As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).
We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.
Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.
The Accountability Imperative
If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”
Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.1 The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.
The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.
Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “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.”1
Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.
Accountability and Autonomy
Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.
Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.2 He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”
Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.
Failure to Perform Not an Option
It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.
Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”
Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.
Dr. Frost is president of SHM.