership; inadequate training and coaching; gaming of performance measures; and a bias against whistleblowers that frustrates a rapid response to--and root cause analysis of--problems. But other flaws in our fabric create mayhem in a pandemic: the inflexibility of rigid bureaucratic boundaries that prevent crossing lines even in times of crisis; the hoarding of vaccine discovery exacerbated by our systems of academic promotion, status, recognition of expertise, and financial incentives; an inability to relax regulations and protocols when necessary; and the ability to "force" collaboration and sharing.

We could do so much better — not only in preparation for this novel crisis but for the ongoing crisis in healthcare safety. The United States has the talent, expertise, intellectual capital, advocacy organizations, data sources, and financial resources to surmount these. The Pittsburgh Regional Health Initiative, in partnership with the Network for Excellence in Health Innovation, began the SWERVE initiative in early 2020 to bring together key experts and leaders representing these perspectives to protect patients and healthcare workers by advancing new directions for patient safety reform. National academic, delivery system, policy, and advocacy leaders have headed the call, and a coalition is in the state of becoming to take a proposal for the National Patient and Provider Safety Authority (NPSA) to the doorsteps of the U.S. Presidential Candidates.

On June 23, the first of three strategic virtual summits took place to plan for the details and messaging of a NPSA proposal. The 40 participants included patient safety leaders, many of whom have been working on this problem for decades, including experts from business and employer groups, consumer groups, patient safety and monitoring groups, and quality and data reporting or monitoring groups. This first summit was co-hosted by Leah Binder, president and CEO of the Leapfrog Group; Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health; Evan Benjamin, MD, MS, FACP, chief medical officer at Ariadne Labs; Charlotte Yeh, MD, chief medical officer at AARP Services, Inc.; and Amy Rosenthal, executive director at Health Care For All. Many themes emerged from the rapid-fire conversation, including interoperability, eliminating waste, saving money, protecting the workforce, and reclaiming the U.S. reputation for the best health system. The resounding consensus on the call was for the urgent need for a NPSA and the growing momentum to push this into the national conversation.

Two additional summits are planned for July, as the SWERVE coalition builds consensus and gains input from leaders of hospitals and health systems, insurance payers, the American Medical Association, academic and professional institutions, foundations, technology companies, and activists from across the country. 

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