The statistics are sobering: Nearly 2 million patients a year develop infections during their hospitalizations, and 90,000 to 100,000 of them die as a result; hand-hygiene rates range from 30 to 70 percent at most acute care facilities; about 4,000 wrong-site surgeries are performed each year; and the number of sentinel events reported to the Joint Commission rose significantly in five of 10 categories in 2009.
Frustrated by those facts, a growing number of hospitals are boosting their current safety-improvement efforts by establishing a new kind of accountability standard for their staff members. This method assumes that hospitals have adequate safety systems in place, but that some physicians and others are not adequately abiding by those strategies. While the hospitals eschew the old "blame and shame" method of singling out individuals who make mistakes, they use peer pressure and other techniques grounded in human factors research to change behavior.
The results have been significant, from achieving nearly universal compliance with hand hygiene protocols to practically eliminating ventilator-associated pneumonias. However, cautions Peter Pronovost, M.D., a Johns Hopkins safety expert and professor of anesthesiology, these hospitals are in a small minority. "Meatpacking plants have more accountability than hospitals do," he says.
Donald Goldmann, M.D., senior vice president of the Institute for Healthcare Improvement, agrees. "Most hospitals do not have a system in place to hold people accountable for violations of safety practices. They do for things like a surgeon who comes in drunk every day. But the accountability for not washing your hands or doing other things that are well-enabled by the hospital is not very strong."
Why haven't hospitals taken a stronger stand? Experts cite two major reasons: First, many fear offending physicians who bring in a lot of business. Second, hospital administrators are reluctant to cross into the clinical territory that has traditionally been governed through peer review.
Hospitals are more likely to discipline nonphysician employees who violate safety rules, says Craig Clapper, chief operating officer of HPI, a firm in Virginia Beach, Va., that advises hospitals on safety practices. When that happens, morale takes a bruising. "In my discussions with hospital staff, it's a major dissatisfier that there is one standard for hospital employees and another standard for physicians, even if they're employed by the hospital," he says.
Disciplinary Methods Vary
Even hospital leaders who believe in accountability view disciplining physicians who consistently violate safety rules as a last resort. The main idea is to build a collaborative culture that "hardwires" safety into the thinking of everyone who works in the hospital, says Robert Connors, M.D., a pediatric surgeon who is president of Helen DeVos Children's Hospital in Grand Rapids, Mich.
That's true, Pronovost says, but once hospitals have reliable safety systems in place, they need the threat of sanctions to ensure that everyone follows the rules. "Everywhere I go, I hear frustrated nurses and hospital leaders say that they still have physicians who refuse to wash their hands, who refuse to gown when they're putting a central line in, who refuse to put on a yellow gown with a patient who has MRSA when they walk in the room," he explains. "Doctors need permission to make mistakes. We're human, we're going to forget things. But we don't have permission to expose patients to unnecessary risks. If a staff member corrects a physician and they flagrantly violate those safety standards, there has to be some accountability."
Pronovost and Robert Wachter, M.D., of the University of California at San Francisco, recently co-authored an article for the New England Journal of Medicine about the need for accountability in health care. In their article, Pronovost and Wachter propose suspending privileges for one week when doctors fail to practice hand hygiene and taking privileges away for two weeks when physicians refuse to participate in a timeout before a procedure or don't mark surgical sites to prevent wrong-site surgery.
Such actions are rare, but one major health care system has made them a matter of policy. Advocate Health Care in Chicago suspends a physician for seven days the first time he or she refuses to participate in a timeout. Refuse the next time and the physician permanently loses privileges at all Advocate facilities. Advocate owns nine hospitals in the Chicago area and two in central Illinois.
In the past year, "there have been a handful of suspensions," says Lee Sacks, M.D.,Â Advocate's executive vice president and chief medical officer. "We have not had any second violations." Nonphysician staff members who are involved in two timeout incidents may also be terminated, Sacks notes.
The most common method of disciplining physicians, Clapper says, is to have a medical staff leader send them a letter. However, that may have a greater impact when it is coupled with other actions.
At Community Health Network in Indianapolis, doctors who flout hand hygiene rules get a letter from their hospital's infection control team, says Clif Knight, M.D., chief medical officer of the five-hospital system. "If the physician doesn't improve or says 'don't bother me with that,' our infectious disease director will send a letter to the physician about it. If anybody gets a third letter, that goes to our medical executive council, and [the physician has] to go before the council and explain it. To this point, we've not had anybody who has gotten three letters."
Novant Health in Winston-Salem, N.C., places copies of letters from medical staff leaders in doctors' recredentialing files. A single safety violation would not result in a physician losing privileges, but a pattern of such behavior would be factored into the recredentialing decision, says James Lederer, M.D., Novant's medical director, clinical improvement.
A Just, Not Blame-Free, Culture
The Joint Commission does not require cooperation with safety procedures as a qualification for recredentialing. But Paul Schyve, M.D., the commission's senior vice president, health care improvement, says the organization is considering changing its sentinel event policy to address accountability for following safety rules.
In Schyve's view, hospitals should follow a "just culture" approach in which they carefully discriminate between systemic issues and individual violations of safety policies. The latter may be the result of accidental lapses, misjudgments that stem from an attempt to help a patient, or reckless behavior.
"If the organization doesn't address reckless behavior, it's seen as an unjust culture, and that unjust culture will break down the trust, and then you don't have the reporting," he says. "So the real issue is not a blame-free environment; it's to have a just culture in which people feel they will be treated fairly, including being held accountable for reckless acts."
Strong Leadership is Key
Hospitals that are serious about accountability start by putting appropriate safety systems in place—for instance, making sure there are functioning alcohol gel dispensers in all key locations for hand hygiene. They also educate everyone in the hospital about the need for safety. Advocate, for example, requires all employees—including physicians, nurses, back-office staff, janitors and hospital executives—to take a safety training course.
No such steps, however, will be successful unless the top management of the health care system, including the CEO and the board of directors, thoroughly supports the safety initiative. Novant launched its hand hygiene program, which has been associated with a 67 percent drop in MRSA infections, after the death of a baby in a neonatal ICU. Novant's president was so shaken by the incident that he took the issue to the board, and as result, better hand hygiene "became the next three-year goal," Lederer says. "That meant that it would impact all of the senior leadership in terms of their bonus opportunities."
Strong leadership from both the hospital administration and medical staff chiefs empowers lower-ranking employees to speak up when they see somebody not following established safety procedures. University Health Centers of Eastern Carolina reinforces that directive by having all top executives, including the CEO, make rounds of the clinical areas to communicate the importance of safety, says Joan Wynn, chief quality officer.
The most effective method for building a culture of safety, Clapper says, is to rely on "instant feedback and constant reinforcement. What drives behavior is the feedback that clinicians get from colleagues in real time. Fifty percent of it comes from their peer group, and the other 50 percent comes from your boss."
Even in places where leaders strongly demonstrate support, peer relationships must be recognized, Clapper says. For example, Novant originally appointed LPNs as ward monitors to check on hand hygiene. But the LPNs were afraid to speak up to the regular nurses who supervised them. So Novant replaced the LPNs with experienced RNs. If these nurses see another nurse or nonphysician violating hand hygiene rules, they talk to them about it and report them to the unit supervisor. However, if they see a physician doing the same thing, they e-mail medical staff leaders to avoid provoking fights with doctors on the ward.
University Health Centers has "safety coaches" who are drawn from all levels of the organization. The safety coaches are expected to communicate with someone who is ignoring safety rules, "but the reality is that they sometimes need a third party to facilitate that," says Paul Schackelford, medical director for quality and safety at UHC's Pitt County Memorial Hospital.
DeVos Children's Hospital gives employees scripts related to patient safety to make it easy for them to communicate with superiors and physicians. "It's not just about the rules," says Sue Teman, a patient safety consultant at DeVos. "It's about giving people tools to enable them to speak to each other in that manner."
Teman feels that this approach is more effective than one that relies mainly on discipline. The latter approach, she says, tends to make people prone to hide errors or unsafe behavior. "In the past, physicians and other providers have found it difficult to approach each other when they observed a behavior that was inconsistent with a safe culture. That's what we're trying to change: to give our teams the skills to do that in a really effective way. There's a right way to have that conversation that won't create a defensive boundary, but lets the provider recognize that his or her behavior is not consistent with a safe culture."
Different Approaches Can Be Effective
Sacks of Advocate takes a harder line. For example, he says, a phlebotomist who fails more than once to label blood tubes at the bedside, as required, would be terminated. Anybody who sees a doctor violate a safety rule is encouraged to "interrupt the physician to remind him and/or send in a report. And we would ask our medical staff leadership to review that and discipline the physician."
Disciplinary actions are only one element of Advocate's safety program—a program that is getting results. Advocate's number of central-line bloodstream infections dropped from 74 in 2005 to 16 in January-July 2009 (the annualized rate would be 32). The number of ventilator-associated pneumonias in the Advocate system fell from 75 in 2005 to just five in the first half of 2009.
On the other hand, DeVos Children's is notching successes without threatening strong individual penalties. Compliance with VAP safety precautions in the pediatric ICU has soared. The hand hygiene rate has leaped from 60 to 97 percent.
At Community Health Network, the VAP reduction program started in one ICU "that had very strong nursing and physician leadership," according to Knight. "As a team, they held themselves accountable to make sure that everybody was following this [safety] bundle, and then, because of the success they had there, we were able to roll it out to the other hospitals in the network." The result: Four of the network's critical care or coronary care units have reported no cases of VAP for at least two years, and one unit has eliminated all cases since December 2003. "The threat of disciplinary action is best held in a quiet way," says the IHI's Goldmann. "The emphasis ought to be on creating reliable systems and social norms. Nobody walks into an operating room to operate who doesn't scrub, gown or mask, and so on. It just isn't done, and it's not because the CEO threatened anybody. It's the social norm."
Ken Terry is a freelance writer in Fanwood, N.J.