Chief of Staff Column
I hope you have already seen the notice about our new mandatory flu vaccine policy for our medical staff members. While preparing that policy, I discussed it informally with a number of physicians. The large majority of those colleagues were very supportive, but a few were disturbed by the prospect – among other concerns, they wanted to know what right I had to require them to be vaccinated.
Putting aside the fact that it’s the Medical Executive Committee, not me, that decides such policy, I’d like to turn that question around. What right does a physician have to needlessly put a patient at risk, when virtually every recognized infection control expert knows that a simple vaccination is an extraordinarily safe measure which will substantially reduce the risk of transmitting a potentially dangerous illness to our own patients?
Turn the question around once more: Don’t our patients have the right to expect their physicians (and other caregivers) to protect their health and safety while they are under our care? Shouldn’t they be able to expect that of course we will get vaccinated against flu, that we will test ourselves for TB, that we will wash our hands between patient contacts, and that in general we will follow those policies and best practices which our health care institutions adopt in order to promote patient safety.
Or to put it more succinctly: It’s the patients, stupid.
Ten years after the publication of the now iconic report, “To Err Is Human”, from the Institute of Medicine, it’s instructive to look back at the evolution of our thinking about how best to promote patient safety.
First came recognition that the longstanding medical culture of “blame and shame” was actually antithetical to patient safety, in that it inhibited identification and reporting of systems failures. It was recognized that systems engineering – the effort to identify and improve those patient care processes which were not robust enough to prevent inevitable human errors from leading to patient harm – was a much more productive approach than simply continuing to identify and punish human errors in the futile hope that we could all be perfect if we just tried hard enough.
But a completely blame-free culture soon came to be seen as unbalanced in its own way, as it was recognized that while it is true that to err is human, it is also true that some measure of accountability is necessary in any important human endeavor.
Fair and Just Culture (FJC) was developed as a framework to re-balance those two perspectives. You may recall that this was the theme of the last SUMC Summit for Clinical Excellence nearly a year ago and that it was discussed in some detail in this column in August/September 2008 and again the following December.
Although Fair and Just Culture provides an excellent philosophical overview of this balance between “no blame” and accountability, and between blameworthy vs. blameless acts, we have come to see over the past few years that very few institutions have managed to translate theory into practice.
In other words, as was recently pointed out by Wachter and Provonost in an excellent NEJM article, nobody is actually holding physicians accountable in an effective way.
Wachter, in a related blog posting, focuses on hand hygiene as an emblematic issue which illustrates this lack of accountability:
“In fact, at my hospital, I will be suspended from the medical staff if I fail to sign my discharge dictations. But if I choose to not clean my hands for the next 5 years, I'll experience no consequences whatsoever. Does that seem right to you?”
Well, no, it doesn’t seem right to me, and I hope not to you. I have no doubt that it doesn’t seem right to patients, regulators and legislators either. I would submit that if we don’t find a way to hold ourselves accountable, others will soon be more than willing to assist us.
Flu vaccination is one way of protecting patient safety that is relatively easily monitored and enforced, and so we intend to do just that. Other patient safety practices which Wachter and Provonost feel are overdue for some accountability include:
- Practicing hand hygiene
- Following institutional guidelines when signing out to another physician
- Performing a “time-out” before surgery
- Marking the surgical site per institutional guidelines
- Using the checklist when inserting central venous catheters
These practices are less easily monitored and enforced, but I do agree with those authors that it is time for us to explore ways to increase physician accountability for following appropriate safety practices. Yes, we must first and always attend to systems issues which inhibit compliance, but at some point we’ve also got to simply insist that folks follow the rules.
I know that grates on the independent sensibilities of some physicians, and I’ll confess that I’m not generally a big fan of rules myself. But honestly, we just have to get over it. It’s not all about us – it’s the patients, stupid. Clinical privileges really are privileges, not rights, and I don’t think it’s unreasonable to expect physicians to follow certain safety rules and protocols if they want the privilege of caring for patients at SHC.
It’s time to wrap our minds around the concept of physician accountability and embrace it, not just for the sake of our patients but also to preserve the degree of self-governance which we currently enjoy - in a society that will not long continue to tolerate the status quo.
Bryan Bohman, M.D.
Chief of Staff
