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It's time for a new model of accountability

From the August 8, 2001 issue

Healthcare is struggling to come to terms with the role of accountability in a non-punitive, system-based approach to error reduction. Even when we seem to understand the system-based causes of errors, it's still hard to let individuals off the hook. We ask, "How can we hold individuals accountable for their actions without punishment?" Some have even suggested that a non-punitive approach to error reduction could lead to increased carelessness as people learn that they will not be punished for their mistakes. In our recent survey on perceptions about a non-punitive culture, 21% of respondents agreed with this premise and another 16% felt that a non-punitive approach to errors absolves staff of personal responsibility for patient safety (see our next issue for a full report about our survey findings). However, a non-punitive, system-based approach to error reduction does not diminish accountability; it redefines it and directs it in a much more productive manner.

Typically, when an error happens, all accountability falls on individuals at the sharp end of an error where the caregiver/patient interaction occurs. But accountability - not for zero errors, but for making patient safety job one - should be equally shared among all healthcare stakeholders. In part, Webster's defines "accountability" as an obligation to provide a satisfactory explanation, or to be the cause, driving force, or source. These definitions offer a glimpse at a more appropriate patient safety accountability model. In this model, accountability lies not in performing perfectly, but in identifying safety problems, implementing system-based solutions, and inspiring and embracing a culture of safety. Below are examples.

Individuals in the workforce should be held accountable for speaking out about patient safety issues, voluntarily reporting errors and hazardous situations, and sharing personal knowledge of what went wrong when an error occurs. On the other hand, healthcare leaders should be held equally accountable for making it safe and rewarding for the workforce to openly discuss errors and patient safety issues. They must hold regular safety briefings with staff to learn about improvement needs, discuss strategic plans, and identify new potential sources of error. When the workforce recommends error prevention strategies, leaders must support them and provide the means necessary within a reasonable timeframe to implement technology and other system enhancements to improve efficiency and safety. Leaders should be held accountable for understanding and addressing barriers to safe practice such as distractions and unsafe workloads. Likewise, the workforce must be empowered to ask for help when needed and be willing to change practices to enhance safety and quality. Leaders should position patient safety as a priority in the organization's mission and engage the community and staff in proactive CQI efforts, including an annual self-assessment of patient safety. The workforce should be held accountable for working together as a team, not as autonomous individuals. Finally, leaders and staff alike need to follow the safety literature continuously and offer visible support to their colleagues who have been involved in errors.

This model of shared accountability spreads far beyond the walls of individual healthcare settings to encompass licensing, regulatory and accrediting bodies; the federal government and public policy makers; the pharmaceutical industry; medical device and technology vendors; schools for medical training; professional associations; and even the public at large. These often-overlooked participants share equal accountability for doing their part to error-proof healthcare. For example, regulatory, accrediting, and licensing bodies should be held accountable for adopting standards related to error reduction recommendations that arise from expert analysis of adverse events and scientific research. Purchasers of healthcare should provide incentives and rewards for patient safety initiatives. Companies that produce medical devices, pharmaceutical products, healthcare computers and software, and other health-related products should be held accountable for pre-market evaluation and continuous improvement in the design of devices, products, and labels and packages. Educators should seek out patient safety information and use it in curriculum design. Professional organizations should support local and national voluntary reporting systems and disseminate important patient safety information to their members. The public should ask questions and stay informed about their care and ways to avoid errors.

Who can argue with the multidimensional nature of medical care? Isn't it time to accept a multidimensional, shared accountability model for patient safety? Organizational leaders and other stakeholders who simply hold the workforce accountable when an error happens are inappropriately delegating their own responsibility for patient safety. We must stop blaming and punishing those closest to an error, and instead accept a model of shared accountability to collectively translate our sincere concern for patient safety into effective system-based error solutions.

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