UH doctor Peter Pronovost helps draft patient safety report for Biden administration

A University Hospitals doctor played a key role on a council of advisers to President Joe Biden that calls for changes in national health care standards to improve patient safety. Peter Pronovost, chief quality and clinical transformation officer and the Veale Distinguished Chair in Leadership and Clinical Transformation at UH Cleveland Medical Center, was one of 10 members of the Working Group on Patient Safety for the President's Council of Advisors on Science and Technology. PCAST, as it is known, was formed in early 2021 with 28 members "selected for their distinguished service and accomplishments in academia, government and the private sector," according to UH. Its Working Group on Patient Safety was formed one year ago to make recommendations to reduce harm for hospital patients. The group's report, "A Transformational Effort on Patient Safety," was sent to Biden on Thursday. It recommended: - That federal authorities establish and maintain federal leadership for the improvement of patient safety as a national priority - Ensuring patients receive evidence-based practices for preventing harm and addressing risks - Partnering with patients and reducing disparities in medical errors and adverse outcomes - Accelerating research and deployment of practices, technologies, and exemplar systems of safe care. The Biden administration already "has taken key steps to improve the quality of health care for all Americans," according to the PCAST report. "These efforts have focused on tackling cancer, the maternal health crisis, expanding health insurance coverage, lowering health care costs, addressing algorithmic discrimination, and advancing health equity. In addition, federal agencies have made important progress in addressing patient safety through research, education and training, stakeholder engagement, and strengthening standards for health care quality." According to Pronovost and UH, one in four Medicare patients experiences harm from adverse events while hospitalized. Of those events, more than 40 percent are preventable. UH has taken its own steps, he said, but the issue needs to be in the national spotlight, according to Pronovost and the PCAST report. That will take creativity, courage and collaborative leadership, Pronovost said. "The future can be brighter for American patients, and we can facilitate an environment where health care will harm less, cost less and improve faster," he said in a UH news release. Pronovost's past work has involved reducing bloodstream infections in patients, which "killed more people than breast or prostate cancer," he said in an interview Friday. "At the time, doctors and nurses accepted those infections as inevitable." Working in the Johns Hopkins Healthcare System in Maryland, Pronovost found a way to reduce similar infections by 80 percent. He said he hopes to "reframe" the thinking around surgical infections and complications and make healthcare workers see them as preventable. Pronovost's work has made him a national expert on patient safety and harm reduction in hospitals and helped UH win the 2022 Quest for Quality prize from the American Hospital Association, which "recognizes health care leadership and innovation in improving quality and advancing health in communities," according to UH. People including health care workers "are really well-intentioned," but one in four patients are harmed when hospitalized "and that number has been fairly persistent for well over a decade, despite a lot of efforts," Pronovost said in an interview Friday. One thing to recognize is that harm to patients receiving care isn't inevitable — it's preventable, he said. But there is no elected or appointed leader responsible for promoting patient safety at the U.S. Department of Health and Human Services, like there is in transportation safety at the Department of Transportation. The report is "a call for leadership as the accountable leader for safety," Pronovost said. Planes and trains are more visible, carry more people, and the federal government coordinates its safety efforts with the transportation industry including regulators and manufacturers. The Centers for Medicare and Medicaid Services has more than 2,000 measures for patient safety, but there are few efforts to push for patient safety nationwide. Regulators and hospital systems rely on their own internal, local quality improvement efforts "which are important but can't substitute for designing a safe system at the sector level," Pronovost said. That includes sharing data instead of relying "on the heroism of doctors and nurses" who see errors and correct them before more harm is done, he said. Pronovost said he's confident the national work will pay dividends soon. "At UH every day, the goal is zero harm, but we'll have better measures to go by, better tools and system efforts. All of those will accelerate our efforts, and the public shall have better transparency when errors occur," he said. Regulators, patients, doctors, nurses and administrators will all play a part in an "ecosystem where we learn together and learn faster," Pronovost said. "What I say is, we don't know how close to zero harm we can get, but unless we aim for zero, we never know how good we can be," he said. Contact Dave O'Brien at (440) 329-7129 or dobrien@chroniclet.com.