 The relationship you develop with the patient is one of the most loving, giving, honest relationships you can have. That person has entrusted you. You've shared the worst and you share the best. I grew up wanting to be a nurse, never wanted to be anything else. I was probably three years out of nursing school and I was working in a cardiac intensive care unit. One of my patients had suffered a large heart attack and I was in her bedroom, which was open to her nurse's station. And I was laughing and talking with my co-workers and not really paying a lot of attention to what I was drawing up in this range. I went into her room and started injecting the medication and one of the nurses from the desk called out and said, when look at your monitor and her blood pressure had just plummeted. I looked down at my syringe and I realized I had double-dosed her on this very powerful blood pressure medication. I was crying and the patient actually took my hand and comforted me and said, honey, everything will be okay. I'm standing there in the back of the room watching my teammates try to salvage a patient that I harmed. I had potentially killed another human being simply because I wasn't paying attention. It was one of the worst nights of my life. I'll never forget it. We were able to stabilize her. It took about four hours. Stayed there about six days and then she did go home. I questioned whether I was fit to be a nurse. You know, was I morally fit to take care of other human beings if I could be so careless? So I went into grief counseling. I felt renewed. I felt like, okay, this is my fate to be not only a nurse but a champion for patient safety. We built one of the first quality circles in my unit and we looked at medication administration, how we cared for patients, fatigue in nurses. And when a nurse made a mistake, we had a team that would talk with her. We experienced less errors. We developed more processes around checking. We built in redundancy into our systems that we didn't normally have. It took about three years to get all of that set up. She came back to our unit about six months later and she was dying. Her heart was so damaged that it just could not sustain her. And I said, remember we in the hospital before? I'm the nurse that gave you too much medicine. And I said, I want to tell you how sorry I am. But I also want to tell you how much I learned. And she reached up and kind of cupped my hands and hers and said, honey, I told you it was going to be okay. And as long as you learned something, that was great. You know, her name was Shirley. And every time I start a new project, I think about Shirley. She has inspired me for a lot of my 30 years in nursing. Good morning, everybody. I'm Marty Hatley. I'm the CEO and president of Project Patient Care, a Chicago-based coalition that brings the voice of the patient into quality improvement work. I also serve as the co-director of the MedStar Institute for Quality and Safety. And I've had the great honor to serve on the Patient Safety Movement Foundation Board of Directors. The video that you just saw is something we wanted to start with today. It's the Gwen Cox video. That's what we're going to refer to it as. Because everybody in the US right now is talking about the criminal conviction of Nurse Thironda Botte for a deadly medication error at Vanderbilt University. And much of that commentary has focused on the fact that while that error was unintentional, Nurse Botte was terminated from her employment and lost her license. In contrast, the error that Nurse Cox made in the video we just saw had a very different trajectory. That nurse, Gwen Cox, was not fired, terminated, or prosecuted. And it appears to have motivated her to become a better nurse in her organization to become much more focused on prioritizing patient safety. The event led to improvements such as quality circles and teams that looked at medication administration and fatigue. So I'm joined today in this discussion about regulation and the role of regulation in improving patient safety by just a fantastic panel. We've just had the chance to catch up and talk about what we want to talk about today. We could barely stop ourselves from commenting. But I want to introduce them to you here today. And I'm going to do it in alphabetical order. So starting with my friend, Karen Feinstein, who is the president and chief executive officer of the Jewish Health Care Foundation, a long veteran in the patient safety, shaping and programming and thinking in this country, a lot of that work has been done through the Pittsburgh Regional Health Initiative, a program of the Jewish Health Care Foundation, where a lot of your quality and safety improvement work has happened over the years. Welcome, Karen. It's so wonderful to be with you today. Second is Michelle Schreiber, a physician who's the director of quality measurement and value-based incentives group at the Centers for Medicare and Medicaid Services. I get to work with Michelle as she on an annual basis kind of takes CMS's measures under consideration through the NQF process and gets the feedback from that group about what we measure. Karen or Michelle's job at CMS really is about measurement and looking at how CMS can improve safety. And she's a real leader in this space with a deep background before you went to CMS as well. And then Robin Betz is the vice chair of the Patient Safety Movement Foundation board of directors, also vice president of safety, quality, and regulatory services at the Kaiser Foundation hospitals and health plan for the Kaiser Permanente section in Northern California. So welcome, Robin. It's wonderful to have you here with us as well. So let's get back to that Tennessee case that seems to be all anyone is talking about in the patient safety movement. Wherever you go now, it's very, very top of mind. I just want to throw this question open to everyone on the panel about what are your thoughts about the impact of that Tennessee case on both patient safety and the profession of nursing? Why do we think that the responses of the two organizations were so different? Robin, why don't we start with you? I know you're passionate about this issue. Thank you. Well, Marty, the criminalization of medical errors could really have a chilling effect on reporting and process improvement for all of us. The safety of our patients and our employees is really our highest priority. And we're all committed to maintaining an environment where processes, procedures, and technology are really focused on providing the safest possible care. And it's really essential that medical errors are reported in a transparent and timely manner so that they can be appropriately addressed. And that systems and processes can be continually improved. Redonda did the right thing. She immediately reported. And she continued sharing throughout the organizational investigation her actions and mindset so the organization could surface any system issues of which there were many. And it wasn't until criminal actions were taken that Redonda had to consider the notion that she should take action to protect herself. And unfortunately, her transparency was treated by the prosecution as an admission of guilt at a time when all health care professionals have felt the stress of providing safe, high-quality, compassionate care during this historic pandemic. It's more important than ever that these same professionals feel supported by systems and practices that promote accountability, fairness, transparency, and continual process improvement. We need their voices more than ever versus having an environment that instills fear of transparency. Thank you, Robin. I think I mispronounced Ms. Vot's name, too. It's Redonda, not Deronda. So I apologize to that. I mean, we want to acknowledge her as a colleague and a whole person and get her name right in the process. Karen, you've got your thoughts on the impact of this case. Well, I was struck by one thing. I read the chats and all the online articles. And among nurses, there's been a mixed reaction, which I didn't expect. I think this is going to do a lot of damage. I don't want to, in any way, minimize that. Bringing criminal charges for a mistake is not something that is going to reassure nurses who are on the borderline of retiring. So I'm a little concerned about that. I will say, though, looking at the two different cases and the responses of these systems, there is a big difference in Nurse Cox's case. It was one mistake by one nurse. And it wasn't one that necessarily violated all the protocols and procedures. It was a mistake. In the case of Redonda, you have a much more complicated issue because there were so many failures in the system by so many people. It wasn't just one nurse, which makes her criminalization, to me, a little more bizarre. But also, maybe a system didn't even know how to deal with the fact that their procedures and protocols were violated all along the way. And it made it much more complicated. And maybe less easy to deal with. So before I turn to you, I just do want to remind us all that this is a case that's still in process. Ms. Vought has not been sentenced yet to our knowledge. There's likely to be an appeal. I know CMS has been involved in an investigation of this event, but it's not over. And I don't know how much you can say, but I would welcome your thoughts about the impact of the case in general. Thanks, Marty. I really appreciate that. So it is true, CMS did an investigation. It's been posted online. And I think what's important to remember is that in that CMS investigation, there were multiple errors that were found, as Karen pointed out. There were problems within the hospital systems. There were problems along multiple places. And that is what is common in health care. It is rarely just a problem of one person doing one thing. But most of the issues that lead to serious patient events and arm events, they're systematic. And we really need to take a systematic and deeply embedded approach to this. CMS really is committed to deeply embedded safety systems that operate where people feel comfortable speaking up and being transparent for reporting because that's the only way we will learn of events and be able to prevent them. And operate where leadership and governance also prioritize and really lead for safety and quality. So thanks. Sure. Thank you. Another surprising dimension of this case is that the health care organization at least allegedly failed to report this to regulators or to accreditors. And it's alleged that the coroner was led to believe that the patient in this case, Charlene Murphy, died from natural causes. So Michelle, I'm going to turn to you again. I know you can't comment about the specifics, but you and your colleagues, Lee Fleischer and colleagues from CDC, published a powerful piece in the New England Journal in February of this year, really calling for increased accountability and transparency in the health care system as a safety solution. What can you say about what CMS will be doing to really walk that talk of accountability and transparency? That's true that during the COVID pandemic, we really noticed a decline in patient safety. Health care acquired infections, for example, went up 40% that was published by the CDC. And our own internal data showed a rise in complications, increasing patient falls, increasing pressure ulcers, as well as a decline in patient experience scores. And so that's why CDC and CMS really felt compelled to put out a call to action for a refocus on patient safety. It feels like we lost some of the gains that we've had in the last decades. And we hope that everybody will join in this recommitment to safety. Our safety systems, this is getting back to what I was speaking about before. It isn't just one thing. It isn't one person. It is an entire system of safety, communications training, leadership, governance, deeply embedded processes that don't evaporate under times of stress. And so CMS as well as CDC is looking to take much more of a leadership role in terms of promoting patient safety. We know that IHI and AHRQ have a wonderful guideline out around patient safety. World Health Organization has another one out. And we're looking to promote those activities and really again, refocus organizations so that we're all recommitting to safety. I do wanna say another way of doing that that we haven't spoken of yet is how do we engage the patients in safety? How do we allow for patients, for example, to be able to report safety errors and patients to be able to hear about this and be engaged in the conversations and to be allowed to have their medical records so that they can look at them and comment on them. So engaging the patients, I think is another critical aspect of patient safety. Sean, I'm so glad you mentioned that because as you know, I'm very active in that patient engagement space, including being a co-founder of an organization, a network of patient advocates called Patients for Patient Safety US. And when we look at the landscape now, we've spent so much of our time trying to be a good partner, trying to be a partner during the patient care journey, trying to be a partner in improvement work, we haven't done as much in advocacy. And that's, I think, where you're really gonna see patients stand up now and already are seeing it as advocates for change because we can sometimes just say things that people in organizations, whether it's government or private sector, can't say. Michelle, Robin, I wanna, I'm sorry, Karen and Robin, I wanna turn to you because as we know, CMS has a lot of tools to make things happen. Conditions of participation, payment, just among others, contracts. But your thoughts on whether there are things that CMS can do, we'll give Michelle some feedback here or additional things they might do to better motivate organizational leaders to report the way we expect them to do. What more can we use regulation to do to get the kind of transparency and accountability we want? I would love to see, I like what Michelle had to say, we're all cheering in the patient safety world. I think we have to get better among regulators and accreditors at understanding whether the boards are really governing and the C-suite is really leading to create a safe organization. I think if you wait for a whistleblower, a random whistleblower, which happened in the case of Vanderbilt to come forward, that's not the best way to do this. You wanna prevent something from happening. And that is, I think there has to be a way the governing board, the regulators and accreditors talk directly to people on the front lines privately and find out what worries them, what seems hypocritical. Look at all the overrides of good practice that happened at Vanderbilt, all the procedural discrepancies. And I think we have to find a better way such as the simple regulation, but how do we understand what is really happening in an organization, both at the governing board level because they're responsible, but also for the regulators and accreditors. It's something more profound than hoping that a whistleblower will come forward one year after the incident. Yeah, I really appreciate that, Karen. I think those are all great things to say, but how do you operationalize it? And as a person who works in that healthcare system, you really have to, and what we do is we establish various standard work and protocols and workflows so that information does flow up to our board. And I don't know that that exists everywhere. We have a very engaged board that do hold us accountable to quality and safety, and we have a notification policy and the things that have to be escalated to the board. And we have systems that make it easy, for instance, critical issues with our medical staff go into the system and we have a process so that they can clearly see how our credentialing and privilege and gene committees followed up. And for serious safety events, the same thing, what is the protocol within your organization to escalate information to your board because they are the ones who can assure that your efforts are resourced, evaluated, and wanted to, for sustainment, hold everyone accountable. And they are very powerful if they're used and empowered to govern the way that they need to. So Robin, I wanna pick up on this because you mentioned, and actually Karen did too, governance. So governance, I guess, is a kind of regulation for what happens within an organization. And what I wanna probe with you is just the culture of safety because we've been talking about a culture of safety in this country for at least two decades, maybe closer to three and how crucial it is to preventing harm. I mean, your organization has really invested in a culture of safety. You talk about it a lot. People like you represented in the world, I think you're known for it. So what is the role, I mean, you've spoken a bit about governance, but is there anything regulation can do from your point of view to kind of incentivize or require or catalyze the culture of safety work that some organizations seem to do and others not so well? I think it's a great question. And I think we can't forget that our regulators have been with us all along the way. I'm kind of sad that healthcare required the push it did from regulators versus establishing our own self-regulation that we've seen in other industries. So, you know, when you look back at Teaira's Human, when that was published now to now, our regulators have funded performance improvement, aggregated safety performance data at a really broad scale so we can benchmark against each other and established well-vetted industry-based evidence-based safety operation standards and really ensure that we have the governance structures. It is a requirement. Our governing boards are responsible for the quality and safety of the organization and when our regulators come in, they look for that accountability. They trace through the activities of activities up to the board. And when those don't exist, we are held accountable. I think that, you know, I think we can continue to have that partnership and on, you know, there's the regulation side and then there's the collaborative side with we have our regulators and continuing to promote education, especially of our boards is really critical. Karen, I'm gonna get to you about culture of safety in a second, but I'm remembering that Michelle, before you went to CMS, you were at Henry Ford and you were one of the developers, one of the reviewers or developers that worked to develop the latest IHI guidance on optimal practices, best practices for boards in healthcare. Is there anything, you know, that you can think of given that expertise that boards can do more of or do better? There are many things that boards can do to be engaged in quality and safety. I think the first one, frankly is willpower and actually a commitment in placing that as one of their highest priorities, if not my own personal opinion, the highest priority in healthcare. What is more important than taking care of our individuals and our patients in the safest, highest quality, most equitable way? Beyond willpower, you know, there are lots and lots of best practices around high reliability processes that can be put in place, daily safety huddles, deeply embedded communication structures. There are many things that can be put in place, but boards have to make sure that those are placed and make sure that there are resources that are allocated to the organization and that they're hearing about what is going on so that that in and of itself promotes these activities. So I think there's a great deal that it can do. And I have a deep belief that leadership and governance really is absolutely essential in establishing the culture of safety, even tracking the culture of safety, doing those culture of safety feedbacks. I think that's where it starts, but it has to permeate to the front line. So this culture of safety has to go from leadership to the front line and frankly back. Yeah, I'm gonna add to that too. One of the most wonderful things from my point of view about the partnership of patients is the metrics they put into place for person and family engagement. One of which was do you have people who identify primarily as a patient or family member on your board of directors? And when we surveyed, baseline surveyed about that, there was massive variation in the country. There were some communities, some states where everyone had a patient on there. It was just part of the culture and then others where it just wasn't. So I'm personally rooting for that to be a metric at some point in time. But Karen, I now need to turn to you because you and I have had this conversation a couple times over the last couple of weeks about the culture of safety and how long we've been waiting for it and how, I don't wanna pick just on Tennessee because these cases, we get a blockbuster kind of case like this every year or every year or two that hits the papers where you just see an organization not stepping up the way. We think they would be after 20 years of encouraging a culture of safety to be adopted. So what do you have to say? I don't wanna steal your thunder. You're on mute, Karen. Totally cynical. I've been waiting two and a half decades for this culture to emerge. So first of all, payment. You want a culture of safety. You'll get a culture of safety when we pay for healthcare differently. We all could talk about value-based payment but I'm sure that's another panel. But it is, it is in, it is so intrinsic to the culture of safety that I can't separate them. But quite aside from that, surprising to all of you, I'm gonna come down on the side of some regulations. Some things shouldn't be allowed. An example, we regulated crash carts and people adhere to that. We haven't regulated the fibrillators. There were so many, and you know, there were so many things in this particular incident that should have been regulated. But one is, how can you be administering a paralytic high alert agent and not have the rescue med there? I mean, I don't understand that. And how can you be monitoring the waiting room when that agent's been already administered when you can't tell whether the patient is in cardiac distress or brain failure? So, you know, I look at some things that I think at this point, I'll take the fibrillators. That's actually my favorite. Every year our system deals with the fibrillator deaths. Standardize them for heaven's sakes. Standardize things that should be standardized. So you may be surprised. I'm coming down on the side of the regulators here. Thanks, Karen. I wanna get back to that technology point in just a second. But before we leave this sort of culture segment, I'm just cognizant that everybody on our panel today is from the United States. And we do have an audience that is global. And one of the global vectors right now that's very prominent in patient safety is a new global patient safety action plan put up by the World Health Organization last May. So just about a year ago. And it really, you know, it looked at the continuing challenges. It looked at what we've learned over the last 20 years and they come down really hard on, not hard, but really strongly, I should say on national governments really having to step up and lead to create that culture and to create the systems. Michelle, you're our representative from the federal government today. What more do you wanna say about what CMS can do or DHHS can do to really kind of create that culture, not just in the innovators and the early adopters and the organizations like Robbins with really committed leadership, but system-wide? I think that there are a lot of things that are in place already, maybe more deeply embedded and widely spread, but remember the conditions of participation do establish an absolute floor for quality and safety. That's the purpose of the conditions of participation and organizations have to participate in evaluating the quality and safety and they're surveyed for that as well. There's been the quality improvement organizations, the Partnership for Patients, for example, that has provided support across the country. In COVID in particular, provided incredible support to nursing homes for patient safety and have provided support in many activities and really helped drive patient safety as well as then the quality measures that we have that allow us to look and compare one hospital, one facility, one provider to the next with deeply vetted quality measures that have been embedded in now over 20 quality value-based programs that tie performance to payment. Now you could argue maybe we should tie more performance to payment, for example, you could argue that maybe there should be more regulation, more validation of the data, but others then will argue that we're already too intrusive and so there's a middle point in there somewhere. It can't just be government though that's going to solve this issue though. There has to be responsibility at all levels, both local and state governments, boards that we've already talked about, individual providers. So I can't say it can be just government, but we certainly have tried at CMS to be leaders in this role and we are working very hard to align, especially across CDC, AHRQ, CMS to continue to promote and lean in patient safety. And in fairness, I think the World Health Organization is just prescribing what you said about government leading, but multiple stakeholders all having roles, educators, product manufacturers, creditors, patients all having responsibilities to play. Okay, thank you. Karen, I'm gonna go back to you for this one too because I know you're really active in this space through your work at the regional, through your work through the regional, Pittsburgh Regional Health Initiative, but technology, we've seen technology really improve outcomes. I mean, I think the classic example is the pulse oximeter. I mean, when we look now at what's safer, everyone points to anesthesia, but it's been antiseptic hand gel, CPOE, EHRs, a number of tools that have come out of the technology development sector that are improving care. And I know you feel strongly about the fact that we have a lot of tools right now that can actually help us identify and prevent things before they happen. So we don't have situations like the Tennessee case. What more do you wanna say about that? Oh, you know you're hitting my button, one of my favorite topics, but you look at all the things that could have been prevented autonomously, that should never have happened because we have the technology and we have the data now to understand that these could have been prevented and to do something about it. It's also very frustrating to me, this is not an under-resourced center, but the year's 2022, we can land a little helicopter on Mars, little ingenuity hops around. And honestly, we could have prevented the override on the high alert paralytic medication. I think when you issue those meds, you should issue the counter med, the rescue med at the same time. We should have ongoing assessment and maintenance of critical equipment that can be automatic. That does not have to be done by humans. That can be done autonomously. So sort out this common and generic name problem in just what the nurse entered. I mean, that could be fixed. The alert system, we've gotta fix that. How many meetings do we go to? Everyone's gonna nodding their head at these large conferences I have, that the alert system is so imperfect that the doctors and nurses just commonly ignore their alerts. Well, fix it. We have technologies and algorithms that could fix some of this. And I think of the many ways that we could have monitored that patient to know immediately that she was going in the wrong direction. This is all so possible now. So my sense is these autonomous technologies, you know, the way that anyone in our industry would look at safety, they would be in place, you wouldn't even think about it. They would be in place so that the frontline staff doesn't have to constantly be thinking and checking and rechecking. That can be done now. So that we build them a better airplane. We don't rebuild them. So let me invite Robin and Michelle to comment too. What role could regulation play in making what you just said happen? What more could we use our regulatory tools to really get every organization to be doing what you just outlined as possible? Michelle, Robin? Robin? Yeah, you know, I think we take too long. I look at tubing misconnections where a tube feeding is connected to an IV. The male and female connection points were identical. For years and years and years and people died from tubing misconnections. And we tried to put in standard work that would prevent that, such as, you know, when you do a nurse handoff, you trace the lines back to the, from the patient, from the device. But that's a lot of manual work. And of course there's elements of potential human error because of the human factors involved in that process. And, but now finally, the industry has responded and the tubing manufacturers were mandated to make those connections different, to make it easy to do the right thing and hard to do the wrong thing. I feel that, you know, that our government agencies have been good partners in many ways with performance improvement. We had, for instance, in the United States, the Center for Medicare and Medicaid Services had their partnership for patients and they funded activities that reduce hospital-acquired conditions and readmissions. And we had incredible response to that. And I think that we could organize in such a way that we have more prompt identification and then expectations of implementation of corrective actions that permanently protect patients from harm. I think we take too long in our processes. I can understand how people think that we take too long. On the other hand, I have to tell you, it's unusual for me to be on a panel where people are asking for more government intervention and more government regulation. There aren't a lot of people who necessarily vote for that. But I do think with all of these programs, we are trying to encourage and support through the QIOs and the conditions of participation, through public reporting and transparency and through payment policies. We're trying to support quality and safety. But again, it takes everybody to participate. And at the same time, look, I'm a big fan of standardization, please don't get me wrong, but we have to support innovation as well and allow organizations to do what is right for their organization. And so although a lot of us would like to see more standardization as Karen was talking about, we have to allow for innovation and we have to allow organizations to find their best way of doing things too. I just want to take this opportunity. Oh, go ahead, Robin. I just want to say, I don't know that necessarily takes regulation, but like I said, I've really appreciated the partnership and the support that we do get. And you commented on those. And I think just continued more of that is very welcome. And the investment of resources. I mean, we always want more resources, but the partnership for patients, 80% of the hospitals, of the country's hospitals participated in that. And it was a real driver. It was a collaborative on steroids. HRQ was the biggest funder of research on patient safety in the world. So we're doing, it's not like we're not doing anything here. We're actually stepping up in a number of ways and I'm appreciative also, Michelle for CMS leadership there. We have about 15 minutes left before this wonderful session. I will have to sadly come to a close, but I do want to turn to an idea that's out there in a couple of different formats. And that is the idea of a new national agency, a national patient safety board it's often referred to. The Patient Safety Movement Foundation has kind of a call for a moonshot complete model of a federal agency based on the FAA, Federal Aviation Administration. Karen, you've got a more tailored approach that I know you've built an entire coalition around through the facilitation that you've done and it's not a regulator. It would be an independent agency. You're referring to it as a national patient safety board. There's a coalition that would essentially be a home for reviewing patient safety events when they happen. What do you want to tell us about that agency and its role? Well, I do want to thank the Patient Safety Movement for being such good friends and partners along this journey. We've tried so many things at our end at the Regional Health Initiative for 22 years now. And I'm looking for something that is a national home that is an independent, nonpartisan national home, a think tank for ongoing research. Michelle, I love innovation. And by the way, the human factors, people would tell you standardization and innovation are not in conflict. You standardize so that you can innovate. But I'm not sure innovation has to take place unit by unit, hospital by hospital, system by system. I think that we've made a mistake in healthcare. I think we've entrusted a lot of safety innovation to the medical profession. I love my doctors. I love the medical profession, but we're not engaging enough human factors engineers, people who are expert in AI and artificial intelligence, machine learning, robotics, even advanced analytics, predictive analytics, there's so much we could be doing now to anticipate harm and make sure that we've eliminated as much harm as we can before it ever occurs. So the other problem you had, and you saw it in this case in Vanderbilt, we don't have a home with an open portal for patients and families who've encountered an error. So how many times have we seen in cases the family termed a litigation, they didn't want to turn to litigation, but they felt that the death of their loved one was in vain. And so the idea that there's a portal, a place where people can turn to say there's a serious problem. One thing we noted in Vanderbilt, there's nothing new about what happened there. And in fact, I just came from an academy health panel and I put that out there and everyone in the room was nodding their head. These two medications are confused. The problems they had are happening in other hospitals. What went on at Vanderbilt could go on and probably does go on in other places. But I think at the federal level, I'd like to have one home that could constantly, not distracted with a lot of other issues that aren't safety issues. Focus, the resources we have now in terms of technology and data on preventing harm before it occurs and working with the industry, working with the healthcare industry to come up with solutions that are so powerful that what happened at Vanderbilt couldn't happen. Karen, I'm gonna turn to Robin next because I can see her nodding her head, but before I do it quickly, how would an organization like the NPSB that has no regulatory power make a difference? I mean, what would be the mechanism for it actually creating change? Well, as you, Marty and Michelle and others who've been on this journey for years, no, there was nothing new under the sun about this idea. So I'm totally humble. It's been, for three decades now, someone has proposed or some organization something like a national home. We chose the National Patient Safety Board and PSB because the MTSB, the National Transportation Safety Board has been so powerful in terms of bringing about an ongoing trajectory of safety and transportation. They have no regulatory power. They don't penalize, they don't sanction, they don't expose, but they bring together experts whose qualifications are so extraordinary that it couldn't be challenged. And they bring them together and come up with solutions that are endorsed often by the industry, but these solutions are so powerful that they can't be ignored. They are required by Congress to present them to the regulators. The regulators have to respond in 90 days. And so I think it's 80 to 90% of the solutions that came out of the NTSB have been adopted by regulators and are now standard practice in the industry. Robin, your thoughts, I've seen you nodding here. Yeah, you know, I think an organization like this could really reduce administrative burden for one thing. If we could establish a single set of reporting criteria, regulators from federal state to county, as well as the, you know, the PFOs, right? They all have variable disparate taxonomies and this, and they kind of want their own slice and dice and this creates administrative burden that really takes away resource time from actual performance improvement activities. And it would be great to have a single reporting portal that could aggregate data and trends, surface industry vulnerabilities, especially considering the ever-changing environment of healthcare where we have new technologies, medicinal agents that are added to the environment that carry known and unknown risks. And this organization could provide also concurrent performance measurement versus the lagging data that much of our industry-wide data operates against. So I think like sunsetting the PSOs and moving towards a National Patient Safety Board model and then from a federal to county level, the responsibility would be not to report all these places that your responsibility is to participate in the National Patient Safety Board who becomes a strong collaborator and advocate with our regulators as we share across our learnings and promote the level of safety that we need for everyone. Thank you. Michelle, you might have a different opinion here. What are your thoughts about a new federal agency? I'm not sure that I can or will comment on the establishment of yet a new government agency. I will say that I think that there's opportunities even within the agencies that we have to do more standardized national reporting around error. AHRQ, for example, does have a patient safety organization and they get some reporting, but they don't really get all of the national reporting I think that we're talking about here. In providing deep analytic systems, once we have that reporting, so that we can really track trends, look at trends and come up with recommendations. Reporting in a standardized way, I know the CDC through their NHSN is a great portal for reporting healthcare acquired infections and they're looking to report more patient safety data as well. So I think that there are opportunities to use what we have even more efficiently and more effectively, but I don't know that I can comment on yet another agency. No, I understand. We actually did have Paul Yang on this conference last year talking about the 15 year look back at PSOs too with some recommendations about how they can perform better. So we'll wait to see what happens there. Michelle, I wanna stick with you. We're kind of, I wanna hit two more issues before we break today. One of them is the work that I know is a personal leadership effort of yours to look at the role of structural metrics and really advancing priorities of the administration. So you have been the leader in sort of guiding the NQF process on a structural metric on maternal and child health and most recently on health equity, really getting commitments from hospitals to be working in this space. Tell us more about that and can we hope that there might be some kind of approach like this on patient safety? Well, I will say that there are certainly thoughts and conversations around something like that. We recognize that there are people who don't really like structural measures including NQF doesn't always support structural measures. But the truth is a structural measure is a commitment. It's a commitment that an organization is generally engaged in quality improvement is actually looking at their data, their leadership and their governance is engaged. We're talking about maternal safety. We're also talking about equity and something similar for safety could be something that is considered. But we think structural measures actually change behavior and really they are the first commitment of any quality improvement process that any of us undertake is to ensure those things are already in place. It's the same almost PDSA model that involves a commitment from the beginning. I've sat in the hospital workgroup of NQF, the measures application partnership where these have come up. And I know there's skepticism because they can be gained. I mean, they're gonna be the check the box kinds of concerns, but they do send a powerful signal out there that this is what we're prioritizing in this country. This is what we hope that organizations will commit to and making that commitment, I think it would be really an important step, especially now where we see so much of the progress we've made on patient safety lost in the last few years. One last issue I'd like to get to before we close today is nursing homes. I mean, we're coming out of a pandemic where we've just seen the rates of death in nursing homes pointing to big failures in infection control processes and other systems approaches to safety. What should we expect in addressing this issue? Michelle, can we start with you again? Many of you probably saw President Biden's state of the union and that subsequently there's been a long document that has been put out by the White House and supported obviously our cross HHS of a real commitment to obviously advancing equity and driving high quality, but particular for nursing homes because we saw what happened in nursing homes. And there is a multi-pronged approach now to looking at nursing homes, to ensuring that nursing homes have adequate workforce and safety mechanisms in place, looking at staffing levels and staffing turnover, expanding the skilled nursing facility value-based purchasing programs so that payments are tied to performance. So there are multiple initiatives that are ongoing across CMS and HHS, including ramping up what we've talked about earlier quality improvement organization support, which was really vital during the COVID pandemic where not only did we have QIOs that were helping but surveyors were going out and providing guidance as well as oversight for best practices in nursing homes. So I think we can all expect to see a very robust focus on ensuring quality and safety in nursing homes. Thank you for that leadership. I know the quality conference that CMS does every year, that huge conference is happening soon. I hope to hear more there. We are close to the end of our time. We've got just a couple of minutes left. So I just wanted to see if any of you have any last comments that you'd like to make about the session or anything else we've talked about today. Robin, why don't we start with you? Thank you, Marty. I think there's a lot of policies in place and sanctions for failure and in reporting and to really incentivize us to mitigate issues. But so I don't know that we need more at this point, but thinking back to this Tennessee case, I hope our policymakers will evaluate that case and really look to establishing much stronger policy for quality protection. So we can continue to have the learning systems that we've had up to this point. Thank you. Thank you, Robin. I mean, that was so well said. Karen, final thoughts from you. I'm going to finish with a comment about nursing facilities. We did a documentary on what COVID exposed in long-term care. And I want to echo Michelle, we have a real crisis coming up when you look at our demographics. We have a shortage of nursing home beds and a tremendous challenge in keeping our best nursing homes going. And I'll only say that our foundation put $35 million into creating a great nursing home. And we closed it last year. We could not possibly, on the reimbursement we get, keep an excellent nursing home going. And we didn't want to run a low quality one. You cannot put all these requirements on nursing homes without changing the reimbursement. This isn't just a problem for our seniors. It's a problem for everybody of middle age who's going to have to find care for their parents. Michelle, I want to thank you first of all for just bringing the concept of equity into this discussion because we didn't spend much time on it. But the way in which CMS is connecting the issues of safety and equity, we're not going to be able to meet our equity goals unless we have safe systems. I think it's just admirable. Final, so thank you for that. And final thought that you want to leave our audience with today. My final thought is, as you know, over the next coming week, CMS will be unveiling the CMS National Quality Strategy. It really ties a lot of this together and focus on improving outcomes, equity, front and center, safety, innovation, including advanced analytics, digital and our operability of data in most of all, alignment and cooperation across the federal government and reaching out to all of our stakeholders. Because we recognize we can't do this alone, it has to be all of us together. Great. Well, thank you, everyone. I can't, I mean, it seems a little weird to say that I had fun today because our topics have been so serious, but it was just a great pleasure to work with you and talk with you today. And I'm sure it will be of real interest and very provocative and stimulating to our audience at large as well. So thank you very much.