Full Court Press Team Considers Partnerships for the National Patient Safety Board
On August 10, the Jewish Healthcare Foundation and Pittsburgh Regional Health Initiative's Patient Safety Full Court Press Team met to discuss the next stage of advocating for a National Patient Safety Board (NPSB): focusing on potential partnerships for collecting data, studying medical errors, and creating solutions. Like the National Transportation Safety Board (NTSB) on which it is modeled, the NPSB will interface with partners to help carry out its core functions: to determine when to initiate an NPSB study using existing data; to conduct the study with other organizations; and to translate the NPSB's recommendations into daily, autonomous practices implemented by industry partners. The meeting convened national experts to examine similar opportunities for the NPSB.
Co-Chair Steve Irwin, JD, gave the welcome and gave an update on the NPSB Policy & Advocacy Coalition, which has continued to engage patient safety leaders and legislators to build support for the proposal.
Marc Bennett, MA, President & CEO of national, nonprofit healthcare consulting firm Comagine Health and Jennifer Lundblad, PhD, MBA, President & CEO of healthcare quality and safety nonprofit Stratis Health discussed how the NPSB could partner with Centers for Medicare & Medicaid Services (CMS) Quality Innovation Networks and Quality Improvement Organizations (QIN-QIO).
Bennett was a previous board chair for the Network for Regional Health Improvement and a previous president and board chair for the American Health Quality Association. He has served on the Quality Alliance Steering Committee at the Brookings Institution, has been a member of the national advisory board of the Center for Healthcare Quality and Payment Reform, and is a National Quality Forum representative on the John M. Eisenberg Patient Safety & Quality Awards Committee. Bennett is a frequent contributor to national policy forums in health information technology, health information exchange and improvement.
Lundblad has expert knowledge of and experience in rural health quality and actively contributes on groundbreaking improvement initiatives. She is part of federally funded projects for value-driven payment and quality improvement in rural health. Previously, she served as project director for the federally funded Rural Hospital Intervention Support Center to provide technical assistance for Medicare Quality Improvement Organizations (QIO) staff and rural hospitals nationally in the areas of clinical quality and patient safety culture improvement, and as project director for a CMS-funded multi-state project to field test and refine new rural relevant quality measures.
Both Stratis Health and Comagine Health have built networks across the Western U.S. in national healthcare quality and safety, through their work as part of the CMS Network of Quality Improvement and Innovation Contractors (NQIICs) initiative. NQIICs improve healthcare quality by providing technical assistance, continuous improvement processes, and strategic management structure, and they work to increase patient safety across the healthcare spectrum by addressing appropriate prescribing of antibiotics and prevention of infections and hospital readmissions. Bennett, Lundblad, and the FCP Team discussed how this work could present a model for the NPSB, as QIN-QIO Community Coalitions are active in every state and could be a forum for implementing solutions in response to NPSB recommendations.
Arup Roy-Burman, MD, Co-Founder & CEO of startup Elemeno Health then shared the company's innovative healthcare education tool. Elemeno Health provides "just-in-time", mobile-friendly training that helps frontline care teams to provide safer care at the bedside or in practice precisely when needed. Using a cloud-based solution for micro-learning, Elemeno's service includes interactive guidelines, smart checklists, and concise how-to videos, which are available to healthcare workers on-demand, 24/7.
Dr. Roy-Burman first became interested in patient safety after an early, personal encounter with medical error, in which his sister died at a young age. He shared how this impacted his medical and patient safety career; he is now a technological innovator who has pioneered efforts to engage frontline staff and improve outcomes in the inpatient setting. Elemeno Health's technology has already been implemented to reduce errors and alleviate staff burnout in real health settings, and the organization was recognized as the first-place winner of the 2021 JHF Healthcare Safety Challenge. The tool presents a potential solution for the NPSB to address a lack of effective training on patient safety, a common cause of medical error.
Former NTSB Chairman Christopher A. Hart, JD, then joined the meeting to share insights from the NTSB that could apply to the NPSB. Chairman Hart holds a law degree from Harvard University and master's and bachelor's degrees in aerospace engineering from Princeton University. He is a member of the District of Columbia Bar and the Lawyer-Pilots Bar Association, and is a licensed pilot with commercial, multi engine, and instrument ratings. Chairman Hart's family has a tradition of accomplishment in transportation. In 1926, his great uncle, James Herman Banning, was the first African-American to receive a pilot's license issued by the U.S. government.
Chairman Hart presented an overview of the NTSB and how it investigates transportation accidents, determines the cause(s), and makes recommendations to prevent recurrences. He emphasized the advantages of being an independent federal agency, including that the NTSB is completely separate from the events it investigates and can therefore give an objective perspective and report. As Chairman Hart noted that the NTSB uses a collaborative "system think" approach with industry partners to address mishaps that occur frequently, a similar approach could be useful in patient safety to identify and address trends, and develop systemic responses.
The FCP Team discussed all insights presented and how each could apply as the team builds the NPSB proposal and the network of stakeholders grows.
The next Full Court Press meeting, planned for September, will focus on how health systems, like Kettering in Dayton, Ohio, have deployed TeleTracking's Command and Control Centers.