Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act

The Patient Safety and Quality Improvement Act, passed in 2005, has been heralded as an important advance in patient safety. Numerous questions have been raised regarding details of the implementation of the legislation. Recent concern has been expressed that progress in implementing the legislation has been slow, and important issues have not been addressed to transform the legislative intent into a viable patient safety system. To date, no model has yet been offered on how the information exchange between the Patient Safety Organization (PSO) contemplated by the Act and client health care organizations can be completed and acted upon. In this article, we propose a Care Enhancement Model, based on our experience in aviation and health care safety, which describes how information can be prioritized, acted upon, and used for improvement. We present the thematic tenets of the “Care Enhancement Model” as a blueprint to connect the PSO with a provider setting and a national Network of Patient Safety Databases (NPSD) as created by the Act. We then provide detailed roles and responsibilities of each of these components that might provide guidance for an effective tripartite safety system.