Firing physicians?

The Society of Hospital Medicine ( closed its annual meeting with a bang, with hospital medicine rock star Dr. Robert Wachter, calling for balance between individual physician accountability and the no-blame culture that has dominated the patient safety field until recently.

The outside world sees physicians as “circling the wagons” and “not willing to ask the hard questions and take the hard action,” he said. “I think they’re actually completely right.”

The no-blame culture arose from a seminal paper, “The Wrong Patient,” reported in 2002 that examined a patient who was mistaken taken for another patient’s invasive cardiac procedure. A root cause analysis identified 17 distinct errors, no single one of which could have caused the adverse event by itself. The interpretation of this and other cases like it was that the system was at fault and that blame is inappropriate and distracting.

But much has transpired since 2002.

“What’s changed is the recognition that our system produces low quality, unsafe, unreliable care, partly because there’s been no incentive to do any thing other than professionalism, which we’ve come to recognize is too weak an incentive to get systems to completely transform the way they do their work…,” Dr. Wachter said.

Individual physicians have been somewhat insulated from the pressures of accountability because hospitals – by their very size and capacity for data handling – are more likely to end up in the cross hairs of governing agencies, media and patients. Consider the popularity of Web sites like Hospital Compares  and Dr. Wachter’s favorite.

Hospitalists however, may find themselves the target of hospital accountability, he suggests, because they draw most of their dollars from hospitals and have positioned themselves as the quality and safety leaders. “Who are hospitals going to pressure? Neurosurgeons” who bring in thousands of dollars?, he asked.

Still, Dr. Wachter sees this as an opportunity for hospitalists to ultimately change the nature of the way care is delivered in hospitals through leadership and the creation of new quality and safety systems that reduce errors and improve quality. No less than 400 papers detailing such efforts were submitted to SHM 2009 alone.

While there remains a place for withholding blame, the new thinking is that there should be a clear demarcation of blameworthy acts, he said.

“There are firing offenses in every safe industry,” he said. “They mostly are no blame; they want to encourage people to speak up, but they have certain lines that are quite clear that require real action. We have not done that and I think we have to change that.”

-By Patrice Wendling

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