Failure to Follow Safety Standards Needs Penalties

ROSEMONT, ILL. — Despite major patient safety strides during the past decade, health care providers need to create more accountability for medical errors and patient safety lapses in order to continue improving, according to Dr. Robert M. Wachter, professor of medicine at the University of California, San Francisco.

At the Joint Commission national conference on quality and patient safety, Dr. Wachter offered his perspectives on the status of patient safety in health care 10 years after the publication of the first Institute of Medicine report, “To Err Is Human: Building a Safer Health System.” He and Dr. Peter J. Pronovost of Johns Hopkins University, Baltimore, published an editorial on the topic shortly after the conference (N. Engl. J. Med. 2009;361:1401-6).

Balancing a culture of “no blame” with a culture of accountability remains a key challenge for providers. Although it's true that “most errors are committed by caring, competent people trying hard to get it right … the system produces low-quality, unsafe, unreliable care partly because there's been no business case to do otherwise,” he said.

“'No blame' is the right response for innocent slips and mistakes, which turn out to be most errors. But there need to be clear demarcations of blameworthy acts—not just gross incompetence, not just disruptive behavior, but also failure to follow reasonable safety standards,” said Dr. Wachter, who edits two online publications for the Agency for Healthcare Research and Quality: WebM&M (www.webmm.ahrq.govwww.psnet.ahrq.gov

Dr. Wachter cited the fact that average hand washing compliance rates continue to hover at only about 50% as an example of the need for more accountability. “I don't believe that is fully a systems problem,” he said. Part of the problem is that “there have been no penalties for transgressions.”

Although accountability is essential, “my guess is it will go too far,” Dr. Wachter added. “We've created an environment where people don't want to have to talk about errors. We're probably going to have to go too far and then come up with a sweet spot.”

Dr. Wachter also commented on other aspects of patient safety:

▸ Regulation. Health care organizations need regulators to set standards, but the challenge is ensuring that these standards truly help organizations improve safety. Until the Joint Commission developed standards for reading back instructions, “virtually none of us thought of doing that on our own,” he said.

At the same time, “it is extraordinarily difficult to have a set of rules and standards that apply equally in nuanced areas to organizations that are incredibly different in the way they do business, their financial resources, and their capacity,” he added.

For that reason, regulation is useful to get people moving, “but it tends to run out of gas over time,” Dr. Wachter said. To illustrate, he cited the Joint Commission's recent decision to remove adherence to medication reconciliation standards as a requirement for accreditation because organizations struggled to develop appropriate processes.

However, having an “outside organization creating rules and standards we must abide by was extraordinarily important in the first 5 years” after the IOM report, he said. Despite some glitches, “the Joint Commission has improved its processes tremendously” and recently made an important step in the right direction with the creation of the Center for Transforming Healthcare.

▸ Reporting. “The admonition to report everything is silly,” Dr. Wachter said. “Our mistake here was to not be thoughtful about what we are going to do with all of these reports” before requiring them.

However, providers have learned from this experience and begun to think more critically about what should be reported and how the data should be used, he said.

State reporting requirements on the 27 “never events” put forth by the National Quality Forum have led to more focused patient safety efforts. “Until the state reporting system, our process [at UCSF] for doing root cause analysis was pretty haphazard,” he noted. Now the institution holds a weekly 2-hour root cause analysis meeting attended by the same group of leaders.

▸ Information technology. Health care providers have developed a more robust, less naive understanding of the role of health care information technology in patient safety and now realize that it is not a panacea. Improvement efforts are not nearly as effective “if we just do the computer piece but don't educate people,” Dr. Wachter said.

Still, “even though we've got plenty of room to go, I think we should all be proud” of what has been accomplished in the past 10 years, he said.

ROSEMONT, ILL. — Despite major patient safety strides during the past decade, health care providers need to create more accountability for medical errors and patient safety lapses in order to continue improving, according to Dr. Robert M. Wachter, professor of medicine at the University of California, San Francisco.

At the Joint Commission national conference on quality and patient safety, Dr. Wachter offered his perspectives on the status of patient safety in health care 10 years after the publication of the first Institute of Medicine report, “To Err Is Human: Building a Safer Health System.” He and Dr. Peter J. Pronovost of Johns Hopkins University, Baltimore, published an editorial on the topic shortly after the conference (N. Engl. J. Med. 2009;361:1401-6).

Balancing a culture of “no blame” with a culture of accountability remains a key challenge for providers. Although it's true that “most errors are committed by caring, competent people trying hard to get it right … the system produces low-quality, unsafe, unreliable care partly because there's been no business case to do otherwise,” he said.

“'No blame' is the right response for innocent slips and mistakes, which turn out to be most errors. But there need to be clear demarcations of blameworthy acts—not just gross incompetence, not just disruptive behavior, but also failure to follow reasonable safety standards,” said Dr. Wachter, who edits two online publications for the Agency for Healthcare Research and Quality: WebM&M (www.webmm.ahrq.govwww.psnet.ahrq.gov

Dr. Wachter cited the fact that average hand washing compliance rates continue to hover at only about 50% as an example of the need for more accountability. “I don't believe that is fully a systems problem,” he said. Part of the problem is that “there have been no penalties for transgressions.”

Although accountability is essential, “my guess is it will go too far,” Dr. Wachter added. “We've created an environment where people don't want to have to talk about errors. We're probably going to have to go too far and then come up with a sweet spot.”

Dr. Wachter also commented on other aspects of patient safety:

▸ Regulation. Health care organizations need regulators to set standards, but the challenge is ensuring that these standards truly help organizations improve safety. Until the Joint Commission developed standards for reading back instructions, “virtually none of us thought of doing that on our own,” he said.

At the same time, “it is extraordinarily difficult to have a set of rules and standards that apply equally in nuanced areas to organizations that are incredibly different in the way they do business, their financial resources, and their capacity,” he added.

For that reason, regulation is useful to get people moving, “but it tends to run out of gas over time,” Dr. Wachter said. To illustrate, he cited the Joint Commission's recent decision to remove adherence to medication reconciliation standards as a requirement for accreditation because organizations struggled to develop appropriate processes.

However, having an “outside organization creating rules and standards we must abide by was extraordinarily important in the first 5 years” after the IOM report, he said. Despite some glitches, “the Joint Commission has improved its processes tremendously” and recently made an important step in the right direction with the creation of the Center for Transforming Healthcare.

▸ Reporting. “The admonition to report everything is silly,” Dr. Wachter said. “Our mistake here was to not be thoughtful about what we are going to do with all of these reports” before requiring them.

However, providers have learned from this experience and begun to think more critically about what should be reported and how the data should be used, he said.

State reporting requirements on the 27 “never events” put forth by the National Quality Forum have led to more focused patient safety efforts. “Until the state reporting system, our process [at UCSF] for doing root cause analysis was pretty haphazard,” he noted. Now the institution holds a weekly 2-hour root cause analysis meeting attended by the same group of leaders.

▸ Information technology. Health care providers have developed a more robust, less naive understanding of the role of health care information technology in patient safety and now realize that it is not a panacea. Improvement efforts are not nearly as effective “if we just do the computer piece but don't educate people,” Dr. Wachter said.

Still, “even though we've got plenty of room to go, I think we should all be proud” of what has been accomplished in the past 10 years, he said.

ROSEMONT, ILL. — Despite major patient safety strides during the past decade, health care providers need to create more accountability for medical errors and patient safety lapses in order to continue improving, according to Dr. Robert M. Wachter, professor of medicine at the University of California, San Francisco.

At the Joint Commission national conference on quality and patient safety, Dr. Wachter offered his perspectives on the status of patient safety in health care 10 years after the publication of the first Institute of Medicine report, “To Err Is Human: Building a Safer Health System.” He and Dr. Peter J. Pronovost of Johns Hopkins University, Baltimore, published an editorial on the topic shortly after the conference (N. Engl. J. Med. 2009;361:1401-6).

Balancing a culture of “no blame” with a culture of accountability remains a key challenge for providers. Although it's true that “most errors are committed by caring, competent people trying hard to get it right … the system produces low-quality, unsafe, unreliable care partly because there's been no business case to do otherwise,” he said.

“'No blame' is the right response for innocent slips and mistakes, which turn out to be most errors. But there need to be clear demarcations of blameworthy acts—not just gross incompetence, not just disruptive behavior, but also failure to follow reasonable safety standards,” said Dr. Wachter, who edits two online publications for the Agency for Healthcare Research and Quality: WebM&M (www.webmm.ahrq.govwww.psnet.ahrq.gov

Dr. Wachter cited the fact that average hand washing compliance rates continue to hover at only about 50% as an example of the need for more accountability. “I don't believe that is fully a systems problem,” he said. Part of the problem is that “there have been no penalties for transgressions.”

Although accountability is essential, “my guess is it will go too far,” Dr. Wachter added. “We've created an environment where people don't want to have to talk about errors. We're probably going to have to go too far and then come up with a sweet spot.”

Dr. Wachter also commented on other aspects of patient safety:

▸ Regulation. Health care organizations need regulators to set standards, but the challenge is ensuring that these standards truly help organizations improve safety. Until the Joint Commission developed standards for reading back instructions, “virtually none of us thought of doing that on our own,” he said.

At the same time, “it is extraordinarily difficult to have a set of rules and standards that apply equally in nuanced areas to organizations that are incredibly different in the way they do business, their financial resources, and their capacity,” he added.

For that reason, regulation is useful to get people moving, “but it tends to run out of gas over time,” Dr. Wachter said. To illustrate, he cited the Joint Commission's recent decision to remove adherence to medication reconciliation standards as a requirement for accreditation because organizations struggled to develop appropriate processes.

However, having an “outside organization creating rules and standards we must abide by was extraordinarily important in the first 5 years” after the IOM report, he said. Despite some glitches, “the Joint Commission has improved its processes tremendously” and recently made an important step in the right direction with the creation of the Center for Transforming Healthcare.

▸ Reporting. “The admonition to report everything is silly,” Dr. Wachter said. “Our mistake here was to not be thoughtful about what we are going to do with all of these reports” before requiring them.

However, providers have learned from this experience and begun to think more critically about what should be reported and how the data should be used, he said.

State reporting requirements on the 27 “never events” put forth by the National Quality Forum have led to more focused patient safety efforts. “Until the state reporting system, our process [at UCSF] for doing root cause analysis was pretty haphazard,” he noted. Now the institution holds a weekly 2-hour root cause analysis meeting attended by the same group of leaders.

▸ Information technology. Health care providers have developed a more robust, less naive understanding of the role of health care information technology in patient safety and now realize that it is not a panacea. Improvement efforts are not nearly as effective “if we just do the computer piece but don't educate people,” Dr. Wachter said.

Still, “even though we've got plenty of room to go, I think we should all be proud” of what has been accomplished in the past 10 years, he said.