Patient Safety Primer
Individual Clinician Performance Issues
The patient safety field has emphasized the use of the systems approach to improving safety. This approach takes the stance that adverse events occur due to poorly designed systems, which allow predictable human errors to result in patient harm. The systems approach views errors made by individuals as inevitable, although it acknowledges that human error is more likely in certain circumstances (such as when clinicians are fatigued or placed in situations in which they lack adequate training or supervision to perform a task). As such, the approach intentionally deemphasizes the role of individual provider competence in contributing to errors. In health care, errors have historically been attributed to individual failings, but the current, broader understanding of patient safety recognizes the important roles of various system factors, which include individual competencies, and many other aspects of health care delivery that affect safety. There is good reason for this perspective, as analysis of adverse events in many industries has shown that isolated individual errors less commonly result in catastrophic safety failures.
The Swiss cheese model memorably summarized this concept and created a powerful metaphor: namely, that errors made by individuals result in patient harm thanks to system failings (the holes in the cheese). These holes prevent the error from being detected and mitigated, and may at times even amplify the consequences of the error. Use of the systems approach is tightly linked to the development of a culture of safety, which emphasizes a nonjudgmental approach to error reporting and analysis. As Dr. Lucian Leape, one of the leaders of the patient safety field, has said, "The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes."
Nevertheless, it is undeniable that individual clinicians vary in their skill level, and this variation may have safety consequences for patients. As one piece of evidence, studies have consistently shown that a small proportion of clinicians are responsible for a disproportionate number of patient complaints and malpractice lawsuits. For example, an Australian study found that just 3% of physicians accounted for 49% of all complaints filed by patients, and a United States study found that 1% of physicians accounted for 32% of all malpractice complaints over a 10-year period. Highly publicized cases of individual physicians who repeatedly provided substandard—and even dangerous—care have also served to highlight the problem of individual clinician performance issues. Although comparable data is not currently available for other health professions, some reports have raised the concern that similar problems may exist among nurses.
Detection of Individual Performance Issues
Individual clinician performance issues may relate to technical competence to perform specific tasks or procedures necessary to provide safe patient care. Alternatively, a clinician may be technically proficient—or even outstanding—but provide unsafe care for a variety of other reasons, including poor communication skills, lack of professionalism, or medical or mental health conditions. This broader concept of individual clinician performance that also includes how individuals engage and work with other clinicians and the system in general is supported by an expanding body of scientific evidence and practical experience. Health care organizations increasingly understand that safe, high-quality care cannot be achieved without well-designed systems of care that are supported by individuals with a full range of competencies. They also appreciate that individual awareness of systems science and how to apply it to health care can be as critical to a patient's care as effectively applying the traditional base of medical knowledge.
The health professions educational system aspires to train clinicians to achieve basic proficiency in technical and nontechnical skills in order to be able to practice independently, but variation in skill among physicians can affect patient safety. A seminal 2013 study used video recording of bariatric surgical procedures to evaluate the correlation between objectively assessed technical skill and patient care outcomes. The study found that surgeons rated in the lowest quartile of surgical skill (as assessed by peer review of videotaped operations) had rates of surgical complications nearly three times as high as those rated in the highest quartile of surgical skill. As this study involved practicing surgeons with considerable experience with the procedure in question, the study vividly demonstrated the link between individual clinician skill and patient outcomes. Although many studies document variation in clinician practice patterns, few other studies definitively link variation in technical skills to safety outcomes.
Yet even clinicians who have the knowledge and skill to provide safe care may not always do so. Health care is a team endeavor, and clinicians who lack the ability to work productively within a team context certainly pose risks to their patients. The link between overtly disruptive and unprofessional behavior and patient safety has been well documented, and considerable efforts are underway to end a "culture of disrespect" that permeates many organizations. Even highly competent and professional clinicians can, over the course of their careers, find themselves in situations that prevent them from providing high-quality and safe care. The growing prevalence of burnout among clinicians has been linked to adverse patient outcomes and is discussed in detail in a 2015 Annual Perspective. Impaired clinicians—those unable to perform competently due to illness, mental health conditions, or substance use—also pose a threat to patient safety; studies estimate that 10%–12% of physicians develop a substance use disorder at some time during their career.
Addressing Individual Performance Issues
The first step in addressing individual performance issues requires addressing a philosophical tension: how should the patient safety field balance the systems approach with the need for individual accountability? A 2015 Annual Perspective discussed this question. There is now a general consensus that a just culture approach—which seeks to draw clear boundaries around "at-risk" behaviors that clearly endanger patient safety and define consequences for these behaviors—is a more appropriate and nuanced approach than a blanket "no blame" philosophy. There is also a consensus among clinicians and patients that clinicians should be held accountable and face disciplinary consequences for engaging in at-risk behaviors, such as refusing to perform a preprocedural timeout. As evolving evidence identifies safe practices and defines clearer safety standards, individual clinician accountability for adhering to such practices will become more important.
The studies cited above identify a subpopulation of physicians that are disproportionately prone to allegations of malpractice or complaints by physicians. These studies also found a high recidivism rate, in that a physician who was the subject of a complaint or lawsuit was likely to be the subject of further concerns about their performance. There were also variations between specialties, with surgical specialists and obstetricians at the highest risk of both lawsuits and complaints. These findings raise the question of whether clinicians with performance issues can be detected—and intervened upon—before they pose safety risks.
A classic study found that medical students who demonstrated unprofessional behavior (as students) were significantly more likely to be disciplined by state licensing boards once in practice. Analysis of malpractice and patient complaint databases have also identified some predictors of performance concerns, including male gender, procedural specialty, the number of complaints, and time since the last complaint.
However, much remains unknown about physicians who experience recurrent performance concerns. As discussed in a PSNet perspective, it remains unclear what proportion of physicians with problems lack skill in specific areas (i.e., insufficient technical competence) versus in multiple dimensions of care (i.e., poor communication skills, inability to reflect upon errors, or failure to incorporate new knowledge). We also do not know what proportion of clinicians fail to perform competently due to time-limited, potentially reversible events (such as an episode of burnout or depression) versus general lack of or deterioration in skill. Early detection of poorly performing clinicians thus remains a challenge, exacerbated by the fact that clinicians often do not report impaired colleagues even when they have first-hand knowledge of performance issues.
A variety of approaches can potentially be used to intervene in the cases of clinicians who pose safety risks to patients. Simulation has proven to be a very effective educational approach, and the combination of simulation and individualized coaching can reduce adverse events associated with specific procedures. Building upon the bariatric surgery study cited above, it is likely that video recording of procedures and other types of clinical encounters will become routinely used both for assessment and improvement purposes. Finally, physicians are required to participate in some form of Continuing Medical Education (CME) and Maintenance of Certification (MOC) to retain their professional licensure and credentials, and these programs are being revamped to ensure they achieve their goal of ensuring professional competency. The trend to align quality improvement initiatives and individual certification requirements so that they collectively address shared goals offers the potential to increase uptake and value of these related activities and also decrease burden on clinicians.
For a small subset of clinicians, disciplinary action is needed to protect patients. State licensing boards are tasked with identifying physicians who pose a threat to patient safety and intervening as needed. Unfortunately, states vary considerably in the rate of both major and minor disciplinary actions taken against physicians, which implies that there may be a role for standardizing states' approaches to disciplining physicians who pose a safety risk.
Professional organizations and regulatory bodies have drawn attention to safety issues related to individual clinician performance, most prominently with regard to disruptive and unprofessional behavior. Most health care organizations, and many states, mandate that health professionals formally report colleagues who they suspect of being impaired or otherwise unable to fulfill their patient care duties. It seems likely that the emergence of new approaches to health care delivery and documentation (including electronic health records, simulation, and new methods of measuring quality) will pave the way for new approaches to performance assessment and improvement.
It should be noted that most research on individual clinician performance pertains only to physicians. There are few studies on the prevalence of adverse events or errors due to performance issues among other health professionals, and little to no evidence on methods to address performance concerns. Research into the relationship between clinician performance and safety should not only seek to define clinician factors that predispose to performance issues and adverse events, but should also examine the role of skill and professional competence of other members of the health care team.