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