Call to Action on Transparency in Health Care from the National Patient Safety Foundation’s Lucian Leape Institute

Share Article

Report Urges Leadership in Four Domains of Transparency as a Means to Improve Patient Safety

Transparency has been largely overlooked as a patient safety tool, in part because it requires a foundation of a safety culture and strong organizational leadership.

Open communication and a free flow of information represent the “magic pill” needed to improve many of the issues in health care related to safety, according to a new report released today by the National Patient Safety Foundation’s Lucian Leape Institute. Shining a Light: Safer Health Care Through Transparency defines transparency as “the free, uninhibited flow of information that is open to the scrutiny of others,” and calls for sweeping action within and across organizations, between clinicians and patients, and in public reporting.

“We hope this report will help convince people that transparency is not only the right thing to do, but that it will lead to improved outcomes, fewer errors, more satisfied patients, and reduced costs of care,” said Robert M. Wachter, MD, associate chair, Department of Medicine, University of California San Francisco. He and Gary Kaplan, MD, FACMPE, chief executive officer, Virginia Mason Health System, both members of the NPSF Lucian Leape Institute, served as co-chairs of this initiative.

The report addresses four distinct yet overlapping domains where the open exchange of information is necessary to improve safety:

  • Between clinicians and patients to ensure patients are well informed at all stages of their care
  • Among clinicians to ensure the practices of high performers are shared with their peers
  • Between organizations to allow greater collaboration on safety protocols and events
  • With the public through meaningful measures and data that is understandable and useful to health care consumers

The authors provide specific recommendations relevant to each domain and to the areas of measurement and leadership. In all, more than three dozen recommendations are outlined in the report addressing issues such as disclosure of conflicts of interest, shared decision making with patients, and development of core competencies for communicating about medical errors and quality measures to patients, families, other medical professionals, and the public.

“Transparency has been largely overlooked as a patient safety tool, in part because it requires a foundation of a safety culture and strong organizational leadership,” said Dr. Kaplan. “The barriers are not necessarily easy to overcome, but we will never truly achieve safe patient care without improvements in transparency in each of the domains we cite.”

Increased transparency, the report says, will yield broad benefits by promoting accountability; catalyzing improvements in quality and safety; promoting trust and ethical behavior; and facilitating patient choice. The result of two roundtable meetings that included participants with a broad range of expertise, the report also includes case studies of how transparency is applied in practice.

“We are grateful to our roundtable participants for the time and expertise they contributed to this report,” said Tejal K. Gandhi, MD, MPH, CPPS, president and CEO of NPSF and president of the Lucian Leape Institute. “This is a complex issue, and it is not going to happen overnight, but we believe advances in transparency will significantly improve patient safety.”

This report is the fifth in a series about issues that the NPSF Lucian Leape Institute has identified as transforming concepts to improve patient safety. The first, Unmet Needs: Teaching Physicians to Provide Safe Patient Care (2010), addresses the need for teaching quality and safety principles in medical education. In 2012, the Institute published Order from Chaos: Accelerating Care Integration, which looks at the problem of fragmented care and possible solutions. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care, released in 2013, details the profound problem of physical and psychological risks to the health care workforce. Safety Is Personal: Partnering with Patients and Families for the Safest Care looks at patient and family engagement in health care. All reports are available on the Institute's web pages.

In addition to Drs. Leape, Gandhi, Kaplan, and Wachter, current members of the NPSF Lucian Leape Institute include Janet Corrigan, PhD, MBA, distinguished fellow, Dartmouth Institute for Health Policy and Clinical Practice; Susan Edgman-Levitan, PA, executive director, John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital; Gerald B. Hickson, MD, senior vice president for quality, safety and risk prevention, Joseph C. Ross Chair in Medical Education & Administration, assistant vice chancellor for health affairs, Vanderbilt University Medical Center; Julianne Morath, RN, MS, president and CEO, Hospital Quality Institute of California; Paul O’Neill, former chairman and CEO, Alcoa, and 72nd Secretary of the US Treasury; and Dennis S. O’Leary, MD, President Emeritus, The Joint Commission.

Members of the Institute’s Roundtable on Transparency will discuss the new report in a live webinar on February 12, 2015, from 12 noon to 1:00 pm Eastern Time. Registration is free of charge and open to all. Details are available at

For more information about the report or the NPSF Lucian Leape Institute, visit

The National Patient Safety Foundation’s Lucian Leape Institute gratefully acknowledges the following organizations for their generous support of the production and dissemination of Shining a Light: Safer Health Care Through Transparency and their commitment to transparency as an essential element in the delivery of safe care: Mallinckrodt Pharmaceuticals; MagMutual Patient Safety Institute; Cincinnati Children’s; Duke Medicine; Edward P. Lawrence Center for Quality & Safety at Massachusetts General Hospital; Johns Hopkins Medicine; the Leapfrog Group; University of Michigan Health System; Virginia Mason Health System.

About the NPSF Lucian Leape Institute
The National Patient Safety Foundation’s Lucian Leape Institute, established in 2007, is charged with defining strategic paths and calls to action for the field of patient safety, offering vision and context for the many efforts under way within health care, and providing the leverage necessary for system-level change. Its members are national thought leaders with a common interest in patient safety whose expertise and influence are brought to bear as the Institute calls for the innovation necessary to expedite the work and create significant, sustainable improvements in culture, process, and outcomes critical to safer health care.

About the National Patient Safety Foundation
The National Patient Safety Foundation’s vision is to create a world where patients and those who care for them are free from harm. A central voice for patient safety since 1997, NPSF partners with patients and families, the health care community, and key stakeholders to advance patient safety and health care workforce safety and disseminate strategies to prevent harm. NPSF is an independent, not-for-profit 501(c)(3) organization. To learn more about the Foundation’s work, visit

Share article on social media or email:

View article via:

Pdf Print

Contact Author

Patricia McTiernan
Follow >
Visit website