Would an NTSB Approach Succeed in Healthcare?
A Seductive Proposal
Industry experts such as John Nance (author of the book Why Your Hospital Should Fly, among other best-sellers) along with national hero “Sully” Sullenberger, have suggested that healthcare establish a National Patient Safety Board (NPSB) to mirror the function of the National Transportation Safety Board (NTSB). This recommendation is interesting, if not seductive. Let’s examine briefly the context of the NTSB’s success as an independent investigative body. In 1959, the Federal Aviation Act established two separate governmental aviation authorities: the NTSB and the Federal Aviation Administration, or FAA. The NTSB was set up to report directly to Congress, and holds no regulatory enforcement function. Its mission is simply to investigate transportation accidents and make recommendations to the regulatory oversight entities, including the FAA.
Now the FAA was established under the federal Department of Transportation (DOT). The FAA’s statutory responsibility is a dual mandate: to promote air commerce and promulgate and enforce regulations in a manner that reduces the likelihood of accidents. What’s fundamental to an understanding of the role of the FAA is that the agency is charged with overseeing aviation from start-to-finish. In other words, the FAA regulates the way aircraft are designed, manufactured, dispatched, flown, maintained, and controlled within the national air space system. The FAA is a single regulator overseeing all aspects of the aviation enterprise, which gives the agency an enormous advantage over other regulators in seeing risk across the spectrum of delivery. If the FAA detects a safety problem within the airline industry, it has the authority to efficiently and effectively require changes to the system or activity in short order. For example, the FAA can ground a particular airline, aircraft fleet type, or air traffic control facility immediately, if needed.
A Complex Relationship
Understanding the origins and design of the FAA and NTSB helps us to understand the fundamental relationship between the two agencies, which has not been without tension and controversy. One of the NTSB’s chief attributes - the fact that the Board is independent and without regulatory authority - makes its recommendations easy for the FAA to refute or even ignore. In fact, since its inception in 1959, the NTSB’s success rate at having the FAA adopt or satisfy the NTSB’s many recommendations have waxed and waned. In some years, a majority of the NTSB’s recommendations simply went unheeded. In recent years, it must be said, both agencies have placed a priority on resolving unanswered or disputed recommendations, but the resolution process remains today more a matter of diplomacy than protocol. This complex relationship warrants a deeper scrutiny and understanding before healthcare considers adoption of a similar patient safety investigative board.
A Few Differences between Aviation and Healthcare
Rather than focus on the similarities between aviation and healthcare (and there are many), we should first look at the differences. Let’s start by considering how healthcare is regulated today. Contrary to commercial aviation, healthcare is regulated at both the state and federal level. Each of the fifty states has established departments of health and safety, along with at least three professional boards (medicine, nursing, and pharmacy). At the national level the Federal Drug Administration (FDA) regulates the standards for drug research, development, manufacture, and delivery of pharmaceuticals. In addition, the Centers for Medicaid and Medicare Services (CMS), along with its sub-entity, The Joint Commission, wield enormous purchasing power and influence on healthcare delivery. Now imagine how the proposed National Patient Safety Board would work inside such a complex regulatory environment. At a minimum, we should expect the “push back” from many of the regulatory oversight agencies to be strong, and in some cases, rather contentious. Who then, would arbitrate these inevitable differences of opinion? By what authority would this entity resolve the disputes? Who would pay for the cost of implementation? How would society measure the value of such as institution?
So what do we think of the recommendation for a national patient safety investigative board? Some might argue that the complexities in the way healthcare is regulated today serve as even more justification for a National Patient Safety Board. Perhaps the myriad state and regulatory dynamics shaping healthcare today would be better served by a federal and independent investigative body such as the NTSB, without economic or parochial interests. Perhaps they would be right; but at the very least, we should understand the differences that exist between the transportation and healthcare industries before we spend our limited resources in this area. If we look hard at the initial failings in aviation, then perhaps we can learn why things often go wrong, before they go right. We don’t have to look far within government to see examples where a lack of collaboration has stymied our approach to better outcomes. (Perhaps that’s a Viewpoint article for another day.)
On the other hand, the secret to aviation’s success has been the collaborative approach to common goals – resulting in a 78% reduction in the fatal accident rate in the US between 1995 and 2005. With respect to the proposed National Patient Safety Board, our view is that due diligence must be done in a collaborative fashion before we invest our resources in the hope that emulation will work. Success is within our grasp, but it requires a clear view of the collaborative steps it will take to reach our goals.