Biden-Harris Administration Announces Progress & New Commitments to Improve Patient and Health Care Workforce Safety

In recognition of World Patient Safety Day, the Biden-Harris Administration is announcing actions to address patient and workforce safety in our health care system. Last year, President Biden tasked his Council of Advisors on Science and Technology (PCAST) to identify a path forward to tackle these systemic and pervasive challenges.

In response, PCAST made actionable recommendations, including:

• Enhance federal leadership and prioritization of patient and workforce safety;
• Increase adoption of evidence-based practices for preventing harm and addressing risks;
• Partner with patients and other stakeholders to address disparities and increase transparency; and
• Accelerate research and deployment of technologies to spur innovation and quality improvement.

On September 27, the White House convened health organization leaders, patient and workforce advocates, health care system executives, and Biden-Harris Administration officials to discuss how to achieve these recommendations. The federal government and organizations across society also announced actions to make concrete progress toward these priorities:

• The Agency for Healthcare Research and Quality (AHRQ) at the Department of Health and Human Services (HHS) launched the National Action Alliance for Patient and Workforce Safety (NAA). The alliance is a collective effort of federal agencies, including those in HHS, Department of Defense (DoD) and the Department of Veterans Affairs (VA), as well as a growing number of private partners, including patient led-organizations, health care systems, professional associations, and policymakers. On November 1, NAA will deliver the first version of a National Healthcare Safety Dashboard to transparently monitor the nation’s progress toward eliminating the highest priority preventable patient and workforce harms across all settings, beginning with hospitals.
• The Centers for Disease Control and Prevention (CDC) is releasing new guidance that will help hospitals nationwide establish programs to ensure that the right tests are completed for the right patient and that results are communicated promptly. Additionally, working with the Centers for Medicare and Medicaid Services (CMS), the CDC will develop new measures to advance recognition and treatment of sepsis, a life-threatening condition that takes the lives of more than 300,000 Americans each year.
• CDC’s National Institute for Occupational Safety and Health renewed their commitment to provide nationally-accredited training in preventing workplace violence to health care providers and academic degree programs. The training identifies potential risk factors for violence and includes recommendations for preventing or lessening violent events. Nonfatal injuries due to violence occur most frequently in the health care and social assistance sector than any other industry in the United States.
• CMS, the largest payer of health care services in the United States, overseeing insurance programs for nearly 160 million Americans, has committed to the goal of reducing patient harm and promoting a culture of safety for patients nationwide. To increase transparency and accountability, CMS will incorporate a patient safety element, such as the patient safety structural measure or a policy component into its public reporting and quality programs and evaluate available authorities to prevent, where appropriate, paying for services that result in harm. For example, CMS recently finalized the adoption of the Patient Safety Structural Measure in to the Hospital Inpatient Quality Reporting Program beginning with the CY2025 reporting period. Additionally, CMS will address health care disparities and empower patients’ voices in safety by developing, by 2026, a patient-reported safety measure to ensure the voice of the patient is always included.
• DoD is committed to providing safe, high-quality care to its 9.6 million uniformed service members, military retirees, and family members within its Military Health System (MHS) in the United States and abroad. DoD will establish a lead to coordinate patient safety across the MHS enterprise. Additionally, DoD will modernize its patient safety reporting system in order to standardize workflows and conduct advanced analytics.  These actions will reduce variation in how care is provided and allow for robust health care disparity analysis.
• The Health Resources and Services Administration (HRSA) will fund the Nurse Education, Practice, Quality and Retention – Workforce Expansion Program to address the critical nurse shortage in rural and underserved areas, specifically in acute and long-term care settings. In September, HRSA will make five awards, for a total of $4.875 million.
• The Veterans Health Administration (VHA), the largest integrated health system in our country, serving 9.1 million enrolled veterans annually, commits to advancing high reliability principles and practices across 1,380 health care facilities, 170 VA medical centers and 1,193 outpatient sites, toward the achievement of zero preventable harm. VA health system leaders will sign a Safety Culture Commitment  by the middle of 2025; VHA will establish a new national program in 2025 for the prevention and management of patient falls across care settings; and VHA will modernize its data systems in 2025 in conjunction with the Defense Health Agency, by specifically making the data interoperable, to identify and reduce harms across the military and veteran health systems.

The Biden-Harris Administration and PCAST recognize the importance of a whole-of-society approach in tackling health care safety, for both patients and the workforce. Today, 22 leading national and regional organizations have made the following commitments:

• Patients for Patient Safety US commits to leading Project PIVOT, an initiative that will convene a diverse group of stakeholders to identify and prioritize validated patient-reported experience and patient-reported outcomes questions that address patient safety and racial or ethnic bias for further development and use in patient survey programs. These patient-prioritized questions will result in improved national reporting of patient safety events, missed or delayed diagnoses, and experiences of bias and discrimination.
• Ambulatory Surgery Center Association, in partnership with the Ambulatory Surgery Center Quality Collaboration, will share a new quality measurement tool with more than 6,300 Medicare-certified surgery centers in the United States to assess a center against the expected standard of safe, high-quality care.
• The Association of American Medical Colleges commits to releasing a revised set of educational competencies that focus on patient safety and quality improvement, helping to ensure that physicians have the necessary knowledge, skills, and abilities to provide safe care everywhere and zero preventable harm for all.
• Press Ganey commits to building a first-of-its-kind artificial intelligence (AI)-enabled integrated analytics dashboard in 2025 to bring together crucial data on patient and workforce safety, safety culture, safety incident reporting, and patient perceptions of safety, in addition to continued AI analyses of Press Ganey Patient Safety Organization data. These comprehensive tools will equip leaders with clear, prioritized, and actionable insights, including potential contributions of inequities.
• A&M Rural Community Health Institute Patient Safety Organization, a component PSO of Texas A&M Health Science Center, commits to launching a “Just Culture” collaborative in rural health systems, a year-long initiative to build a learning community of rural providers with a goal to prevent harm and reduce disparities for the 4.2 million Texans who live and work in rural areas.
• The Jewish Healthcare Foundation and Pittsburgh Regional Health Initiative commit to supporting advances in patient safety through the Patient Safety Technology Challenge. The technology challenge seeks to inspire and engage the next generation of innovators and researchers, encouraging the use of technology to solve problems in patient safety. Entrants for the Patient Safety Technology Award are competing for a new prize pool of $25,000 through the Grand Challenge and finalists of the Grand Challenge will be featured on stage at CES 2025.

In addition, 16 of the nation’s leading health care systems committed to actions that support providing safe care and zero preventable harm for all. Together, these systems provide health care to more than 30 million patients and employ hundreds of thousands of dedicated health care workers providing their service and expertise to adults and children living in both urban and rural communities across the country, including:

• Ascension, St. Louis, Missouri
• Baylor, Scott and White Health, Dallas, Texas
• Beth Israel Lahey Health, Cambridge, Massachusetts
• Braden Health, Ave Maria, Florida
• CommonSpirit Health, Chicago, Illinois
• Highmark Health, Pittsburgh, Pennsylvania
• MedStar Health, Columbia, Maryland
• Mercy Health, St. Louis, Missouri
• Nemours Children’s Health, Jacksonville, Florida
• Novant Health, Winston-Salem, North Carolina
• Prisma Health, Greenville, South Carolina
• Sanford Health, Sioux Falls, South Dakota
• SSM Health, St. Louis, Missouri
• Trinity Health, Livonia, Michigan
• University of California Health, Oakland, California
• University Hospitals, Cleveland, Ohio