Friday, March 16, 2012

The Accountability Paradox: Personal Consequences and Blame

A recent piece in The Journal of Patient Safety, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate" by experienced, highly-competent Aviators and Medicos prompted me to ask a question about on the subject of Dr Brent James, Chief Quality Officer of Intermountain Healthcare:
The NTSB only recommends, the FAA makes sure those things (and more) are done.
As a regulatory and compliance organisation, the FAA is able to hand out "direct, personal consequences" - and make them stick. [Natural Justice suggests proportionality as well].

Any Aviation Professional who repeats, or allows, a Known Error, Fault or Failure will be discovered and will suffer the consequences. [Hence would a medical version need two bodies?]
Dr James kindly responded to me and I was gently reminded of James Reason's "Blame Cycle" [below] and Dr James own comments on the 2001 ABC's Health Report, "Minimising Harm to Patients in Hospital":
Norman Swan: So remove the culture of blame, sort out the legal liability problems, without ignoring the fact that there will be the odd rogue doctor or rogue nurse who needs to be sorted out. What we should be seeing here, we haven't really emphasised it up till now, is that most of the problems that occur when injuries occur, are system problems, the hospital, the management, the organisation of the hospital, rather than an individual going wrong?

Brent James: Exactly. We know that the individuals will have problems. How do we create an environment in which it's easier to do it right, and hard to fail? That's the real issue. It's an institutional responsibility not an individual responsibility. The next thing that we need is an organisational structure. In the United States we're calling them Patient Safety Officers, and in the Institute of Medicine Report we asked that all care delivery groups appoint Patient Safety Officer, usually from existing personnel, usually a good clinician.
The Military have a "Rule of Three" for all leadership roles [definitions from the Apple dictionary App]. The three have to be aligned for every role or either the task/function won't be done well, or the individual in the role will be falsely held to account for actions they are unable to control:
  • Responsibility:
    "a thing that one is required to do as part of a job, role, or legal obligation"
  • Accountability
    to be held to account for actions. "(of a person, organization, or institution) required or expected tojustify actions or decisions; responsible"
  • Authority:
    "the right to act in a specified way, delegated from one person or organization to another", including "to give orders, make decisions, and enforce obedience".
These are very specific meaning for the words "responsibility" and "accountability".
In normal, conversational English, the words are mostly used interchangeably.

In this more formal sense, there is a difference drawn between "a task or function delegated to an individual" (responsibility) and "an item for which you may be held to account" (accountability), a fine, but important, distinction.

It is in this second, more formal sense that I wish to use "Accountability" here.

My central concern with the NTSB-for-Medicine proposal is the necessity for the organisation to not be a "toothless tiger", to have the power to cause change, but simultaneously engender a "Safety Culture" where Openness and Transparency are the norm and individuals do not feel threatened by the system.
Audit reports and Commissions of Inquiry into major failures (QLD) say what's wrong, but have no powers to cause change. They are equivalent to the NTSB, but lack the ability of the FAA to implement, to cause or require necessary change and to check that it is done.

Reason's "Blame Cycle", and my own more extreme "Blame Spiral", require Dr Demings' exhortation to "Drive out Fear" be scrupulously and systemically be applied.

How can these two conflicting objectives be achieved? I've no experience in this.
This is The Accountability Paradox:
For real change in the system, any person who repeats, or allows, a Known Error, Fault or Failure, must be held personally liable (including criminally if they caused death or severe injury/disability),
BUT if that is perceived as the Primary Role of the compliance and governance organisation, then it will be ineffective, instead it will engender the "Blame Cycle" as a minimum.
We know that in the USA the NTSB/FAA work together, in the UK the AAIB/CAA, in Australia the NTSB/CASA and, from outside, there are well developed and sustainable "Safety Cultures" operating within them all (vs Blaming Cultures).

So how can our Public Healthcare get there from here and avoid perverse outcomes, like the "Blame Cycle"?

How can Hospital and Healthcare systems in Australia copy the Intermountain Healthcare model and move from chaotic, inconsistent "heroics" to a consistent Safety and Quality Culture, embracing Continuous Improvement whilst driving down waste and system inefficiencies?

How can Australia both create a system where the Public Healthcare system improves both its performance and accountability, so the 2004 "Dr Death" scandal in QLD is never repeated but where all Healthcare workers trust they will not be blamed for speaking truth to power,  to know they can raise important issues and be properly heard, unlike Toni Hoffman in Bundaberg?

I'm sure the Medical Error Action Group would love to post a final message saying "the system has been changed to pick up its own problems, we're not needed anymore."

Some references to Prof. Reasons' "Blame Cycle":
"Diagnosing “vulnerable system syndrome”: an essential prerequisite to efffective risk management" (2001, Qual Health Care 2001;10:ii21-ii25 doi:10.1136/qhc.0100021) and
"Managing the Risks of Organizational Accidents" [1997].

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