By BOB WACHTER, MD

In a recent New England Journal, Peter Pronovost and I make the case for striking a new balance between “no blame” and accountability. Come on folks, it’s time.

At most hospitals, hand hygiene rates hover between 30-70%, and it’s a near-miracle when they top 80%. When I ask people how they’re working to improve their rates, the invariable answer is “we’re trying to fix the system.”

Now, don’t get me wrong. I believe that our focus on dysfunctional systems is responsible for much of our progress in safety and quality over the past decade. We now understand that most errors are committed by good, well-intentioned caregivers, and that shaming, suing, or shooting them can’t fix the fallibility of the human condition.

But not washing hands? When I hear, “It’s a systems problem,” my BS detector goes a little bit haywire, particularly after I walk around the hospital and see alcohol gel dispensers every 2 feet and glossy photos of smiling clinical leaders cleaning their hands at every turn. I think all of us realize that in 2009, failure to clean hands is no longer primarily a systems problem. It’s an accountability problem.

That’s not to say that the system can’t be improved. The Joint Commission recently launched its new Center for Transforming Healthcare, which focused on hand hygiene as its first initiative. The Center identified several system changes that will help – like installing cameras to monitor hand washing or alarms that go off if providers approach patients without giving the alcohol gel dispenser a pump. That’s all for the good.

But the question remains: what do we do with the doc or nurse (and I’m mostly talking about docs here) who refuses to clean his hands, or to perform the pre-surgical time out, or to use a checklist when he should? Today, the answer is: absolutely nothing. And therein lies the problem.

In fact, at my hospital, I will be suspended from the medical staff if I fail to sign my discharge dictations. But if I choose to not clean my hands for the next 5 years, I’ll experience no consequences whatsoever. Does that seem right to you?

Captain Chesley “Sully” Sullenberger gave the keynote to the 600 attendees at my annual hospital medicine conference last week. Sully was everything I hoped for – dignified, understated, and forceful. (And what a good egg – he stayed for nearly an hour after his talk, taking pictures with and signing autographs for attendees.) In discussing the parallels between aviation and healthcare safety, he projected the cover picture of my book Internal Bleeding, and said…

In 2005, when it first came out, a pilot’s wife sat reading Internal Bleeding… Her husband, a colleague of mine, pointed to the cover illustration, which clearly shows a hemostat left in this person’s pelvis, and simply said, “Checklist shoulda caught that.” The wife reading the book explained that, at the time, surgical checklists were very rare.  Her husband, who relied on checklists every day, responded, “No – there’s GOT to be a checklist. They couldn’t do something that important without a checklist!”  She kept insisting there wasn’t one, he kept insisting there must be, and their back-and-forth went on for several minutes – he found it nearly impossible to believe that surgical teams did not have a key safety tool that airlines had been using for over seventy years.

I asked Sully what would happen if a pilot refused to complete a pre-flight checklist, and he assured me that his co-pilot would never agree to take off. And then the pilot would be fired. You see, in aviation, once a safety procedure is accepted, following it is no longer a choice. It’s a requirement.

But in medicine, we kill thousands of people each year because folks choose not to (or forget to) clean their hands, or use a safety checklist, or perform a pre-operative time out, or follow reasonable procedures for handoff communication. We react to these transgressions, particularly when the perp is a physician, not with outrage but with shoulder shrugs. Nothing we can do, we sigh, as patients die around us.

The need to draw a blame line is not a new idea – David Marx’s work on “Just Culture” helps us identify blameworthy acts, as does James Reason’s accountability algorithm. But we wrote today’s New England Journal article because neither of us has stumbled upon a single hospital that has mustered up the guts to enforce meaningful penalties for habitual failure to adhere to reasonable safety rules. As Kissinger once said, “weakness is provocative,” and our failure to act has provoked unsafe behaviors for far too long.

We concluded today’s NEJM article this way:

“No blame” is not a moral imperative — and even if it seems that way to providers, it most definitely does not to patients and their advocates. Rather, it is a tactic to help us achieve ends (safe and high-quality care) for which we will, quite appropriately, be held accountable. Said another way, “no blame” is a tool, and often an extraordinarily useful one. But for some mature patient-safety practices, it is simply the wrong tool…

Part of the reason we must [enforce penalties for repetitive failure to follow reasonable safety rules] is that if we do not, other stakeholders, such as regulators and state legislatures, are likely to judge the reflexive invocation of the “no blame” approach as an example of guild behavior — of the medical profession circling its wagons to avoid confronting harsh realities, rather than as a thoughtful strategy for attacking the root causes of most errors. With that as their conclusion, they will be predisposed to further intrude on the practice of medicine, using the blunt and often politicized sticks of the legal, regulatory, and payment systems. Having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism and thus represent our best protection against such outside intrusions.

But the main reason to find the right balance between “no blame” and individual accountability is that doing so will save lives.

We wrote this article to be deliberatively provocative, and ever since the Journal accepted it, I’ve been bracing for a backlash. In fact, I ran into NEJM editor Jeff Drazen at a conference a couple of months ago, and joked that I already had my Kevlar suit ready for action. “You might have needed that a few years ago,” he said. “But today, I think most of the responses will be from people, including docs, who ask, ‘why didn’t we do this a long time ago?’.”

I hope he’s right.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World,” where this post first appeared.