Physician Accountability for Violation of Safety Rules: The Time For Excuses Has Passed

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.

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. I think all of us realize that in 2009, failure to clean hands is no longer primarily a systems problem. It’s an accountability problem.

That’s not to say that the system can’t be improved. The Joint Commission recently launched its new Center for Transforming Healthcare, which focused on hand hygiene as its first initiative. The Center identified several system changes that will help – like installing cameras to monitor hand washing or alarms that go off if providers approach patients without giving the alcohol gel dispenser a pump. That’s all for the good.

But the question remains: what do we do with the doc or nurse (and I’m mostly talking about docs here) who refuses to clean his hands, or to perform the pre-surgical time out, or to use a checklist when he should? Today, the answer is: absolutely nothing. And therein lies the problem.

In fact, at my hospital, I will be suspended from the medical staff if I fail to sign my discharge dictations. But if I choose to not clean my hands for the next 5 years, I’ll experience no consequences whatsoever. Does that seem right to you?

Captain Chesley “Sully” Sullenberger gave the keynote to the 600 attendees at my annual hospitalSully medicine conference last week. Sully was everything I hoped for – dignified, understated, and forceful. (And what a good egg – he stayed for nearly an hour after his talk, taking pictures with and signing autographs for attendees.) In discussing the parallels between aviation and healthcare safety, he projected the cover picture of my book Internal Bleeding, and said…

In 2005, when it first came out, a pilot’s wife sat reading Internal Bleeding… Her husband, a colleague of mine, pointed to the cover illustration, which clearly shows a hemostat left in this person’s pelvis, and simply said, “Checklist shoulda caught that.” The wife reading the book explained that, at the time, surgical checklists were very rare.  Her husband, who relied on checklists every day, responded, “No – there’s GOT to be a checklist. They couldn’t do something that important without a checklist!”  She kept insisting there wasn’t one, he kept insisting there must be, and their back-and-forth went on for several minutes – he found it nearly impossible to believe that surgical teams did not have a key safety tool that airlines had been using for over seventy years.

I asked Sully what would happen if a pilot refused to complete a pre-flight checklist, and he assured me that his co-pilot would never agree to take off. And then the pilot would be fired. You see, in aviation, once a safety procedure is accepted, following it is no longer a choice. It’s a requirement.

But in medicine, we kill thousands of people each year because folks choose not to (or forget to) clean their hands, or use a safety checklist, or perform a pre-operative time out, or follow reasonable procedures for handoff communication. We react to these transgressions, particularly when the perp is a physician, not with outrage but with shoulder shrugs. Nothing we can do, we sigh, as patients die around us.

The need to draw a blame line is not a new idea – David Marx’s work on “Just Culture” helps us identify blameworthy acts, as does James Reason’s accountability algorithm. But we wrote today’s New England Journal article because neither of us has stumbled upon a single hospital that has mustered up the guts to enforce meaningful penalties for habitual failure to adhere to reasonable safety rules. As Kissinger once said, “weakness is provocative,” and our failure to act has provoked unsafe behaviors for far too long.

We concluded today’s NEJM article this way:

“No blame” is not a moral imperative — and even if it seems that way to providers, it most definitely does not to patients and their advocates. Rather, it is a tactic to help us achieve ends (safe and high-quality care) for which we will, quite appropriately, be held accountable. Said another way, “no blame” is a tool, and often an extraordinarily useful one. But for some mature patient-safety practices, it is simply the wrong tool…

Part of the reason we must [enforce penalties for repetitive failure to follow reasonable safety rules] 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. Having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism and thus represent our best protection against such outside intrusions.

But the main reason to find the right balance between “no blame” and individual accountability is that doing so will save lives.

We wrote this article to be deliberatively provocative, and ever since the Journal accepted it, I’ve been bracing for a backlash. In fact, I ran into NEJM editor Jeff Drazen at a conference a couple of months ago, and joked that I already had my Kevlar suit ready for action. “You might have needed that a few years ago,” he said. “But today, I think most of the responses will be from people, including docs, who ask, ‘why didn’t we do this a long time ago?’.”

I hope he’s right.

28 Responses to “Physician Accountability for Violation of Safety Rules: The Time For Excuses Has Passed”

  1. menoalittle October 1, 2009 at 2:35 am #

    Bob,

    Apropo and wonderful commentary and blog summary.

    Hand hygiene is cheaper than computerization and will have a preferred cost and mortality benefit. You will see.

    CPOE usage is enforced, hand hygiene is not. Besides, keyboards in patient rooms and on cows outside the rooms most assuredly will spread disease.

    Too little attention is being paid to the feet as carriers. Shoes carry all sorts of things from a c diff room to another. Patients drop things on the floor, like IS gadgets, to be put in the mouth later, for deep inhalation (of the floor germs).

    Best regards,

    Menoalittle

  2. Jim Conway October 1, 2009 at 9:54 am #

    Bob (and Peter). It is time! In my travels around governance and executive leadership of quality, the discsussions over the struggles with the failure to deal with sub-optimial performance in clinical, behavioral, and administrative practice are everywhere and the negative implications profound for patients, families, and other staff. Growing expodentially is the frustration–lets bring on the action. It is time that we all do what a trustee in the food service industry told me years ago:
    — set the expectation
    — POSITION PEOPLE FOR SUCESS
    — hold them, and yourself, accountable.
    Then he said, when deviance occurs, it stands out immedialty and can be called.

    Handwashing is a great place to start today. Thanks (now I have to find time to read the full article!), Jim

  3. Bob Wachter October 1, 2009 at 10:15 am #

    Jim —

    Thanks for your leadership on this. From your time at Dana Farber to today, you have been one of the key people who has inspired us to “do the right thing.” It just took us a little while to get there on finding, and articulating, this delicate balance between “no blame” and accountability. Thanks for your note.

    — Bob

  4. Jan Krouwer October 1, 2009 at 11:23 am #

    The NEJM article is great, but I don’t understand how you could previously rant about incident reporting systems. One needs to think in terms of a closed loop.

    Report incidents
    Classify and rank incidents
    Propose and implement corrective actions
    Measure incident rate

    (After Measure incident rate, the arrow in the loop would point to Report incidents.)

    Since you reference Marx’s just culture, in one of his examples, blame is apportioned to those who fail to report incidents.

  5. Jan Krouwer October 1, 2009 at 11:24 am #

    The NEJM article is great, but I don’t understand how you could previously rant about incident reporting systems. One needs to think in terms of a closed loop.

    Report incidents
    Classify and rank incidents
    Propose and implement corrective actions
    Measure incident rate

    (After Measure incident rate, the arrow in the loop would point to Report incidents.)

    Since you reference Marx’s just culture, in one of his examples, blame is apportioned to those who fail to report incidents.

  6. exodus October 2, 2009 at 1:06 am #

    By no means do I intend to condone the abysmally low rates of handwashing. Certainly, there is a lot of evidence to indicate it saves lives and prevents nosocomial transmission.

    However, I doubt the clinical leaders featured in the glossy pictures have tried washing their hands with soap and water while singing their A-B-C-D’s before and after each patient contact, while seeing a minimum of twenty patients a day; four-and-a-half days a week, at the height of the midwestern winter. Trust me, I’ve done this and my fissured hands were not the most comfortable parts of my anatomy.

    Here is where the dichotomy lies between clinical leaders and those on the front lines. Unless frontline professionals groom themselves selves into being the key opinion leaders of their organizations and speak for those who deliver patient care, handwashing is likely to take a back seat.

  7. Erik October 2, 2009 at 5:34 am #

    Doctors are to blame but there are systems problems here. We all remember days where there was no soap on the floor, no sink that worked, no foam (27 empty dispensers on the unit!), and the unbiquitous no paper towels.

    If hospitals are serious about this, then someone needs to make sure sinks work, there is soap and towels around each sink (not just an empty dispenser) and, most importantly, that empty foam dispensers are replaced in a timely manner.

    After that – it is the doc’s fault.

    No excuses means no exucses from either party.

  8. Prospero October 2, 2009 at 6:05 pm #

    And now for the response from the Loyal Opposition:

    No one can (rationally) argue with handwashing, but it does not follow that all safety initiatives are useful and should be enforced punitively. The expanded rush to mandate ever more layers of “show of process” (e.g. more forms, badly designed checklists) and “one size fits all” protocols does not have a good philosophical grounding.

    “Accountability” is merely another facet of professionalism, a trait that, sadly, a number of practitioners appear to lack. But trying to force a lot of half-baked committee-cooked “best practices” onto professionals who are the ones doing it right in a business vastly more complex than aviation will be demoralizing at best.

    Medicine is drowning in fashionable nonsense, from overzealous IRB’s that freeze out research, to the ACGME’s hilariously meaningless “core competencies,” to ever increasing (and never validated) CME requirements (with their own escalating demands for “learning objectives” and other “justification”), to more and more mandated hand entry of computer data, to all types of committees of disinterested (and therefore necessarily “unqualified”) people whose default answer is “no,” to now this idea of holding penalizing those who resist to the facile brainstorms of those like Wachter who hold themselves out as knowing better than thou.

    This trend toward hyperbureaucratization of medicine will not increase safety in hospitals because what endangers patients is not too little process or too few forms. It certainly is not because of too little punishment of clinicians.

    Safety means a lot of things, and there are lots of routes to it and a lot of smart people working to find those routes. But there appears to be a secret conceit among those making their careers in patient safety, an unspoken impulse that if voiced would be: “Everything will be better if all you horrible people just do what I say!”

  9. Annie October 2, 2009 at 7:56 pm #

    Years ago a brilliant nurse – Laura Gasparis – included in her workshops an anecdote about her critical care patients. Struggling to get physicians to order food and nutrition for long term ICU patients, one day she began to post a single number at the head of her patients’ beds. Everyone wanted to know what the number represented. Soon the docs and nurses were speculating that the higher the number, the better the patients’ management. When Laura was fairly certain that she had everyone’s attention, she revealed the “secret” code: the number stood for the number of days that patient had endured without nutrition. Not surprisingly, nutrition orders increased exponentially thereafter and remained satisfactory.

    The same process is in play here with accountability: publish compliance and infection rates by provider along with patient case load data. Some of handwashing compliance is directly related to patient case load, and so physician direct patient time/ case load and nurse staffing/ patient assignments will come under heightened scrutiny. This data will lend support to determining safe and manageable patient case loads.

  10. Legacy Flyer October 4, 2009 at 4:24 am #

    With respect to the retained surgical instrument in the pelvis alluded to by the pilot and his wife. His comment “checklist should have caught that” is naive. There is in fact a “checklist” to make sure that all instruments have been removed from the patient. It is called the “instrument count”. In all the operations that I have attended, at the end of the procedure an “instrument count” is performed by nurses. All packs of surgical instruments contain a known number of instruments – at the end of the procedure instruments are counted to make sure the count matches.

    The problem is that the “checklist” or “instrument count” sometimes is incorrectly performed. I have seen many cases where an instrument is counted as missing, but X-Rays show that it is not in the patient. Where did it go? Who knows, probably in the trash with the drapes. Similarly, presumably there were “correct” instrument counts in cases in which an instrument was left behind.

    In essence the problem is not that there is no “checklist” to prevent a retained instrument, the problem is that there is a “checklist” that was improperly performed. The solution to that problem is more complicated.

  11. Seema Syed October 5, 2009 at 8:45 pm #

    Great article again Bob! I too am a great fan of David Marx’s and James Reason’s work, but you are right, I have not seen much in being practiced, if it is, it is done for minor events and for major ones management prefers to take the axe approach:-)
    Recently when I was reading Michael Cohen’s book, Medication Errors, 2nd edition, I came across an interesting example on hand washing and was reminded of it upon reading your blog. Accordingly 4 studies were conducted whereby the PATIENTS started reminding the physicians/nurses to wash their hands. Consequently there was a 42% increase noted in the consumption of liquid antibacterial hand soap!
    Michael Cohen is the president of ISMP, Institute of Safe Medication Practices, and is quite well recognized.
    I guess involving the patients in their own care might “convince” health care professionals to wash their hands, take time out before surgery..etc…

  12. Seema Syed October 5, 2009 at 8:52 pm #

    Great article again Bob! I too am a great fan of David Marx’s and James Reason’s work, but you are right, I have not seen much in being practiced, if it is, it is done for minor events and for major ones management prefers to take the axe approach:-)
    Recently when I was reading Michael Cohen’s book, Medication Errors, 2nd edition, I came across an interesting example on hand washing and was reminded of it upon reading your blog. Accordingly 4 studies were conducted whereby the PATIENTS started reminding the physicians/nurses to wash their hands. Consequently there was a 42% increase noted in the consumption of liquid antibacterial hand soap!
    Michael Cohen is the president of ISMP, Institute of Safe Medication Practices, and is quite well recognized.
    I guess involving the patients in their own care might “convince” health care professionals to wash their hands, take time out before surgery..etc…

  13. Bob Wachter October 5, 2009 at 9:01 pm #

    Thanks, Seema — there’s another article with the same “what can patients do about their caregivers’ hand hygiene?” theme in this month’s Joint Commission Journal on Quality and Patient Safety; the abstract is here.

    The study found that, in the ambulatory setting, patients appeared willing to monitor and report on their providers’ adherence to hand hygiene, and their observations correlated well with other audit methods.

    That said, I remain skeptical that having patients monitor us and give us feedback is the right answer — too many patients will be concerned about polluting their relationship with their physician or nurse.

    More importantly, why should it be the patient’s job? The fact that this option even crosses our mind vividly illustrates the failures of both our systems and our professionalism.

  14. Seema Syed October 6, 2009 at 5:19 pm #

    Hi Bob! Very well said! It would be more and humiliating for us to be reminded of our professional responsibilities and duties. Yes, we should both behave professionally and treat patients professionally as well.. after all we are together in the quest for prevention of harm.. Once we are reminded of this, all safety policies and procedures will make sense and our compliance with them will increase, since we will become aware that there is no option to choose in performing safety initiatives. They have to be done for patients to be safe, just as we have to breathe to be alive!

    just some thoughts:-)

  15. docanon October 6, 2009 at 8:34 pm #

    I’m struggling for the meaning here. Part of me thinks this NEJM piece is just another straw man argument.

    Why is there a tension between the concepts “systems problem” and “individual accountability?” Isn’t this a false choice? After all, I can easily counter you: an organizational culture that tolerates repeated non-handwashing is a prime example of a systems problem. As James Reason says, you’ve gotta drain the swamp (fix the culture), not just swat the flies.

    I think what you’re really getting at is this: the phrase “systems problem” is sometimes misinterpreted to mean the exclusion of individual accountability…especially when people just chant the mantra “no blame.” However, there is no inherent conflict whatsoever between system-oriented thinking and individual accountability.

    So here’s your NEJM piece, in 7 word:
    “systems problem” does not equal “no blame”

    You can sever the monosynaptic connection to your BS detector now.

    At the end of the day, what matters is achieving the objective of decreasing nosocomial infection. If changing organizational culture is the low-hanging fruit in this endeavor, let’s grab it. But be warned: culture change is extremely difficult, especially in an environment of perverse incentives (we have exactly the health care system we’re paying for, right?). If a hospital rushes from one extreme (“no blame”) to another (culture change = top priority), it may overlook better options.

  16. Ashish Sethi October 7, 2009 at 2:35 am #

    I totally agree with you from a medical school perspective because we are taught from the very beginning about hand hygiene, which should make a dramatic difference in the near future, because I do notice that the students in my class have reaching for the hand sanitizer a mentally programmed action, just as many individuals my age are mentally programmed to wear a seat belt, whereas I sometimes catch my parents having to “remember” to wear that life saving strap. When I started driving 6 years ago (in Virginia) I know that wearing a seat belt was part of the grading system at our high school, just as now in school we cannot pass the clinical skills exam unless we both wash our hands prior to entering the room as well as wash our hands before we even touch the patient. I do not believe it is unreasonable at all for credentialing to mandate hand hygiene in the near future especially if other schools are taking as vigorous of an approach to prepare up and coming physicians.
    Also, on a side note in which I remember discussing a study about clothing (specifically ties), I do know that we are not allowed to wear ties, long sleeves, or white coats when seeing patients to prevent spread of infection. We have had three lectures completely dedicated to hand hygiene in half a semester of 2nd year and for comparison purposes we have had two hours dedicated to Hypertension. On top of that we also have periodic mandatory meetings to discuss infections spread from health care providers.
    Thanks for the great discussion!
    Ashish

  17. Kirsten Kangelaris October 7, 2009 at 11:08 pm #

    Hi Bob,

    I really enjoyed your NEJM piece and am convinced that enforcing accountability is critical to improving patient safety. I really liked that you laid out what specific penalties might look like to help jumpstart the accountability culture. I wondered if you had considered a monetary fine for early transgressions (a la pro-sports style) in addition to mandatory education, rather than loss of patient care privileges? The idea that physicians may be taken off wards or out of the operating room for not following protocol, say 3 times, would potentially also punish colleagues (who pick up the slack) and patients, whose care may be delayed. An unintended consequence may be a culture of not reporting observed transgressions. Also, do you envision that loss of privileges would be compounded with a paycheck cut? If not, time off may be seen as a welcome (if not a bit humiliating) paid vacation. $$$ talks!

    Great discussion!
    Kirsten

  18. Bob Wachter October 8, 2009 at 3:22 am #

    Thanks, Kirsten — some of this relates to governance; in general, it is difficult for medical staffs to enact fines. Rather, the usual way of dealing with transgressions is through suspensions which, for most physicians (who are paid fee-for-service) has the effect of a fine. The salaried physician could theoretically be suspended without pay, for the same impact. But it is useful to think out of the proverbial box.

    My hope, of course, is that most hospitals would have to suspend and/or fine relatively few physicians. My guess is that once the rules and penalties were established and the institution demonstrated that it was serious and that there would not be exceptions (yes, even for the high-earning CT surgeon), the problem would largely go away. But there will undoubtedly need to be a few test cases to demonstrate that level of seriousness.

  19. wrs October 8, 2009 at 4:24 pm #

    A southerner once told me, “Culture just ain’t somethin’ that grows in a deeesh”. I guess that’s true unless we’re talking about poor handwashing rates.

  20. sranji October 8, 2009 at 5:26 pm #

    Ashish Sethi said:
    “We have had three lectures completely dedicated to hand hygiene in half a semester of 2nd year and for comparison purposes we have had two hours dedicated to Hypertension.”

    Then your school’s priorities may be out of whack–and I say this as someone who teaches about quality and safety for a living.

  21. Paradigmatic October 14, 2009 at 2:21 pm #

    When reading your article, I felt very energized, and to be honest elated that someone was finally moving beyond politically correct rhetoric: however, when reading the comments, I was reminded of a radical political operative who once stated that “if you can’t logically defeat the openent, then laugh at them, because moving forward all people will remember is that people laughed at the other speaker, and from that point forward, nothing else they have said matters.”

    Another aspect that seems to be at play is not just that workplaces take forever to change behavior, but more importantly, they “CHOOSE” to delay making change by failing to plan for continual change or failing to encouraging change as part of their “normalized” operational behavior.

    By nature I have seen where people are slow to adopt ideas, change policies and procedures, or even accept operational changes that they know are beneficial: it is not that preserving the “status quo” is important, but rather that they “feel comfortable” and “safe”: in other words, they will change only if you can prove 100% zero-defects in the new behavior. They would prefer to live with mediocrity, than take necessary over new, and often uncertain, ground.

    For the writer who used the example of seatbelts: great example. Not pie in the sky, hypothetical, unrealistice, or naive. If physicians just got used to handwashing as a normalized part of every encounter, and other staff were actually in a “safe place” to comment on transgressors – just imagine the possibilities when extended beyond something like handwashing: this concept should already be a no-brainer in any professional organization.

  22. David Feldman October 30, 2009 at 2:17 am #

    Bob,
    Really enjoyed your article and was inspired by it’s message. Unfortunately, accountability for a somewhat nebulous and team-based process like a time-out is a bit more tricky to address then the black and white question of “did you wash your hands.” Nevertheless, our Periop Exec Committee is committed to holding our OR teams to a reasonable standard. I’m anxious to hear other’s comments on how to establish standards for an appropriate time-out and how to monitor these in an objective way.

  23. Julie George November 20, 2009 at 9:16 pm #

    As a proponent of Just Culture in occupational regulation, I was very pleased to see that you referenced it in your NEJM article.

    One hurdle to achieving balance between “no blame” and “individual blame” continues to be the desire for punishment when harm occurs. It seems that the employer or licensing board often determine culpability based on the outcome of an event rather than the intent or level of risk. “No harm, no foul” seldom rankles anyone, but when harm occurs, demands for punishment usually follow.

    Thank you for this insightful and provocative article.

  24. Sarah Hein December 2, 2009 at 7:39 pm #

    Bob,

    I agree with you completely: the equipment for handwashing is everywhere, the evidence for doing it is clear, so there’s really no excuse – it should be a “skill-based” or “automatic” habit at this point. The thing that bugs me is that there can still be lapses in skills-based processing. A person could be very very good about handwashing, but have a rare, momentary lapse, and miss one in error. I’d hate to see someone get fired or suspended over that.

    Sarah

  25. Bob Wachter December 4, 2009 at 4:28 am #

    For your information, in November, 2009 we hosted a poll on the site, which asked, “Should there be penalties (ie, suspension, fines) for caregivers who chronically fail to clean their hands before patient contacts?”

    The results further support my feeling that our profession is finally ready for a more accountability-oriented approach to violations of evidence-based safety rules. There were 50 total votes: 44 (88%) said yes, 3 (6%) said no, and 3 (6%) said that they weren’t sure.

    Per the last paragraphs of my original blog, I think that Dr. Drazen was correct.

  26. Sarah Hein December 7, 2009 at 4:37 pm #

    The key word being ‘chronically’ – I, too, vote yes.

  27. JG January 2, 2010 at 10:40 am #

    This dialogue is fascinating. Its great that we all differing opinions but in the end we all must wash our hands just like we all learned to put trash in the waste basket. Not washing hands is linked to the convenience and selfishness of the nurses and doctors back on themselves rather than the patient.
    Anyone actually concerned with compassion for patients will wash their hands. You cant tell me professionals cant remember to wash hands…I have been a nurse for 30 years before the hand gels every 2 feet. It couldnt be easier than today. When care providers care for patients enough to do what is required and expected..things like hand-washing gets done…Our medical professionals need to remember what business they are in and stop misbehaving. Its the regulatory law and we should hold our docs and nurses accountable and we should call out practice variations when we see it…

  28. Bob Wachter March 9, 2010 at 4:20 am #

    A nice article on philly.com on Abington Hospital’s efforts to avoid hospital-acquired infections using both carrots (raffle tix) and sticks (threats of loss of medical staff privileges for those caught not cleaning their hands), handed out by nurse-“spies”. They should be commended for taking this on, and for using a dramatic and fatal case of MRSA to motivate the staff to take hand hygiene seriously.

    http://www.philly.com/philly/news/homepage/86795712.html?viewAll=y

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