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discussion post over healthcare regulation & ethics
provide a post.
read the article “Personal Accountability in healthcare: searching for the right balance”. Familiarize yourself with the story of Scott Torrence and lets talk a bit about accountability. The ER doctor’s intuition was that Scott had more than just vertigo and felt he would need a higher level of treatment urgently, but instead she sided with the Neurologist who refused care and later Scott died. Let’s talk about accountability: Who’s fault is it Scott died?
Do you think the ER doctor is accountable for Scott’s death? The rural hospital is not equipped with an MRI or CT scanner, how does that impact patient care? Is the rural healthcare system responsible for Scott’s death?
If the ER doctor felt strongly something more than vertigo was wrong with the patient, should she have contacted hospital administration to override Dr. Jones? Can she do that?
Does Scott’s girlfriend have the right to make choices for him?
Do you think Dr. Jones made an honest mistake? Should he be punished for this incident?
What can both healthcare systems do to prevent an incident like this happening again in the future?
How does the Joint Commission and NCQA aid in patient safety?
One of the sources that may be used is Ethics in Health Administration: A Practical Approach for Decision Makers by Eileen
Morrison, 4th Ed. Jones and Bartlett Learning. it can found on library
Thought paper May 2012 Robert Wachter Personal accountability in healthcare: searching for the right balance In this thought paper, Professor Robert Wachter explores the issue of personal accountability in healthcare and describes how accountability for performance is a key element for a safe system. Research shows that when patient safety breaks down, it is usually caused by clinical processes and systems rather than individuals. The Health Foundation’s improvement programmes help healthcare organisations to redesign unreliable processes and to develop a culture that supports patient safety with strong leadership, accountability and enthusiasm. Health Foundation thought papers are the author’s own views. We would like to thank Professor Wachter for his work, which we hope will stimulate ideas, reflection and discussion. About the author Professor Robert Wachter Robert Wachter MD is Professor and Chief of the Division of Hospital Medicine at University of California, San Francisco. He is also a US-UK Fulbright Scholar, Imperial College London (2011). An international leader in the fields of quality, safety and healthcare policy, he has published 250 articles and six books, including the recently released second edition of Understanding Patient Safety. In 2012–13, he will serve as the chair of the American Board of Internal Medicine. In 2012, he was named as number 14 in Modern Healthcare’s list of the most influential physician-executives in the US, and has been included in the top 50 for each of the last five years. 2 Thought paper May 2012 Summary While the patient safety field has emphasised as its central theme ‘systems thinking’, experts have pointed to the need to balance this ‘no blame’ approach with the need for accountability in certain circumstances, such as failure to heed reasonable safety standards. Our growing appreciation of the importance of accountability raises several new questions, including the relative roles of personal versus institutional accountability, and the degree to which personal accountability should be enforced by outside parties (such as peers, patients, healthcare systems, or regulators) versus professionals themselves (‘professionalism’). Identifying the appropriate locus for accountability is likely to be highly influenced by the structure and culture of the healthcare system; thus, answers in the UK will undoubtedly be different from those in the US. Ultimately, a robust approach to patient safety will not only balance ‘no blame’ with accountability, but will also parse the correct target for accountability in a way that maximises fairness and effectiveness. Introduction Of the many vexing problems in patient safety, none are trickier than balancing the ‘no blame’ systems approach to medical errors with the need for accountability – at the individual, managerial, and organisational levels. Informed by the pioneering work of Professor James Reason,1,2 the patient safety field embraced the former approach in its early years – both because it is largely correct (most errors are, in fact, committed by good people trying their very best) and because it was politically expedient. In the US, in particular, where mentioning ‘medical errors’ to a doctor immediately evokes near-Pavlovian thoughts of being named in a malpractice suit, the ‘no blame’ approach represented the only hope to engage physicians in safety efforts. While ‘systems thinking’ has led to many improvements in safety (for example, computerised order entry, bar coding, standardisation and simplification of processes, and improved equipment design), it tells an incomplete story. Specifically, a ‘no blame’ approach seems apt for some errors but not others; the latter category includes errors committed by incompetent, intoxicated, or habitually careless clinicians, or by those unwilling to follow reasonable safety rules and standards. This recognition has led to efforts over the past few years to balance ‘no blame’ and accountability. This rebalancing gained momentum as both the US and UK healthcare systems enacted policies to promote institutional, if not individual, accountability for performance. In the US, Personal accountability in healthcare: searching for the right balance Robert Wachter 3 such policies include more aggressive hospital accreditation requirements by the Joint Commission, as well as public reporting of safety hazards, ‘no pay for errors’ initiatives, and ‘Value-Based Purchasing’ by Medicare.3,4 In the UK, accountability has been promoted by incentive-based payments for general practitioners and high-profile investigations by the Care Quality Commission on reported safety lapses in individual hospitals.5,6 The next morning, Benamy re-evaluated Torrence, and he was markedly worse, with more headache, more vertigo, and now vomiting and photophobia (bright lights hurt his eyes). She called neurologist Jones again, who again refused the request for transfer. Completely frustrated, she hospitalised Torrence for intravenous pain medications and close observation. The next day, the patient was even worse. Literally begging, Benamy found another physician (an internist named Soloway) at Regional Medical Center to accept the transfer, and Torrence was sent there by air ambulance. The CAT scan at Regional was read as unrevealing (in retrospect, a subtle but crucial abnormality A representative case was overlooked), and Soloway managed Scott Torrence, a 36-year-old insurance Torrence’s symptoms with more pain broker, was struck in the head while going medicines and sedation. Overnight, up for a rebound during his weekend however, the patient deteriorated even basketball game. Over the next few hours, a further – ‘awake, moaning, yelling’, mild headache escalated into a thunderclap, according to the nursing notes – and needed and he became lethargic and vertiginous. to be physically restrained. Soloway called His girlfriend called an ambulance to the neurologist, Dr Jones, at home, who told take him to the emergency room in his local him that he ‘was familiar with the case and rural hospital, which lacked a CAT the non-focal neurological exam and the or MRI scanner. normal CAT scan made urgent clinical The emergency room (ER) physician, problems unlikely’. He went on to say Dr Jane Benamy, worried about brain that he would ‘evaluate the patient the bleeding, called neurologist Dr Roy Jones next morning’. at the regional referral hospital (a few But by the next morning, Torrence was hundred miles away) requesting that dead. An autopsy revealed that the head Torrence be transferred. Jones refused, trauma had torn a small cerebellar artery, reassuring Benamy that the case sounded which led to a cerebellar stroke (an area of like ‘benign positional vertigo’. Benamy the brain poorly imaged by CAT scan). was worried, but had no recourse. She Ultimately, the stroke caused enough sent Torrence home with medications for swelling to trigger brainstem herniation – extrusion of the brain through one of the vertigo and headache. 4 Thought paper May 2012 holes in the base of the skull, like toothpaste squeezing through a tube. This cascade of falling dominoes could have been stopped at any stage, but that would have required the expert neurologist to see the patient, recognise the signs of the cerebellar artery dissection, take a closer look at the CAT scan, and order an MRI.7 While one could envision system improvements that might have helped prevent this tragic outcome, Dr Jones’s refusal to come to the hospital to see a rapidly deteriorating patient seems like a personal failing. Of course, doctors are human (there was a reason that the Institute of Medicine’s seminal report on patient safety was called To err is human8), and thus a healthcare system that relies on human perfection is destined to disappoint. But cases like this one illustrate that challenging lines must be drawn, lines that distinguish expected human frailties from levels of performance that fall below professional standards. The latter circumstances require an accountability approach. As Dr Lucian Leape, widely considered the father of the patient safety movement in the US, once told me: There is no accountability. When we identify doctors who harm patients, we need to try to be compassionate and help them. But in the end, if they are a danger to patients, they shouldn’t be caring for them. A fundamental principle has to be the development and then the enforcement of procedures and standards… When a doctor doesn’t follow them, something has to happen. Today, nothing does, and you have a vicious cycle in which people have no real incentive to follow the rules because they know there are no consequences if they don’t. So there are bad doctors and bad nurses, but the fact that we tolerate them is just another systems problem.9 In the US, the hypertrophied malpractice system partly arose through political happenstance (lawyers represent a powerful political force). But it also represents a lack of public trust in the medical profession’s ability to enforce its own accountabilities. This is a damning indictment. One of the core attributes of professions is that, in exchange for unique powers and privileges, the public assumes that the profession will regulate itself. For a variety of reasons, medicine does poorly in this regard. Unlike attorneys, who are trained to challenge others, physicians are socialised to be collegial and nonconfrontational. Moreover, because medicine is so specialised, doctors asked to review the performance of peers are likely to be from the same small community of specialists, raising the possibility that they will either be colleagues or competitors. There is strong evidence of physicians’ discomfort with peer review: a 2010 survey found that more than two-thirds of physicians believe that it is their responsibility to report an impaired or incompetent colleague to the appropriate authorities. However, when physicians could name just such a colleague, one-third confessed that they failed to report them.10 Personal accountability in healthcare: searching for the right balance Robert Wachter 5 The Just Culture model It is challenging to draw lines between the expected flaws of mortals and those transgressions that merit an accountability approach. Interestingly, although James Reason’s work on human error is often cited as the driving force behind the ‘no blame’ approach to medical mistakes, Reason was acutely aware of the need for accountability. In his classic book, Managing the risks of organizational accidents, Reason described the need to deal with clinicians who habitually choose to ignore important safety rules: – but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.2 David Marx, a US attorney and engineer, has popularised the Just Culture concept by developing a model that distinguishes between ‘human error’ (an inadvertent act, such as a ‘slip’ or ‘mistake’), ‘at-risk behaviour’ (taking shortcuts that the caregiver does not perceive as risky – the equivalent of rolling through a stop sign at a quiet intersection), and ‘reckless behaviour’.11 Only the latter category, defined as ‘acting in conscious disregard of Seeing them get away with it on a daily basis substantial and unjustifiable risk’, is does little for morale or for the credibility of blameworthy. Other versions of the Just the disciplinary system. Watching them Culture algorithm, including an ‘incident getting their ‘come-uppance’ is not only decision tree’ produced by the UK’s National satisfying, it also serves to reinforce where the Patient Safety Agency (NPSA), are boundaries of acceptable behavior lie… available.12 Another model, developed by Justice works two ways. Severe sanctions US safety experts Allan Frankel and Michael for the few can protect the innocence of Leonard,13 guides users to reflect on several the many. questions before deciding whether punishment is warranted: Reason then introduced the concept of the • Was the individual knowingly impaired? Just Culture: (If yes, punishment may be warranted.) • Did the individual consciously decide A ‘no-blame’ culture is neither feasible nor to engage in an unsafe act? (If yes, desirable. A small proportion of human punishment may be warranted.) unsafe acts are egregious… and warrant • Did the caregiver make a mistake that sanctions, severe ones in some cases. A individuals of similar experience and blanket amnesty on all unsafe acts would lack training would be likely to make under credibility in the eyes of the workforce. More the same circumstances (‘substitution importantly, it would be seen to oppose test’)? (If no, punishment may natural justice. What is needed is a just be warranted.) culture, an atmosphere of trust in which • Does the individual have a history of people are encouraged, even rewarded, for unsafe acts? (If yes, punishment may providing essential safety-related information be warranted.) 6 Thought paper May 2012 While all these models are helpful to leaders who are trying to identify acts that merit an accountability approach, many hospitals (including those in the US that have engaged pricey consultants to deliver Just Culture training) have continued to shy away from disciplinary approaches, particularly when the culprits are physicians. Here, an important difference between the healthcare systems of the US and UK influences this response. Most US physicians are self-employed, not working for hospitals or large healthcare systems (although there is a trend toward more employment as payments for physicians fall and pressure grows to deliver integrated, coordinated care). This means that the job of hospital leaders historically has been to attract physicians to their facility, since the physicians bring their patients (and associated revenue) with them. Because doctors could threaten to shift hospitals if they were unhappy, few hospitals were enthusiastic about setting and enforcing standards of behaviour and practice. The result was a tradition of non-accountability for physicians, even in hospitals that have disciplined nurses (who are employed by the institution) for ‘reckless behaviour’ – clear evidence of a double standard. In light of this, Pronovost and I have argued the need to enforce uniform standards of accountability for all healthcare providers, including physicians. In a 2009 paper, entitled ‘Balancing “no blame” with accountability in patient safety’, we used the example of hand hygiene to make our case.14 We recommended that an accountability approach be considered when all of the following conditions are met: • The patient safety problem being addressed is important. • The evidence is strong that adherence to the practice decreases the chances of harm. • Clinicians have been educated about the practice and the evidence. • The system has been modified to make it easy to adhere to the practice, and unanticipated consequences have been addressed. • Physicians understand the behaviours for which they will be held accountable. • A fair and transparent auditing system has been developed. Once these conditions are met, it is vital that transgressions are viewed through an accountability rather than a ‘no blame’ lens, and that appropriate discipline (everything from stern rebukes to fines and suspensions) be meted out. In our New England Journal article, we explained why this was so important: Part of the reason we must do this is that if we do not, other stakeholders, such as regulators and state legislatures, are likely to judge the reflexive invocation of the ‘no blame’ approach as an example of guild behavior – of the medical profession circling its wagons to avoid confronting harsh realities, rather than as a thoughtful strategy for attacking the root causes of most errors. With that as their conclusion, they will be predisposed to further intrude on the practice of medicine, using the blunt and often politicized sticks of the legal, regulatory, and payment systems.14 Personal accountability in healthcare: searching for the right balance Robert Wachter 7 Personal versus institutional accountability Interestingly, at this point, most of the pressures for accountability (at least in the US) fall on hospitals and healthcare organisations rather than individual physicians. For example, Medicare’s Value-Based Purchasing program, which is due to be launched in late-2012, penalises hospitals, but not individual clinicians, for poor performance on measures of safety, quality and patient satisfaction.4 Because of this, most of the pressure today for individual accountability is not coming from outside regulators, payers, or accreditors, but rather from hospitals that are being held accountable for their performance and are pushing those accountabilities down toward clinical units and even individual clinicians. But independent of the policy levers used to promote accountability, it is worth reflecting on yet another tension: not between ‘no blame’ and accountability, but between individual versus collective accountability. In a 2011 article, Bell and colleagues emphasised the importance of collective accountability – accountability at the level of the individual clinician, the healthcare team, and the institution.15 This is an important distinction, because one can easily push the concept of individual accountability too far down the organisational chain. Safety expert Dr Charles Denham recounts the story of Jeannette IvesErickson, a nursing leader at Massachusetts General Hospital, whose habit was to call a nurse into her office after a bad error. She 8 asked one simple question: ‘Did you do this on purpose?’ If the answer was no, then Ms Ives-Erickson would say, ‘Well then it is my fault… Errors stem from system flaws, and I am responsible for creating safe systems.’ Denham points out that it is ‘easy to automatically fall into a name-blame-shame cycle, citing violated policies, and ignore the laws of human performance and our responsibility as leaders’.16 Paul Levy, the former Chief Executive Officer of Beth Israel-Deaconess Hospital in Boston, reflected on this tension in his recent book, Goal play! Leadership lessons from the soccer field.17 While noting that many management experts recommend individual performance reviews and enforcement of strict guidelines as the cure for poor organisational performance, Levy writes: That guidance suggests that a successful organization depends on holding people accountable to do good quality work in support of corporate objectives. I assert instead that it is not only impossible to hold people accountable in an organization, but trying to do so is a misallocation of a leader’s attention. You say, ‘What? How will you make sure people are performing up to spec if you don’t hold them accountable?’ I view the job quite differently. I view the leader’s job as helping to create an environment in which people are given the right tools for doing their jobs and are so comfortable with their role in the organization that they hold themselves accountable. After all… most people want to Thought paper May 2012 do well in their jobs and want to do good in fulfilling the values of the enterprise. Why not trust in their inherent desire to be successful personally and collectively? Instead of focusing on measuring their performance against static metrics, why not create a setting in which they use their native intelligence, creativity, and enthusiasm to solve problems in an inevitably changing environment?… In short, give them the chance to learn tools that enable them to meet a high standard, both individually and as a team. Then, spend your time praising them and making sure they get the credit. Conclusion The patient safety field is at a crossroads as it grapples with a variety of fundamental but challenging questions. In the early years, we embraced the notion of ‘no blame’ and systems thinking as the cure-all for safety – it was novel (for healthcare, at least), had yielded strikingly positive results in other industries such as commercial aviation and nuclear power, and was politically astute, since it encouraged clinicians (particularly physicians) to participate in the safety enterprise. A decade later, our thinking has become more nuanced. We now recognise that ‘no blame’ is the appropriate response for many errors, but not all. With this recognition has come increasingly powerful efforts, including policy changes, to promote accountability, which have exposed a new tension: whether that accountability is best targeted at individual clinicians or the organisational leaders who establish the systems and enforce the policies. Like most complex questions in life, this one has no single easy answer. In calibrating ‘no blame’ versus accountability, and then further determining the locus of accountability, we should aim for the approach that best answers a series of crucial questions: • Do patients and their representatives feel that professionals – both clinicians and leaders – have attacked medical errors with the seriousness that they deserve? • Do individuals in the systems – both clinicians and leaders – feel that they are being treated fairly? • Most importantly, have we made care safer? The 19th-century German philosopher Arthur Schopenhauer once said, ‘Opinion is like a pendulum and obeys the same law. If it goes past the centre of gravity on one side, it must go a like distance on the other; and it is only after a certain time that it finds the true point at which it can remain at rest.’18 In the first few years of the patient safety movement, the pendulum swung too far toward systems. It is now swinging back toward individual and collective accountability. The ultimate success of our efforts to prevent harm will depend on ensuring that the pendulum comes to an optimal resting point. Personal accountability in healthcare: searching for the right balance Robert Wachter 9 Key practical points for healthcare staff • The fundamental tenet of the patient safety field has been that most errors involve dysfunctional systems rather than bad individuals. • While this principle is largely correct, we have now come to recognise that accountability for performance is a key attribute of a safe system. • A variety of tools and algorithms have been developed to try to delineate when an error or unsafe act should be viewed through a ‘no blame’ systemsoriented lens, and when it should engender a more accountabilityfocused response. The most popular of these is called the ‘Just Culture’. • Even as we move toward accountability, there remains debate as to whether the focus should be on individual clinicians or the leaders of healthcare systems. Our response to this question will inevitably be coloured by the policy environment, which will have much to say regarding the amount of accountability pressure and where it will be aimed. • As with most difficult questions in life, the right answers will involve balancing competing demands and paradigms. In the end, the solutions should be based on what works best to improve safety and what feels fair to all of the stakeholders involved, including patients, policy makers, healthcare leaders, and individual clinicians. 10 To share your thoughts about this paper, please visit www.health.org.uk/WachterTP. You can also follow the Health Foundation on Twitter at www.twitter.com/HealthFdn Thought paper May 2012 References 1 Reason JT. Human error. New York: Cambridge University Press; 1990. 2 Reason JT. Managing the risks of organizational accidents. Aldershot, Hampshire: Ashgate; 1997. 3 Wachter RM, Foster NE, Dudley RA. Medicare’s decision to withhold payment for hospital errors: the devil is in the details. Jt Comm J Qual Patient Saf 2008;34:116-23. 4 Ferman JH. Value-based purchasing program here to stay: payments will be based on performance. Health Exec 2011;26(3):76,78. 5 Marshall M, Smith P. Rewarding results: using financial incentives to improve quality. Qual Saf Health Care 2003;12:397-8. 14 Wachter RM, Pronovost PJ. Balancing ‘no blame’ with accountability in patient safety. N Engl J Med 2009;361:1401-06. 15 Bell SK, Delbanco T, Anderson-Shaw L, McDonald TB, Gallagher TH. Accountability for medical error: moving beyond blame to advocacy. Chest 2011;140(2):519-26. 16 Denham CR. May I have the envelope please? J Patient Saf 2008;4:119-23. 17 Levy PF. Goal Play!: Leadership lessons from the soccer field. CreateSpace; 2012. 18 Schopenhauer A, Hollingdale RJ (translator). Essays and aphorisms. New York: Penguin Books; 1970. 6 Laverty AA, Smith PC, Pape UJ, Mears A, Wachter RM, Millett C. High-profile investigations into hospital safety problems in England did not prompt patients to switch providers. Health Aff (Millwood) 2012;31:593-601. 7 Case reprinted with permission from Wachter RM. Understanding patient safety, 2nd ed. New York: McGraw-Hill; 2012. (All names have been changed) 8 Kohn LT, Corrigan JM, Donaldson MS (eds). To err is human: building a safer health system. Washington DC: National Academy Press; 2000. 9 Wachter RM, Shojania KG. Internal bleeding: the truth behind America’s terrifying epidemic of medical mistakes. New York: Rugged Land; 2004. 10 DesRoches CM, Rao SR, Fromson JA, Birnbaum RJ, Iezzoni L, Vogeli C, Campbell EG. Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA 2010;304:187-93. 11 Marx D. Patient safety and the ‘just culture’: a primer for health care executives, 17 April 2001. Available at: www.mers-tm.org/support/Marx_ Primer.pdf 12 Meadows S, Baker K, Butler J. The incident decision tree. Clin Risk 2005;11:66-8. 13 Leonard MW, Frankel A. The path to safe and reliable healthcare. Patient Educ Couns 2010;80:288-92. Personal accountability in healthcare: searching for the right balance Robert Wachter 11 The Health Foundation is an independent charity working to continuously improve the quality of healthcare in the UK. We want the UK to have a healthcare system of the highest possible quality – safe, effective, person centred, timely, efficient and equitable. We believe that in order to achieve this, health services need to continually improve the way they work. We are here to inspire and create the space for people to make lasting improvements to health services. Working at every level of the system, we aim to develop the technical skills, leadership, capacity and knowledge, and build the will for change, to secure lasting improvements to healthcare. 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