Do We Need a National Healthcare Safety Board?

A former transportation official has some valuable insights into reforming healthcare – though I’m not sure whether I agree with what he proposes.

Jim Hall served as chairman of the National Transportation Safety Board (NTSB) from 1994 to 2001. He is currently managing partner in a healthcare and safety consulting firm.

In an op-ed piece in The New York Times, Hall discusses the huge costs of medical mistakes and argues that the biggest problem with healthcare is the way people think.

Because American medicine accepts error as an inevitable consequence of treatment, our hospitals, insurers and government do little to respond to unnecessary deaths. If we are to address the problem in a serious manner, we must first change this culture.

What we need, he argues, is a healthcare equivalent of the NTSB.

As a former chairman of the National Transportation Safety Board, I am familiar with the deadly consequences of human error. However, because that agency views every transportation death as a preventable occurrence, our roads, rails and skies enjoy an unparalleled level of safety. After any significant accident, the board undertakes an extensive investigation, and makes recommendations to the parties involved to ensure that such an accident never recurs. While the transportation safety board has no regulatory authority, its recommendations are viewed by the industry and the public as unbiased and therefore credible, and federal regulators usually act with haste to address them.

Such an investigative body could substantially improve the safety of medicine in the United States. While it surely could not investigate every individual instance of error, it could address many well-known maladies. Hospital-acquired infections, for instance, affect millions of Americans each year. A National Medical Safety Board would collect regional data on the problem, paying particular attention to hospitals with high incidences of infection. It would then determine preventive measures and make recommendations to state and federal regulators, hospitals and health care officials.

I agree with Hall’s view of the cultural problem in healthcare. We need a lean mindset where mistakes are viewed not as inevitable, but as the result of process flaws that can be corrected.

However, I’m not sure I agree with his solution. I tend to be skeptical of proposals for new government regulation, though there is logic to his argument. And I’m not sure how his proposed board would work in the maze of federal and state regulations currently governing healthcare.

Do you agree or disagree?