The yin and the yang of patient safety

Two articles crossed my "desk" today that provide useful bookends to the issue of physician responsibility and engagement in patient safety and quality of care.

The first, by Brad Flansbaum at The Hospital Leader, cites an article from the New England Journal of Medicine summarizing the relative lack of effectiveness of pay-for-performance metrics in the National Health Service.  Economists and some public policy folks like to think that, "if you get the pricing right," all good will result.  Well, first of all, getting it "right" is not as easy as it sounds.  Secondly, attempts to use such metrics with many physicians are ineffective at best and counterproductive at worst.

An excerpt:

There are substantial problems with linking patient-experience scores directly to physicians’ pay and this unpopular indicator [access to care] was dropped in 2011. There is some evidence that, as in a previous incentive program in the United Kingdom, the Quality and Outcomes Framework has led to some adverse effects on the quality of care for medical conditions that are not included in the incentive program. As the percentage of physicians’ pay that is tied to performance increases (e.g., above 10%), the effect of the program is likely to increase, but so are the risks of unexpected or perverse consequences.

A complementary point of view is presented by Douglas Hanto in a forthcoming article in the Annals of Surgery, called "Patient Safety Starts with Me."  (Sorry, I don't have a link.) Doug eloquently talks about the personal obligations of doctors:

Our personal responsibility and commitment to the highest quality and safest possible patient care are the foundation of all that we do as surgeons and are reflected in the phrase primum non nocere. Consequently, we should all be change agents for eliminating preventable harm. Patient safety should be our primary core value even if we are not patient safety experts. Although surgical care involves complex systems, it usually begins more simply with the interaction between 1 surgeon and 1 patient. This is where we should redouble our efforts to believe in and, even more importantly, to do patient safety.

What are our personal responsibilities and how can they contribute to making our patients safer? First, surgeons have an obligation in their surgical education and training to achieve competency in patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice.

Second, as part of our training, we all have a responsibility learn the terminology, science, and practice of the field of patient safety, to internalize and apply its principles daily in our own clinical practice, and, at least for some of us, to receive additional training so that we are able to teach patient safety to others.

Third, with the rapid changes in evidence-based medical practice, we have a responsibility as lifelong learners to continually update our surgical knowledge and skills through personal study, courses, and training, as required, and to implement evidence-based and other appropriate changes in our practices.

Fourth, we must continuously evaluate the quality of care we are delivering to our patients. This requires the collection and analysis of data based on meaningful metrics.

Fifth, recognizing that patient safety is a team sport, surgeons need to lead by challenging the authority gradient, asking for discordant opinions, and welcoming team members who speak up and challenge him or her. We should lead the efforts of our hospital and practice quality and safety experts by actively participating in and promoting initiatives such as hand hygiene, central line infection prophylaxis, universal protocol, and so on. We need to model the relevance and importance of these efforts on our patients, students, trainees, and other health care providers. More surgeons must become trained leaders in these efforts. Recognizing that flawed systems are at the root of much preventable harm, we should take personal responsibility for, support, and even lead efforts to implement improved systems that prevent patient harm. If our institution is lagging behind, we should be at the forefront of forcing change.