Do Self-Regulated Quality Monitoring Systems in Health Care Work? — One Survey Suggests, “Not Very Well”

© 2011 Peter Free

 

05 October 2011

 

 

Realism is warranted, where human behavior is concerned — even with monitoring quality in medicine

 

Two days ago, I wrote that I doubted the accuracy of Centers for Disease Control surveys regarding the quality and costs of U.S. health care.

 

Later the same day, Johns Hopkins Medicine published an online overview of Dr. Kendra Harris’ small poll regarding the effectiveness of online error-reporting by radiology specialists:

 

Investigators e-mailed an anonymous survey to physicians, nurses, radiation physicists and other radiation specialists at Johns Hopkins, North Shore- Long Island Jewish Health System in New York, Washington University in St. Louis, Missouri, and the University of Miami, with questions about their reporting near-misses and errors in delivering radiotherapy.

 

Each of the four centers tracks near-misses and errors through online, intradepartmental systems. Some 274 providers returned completed surveys.

 

According to the survey, few nurses and physicians reported routinely submitting online reports, in contrast to physicists, dosimetrists and radiation therapists who reported the most use of error and near-miss reporting systems.

 

Nearly all respondents agreed that error reporting is their responsibility. Getting colleagues into trouble, liability and embarrassment in front of colleagues were reported most often by physicians and residents.

 

Johns Hopkins investigators found . . . that the most common reason among radiation oncologists was fear of getting into trouble and embarrassment.

 

More than 90 percent of respondents had observed near-misses or errors in their clinical practice.

 

The vast majority of these were reported as near-misses as opposed to errors, and, as a result, no providers reported patient harm.

 

© 2011 Vanessa Wasta, Survey Reveals Reasons Doctors Avoid Online Error-Reporting Tools, Johns Hopkins Medicine (03 October 2011) (paragraphs split, reordered, and emphases added)

 

Harris made her observations to the 53rd Annual Meeting of the American Society for Radiation Oncology (ASTRO).   She entitled the report, Learning From Our Mistakes: A Multi-Institutional Survey of Attitudes and Practices Related to Voluntary Error and Near-Miss Reporting.

 

Harris concluded that error reporting is a necessary step in improving care.  But to be effective, she said, online reporting systems have to be embraced as non-punitive.  Blame and sanctions should be avoided.

 

 

A more cynical (and accurate) perspective

 

Inventing monitoring systems that disregard our characteristic impulse to protect ourselves is useless.

 

Dr. Harris’ (very commonly held) perception that we can take the sting out of voluntary error reporting by changing the professional culture is misplaced.  Errors are always contextual.  If we retain the analytically necessary context, at least some colleague providers will detect who it was that screwed up.  Professional embarrassment follows, as does liability in rare instances.

 

As an unintended consequence, the only people doing the reporting will be the most conscientious.  Who, in turn, will predictably suffer negative consequences in promotions and employability.  As is usually the case in such a system, purely self-interested rats will win.

 

Additionally, my experience has been that physicians and surgeons generally exhibit more self-protective ego than the practitioners in the other professions with which I have been associated.

 

In fact, one of the draws of medicine is that it is one of very few occupations that consistently escapes accountability-imposing scrutiny.

 

Note

 

Malpractice litigation does not qualify as accountability-imposing scrutiny.

 

The tort system is badly suited to maintaining quality in medicine.  Too many blameless physicians are sued.  And too many malpractice culprits skate.  When exercised in the medical context, the tort system demonstrates distorted incentives that harm both professions.

 

 

The moral? — Voluntary error reporting does not work

 

Only the self-interested (or obtusely naive) believe that systems are capable of competent self-regulation.  Calls for self-regulation are code for, “Leave us to our own devices so that we can profit, without accountability.”

 

Medicine is no different than any other human endeavor.  Mistakes and near misses are covered up, unless outsiders are attentively watching.