A commentary in the Oct. 1 New England Journal of Medicine (2009;361(14):1401-1406) says physicians should be held more accountable when they violate recognized medical-safety practices. The leader of one of the nation’s largest HM companies agrees with the article’s premise, although hospitalwide discipline change will be difficult to implement.
Robert Bessler, MD, president and CEO of Sound Inpatient Physicians in Tacoma, Wash., says greater accountability should be the overarching goal when the systemic causes of medical errors have been addressed and evidence-based safety processes are established. Once those definitions are in place, “if people still fail to meet recognized safety practices, there should be personal accountability,” Dr. Bessler says. “I applaud the sentiments of the NEJM article, but I can see that this may be hard to implement.”
Coauthors Robert Wachter, MD, FHM, professor and chief of the division of hospital medicine at the University of California at San Francisco, and Peter Pronovost, MD, PhD, director of the quality and safety group at Johns Hopkins University in Baltimore, propose balancing the “no blame” philosophy at the core of the patient-safety movement with provider performance expectations and penalties for failure to adhere to best practices. The authors offer the example of hand hygiene, which rarely rises above 30% to 70% compliance in hospitals despite evidence it prevents infections.
The biggest roadblock to making physicians accountable for practices might be the complex relationship between hospitals and medical staffs—namely, the hospital administrations’ reluctance to anger the physicians who bring in patients, Dr. Bessler says. It might be easier to influence the behavior of hospitalists, he explains, because of the role they play inside the hospital.
As a contract provider of hospitalists, Dr. Bessler’s company exerts influence on the behavior of its physicians through orientation, mutual performance evaluations, and the exchange of quality and performance data. “Physicians who don’t share our core values wouldn’t make partners, so it’s a financial and career development issue,” he says. But the best “stick” for changing behavior, he adds, is sharing actual performance data with physicians, who tend to be competitive about their performance.