In September 2001, the Agency for Healthcare Research and Quality (AHRQ) and the ABIM Foundation jointly sponsored an invitational conference entitled “The Role and Responsibility of Physicians to Improve Patient Safety.” The goal of the conference was to begin a national conversation focusing on the individual clinician's role and strategies physicians might employ to advance patient safety. The authors summarize the main themes and issues that emerged at the conference.
The authors draw from work by the Institute of Medicine (IOM) to support the need for greater emphasis on quality improvement. To date, most of the work in this area has involved a systems-level approach, and physicians are often viewed as obstacles to improvement programs. By contrast, physicians may view population- or systems-based approaches to health care as interfering with the delivery of care to specific patients. The authors argue that physicians, individually and collectively, have a key role in quality improvement efforts, albeit a role that is yet fully defined. After reviewing successful examples involving physicians, the authors explore the major levers to achieve change—removing barriers, creating incentives, emphasizing collaboration, increasing education, and promulgating regulation—and summarize ten recurring themes, including both current and near-term opportunities, for physicians to exercise leadership in quality improvement and patient safety. Finally, they assert that even modest change can lead to substantial improvements, particularly if medical societies and the profession's standard-setting bodies work together.
Ms. Goode is vice president, American Board of Internal Medicine (ABIM), Philadelphia, Pennsylvania; Dr. Clancy is director, Agency for Healthcare Research and Quality (AHRQ), Washington, D.C.; Dr. Kimball is president and CEO, ABIM Foundation, Philadelphia, Pennsylvania; Dr. Meyer is director, Center for Quality Improvement and Patient Safety, AHRQ; the late Dr. Eisenberg was director, AHRQ.
Correspondence and requests for reprints should be addressed to Ms. Goode, American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106; e-mail: 〈email@example.com〉.
The opinions expressed in this article are those of the authors and not intended to represent official policy of the American Board of Internal Medicine, the Agency for Healthcare Research and Quality, the Department of Health and Human Services, or the ABIM Foundation.
The authors gratefully acknowledge the help of Deborah Beryline, PhD, freelance technical writer, Daniel B. Wolfson, MA, executive vice president, the ABIM Foundation, and Eileen Hogan, MPA, project officer, Center for Quality Improvement and Patient Safety, AHRQ.
In this article, we briefly summarize the main themes and issues that emerged at an invitational conference entitled “The Role and Responsibility of Physicians to Improve Patient Safety,” held September 4 and 5, 2001, in Alexandria, Virginia. Background information about the conference and its sponsors is presented in the following section.
Once taken for granted, patient safety in health care has emerged as a central, public concern. The Institute of Medicine (IOM) stirred attention and debate through publication in 2000 and 2001 of two seminal reports, To Err is Human: Building a Safer Health System, and Crossing the Quality Chasm: A New Health System for the 21st Century.1,2 Although much of the information and arguments in the reports is not new, the reports' frameworks and evidence highlighted the enormity and urgency of the problem. Since that time, leaders and experts throughout medicine and health care delivery have taken up the IOM's challenge. Forums for exchange have been provided by this journal and other publications, as well as through public conferences and discussions at professional meetings. The majority of such discussions have focused on systems-level strategies, consistent with the report's emphasis on the critical need for the engagement of all who participate in health care delivery. We have learned a great deal about specific dimensions of patient safety and solutions that can be applied within small and large organizations that deliver health care. Impressive, coordinated advances are under way by leading organizations such as Intermountain Health Care and the Veterans Health Administration.3,4
Less discussion has focused on the role of the individual clinician, particularly the physician. Historically, societal expectations regarding the quality and safety of physicians' practices have been linked to demonstration of competence through objective examinations, derived from an unquestioned assumption of a close relationship between the results of examinations of medical knowledge and clinical performance. The IOM reports, numerous studies of practice variations, and growing demands from purchasers for evidence of value, however, have stimulated new interest in evaluating clinical performance more directly. In short, over the past decade, there has been a growing chorus of voices saying “Show me.” The IOM reports emphasized that the time-honored approach of “blame and shame” is both ineffective and counterproductive.
This observation, however, does not specify how clinicians can collectively embrace the patient safety challenge.
An oft-cited example of what is possible when clinicians work together is the impressive improvements that have occurred in perioperative care. Anesthesiology has made great strides, taking action independently as a profession to develop processes that dramatically reduce the incidence of medication errors in operating suites across the nation. An urgent question for other specialties and clinical disciplines is: How can such successful efforts in quality improvement and patient safety be expanded? A great challenge remains if medicine is to meet the challenges articulated by the IOM, and uphold its social contract by improving the health of the public. As Dr. John Eisenberg observed, “Good enough isn't really just good enough.”5
Physicians are guided by various standards for performance or professional acceptability, including board certification, licensure, credentialing, and other professional norms. Some standards are voluntary (e.g., certification), while others are required (e.g., licensure). To some, the “quality buck stops nowhere in this web of private and public standards.”6 Moreover, physicians are considered by health care leaders to be obstacles to improvement about as often as they are considered leaders of quality improvement. At this juncture, there is an enormous opportunity for the profession to redefine and implement professional leadership. Given the current efforts by large purchasers, state and federal legislative proposals, and continued public concerns about patient safety, it is imperative that health care professionals understand that their personal involvement in efforts to improve patient safety and quality are essential to maintain medicine's credibility. A concept of medical professionalism that incorporates a collective responsibility for safe and effective patient care remains to be fully articulated and operationalized, although a good start has been made recently.7
To begin this critical dialogue, clarify the challenges and opportunities, and establish a foundation for future work, the ABIM Foundation and the Agency for Health Care Research and Quality (AHRQ) commissioned the three papers published in this issue of Academic Medicine.8,9,10 The papers formed the core of the invitational conference mentioned at the beginning of this article; the conference was sponsored by the ABIM Foundation and the AHRQ. Participants were selected to draw a broad range of views from experts and relevant stakeholders. An overarching goal of the conference was to identify specific strategies for effective solutions that engage the best efforts of the medical profession. A central message from To Err is Human is that patient safety is unlikely to improve based on good intentions and regulations alone; the collective commitment of patients, providers, and policymakers is essential. To be successful, greater involvement and a better understanding of professional responsibility and accountability will be required of physicians. The reactions of conference participants to the ideas and opinions presented in the three commissioned papers have been organized into several themes, discussed below.
According to participants, physicians do better at providing one-on-one care to patients than in improving population health. Since the defining approach to clinical care has focused on the individual patient, physicians may regard population-based health systems as interfering with the delivery of care to individual patients. In contrast, the governing boards of hospitals and medical practices focus more on the health of a defined population than on the health of individuals.
While the IOM report brought wide attention precisely because of the clear and tangible dimensions of threats to patient safety it described, meeting participants noted that physicians resist being measured and tend to hide problems out of fear of litigation. Although the governing boards of hospitals and medical practices are usually responsible for quality improvement programs, they do not necessarily have the clinical expertise or the mandate to force change on medical practice. Like physicians, they express reluctance to measure quality out of denial, fear of litigation, or lack of knowledge.
Some participants noted that physicians often believe that quality improvement techniques are a waste of time and therefore do not act on them. Physicians are much more likely to discuss the cost of treatment with their patients than the quality and safety of their care. Participants agreed, however, that physicians care profoundly about providing good patient care. Many physicians believe that it is only the high quality of their skills that keep more patients from being harmed by fault-ridden health care systems.
PERSPECTIVES OF PHYSICIANS, PAYERS, AND PATIENTS
On the whole, conference participants agreed on the need for patient education to improve quality. Representatives of patients and payers also agreed that additional regulations may be needed to improve quality. According to their representatives, patients know that quality of care can vary, while most physicians believe that the quality of the care they provide is generally good.
Participants representing providers and academic institutions emphasized the need for educating physicians at the undergraduate level to change physician behavior. They also argued for the importance of developing better collaborations between physicians and other providers, including nurses and others who provide end-of-life care. Finally, participants warned that although physicians might be impatient for rapid change, it is likely to take years for meaningful change to occur.
For representatives of payer groups such as insurers and employers, motivation and measurement are important keys to improving quality. These participants highlighted the different perspectives of individual physicians and the governing boards of hospitals or medical practices. Both groups need to focus on helping individual patients and improving the overall health of communities and society.
Patient representatives noted that being able to choose a provider is perceived to be the patient's protection against variations in quality and safety. Patients want to preserve their freedom to choose. In a recent study, physician—patient communication was identified by 57% of Americans as an essential indicator of quality. In contrast, only 36% of Americans felt that whether the physician had attended a well-respected medical school or training program was important.11
WHAT CAN LEAD TO CHANGE?
The perception that health care quality does not need to improve is a significant barrier to changing behavior. The removal of this barrier will require, at the very least, that physicians be educated about quality and accept assessment of clinical performance as an opportunity to learn and improve. Another barrier to changing physician behavior is the lack of motivation to change. Although some participants argued that physicians know that quality is too frequently poor, others thought that physicians believe that the care they provide is uniformly good and therefore not in need of change.
The system's current tendency to “reduce” quality by, for example, encouraging overuse of certain procedures is a significant barrier to change. If there are instances (such as payment policies) in which overuse of selected procedures is implicitly encouraged, the result will be lower quality at higher cost. For this and other reasons, participants under-scored the need to develop a “business case for quality” to support sustained improvements. Because jargon and classification issues present technical barriers to improvement, the participants called for a standard taxonomy and language to approach safety. A final barrier to changing behavior is the difficulty of discussing safety without producing fear of both legal consequences and, perhaps more important, professional shame.
What will motivate physicians to take on more responsibility for patient safety than they have in the past? Many felt that physicians' levels of discomfort with current quality need to increase to persuade them to change. Some participants argued that positive incentives are needed to change the behaviors of physicians. Such incentives might be directed at physicians' concerns for their patients and a desire to provide high-quality care, i.e., medical professionalism and pride in doing a good job. However, other participants argued that appealing to medical professionalism is not enough. The quality of care provided by physicians should be measured and made public. This strategy is consistent with recent studies of the impact of clinical performance measurement.12 Moreover, consistent application of performance measurements may expose the reality that physicians are not doing as well as they think, offering specific motivation to change. Financial incentives are also important. Actions need to be identified that have a positive impact on the balance sheet or, at least, they should not have a negative financial impact. Unfortunately, some errors or low-quality activities actually increase compensation to providers. For example, it has been observed that errors that result in longer hospital stays are usually associated with increased reimbursement. Such perverse incentives must be neutralized. Throughout the discussions, a critical tension focused on whether financial incentives that reward high quality, i.e., “pay for performance,” will reinforce or weaken the underpinnings of the profession's compact with society.
Training superb clinicians for the 21st century must include skills in teamwork and collaboration and a focus on population needs. As emphasized in Crossing the Quality Chasm, the focus in health care must be shifted from acute to chronic care, with its more complex morbidities, and reliance on a team approach. The culture needs to change to one of helping others —both colleagues and patients. Safety may require a new culture of collaboration in which effective communication is a key element. Approximately 80% of providers at the bedside are nurses, and the quality movement needs to engage the entire workforce. Many seasoned nurses are leaving the profession, while others are working in new health care areas, a reality that many physicians confront daily.
Safety and quality need to be integrated into the undergraduate medical school curriculum at the contextual level. Although students are more concerned about molecular biology than health care systems issues, they need to see the links between scientific advances and improving health care outcomes. Patients are part of the problem and must be part of the solution. Patients can be brought into the patient safety issue through organizations such as the AARP, payers, and employers, who can help them understand what constitutes health care quality and the steps they need to take to maximize quality. Playing a more active role in their own medical care, consistent with the concept of “activated patients” developed by Ed Wagner, Sherrie Kaplan, and others, requires that patients learn about self-management and how to communicate effectively with doctors.
Instead of changing behavior through motivation, physician behavior could be changed by regulations that require quality improvement. The aviation industry used regulations imposed by the Federal Aviation Administration to complement voluntary actions to improve safety. Fearing a loss of professionalism, some conference participants argued that the profession could improve quality without redesigning the health care marketplace and imposing yet more regulations. However, as familiarity with gaps in safety and quality increases, public demand will increase for external oversight. Legislators will get involved when public pressure for change becomes great enough.
Some conference participants argued that medical errors in hospitals are only part of the patient safety story, because most Americans receive most of their health care in ambulatory settings, not hospitals. Therefore, the focus needs to shift to the primary care setting and to errors that occur as patients move from one setting to another. However, others responded that all settings require the same kinds of approaches to quality as does the hospital. A great deal of health care takes place in the last two to three years of life, which is also when many errors occur. Approaches are needed to address the patient safety problems in nursing homes and home care. Some participants believe that physicians should not take the lead on end-of-life issues, but instead should learn to function as team members.
Although the barriers and challenges seem daunting, there is good news. The medical profession has powerful levers to create change. And even modest change can lead to substantial improvement. Ten recurring themes emerged from the conference. These are outlined in Table 1 and include both current and near-term opportunities.
In addition to these themes, participants identified a number of longer-term and larger-scale issues that will require coordinated efforts. These include faculty development, incorporating systems analysis into training programs, the creation and adoption of a standard curriculum for safety and quality, development of appropriate incentives to encourage quality improvement, and a professional consensus on exactly what information should be in the public domain. Beginning to lay the groundwork for these more ambitious longer-term priorities should be concurrent with addressing the ten themes. In both cases the issue of patient safety will be a stimulus for re-establishing the importance of medical professionalism.
Although hard work will be required to disentangle the problems and solutions to greater safety and quality, the ABIM Foundation and the AHRQ will continue to advocate strategies that keep the profession's focus on increasing quality and reducing errors. Much greater input is needed from medical societies and professional standard-setting bodies, including the umbrella organizations, the Council of Medical Specialty Societies, and the American Board of Medical Specialties. We believe this conference met its goal of beginning a dialogue about the medical profession's responsibility to improve patient safety and were heartened to hear unanimous support for advancing such efforts. It is now time to get to work.
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4. Intermountain Health Care. Various citations on their Web site, 〈http://www.ihc.com
〉〉. Accessed 7/5/02.
5. Eisenberg J. Opening remarks at “The Role and Responsibility of Physicians to Improve Patient Safety” conference, Alexandria, VA, September 4, 2001.
6. Galvin R. A vetting of accountability. Paper delivered at a conference entitled “The Role and Responsibility of Physicians to Improve Patient Safety,” Alexandria, Virginia, on September 4, 2001.
7. Project of the ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine (“Medical Professionalism in the New Millennium: A Physician Charter”). Ann Intern Med. 2002;136:243–6.
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11. National Survey on Americans as Health Care Consumers: An Update on the Role of Quality Information. Kaiser Family Foundation/Agency for Healthcare Research and Quality. Menlo Park, CA: Henry J. Kaiser Family Foundation, 2000.
12. Marshall M, Shekelle P, Leatherman S, Brook R. The public release of performance data: what do we expect to gain? JAMA. 2000;283:1866–74.