Responding to clinicians who fail to follow patient safety practices: Perceptions of physicians, nurses, trainees, and patients

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<ul><li><p>ORIGINAL RESEARCH</p><p>Responding to Clinicians Who Fail to Follow Patient Safety Practices:Perceptions of Physicians, Nurses, Trainees, and Patients</p><p>Todd H. Driver, BA1, Patricia P. Katz, PhD2, Laura Trupin, MPH2, Robert M. Wachter, MD2*</p><p>1School of Medicine, University of California, San Francisco, San Francisco, California; 2Department of Internal Medicine, University of California, SanFrancisco, California.</p><p>BACKGROUND: The field of patient safety grapples withthe tension between a no-blame systems approach andthe need to hold providers accountable for substandardperformance. Attitudes of clinicians and patients regardingmethods of promoting adherence to safety practices havenot been described.</p><p>METHODS: We surveyed attending and resident physiciansin the University of California, San Francisco (UCSF) Depart-ment of Medicine, nurses and inpatients at the UCSF Medi-cal Center, and UCSF medical students regarding attitudestoward violations of 3 safety protocols: hand hygiene, fallrisk assessment, and preoperative time-out.</p><p>RESULTS: Responses to protocol lapses were groupedinto 3 categories: feedback (universally endorsed and thusexcluded from the analysis), public reporting, and penalty(fines, suspension, firing). We examined group differencesregarding whether public reporting and penalties were everappropriate and the number of transgressions at which</p><p>public reporting and penalties were favored. Respondents</p><p>favored both public reporting and penalties more frequently</p><p>for not conducting a preoperative time-out or fall risk</p><p>assessment than for hand-hygiene lapses (public reporting:</p><p>time-out, odds ratio [OR]: 2.82 [95% confidence interval</p><p>{CI}: 2.03-3.91]; fall, OR: 1.47 [95% CI: 1.09-1.98]. Penalty:</p><p>time-out, OR: 4.29 [95% CI: 2.97-6.20]; fall, OR: 1.74 [95%</p><p>CI: 1.27-2.37]). Penalties were endorsed more frequently</p><p>than public reporting for all groups and scenarios. Attending</p><p>physicians and patients expressed similar attitudes regard-</p><p>ing public reporting and penalties, but patients favored pen-</p><p>alties after significantly fewer transgressions (P&lt; 0.05).</p><p>CONCLUSION: After a decade emphasizing no-blameresponses to patient safety hazards, both healthcare pro-viders and patients now believe clinicians should be heldaccountable for following basic safety protocols. Journal ofHospital Medicine 2014;9:99105. VC 2013 Society ofHospital Medicine</p><p>Healthcare delivery organizations are under increasingpressure to improve patient safety. The fundamentalunderpinning of efforts to improve safety has been theestablishment of a no-blame culture, one thatfocuses less on individual transgressions and more onsystem improvement.1,2 As evidence-based practices toimprove care have emerged, and the pressures todeliver tangible improvements in safety and qualityhave grown, providers, healthcare system leaders, andpolicymakers are struggling with how best to balancethe need for accountability with this no-blameparadigm.</p><p>In dealing with areas such as hand hygiene, wherethere is strong evidence for the value of the practiceyet relatively poor adherence in many institutions,Wachter and Pronovost have argued that the scalesneed to tip more in the direction of accountability,including the imposition of penalties for clinicians</p><p>who habitually fail to follow certain safety practices.3</p><p>Although not obviating the critical importance of sys-tems improvement, they argue that a failure to enforcesuch measures undermines trust in the system andinvites external regulation. Chassin and colleaguesmade a similar point in arguing for the identificationof certain accountability measures that could beused in public reporting and pay-for-performanceprograms.4</p><p>Few organizations have enacted robust systems tohold providers responsible for adhering to account-ability measures.4 Although many hospitals have poli-cies to suspend clinical privileges for failing to signdischarge summaries or obtain a yearly purified pro-tein derivative test, few have formal programs to iden-tify and deal with clinicians whose behavior ispersistently problematic.3 Furthermore, existing modesof physician accountability, such as state licensingboards, only discipline physicians retroactively (andrarely) when healthcare organizations report poor per-formance. State boards typically do not consider pre-vention of injury, such as adherence to safetypractices, to be part of their responsibility.5 Similarly,credentialing boards (eg, the American Board of Inter-nal Medicine) do not assess adherence to such prac-tices in coming to their decisions.</p><p>It is estimated that strict adherence to infection con-trol practices, such as hand hygiene, could prevent</p><p>*Address for correspondence and reprint requests: Robert M.Wachter, MD, Department of Medicine, Room M-994, 505 ParnassusAvenue, San Francisco, CA 94143-0120; Telephone: 415-476-5632;Fax: 415-502-5869; E-mail:</p><p>Additional Supporting Information may be found in the online version ofthis article.</p><p>Received: September 25, 2013; Revised: November 20, 2013;Accepted: November 24, 20132013 Society of Hospital Medicine DOI 10.1002/jhm.2136Published online in Wiley Online Library (</p><p>An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 9 | No 2 | February 2014 99</p></li><li><p>over 100,000 hospital deaths every year; adherence toother evidence-based safety practices such as the useof a preoperative time-out would likely preventmany more deaths and cases of medical injury.3,6</p><p>Although there are practical issues, such as how toaudit individual clinician adherence in ways that arefeasible and fair, that make enforcing individual pro-vider accountability challenging, there seems littledoubt that attitudes regarding the appropriateness ofenacting penalties for safety transgressions will be keydeterminants of whether such measures are consid-ered. Yet no study to date has assessed the opinionsof different stakeholders (physicians, nurses, trainees,patients) regarding various strategies, including publicreporting and penalties, to improve adherence tosafety practices. We aimed to assess these attitudesacross a variety of such stakeholders.</p><p>METHODSSurvey Development and Characteristics</p><p>To understand the perceptions of measures designedto improve patient safety, we designed a survey ofpatients, nurses, medical students, resident physicians,and attending physicians to be administered at hospi-tals associated with the University of California, SanFrancisco (UCSF). Institutional review board approvalwas obtained from the UCSF Committee on HumanResearch, and all respondents provided informedconsent.</p><p>The survey was developed by the authors and pilottested with 2 populations. First, the survey wasadministered to a group of 12 UCSF Division of Hos-pital Medicine research faculty; their feedback wasused to revise the survey. Second, the survey wasadministered to a convenience sample of 2 UCSF med-ical students, and their feedback was used to furtherrefine the survey.</p><p>The questionnaire presented 3 scenarios in which ahealthcare provider committed a patient-safety proto-col lapse; participants were asked their opinions aboutthe appropriate responses to each of the violations. The3 scenarios were: (1) a healthcare provider not properlyconducting hand hygiene before a patient encounter,(2) a healthcare provider not properly conducting a fallrisk assessment on a hospitalized patient, and (3) ahealthcare provider not properly conducting a preoper-ative timeout prior to surgery. For each scenario, aseries of questions was asked about a variety of institu-tional responses toward a provider who did not adhereto each safety protocol. Potential responses includedfeedback (email feedback, verbal feedback, meetingwith a supervisor, a quarterly performance reviewmeeting, and a quarterly report card seen only by theprovider), public reporting (posting the providersinfractions on a public website), and penalties (fines,suspension without pay, and firing).</p><p>We chose the 3 practices because they are backedby strong evidence, are relatively easy to perform, are</p><p>inexpensive, are linked to important and commonharms, and are generally supported within the patient-safety community. Improved adherence to handhygiene significantly reduces infection transmission inhealthcare settings.711 Performing fall risk assess-ments has been shown to reduce falls in hospitalizedpatients,12 and using preoperative checklists, includinga surgical time-out, can reduce mortality and compli-cation risks by approximately 40%.13</p><p>Respondents were asked how many cases of docu-mented nonadherence would be necessary for the pen-alties to be appropriate (1 time, 25 times, 610times, 1115 times, 161 times, or would never beappropriate). Finally, respondents were asked to ratethe potential harm to patients of each protocol lapse(nonelow, medium, or high).</p><p>Demographic information collected from the health-care providers and medical students included age, gen-der, position, department, and years experience intheir current position. Demographic information col-lected from the patients included age, gender, insur-ance status, race, education level, household incomelevel, and relationship status.</p><p>Survey Administration</p><p>Surveys were administered to convenience samples of5 groups of individuals: attending physicians in theUCSF Department of Internal Medicine based atUCSF Medical Center and the San Francisco VeteransAffairs Medical Center, nurses at UCSF Medical Cen-ter, residents in the UCSF internal medicine residencyprogram, medical students at UCSF, and inpatients inthe internal medicine service at UCSF Medical Cen-ters Moffitt-Long Hospital. Attending physicians andnurses were surveyed at their respective departmentalmeetings. For resident physicians and medical stu-dents, surveys were distributed at the beginning of lec-tures and collected at the end.</p><p>Patients were eligible to participate if they spokeEnglish and were noted to be alert and oriented toperson, time, and place. A survey administratorlocated eligible patients in the internal medicine serv-ice via the electronic medical record system, deter-mined if they were alert and oriented, and approachedeach patient in his or her room. If the patients ver-bally consented to consider participation, the surveyswere given to them and retrieved after approximately30 minutes.</p><p>Healthcare professionals were offered the opportu-nity to enter their e-mail addresses at the end of thesurvey to become eligible for a drawing for a $100gift card, but were informed that their e-mailaddresses would not be included in the analytic data-set. Inpatients were not offered any incentives toparticipate. All surveys were administered by a surveymonitor in paper form between May 2011 andJuly 2012.</p><p>Driver et al | Following Patient Safety Practices</p><p>100 An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 9 | No 2 | February 2014</p></li><li><p>Data Analysis</p><p>Data analysis was conducted using the StatisticalAnalysis Software (SAS) package (SAS Institute Inc.,Cary, NC) and Stata (StataCorp, College Station,TX). Descriptive analysis and frequency distributionswere tallied for all responses. Responses to protocollapses were grouped into 3 categories: feedback, pub-lic reporting, and penalty as described above. As allsurveyed groups endorsed feedback as an appropriateresponse to all of the scenarios, we did not examinefeedback, concentrating our analysis instead on publicreporting and penalties.</p><p>Appropriateness ratings for each response to eachprotocol lapse were aggregated in 2 ways: ever appro-priate (ie, the response would be appropriate aftersome number of documented lapses) versus neverappropriate, and the threshold for the response.Whereas public reporting was only asked about as asingle option, 3 separate responses were collapsed intothe single response, penalties: fine, suspension, orfiring. Individuals were classified as endorsing a pen-alty if they rated any 1 of these responses as everappropriate. The threshold for penalty was the small-est number of occurrences at which 1 of the penaltyresponses was endorsed.</p><p>Differences among the 5 groups in the perceivedharm of each protocol lapse were tested with v2 anal-yses. Group differences in ratings of whether publicreporting and penalties were ever appropriate weretested with logistic regression analyses for eachscenario separately, controlling for age, sex, andperceived harm of the protocol lapse. To determine ifthe 5 groups differed in their tendency to support pub-lic reporting or penalties regardless of the type ofprotocol lapse, we conducted logistic regression analy-ses across all 3 scenarios, accounting for multipleobservations per individual through use of cluster-correlated robust variance.14 Differences amonggroups in the number of transgressions at which pub-lic reporting and penalties were supported were exam-ined with log-rank tests.</p><p>RESULTSA total of 287 individuals were given surveys, and183 completed them: 22 attending physicians, 33 resi-dent physicians, 61 nurses, 47 medical students, and</p><p>20 patients (overall response rate 64%). Responserate for attending and resident physicians was 73%,for nurses 59%, and for medical students 54%.Among patients who were approached and agreed toaccept a survey, 87% returned completed surveys(Table 1). The average age of attending physicianswas 35.8 years (standard deviation [SD]: 5.3), resi-dents was 28.3 years (SD: 1.7), nurses was 43.6 years(SD: 11.1), medical students was 26.6 years (SD: 2.9),and inpatients was 48.2 years (SD: 15.9). Thirty-twopercent of attending physicians were female, 67% ofresident physicians were female, 88% of nurses werefemale, 66% of medical students were female, and47% of inpatients were female.</p><p>Perceived Harm</p><p>Out of the 3 scenarios presented in in the survey, par-ticipants believed that not conducting preoperativetime-outs in surgery presented the highest risk topatient safety, with 57% (residents) to 86% (nurses)rating the potential harm as high (Figure 1). Not con-ducting fall risk assessments was perceived as secondmost potentially harmful, and not properly practicinghand hygiene was perceived as least potentially harm-ful to patient safety. There were significant differencesamong groups in perceptions of potential harm for all3 scenarios (P&lt; 0.001 for all).</p><p>Appropriateness of Public Reporting and Penalties</p><p>Public reporting was viewed as ever appropriate by34% of all respondents for hand-hygiene protocollapses, 58% for surgical time-out lapses, and 43% forfall risk assessment lapses. There were no significantdifferences among groups in endorsement of publicreporting for individual scenarios (Figure 2). Penaltieswere endorsed more frequently than public reportingfor all groups and all scenarios. The proportion ofattending physicians and patients who rated penaltiesas ever appropriate were similar for each scenario.Residents, medical students, and nurses were lesslikely than patients an...</p></li></ul>


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