Is it time to put “no blame” in the corner?

Is it time to put “no blame” in the corner?

December 2009

Published in the December 2009 issue of Today’s Hospitalist

THE INSTITUTE OF MEDICINE’S “To Err is Human” report in 1999 ushered in a new era of inpatient safety. With many thousands of patients falling victim each year to errors, hospital systems needed a top-to-bottom overhaul to figure out how to build in protections against human fallibility. Instead of continuing to point fingers at individual providers, a new no-blame culture would focus instead on system solutions to saving patient lives.

Coming of age in that no-blame era, hospitalists have taken the lead to retool hospital systems, authoring evidence-based checklists and championing technology to take some guesswork out of medicine.

Yet two of the godfathers of the patient-safety movement claim that in some broad safety areas, the no-blame approach “is simply the wrong tool.” That’s the conclusion reached by Robert Wachter, MD, of the University of California, San Francisco (UCSF) and Peter Pronovost, MD, of Johns Hopkins University, in a provocative opinion piece in the Oct. 1 New England Journal of Medicine.

Put simply, the authors argue, “no blame” should be balanced with a dose of personal accountability, particularly for willful offenders at the top of the inpatient hierarchy: physicians. The authors advocate shifting from a no-blame culture to a “just culture,” complete with requirements for personal behavior and penalties for violations.

In a speech at UCSF’s management of the hospitalized patient conference this fall, Dr. Wachter characterized the balance needed between “no blame” and accountability as “Oprah vs. Dick Cheney.” He spoke with Today’s Hospitalist about how to achieve that balance.

What are some no-blame success stories?

All sorts of things work better than they once did. The system for preventing medication errors in most hospitals is much tighter than it once was, and we have better approaches to reducing infections and preventing surgical complications.

But you can’t have a 50% hand hygiene rate and still believe that the problem is “the system,” once education and the ubiquitous gel dispensers have long been in place.

At some point, you have to say, “Now, you’re required to do it.” When I went to elementary school, “required” meant you had to do it and there were consequences if you didn’t.

The article mentions several safety practices that physicians would be penalized for ignoring, such as hand hygiene and sign-out guidelines. Do you know of hospitals that use such penalties?

I don’t, except in cases of regulatory requirements like losing privileges when doctors fail to sign discharge summaries. For patient safety-oriented practices, lots of hospitals are thinking about it, but precious few have taken the bold step of enforcing these standards.

Our intention with the article was to promote a tipping point. To me, it’s more important to get started and pick several areas where we know what the right thing is, yet adherence is embarrassingly low.

As for what should be considered blameworthy behavior, it’s a little like the Supreme Court on pornography: We all know it when we see it. We’re not talking about penalties for occasional slips made by hard-working people, but for individuals who repeatedly ignore sensible, evidence-based safety standards, and have been warned and educated.

I’ve had people say to me, “You’re going to have to fire half the medical staff.” I don’t think so. My suspicion is that you’ll have to suspend one physician, and then you’ll be done.

Hospitalists have re-engineered hospital systems in the no-blame era. Have they also made advances with personal accountability?

I know my own group at UCSF has attacked this issue on cultural grounds “such as setting clear behavioral expectations on things like sign-outs “and as a group we hold each other accountable. That said, we have not done a lot of random auditing, and if we did, I would probably find a few surprises.

Because we’ve grown up as a specialty in the same era as the quality and safety fields, hospitalists are more likely than older specialties to be actively struggling with these issues. We’ve rolled up our sleeves to work on system issues, but I think over the last few years, we’ve begun to feel odd when we find ourselves saying, “this is a system problem” in areas like hand hygiene. There are times when blame is appropriate, and hospitalists are probably a little ahead of the curve in thinking through how to strike the right balance.

Some hospitals now videotape people washing their hands and report per-unit compliance rates on an hourly basis. If you start assessing penalties, what type of auditing do you need?

In some places, that kind of technology will be too expensive. But in others, the cultural issues and hierarchy will just be so steep that you can’t count on a nurse or clerk or patient calling a physician on some chronic behavioral lapse. I don’t think we know the right mix in terms of peer pressure vs. some type of external audit. It’s an area that’s ripe for experimentation.

Your article credits David Marx, JD, for the “just culture” phrase. How hard will that be to establish in hospitals?

David’s work was immensely helpful in framing the issues, and some hospitals have been working on “just culture.” But we wrote the NEJM piece because we felt that few had solved the dilemma, particularly as it related to MD accountability.

Part of the trick will be to ensure that rules are clear and enforced fairly, whether you are a med-surg nurse or the chief of neurosurgery. This is tough stuff, but there is no other way to establish a just- and safety-oriented culture.

And we lose credibility in the eyes of stakeholders when our reflexive answer is, “It’s all the system.” We felt the time was right to say that and that the people saying it needed to be within the medical profession, not from the outside.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.