September 7, 2023
At long last!
On behalf of the Leapfrog Group and the employers and purchasers who founded us, we applaud the President’s Council of Advisors on Science and Technology (PCAST) and its working group on patient safety for today’s groundbreaking report, which at long last puts a priority on one of the most devastating issues in American health care. The patient safety problem is estimated to be the third leading cause of death in the country, exceeded only by cancer and heart disease, yet there is no one individual or government agency responsible for solving it. The patient safety problem is not impossible to solve—we know how to prevent these errors.
We especially applaud PCAST for recommendations that build on bipartisan achievements to address patient safety, beginning with the achievements of the administration of President George W. Bush with bipartisan congressional support to report the occurrence of never events and reduce payments under Medicare when they occur. The report also builds on continuing bipartisan leadership since then to identify and publicly report a range of quality and safety indicators and link them to payment. We have seen real progress from this leadership, and the PCAST recommendations, if enacted, would sustain and grow the momentum for transformation.
The two recommendations that we believe will have the most impact include:
1. A recommendation to publicly report Never Events by individual facility. Transparency and public reporting have been the most effective strategy for change in patient safety. Currently the federal government allows reporting of safety problems by corporate health care system, and doesn’t require it by individual hospital or facility. This report insists on reporting by individual facility. We must report patient safety by facility so the public can make informed decisions about their care. Patients do not seek care from a corporation, they seek care from a hospital or a health center.
2. The recommendation to establish a National Patient Safety Team. Leapfrog has been part of a national coalition led by Karen Feinstein and the Jewish Health Care Foundation to establish an entity like this, and we are excited to see the recommendation on the President’s desk. Such a team will bring focus and accountability to patient safety and assure a voice for patients hurt by this terrible problem. The NPST can also help providers learn in real time how to prevent problems from recurring.
We also appreciate the important recommendations for using data and generative AI to improve how we track this problem and prevent it in the future. We are strongly supportive of the recommendations for full engagement of patients and families and for health equity.
We want to especially thank Joe Kiani, the PCAST member who co-led the work group that developed this report. His passion for patient safety brought this to the White House. We look forward to his keynote address at Leapfrog’s Annual Meeting in Washington DC on December 5.
About the Leapfrog Group
The Leapfrog Group is a national nonprofit founded by employers and other purchasers of health care who join to improve patient safety. We publish the Leapfrog Hospital Safety Grade, assigning an A, B, C, D, or F to every general hospital on how safe they are for their patients.