Tuesday, October 06, 2009

The competing ideas of accountability and no blame

A decade ago the Institute of Medicine (IOM) issued its landmark patient safety recommendations. Included was the statement that medicine should move away from a culture of individual blame toward a systems based approach of safety enhancements. Don Berwick, president of the Institute for Health Care Improvement, echoed this sentiment in his address at SHM 2008. He said that the onus for patient safety should shift away from individual doctors because they, most of them anyway, traditionally run at top speed. To continually ask overstressed doctors to do “just a little more” to fix safety problems, he argued, would be counterproductive. Among the benefits of a blame-free approach, many patient safety experts also agreed, would be a new culture of transparency.

Ironically, the IOM, with the issuance of its report, undermined its own aspirations for a culture of transparency right out of the gate! They did this by indiscriminately referring to a broad spectrum of adverse patient outcomes as “errors.” This unfortunate attribution, based on faulty analysis of a landmark study on adverse hospital events, I have argued, did much to sabotage the cause of patient safety in the decade that followed. (For the original investigator’s own criticism of the IOM’s interpretation see this editorial). Instead of an era of transparency we entered a heightened culture of blame and finger pointing. The most vivid example of this, of course, is Medicare’s never events policy, of which we are just beginning to realize the adverse consequences. According to a recent report by the Patient Safety Project we’ve effectively implemented virtually none of the IOM’s patient safety recommendations for system improvement and transparency. I argued that this should not be surprising given the heightened culture of blame fueled by faulty analysis of research findings, sloppy use of language and media hype.

So now we have Bob Wachter offering a little different take. He wonders whether we’ve taken the no-blame idea too far:

In this week’s New England Journal, Peter Pronovost and I make the case for striking a new balance between “no blame” and accountability. Come on folks, it’s time.

I agree with much of the substance of Bob’s argument although I have a problem with his tone and choice of terms. We can start with the premise that either of the two competing ideas, blame and no-blame, can be taken to an unhealthy extreme. We can also agree that if a health care worker repeatedly flouts safety rules there should be consequences.

Bob goes on to address the problem of hand washing compliance:

At most hospitals, hand hygiene rates hover between 30-70%, and it’s a near-miracle when they top 80%. When I ask people how they’re working to improve their rates, the invariable answer is “we’re trying to fix the system.”

Now, don’t get me wrong. I believe that our focus on dysfunctional systems is responsible for much of our progress in safety and quality over the past decade. We now understand that most errors are committed by good, well-intentioned caregivers, and that shaming, suing, or shooting them can’t fix the fallibility of the human condition.

But not washing hands? When I hear, “It’s a systems problem,” my BS detector goes a little bit haywire, particularly after I walk around the hospital and see alcohol gel dispensers every 2 feet and glossy photos of smiling clinical leaders cleaning their hands at every turn.

Well, if as many as 70% of hospital personnel are not washing their hands I’d say the problem is pretty systematic. At SHM 09 Bob mentioned a company that installs video surveillance equipment, monitors and gives real time feed back on hand washing compliance rates on individual wards. He’s been lobbying to get it installed at his institution, UCSF. It looks like a great idea and guess what? It’s a system enhancement!

Meanwhile our culture of blame devolves. The notion that “adverse event equals medical error” has been codified administratively by Medicare. The trial lawyers are watching.

We should learn from the failed IOM initiative that words like “error” mean things. We need to be more careful how we use them.

No comments: