Learning Accountability for Patient Outcomes

EACH YEAR, AN ESTIMATED 100 000 PATIENTS DIE OF health care–associated infections, another 44 000 to 98 000 die of other preventable errors, and tens of thousands more die of diagnostic errors or failure to receive recommended therapies. Physicians are overconfident about the quality of care they provide, believing things will go right rather than wrong, assuming they provide higher-quality care than the evidence suggests, and thinking they alone have sufficient knowledge and skills to provide care. Teamwork failures are common contributors to harmful errors. In many cases, someone knew something was wrong and either did not speak up or spoke up and was ignored. It is unclear how many teamwork and communication failures result from arrogance. Most clinicians have personal stories of arrogance causing patient harm. My own involved a patient who had classic signs of a latex allergy, but for whom the operating surgeon refused to change gloves, convinced the patient was not experiencing a latex allergy. Only after I threatened to call the dean did he change gloves. Patients also share stories of physicians who made it clear that they were not to be questioned. Despite a decade-long effort to improve safety, there is limited empirical evidence of improved patient outcomes. To be accountable for patient harms, health care needs valid and transparent measures, knowledge of how often harms are preventable, and interventions and incentives to improve performance. The science of patient safety is immature and underfunded. Few patient harms can be accurately measured or the extent of preventability even known. Central line–associated bloodstream infection (CLABSI) is an exception. This infection is common, costly, and is associatedwiththedeathof31 000patientsannuallyintheUnited States,yet itcanbeaccuratelymeasuredandlargelyprevented. For instance, a multifaceted intervention (which involved a checklist of prevention practices, strict measurement of infectionrates,andtoolstoimprovecultureandteamworkamong physicians,nurses, andadministrators) implemented inmore than 100 intensive care units in Michigan reduced CLABSIs by 66%, and sustained a median infection rate of zero and a mean of 1 infection per 1000 catheter-days for more than 3 years. Others have achieved similar results. CLABSI is a bellwether for holding health care professionals accountable for patient outcomes. Accountability for patient outcomes traditionally rests with professional selfregulation. When evaluating a hospital’s infection rate comprising the practices of many clinicians, hospital leaders also must be accountable. Too often, neither physicians nor hospital leaders hold themselves accountable for patient outcomes. Many hospital infection rates are substantially higher than the national average, and public reporting seems essential to garner the attention these infection rates deserve. The CLABSI intervention is being spread to other states. The secretary of the Department of Health and Human Services called for a 50% national reduction in CLABSI over 3 years, creating the first quantifiable patient safety goal in the United States. Hospital enrollment in the program has been surprisingly slow. In many states, less than 20% of hospitals have volunteered to participate. Some hospitals have reduced infection rates, most have not. Some hospitals claim they use the checklist, despite having high or unknown infection rates. Some hospitals are content to meet the national average, despite evidence that these rates may be reduced by half. Some hospital administrators say their patients are too sick; these infections are inevitable. Yet, intensive care units in several large academic hospitals have nearly eliminated CLABSIs. Some hospitals blame competing priorities for their inattention to these infections. If these lethal, expensive, measurable, and largely preventable infections are not a priority, what is? Perhaps most concerning is the response from nurses in participating hospitals when asked: “if a new nurse in your hospital saw a senior physician placing a catheter but not complying with the checklist, would the nurse speak up and would the physician comply?” The answer is almost always, “there is no way the nurse would speak up.” Doubly disturbing, physicians and nurses uniformly agree patients should receive the checklist items. What other industry would accept a routine safety violation that is associated with the deaths of tens of thousands of patients and not be held ac-