Given that quality improvement is both necessary and possible, the question then becomes, who should spearhead this process? Although consumers, purchasers, government, insurers, academic medicine, organized medicine, and health care providers all hold stakes in the process, it is physicians, with their history of patient advocacy and scientific innovation, who are best situated to provide the needed leadership.121,128 Such advocacy and innovation are a primary basis of the trust placed in the medical profession; to decline the challenge to improve health care quality may seriously undermine this trust. When trust is forfeited, the consequences can be dire, as the recent history of the accounting industry illustrates.
Excellent examples of physician-led efforts at quality improvement exist, but they remain relatively isolated. Unless physicians act to expand such efforts significantly, groups outside the profession are likely to fill the void and possibly close the window of opportunity for physician leadership. For instance, the Leapfrog Group (http://www.leapfroggroup.org), which represents more than 26 million Americans, has already conducted hospital surveys regarding computerized drug orders, ICU physician staffing, coronary artery bypass surgery, coronary angioplasty, abdominal aortic aneurysm repair, carotid endarterectomy, esophageal cancer surgery, high-risk obstetrics, and neonatal critical care, with a particular eye to identifying preventable adverse events and evaluating the relation between volume and outcome.
One potential policy implication of these findings is that health care purchasers might adopt policies that transfer patients needing a particular procedure to high-volume providers with demonstrated good outcomes.132 Such policies might affect the overall distribution of health care services and unfairly penalize low-volume, high-quality providers, while teaching us little or nothing about precisely which system components are relevant to improved outcome. The data on volume-outcome relations are intriguing, but many of the studies done to date have major methodological problems.68-70,102 Moreover, the majority of patients and physicians are not convinced that such regionaliza-tion would be effective.2 For now, at least, it seems premature to adopt such a policy.
For any successful improvement in patient safety, an effective reporting system is vital. It is generally agreed that such systems should be being nonpunitive and strictly confidential (if not anonymous).133 There is some debate, however, as to whether they should be voluntary or mandatory. On one hand, voluntary reporting has a high inaccuracy rate even when mandated by state or federal regulations. On the other hand, many surgeons believe that mandatory reporting may increase the pressure to conceal errors rather than analyze them; that it is unworkable in the current legal system; and that it may result not in constructive error-reducing solutions but merely in more punishment or censure.134
There is also some debate as to whether patient-safety efforts should (at least initially) focus on medical injuries or on medical errors.135,136 An approach focusing on injuries recognizes the difficulty of identifying medical errors and is based on a public health improvement model that has proved useful in addressing other types of injuries; it also recognizes that most medical injuries are not caused by negligence. Such an approach seems more compatible with the current liability system and may help restore physicians' stature as patient advocates. An approach focusing on errors suggests that focusing on injuries diverts attention from cases where there is an underlying system flaw, with the result that the flaw is not corrected. Although this is probably true, the first approach is likely to achieve greater initial buy-in on the part of physicians and thus may be a more pragmatic first step.
Successful change requires not only agreement that a change is necessary and desirable but also agreement on what the change should be. In that regard, the aviation industry is frequently proposed as a model for health care. However, aviation safety is enhanced by the availability of various monitors (e.g., flight data recorders) that supply information on aircraft position and flight conditions. A model applying these techniques to surgery has been described,101 but independent confirmation of relevant factors still seems impractical in most clinical surgical situations. Actually, surgery may be more akin to the maritime industry, in which the ship captain makes judgments about circumstances that are difficult to verify, than it is to the aviation industry. If so, it is probably relevant that the maritime industry has been less successful at safety improvement than the aviation industry has. In any case, there are many underutilized opportunities for quality improvement in health care, and the training lessons of aviation, whereby pilots are forced to deal with unusual situations that help reveal gaps or errors in their understanding, are one such opportunity. Even if the aviation model does not fully apply, its level of success should remain a goal.
Particular attention should be paid to incorporating current concepts of performance and error into surgical education.137 An optimal structure for such education might be an objective-based curriculum that provides residents with defined skills, rules, and knowledge.138,139 The blame-and-shame approach must be eliminated from the learning atmosphere. Once made aware of their tendencies in the presence of uncertainty, residents (like pilots) may develop better responses to underspecified situations. Residents should also be monitored to ensure that they learn to assess and address knowledge deficits as well as learn healthy habits in responding to errors. In this way, the learning curve can be made less painful for all concerned.140
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