Annual Perspective 2015
The tension between the no-blame culture espoused in the early years of the safety movement and the need for individual accountability has been a subject of robust discussion over the past year. New articles exploring the role of individual skill in safety have heightened the need for an approach to patient safety that responsibly balances the fact that most errors result from system failures with the need to establish clear standards and accountability at the individual level.
In this Annual Perspective we review the context of the no-blame movement and the recent shift toward a framework of a just culture that incorporates appropriate accountability in health care. While the patient safety world has largely embraced the concept of a just culture for many years, this past year saw the discussion gather more steam and move toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal.
Why a No-Blame Culture Made Sense for the Patient Safety Movement
Traditionally, medical errors were often met with blame and shame for the responsible clinician. This approach to mistakes was an ineffective strategy for preventing further patient safety mishaps, particularly considering that the majority of errors are committed by well-meaning, dedicated clinicians working in broken or unsupportive systems. James Reason's classic Swiss cheese model of organizational accidents spurred an initial focus in the 1990s on systems-based approaches to improving patient safety. This approach was codified as the cornerstone for the field of patient safety by its central role in the Institute of Medicine report, To Err Is Human, published in 2000, which launched the modern safety movement.
The systems-based approach was not only more likely to fix underlying patient safety problems, but it was also a pragmatic solution to engage physicians, who otherwise equated a focus on medical errors with malpractice litigation, in patient safety efforts. Looking back over the past 15 years, it seems clear that the decision to emphasize no blame and a systems approach was critically important in advancing the patient safety movement and garnering widespread support for it.
However, even now, safety conferences (such as local Morbidity and Mortality conferences) still do not always support blame-free approaches to errors, resulting in detrimental effects on local safety culture. The 2015 United Kingdom government report, titled Learning Not Blaming, which investigated three large-scale failures at the National Health Service, offers a prominent illustration of this problem. This publication starkly lays out the tension in its call for creating supportive environments that welcome open discussions around errors as a vital component of patient safety. As the public and professionals call for individual accountability for certain types of unsafe acts, it is legitimate to worry that moving back toward such accountability will hinder the progress of the patient safety improvement. The concern is that such a movement may result in adverse unintended effects by driving the wrong behaviors and forming a distraction from useful (system-based) patient safety interventions.
The Arguments for More Accountability
Errors are a part of the human condition; it will never be possible for an individual to avoid all errors. However, some adverse events result from at-risk behaviors, such as taking short cuts, or from individual clinicians recklessly ignoring required safety steps. For example, failing to perform hand hygiene demonstrably leads to health care–associated infections, yet clinicians frequently do not wash their hands, especially when they think nobody is looking. A recent study found hygiene rates are about three times higher when an auditor is present. These types of errors are not necessarily solved through systems approaches; they may require actions focused on individual performance (including penalties or other sanctions) to generate improved performance and enhanced safety in these domains.
A recent survey of physicians, nurses, medical students, and hospital patients found that both health professionals and patients believe clinicians should be held accountable for basic safety practices, such as hand hygiene, fall risk assessments, and preoperative timeouts. The majority of respondents, in all groups, endorsed punitive measures such as fines, suspensions, or firing for repeated violations.
In addition, a 2015 BMJ Quality and Safety article detailed the lively Oxford-style debate at a National Patient Safety Foundation meeting over a resolution that stated: "Certain safety practices should be inviolable, and transgressions should result in penalties, potentially including fines, suspensions, and firing." The debate highlighted common struggles that arise when trying to draw the line between systems and individual failings, and differentiating between simple mistakes (lapses) and willful misconduct. Ultimately, 78% of the audience, which included health professionals and patient advocates, agreed with the premise of the resolution, sending a strong signal that, despite the operational challenges, there is a professional consensus for the move toward increased accountability in patient safety.
Nevertheless, the scope of behaviors that fall under individual accountability is still controversial. Most endorse that clinicians who commit disruptive or unprofessional behaviors should be punished, and The Joint Commission recommends a "zero tolerance" approach to this type of misconduct. Despite this global recognition of the problems caused by unprofessionalism, a 2015 survey at an academic medical center found that 1 in 8 respondents reported witnessing a disruptive behavior that directly resulted in harm to a patient. In addition, patient harms from unprofessional behaviors can be insidious and indirect; a recent simulation study found that neonatal intensive care unit teams exposed to rude comments from an external observer performed worse on their assigned patient care task than those who received neutral comments. There is little doubt that disruptive behaviors harm patients, work environments, and staff morale, and that the problem warrants appropriate action. A prior PSNet perspective summarizes a stepwise approach for managing problem behaviors.
Perhaps more controversially, a 2015 commentary in BMJ Quality and Safety advanced the idea that individual accountability should extend to emotional harm from insufficient respect for patients. With the growing focus on patient-centered care, the concept of emotional harm is likely to garner more traction. The authors encourage institutions to promote voluntary reporting of these types of harms and to apply the same level of rigor as physical patient harms.
Shifting the conversation, a recent robust ethnographic study by Mary Dixon-Wood's research group called for a more nuanced understanding of accountability and systems. The researchers worried that "rule-based, calculus-like approaches intended to support a 'just culture'" did not adequately capture the complicated interplay of individuals and systems. Drawing from practice theory, political science, ethics, and in-depth social studies at five diverse hospitals, they introduced a model of a shared moral community, co-created by individuals and organizations. They suggested that rather than attempting to create a just culture that balances a systems approach against one emphasizing individual accountability, organizations should appreciate the interdependencies between these two approaches and aim to create environments where opportunities for workers to "be good" are logistically feasible and culturally reinforced.
The no-blame paradigm was crucial to launching the patient safety movement, but as the field matures there has been a logical, predictable need to reexamine the balance between the accountability of systems and individuals. As evidence of the growing interest in recalibrating our traditional approach, a number of upcoming national meetings in 2016, including the American College of Healthcare Executives Congress on Healthcare Leadership, will focus on the fundamentals of establishing a just culture.
In 2015, patient safety advocates advanced the conversation on how to meaningfully implement structures that introduce more accountability in patient safety. The work that lies ahead for the field is to develop a sophisticated understanding of the best methods for implementing appropriate accountability while not undermining the gains earned by the systems-based approach to patient safety.