Quality

To Err is Human


 

The challenges facing SHM are very different than they were 10 years ago. In the 1990s, the focus was on building a society that would represent the needs of the practicing hospitalist. Converting NAIP, with its 200 members, to SHM, with its now 10,000 members, was certainly no easy task, but the society then enjoyed some luxuries no longer afforded to an organization the size of the modern-day SHM. Early on, SHM was far from the public eye, escaping public scrutiny for each of its actions. With only a few hundred members, the society was intimate: Almost every member knew of every action before it happened. And the agenda, compared with today’s standards, was reasonably focused.

But times are different now. The organization is much larger and complex, and the challenges we now face are collectively a product of our success. SHM is squarely in the spotlight; every decision is closely monitored by the public eye. We now have a voice such that when we speak, people listen. But with greatness comes responsibility, and because we are in the spotlight, we must be especially careful in how we speak, lest the message be misunderstood. Further, with more than 10,000 members, 50 full-time staff, 44 committees, and nearly 500 physician volunteers, the organization no longer has the luxury of every action being known by every member prior to its enactment.

More challenging still is our agenda, which has grown to be a diverse and far-reaching strategy. While impressive and admirable, the size of this “footprint” creates new challenges in balancing the need to be “nimble” (i.e., being able to act quickly enough to be timely and effective) versus being “thorough” (i.e., ensuring that each action is appropriately vetted prior to execution).

I suspect that there are few practicing hospitalists who have not read To Err is Human or Crossing the Quality Chasm.1,2 Both make this essential point about quality: In complex systems, mistakes are bound to happen. And when errors do occur, each member of the team must be ready to take responsibility for the mistake, and immediately begin seeking systematic solutions to ensure that it does not happen again. SHM’s focus is to advance quality for all hospitalized patients. But an organization can only be effective if it emulates the principles that it hopes its members will individually espouse.

10 Principles of SHM Business Relationships

  1. The relationship will promote the values and mission of SHM.
  2. The relationship will maintain SHM objectivity and independence.
  3. Program content will not reference or consider specific brands or products.
  4. Strong consideration should be given to using multiple sources whenever possible for sponsorship of SHM events, services, programs, conferences, or products.
  5. The relationship does not constitute an endorsement by SHM.
  6. SHM will be fully transparent with regard to the funding relationship.
  7. Program content will be developed by SHM in the manner in which SHM chooses, in accordance with accepted practices.
  8. Programs developed with support from external funders are operationally managed by SHM.
  9. SHM will not disclose contact information for program participants to funders unless the individual participant gives specific permission to be contacted.
  10. SHM and funder will determine program/project goals and objectives in advance of developing the partnership and will agree to these in a written memo of understanding or business agreement.

So let me start with this: There have been mistakes along the way.

That’s the hard truth. I believe that none of the mistakes have been intentional; rather, these missteps have been a product of an organization that has grown so fast, and whose success has gained so much public attention, that its infrastructure has struggled to keep pace with its growth. Any hospitalist who has seen his or her service size double in the span of a year or two knows of what I speak: As growth occurs, the approach to dealing with daily business has to evolve to meet new demands. If it does not, errors result.

One of the areas in which SHM’s growth has outpaced its policies and procedures regards SHM’s relationship with industry. I will say from the outset that having relationships with industry is not in and of itself a mistake. The reality is that without such relationships, in the setting of a landscape where governmental and philanthropic funding is disproportionately in deficit to the need, it would be almost impossible to advance the quality initiatives that have defined SHM’s success. SHM has, and will likely continue to have, relationships with industry. But requisite for having these relationships, especially for an organization that is a national leader, is going above and beyond the minimum standards to ensure transparency and ethics.

Two years ago, SHM began the arduous process of reviewing its partnerships and how it interacts with industry. I am pleased to announce that this has culminated in the Council of Medical Specialty Societies (CMSS; www.cmss.org) asking SHM to apply to become an affiliate member. Acceptance of SHM into CMSS is evidence of SHM’s demonstrated compliance with CMSS’s requirements, with respect to industry relationships, disclosure of conflicts of interest, and other measures of organizational transparency, all of which can be found at www.hospitalmedicine.org/industry.

But meeting the minimum standards has never been sufficient for SHM. The cost of greatness is responsibility, and as a national leader, SHM has a responsibility to ensure that its approaches to potential conflicts of interest and external relationships are above reproach.

COI Disclosure

The conflict of interest statements for each board member have long been posted on the SHM website. In an effort to go above and beyond the minimum standards, the format of the disclosure form has been revised, making it the most compete and detailed COI disclosure form of any physician organization in the country. In the coming months, SHM will make even tighter restrictions regarding disclosing potential conflicts of interest. While board members are required to report any and all financial receipts, the amended version will require board members who receive any contribution in excess of $5,000 to provide a detailed narrative as to what was required in service for the receipt of those funds. Further, to ensure collective accountability, any board member may call upon any other board member to provide a similarly detailed description of any item on his or her COI disclosure form.

Recognizing that other leaders in the organization might also have influence over important decisions, thereby being at risk for a conflict of interest, SHM is one of the first physician organizations to require public reporting of COI disclosures for all editors, course directors, and senior staff.

Next year, all committee chairs and quality-improvement (QI) project leaders will be required to submit similar COI disclosures.

But reporting potential conflicts is one thing; ensuring that those with significant conflicts are not put in a position of inescapable conflict of interest by virtue of their appointments is another. To be proactive, the executive committee has a designated meeting each year to individually review each nominee being considered for election to the board, committee chairs, editors, and course directors prior to their appointment.

The society will enforce CMSS Standard 1.4, which prohibits key society leaders (president, past-president, president-elect, CEO, editors, course directors) from having direct financial relationships with companies during his or her term of service. All people seeking such positions will be required to attest, at the time of the nomination, to cease all direct financial relationships prior to seeking office; failure to do so will negate their candidacy for the position they seek.

One of the areas in which SHM’s growth has outpaced its policies and procedures regards SHM’s relationship with industry. I will say from the outset that having relationships with industry is not in and of itself a mistake. The reality is that without such relationships … it would be almost impossible to advance the quality initiatives that have defined SHM’s success.

External Communications Regarding Industry

It is one thing to have potential conflicts disclosed on a website; it is quite another to ensure, with 100% confidence, that all recipients of all communications from SHM are aware of this website. Reminding all representatives of SHM to alert communication recipients to our potential conflicts of interest is a good start, but in quality parlance, this is tantamount to “telling people to try harder,” which is rarely an effective strategy to ensure 100% compliance. In response, SHM has designed a fail-safe systems solution to ensure that every communication alerts the recipient to SHM’s potential conflicts of interest. Beginning this year, SHM letterheads and e-mail, used for all written communications with external parties, will carry the following statement on the bottom of each page: “To Learn More About SHM’s Relationship with Industry Partners, Visit www.hospitalmedicine.org/industry.

One of SHM’s missteps over the years has been the failure to distinguish external communications regarding pharmaceuticals/devices as being different from the organization’s other nonpharmaceutical communications. This unintentional oversight has been a product of the exponential increase in the society’s external communications during the past 10 years. But nonetheless, the distinction between these types of communications is important, especially for a society that receives industry support for its quality initiatives.

At the August board meeting in Chicago, a special ad hoc committee was appointed to develop specific policies regarding SHM’s communication strategy. This committee will bring to the board in November the following policy for approval: “Before SHM makes a specific comment, writes a letter, or posts an official statement on the SHM website about a pharmaceutical agent, a medical device, a specific disease state, or any medical IT services or products, the communication must be approved by the Executive Committee and reflected in the minutes of the Executive Committee. At the President’s discretion, the proposed communication will be brought to the entire Board for discussion and approval.

As noted below, all agendas and decisions by the executive committee are communicated to the board, further ensuring accountability and oversight for any such decision.

Choices and Definitions

In the early years, all external relationships were initiated by SHM. Because SHM was a relative unknown on the national scene, if a relationship was to be entertained, it was based on SHM’s initiative to do so. Naturally, the smaller number of relationships, and the fact that the choice and nature of the relationship were initiated by SHM, made it easier to define the scope of such relationships. But now things are different: SHM’s agenda now encompasses a vast set of domains, and SHM is regularly on the receiving end of invitations to establish relationships with other organizations. Once again, as a leader of medical specialty organizations, SHM’s policies and procedures have to adapt to fit the needs of a larger and more diverse organization.

An intense amount of work has been devoted to evolving the mechanism by which SHM chooses and defines its relationships. An ad hoc committee from the board of directors has defined the 10 principles of SHM’s business relationships (see “10 Principles of SHM Business Relationships,” p. 42). In November, the board will adopt policies and procedures that will ensure that SHM will continue to only enter into relationships with external organizations with which it shares common interests or goals for advancing the quality and safety of patient care. SHM will continue to avoid influence from external organizations with respect to the policies, conduct, actions, and priorities of SHM.

Further, by policy, SHM will continue to reserve absolute control over all content and speakers at its educational conferences; content will continue to not be influenced by brand or product consideration during development or revisions. All potential partners will be informed from the outset that a partnership with SHM does not imply that SHM endorses the policies, values, and missions of the partner organization; any significant deviation from the values and mission of SHM will dissolve the partnership. SHM will establish from the outset that a partnership does not imply SHM’s support or endorsement of any products from a partner. As noted above, transparency of these relationships will be of paramount importance: All relationships, including the dollar amounts received as a product of those relationships, will be posted on SHM’s website.

Transparency in Decision-Making

As noted from the outset, the benefit of small organizations with limited agendas is that every member knows every decision. With limited decisions to be made, the vetting and review process is virtually assured. As organizations grow, as agendas expand exponentially, and as the pace quickens, the multiperson review of each decision becomes difficult to assure. The result is that errors start to appear—not due to intentional wrongdoing, but because the luxury of intense oversight is lost as the organization expands. For an organization to grow and still maintain oversight of its decision-making process, it is vital that the organization evolve to develop new methods of accountability and transparency.

To meet this need, SHM has enacted a change in its communication infrastructure to ensure “double-checks” for all of the important organizational decisions. An SHM leadership and staff “wiki” has been developed to promote and ensure transparency of all organizational decisions. Because it is accessible only to the SHM staff, board, and committee chairs, the wiki is invisible to the SHM membership. Nonetheless, you should know of this important innovation.

The wiki requires that all committee chairs post the results of their committee activities. This ensures that staff and committee leadership are on the same page, ensures that other committees are not duplicating work, augments collaboration across committees, and, most importantly, ensures collective accountability for each decision made.

Technology-based innovations have been enacted to improve the transparency of the executive leadership of the organization. The board of directors meets four times a year; the purpose of the board is to ensure oversight for all SHM decisions. Because the board comprises exclusively volunteer members meeting only four times a year, it is practically impossible for the board to approve every decision made by an organization as large as SHM. To ensure the necessary efficiency and effectiveness (i.e., being sufficiently “nimble” to act on important issues in between scheduled board meetings), the executive committee (EC) was established years ago. The EC, comprised of the president, the past-president, the president-elect, and the CEO, meets every two weeks via teleconference to review and approve all essential SHM decisions.

As an innovation to augment accountability and transparency, the agenda and minutes of the EC are now posted on the SHM board portal, allowing all board members to review and comment upon the decisions made by the president, the CEO, or the EC as a whole. Any board member, at any time, can request that the full board be convened to review an agenda item or decision.

And underlying all of these initiatives to improve an already exceptional organization are the tireless efforts of the SHM staff. Though there are nearly 50 staff members now, each continues to do the work of multiple people. SHM is arguably the fastest-growing organization in history, and advancing the organization to level after level has been an exceptional challenge. But regardless of the challenge, SHM leadership and staff has come through. I have no doubt that during this next chapter in SHM’s history, the result will be the same.

SHM is committed to advancing quality. Intrinsic to the “culture of quality” is the commitment to honesty, transparency, and ethics. Any permutation of the society that does not fully exemplify these standards will be ineffective in accomplishing our wished-for goal. In short, the actions of the society must model those that we wish to inspire in the day-to-day practice of our members. Although the unprecedented growth of the society is responsible for errors in the past, the importance of admitting our shortcomings is no less significant. We’ve had some missteps along the way, and while these mistakes are a product of events preceding my tenure, it does not matter. As president of the organization, I am taking responsibility for them, with a pledge to devote all time and energy, with all due speed, to finding systematic solutions that will prevent these errors from happening again.

And let me be even more honest. As we go forward, there are probably going to be more missteps; such is the nature of a growing and active organization. I cannot promise an error-free organization, but I can promise that if and when errors are made in the future, the same intensity will be applied to seek systematic solutions to ensure that we continue to evolve in becoming an organization that is emblematic of quality. Such is the promise of SHM; such is the promise of the hospitalist. TH

Dr. Wiese is president of SHM.

References

  1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 2000.
  2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001.

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