Let's go for autonomy, mastery, and purpose

(Please read this in conjunction with the post below.)

A number of regular readers were appalled the other day when I asked for comments about an idea, that malpractice insurance should not cover cases in which surgeons failed to conduct time-outs and therefore harmed patients.

One person said:  "As Wachter and others have indicated, the balance between a just culture and individual accountability is a very difficult subject."

Another argued:

I suspect that such a measure would result in 100% of DOCUMENTATION of the use of the Universal Protocol. As we all know, this is not the same thing as the cultural commitment to the underlying ideas of respect for the patient that leads to this thoughtful pause and confirmation. I suspect, however, that rate of wrong site surgeries would not fall appreciably. Unfortunately, there is no shortcut to the culture that is committed to eliminating patient harm. In some ways, regulation of good behavior IMCO has led to the illusion that this is possible.

I had hoped that my straw-man proposal would provoke some controversy, and I think these comments join the issue perfectly. We want to create a learning organization, one that cherishes mistakes and near-misses to undercover systemic problems.  Yet, we also want to know that we can rely on personal accountability to comply with protocols that reduce variation and enhance proven standardized approaches.

My blog post set forth the classic regulatory type of solution to this problem:  Impose a "contingent motivator."  If you do A, the consequence is B.

In this TED talk, Dan Pink explains the problem with such incentives.  You can watch the whole thing, but the main point is that it has been demonstrated that contingent motivators do harm.  They tend to "narrow our focus and concentrate our minds," just the opposite of what is needed in a learning organization.  He calls this "the lazy, dangerous, and crazy industry of carrots and sticks."  Indeed, I have set forth just that kind of argument with regard to financial penalties related to rates of readmissions.

Instead, research has shown that ideas develop and organizations improve when the environment is structures to give autonomy, mastery, and purpose to people.

But wait, isn't that the problem in medicine? Doctors are taught to be individual players, relying on their judgment, experience, and good intentions in taking care of patients.  The result is a high degree of variability, producing uncertain clinical outcomes, causing preventable harm to patients, and unnecessarily costing a lot of money.

Brent James and others offer the answer, one that is ideally suited to the personalities and abilities of the people who become doctors.  He says that we want to provide mastery in the use of the scientific method in clinical process improvement.  We want to allow autonomy, but within the context of that scientific method.  Purpose will carry us the rest of the way.  When Brent received an award last year it was:

[F]or his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

I summarized the Intermountain approach here:  

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Note that this approach demands that doctors modify shared protocols on the basis of patient needs.  The aim is not to step between doctors and their patients.  This is very different from the free form of patient care that exists generally in medicine.  Notes Brent, “We pay for our personal autonomy with the lives of our patients.  This is indefensible.”  The approach used at Intermountain values variation based on the patient, not the physician.

 
As the Lucian Leape Institute has noted, though: 

Medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care.

I am not sure we should be optimistic yet, but there is some movement on the education front.  Medstar's David Mayer likes to say, "Educate the young. (And on occasion, regulate the old.)" While that still leaves unstated how and where to "regulate the old," it puts the emphasis where it needs to be.  The current system of care has evolved over decades.  It is unlikely that we will effectively use regulation to bring about change.  Years ago, I suggested that change must come from within.  It will, when we give mastery and autonomy to rising doctors to practice their craft in a way that is consistent with their underlying purpose.