Accountability: To Whom? For What?

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Presentation transcript:

Accountability: To Whom? For What? Lucian L. Leape, MD Harvard School of Public Health 10th Anniversary of To Err is Human The Commonwealth Fund and Alliance for Health Reform March 17, 2010, Washington, DC

Accountability today Blame and punish – Who will be fired? Mandatory reporting – Serious Reportable Events No pay for Serious Reportable Events

Accountability today – what’s wrong Retrospective – after the patient has been harmed Blame and punishment all over again Safety is about prevention - prospective We don’t want to hold people accountable for hurting people, we want to hold them accountable for NOT hurting people

A shared vision of what health care can be Provided by an organization that is responsible for all the health needs of a population Care that is evidence-based, patient-centered, safe, timely, efficient, and equitable In an environment that is transparent, non-punitive, supportive, but accountable By caregivers who are competent, compassionate, and collaborative, and share a sense of responsibility

Prospective Accountability Individual Institution Regulator

Prospective Accountability Individual Technical competence – keeps up Social competence – respect, empathy, collaboration Accountable – follows safe practices, works to improve Institution Regulator

Prospective Accountability Individual Institution Provides a safe, non-punitive environment – a “just” culture Implements all known safe practices Provides the resources and training needed Monitors practices Monitors performance Takes corrective action when needed Regulator

Prospective Accountability Individual Institution Regulator Sets standards for practice and performance Safe practice – NQF list Environment, working conditions Credentialing Worker safety Monitors compliance Sanctions when necessary

Reciprocal Accountability Regulators Hospitals Professionals

Reciprocal Accountability Regulators Patients Hospitals Professionals

Do we need a Federal Patient Safety Agency?