Abstract
For more than a decade the international literature has attested to the fact that medical error is a chronic threat to public health. The Harvard Medical Practice Study [1] and the Bates Medication Error Study [2] are typical of published reports. In Australia Wilson et al. [3] confirm that Australian medical practice is risky to health, while Davis [4] had demonstrated that New Zealand is in a similar position.
This issue is not a new one. Napoleon Bonaparte (1769–1821) is quoted as saying: ‘I do not want two diseases – one nature-made, one doctor-made’.
The magnitude of the problem is reflected in the following figures from the Quality in Australian Health Care Study [3]: potentially preventable adverse events, 300 000; preventable permanent disability 50 000; preventable serious disability, 15 000; potentially preventable death, 12 000; and all injury and suicide deaths, 6000, all per annum.
Vincent [5], [6], found one in 10 patients, admitted to two London hospitals, suffered adverse events. He estimated that medical error kills around 40 000 people a year in the UK. This means that medical error is the third most common cause of death after cancer and heart disease.
In 1998 Chassin and Galvin [7] reported from the National Roundtable on Health Care Quality: ‘Serious and widespread quality problems exist throughout American medicine. These problems. occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee for service systems of care. Very large numbers of Americans are harmed as a result.’
Although there are no studies that are psychiatryspecific, anecdote, analysis of rate and types of complaint and reports of serious incident reviews strongly suggest that psychiatry is as much at risk of producing harm as any other branch of medicine.
The literature paints a grim tale about the safety of health services. It is useful to review what are the public expectations of health service quality. The expectations of the New Zealand government are clearly spelt out [8]: ‘The central concern for health professionals and provider organizations is to ensure that clinical care is safe, effective and efficient, as well as appropriate to the needs of a particular service user. The challenge for health professionals is not just to identify inadequate care, but also to make changes that improve clinical practice and health care service delivery. Meeting this challenge is primarily a health service responsibility involving a range of health professionals represented in the team who contribute to patient outcomes.
Before examining how health professionals might assume this responsibility we need to ask why things go so badly?
Lucian Leape [9] suggests that: ‘Human beings make mistakes because the systems, tasks and processes they work in are poorly designed’ and ‘the vagaries of biology and human behaviour make perfection unattainable’. James Reason [10] notes that ‘all human beings, without exception, make mistakes’.
Reports of the US Institute of Medicine Committee on Quality of Health Care brought the matter of patient safety to the top of the health service agenda. To err is human [11] galvanized a previously minimally reactive public, the media and subsequently the medical profession. Medical error was identified as a threat to health of similar proportion to breast cancer, motor vehicle accidents or AIDS. The subsequent report, Crossing the quality chasm [12] suggested ways that the performance of the health care system could improve.
The Institute Of Medicine report includes definitions of relevant terms: overuse, underuse and misuse. Overuse refers to the deployment of resources and procedures in the absence of evidence they actually help. Conversely, in underuse health care practices of proven benefit are not utilized. The term misuse is applied where plans and procedures are not properly applied.
A framework to understand the changes needed has been developed [13]. This involves four levels: level A refers to the experience of the patients; level B addresses the functioning of small units of care; level C the functioning of the organizations that house and support these units of care; and level D is the environment of policy, payment, regulation and accreditation. A hierarchical model applies in that the quality initiatives at one level define actions at the next. Ultimately, levels B, C and D promote the quality of the product experienced by the patient (level A). This approach reflects the position of the President's Advisory Committee that: ‘The purpose of the health care system is to reduce continually the burden of illness, injury and disability, and to improve the health status and function of the people of the United States’ [14].
The ‘Chasm’ report [12] contains six goals: safety, effectiveness, patient centredness, timeliness, efficiency and equity. These aim to improve services so that patients are as safe in the health system as in their own home. The care delivered will be matched to science, with avoidance of overuse of ineffective care and underuse of effective care. Services will recognize the patient's culture, social context, choices and specific needs. Reduced waiting times and delays and diminished waste will reduce costs. Equity will be seen in the closure of racial, ethnic and class gaps.
The Institute of Medicine's reports [11], [12], conclude that health care cannot, without fundamental revision, turn itself into what it should be. Injury from care is inherent to current systems and safer care will require new designs. Blaming clinicians for patient injuries is inappropriate. Rather, there is a need to address systemic failures such as unrealistic reliance on human memory, poor communication systems, unreasonable expectations of human vigilance, lack of appreciation of the consequences of fatigue and reliance on handwriting in a computer age. Exhortation, blaming and trying harder are not the means to improve safety. We need to pursue the substitution of new, scientifically valid systems for old unreliable ones.
Friedson [15] argues that: ‘The overall strategy of social policy should be aimed at keeping the professional model at the centre of health care and other business services while checking and correcting the vices of its practitioners by carefully chosen elements of the other (free market and bureaucratic organizational) models.’ Professional shortcomings include arrogance, sanctimoniousness, insularism, suspicion of other practitioners, aversion to self-regulation and unwillingness to be regulated by others.
Luce [16] proposes ways physicians can enhance professionalism and thereby promote the professional model proposed by Friedson. These include taking responsibility for strengthening ties with patients by being their advocates, enhancing peer review, sharing power with other practitioners including nurses, advancing knowledge including evidence-based medicine and improving quality of care. The free market and/or state should appreciate the unique nature of professionalism generally, and the medical profession specifically, and allow physicians to manage themselves wherever possible. Support of quality initiatives physicians bring forward and prevention of frustration with the work environment will let them do good work.
As well as the guidance to improve health care there is good direction about what not to do. Reason [17] has reminded the health sector that: ‘The person approach (to human error) has serious shortcomings and is illsuited to the medical domain. Indeed, continued adherence to this approach is likely to thwart the development of safer health care institutions’. West [18] has argued against ‘… automatically ascribing errors in organizations to the ignorance, incompetence or immorality of individuals’. She supports ‘… efforts to move the culture of healthcare organizations away from blame and exhortation of individuals’.
Role of professional organizations
Duggan [19] suggests that medical colleges have a key role in the quality of healthcare. Such bodies contribute less in Australia than their counterparts in the UK. He advocates participating in or leading practice audits, promulgating clinical guidelines, strengthening links with and access to knowledge pools and promoting CME.
However, he sounds a warning: ‘… in Australia there is increasing emphasis at state and federal level on politicization of quality studies divorced from the professions. A striking feature of the Australian scene is the total lack of co-ordination or leadership throughout the system. Essentially, in the absence of a significant role for the professional bodies and a catalytic/funding role for governments, advances are unlikely.’
Practitioners in several health disciplines are required by their professional bodies to engage in continuing education and in activities to maintain professional standards in order to maintain membership (the internal regulatory process). Increasingly we are seeing in both New Zealand and Australia an insistence on certification of satisfactory participation in such professional body schemes to satisfy ongoing registration requirements. These activities include clinical audit and peer review. In an increasingly complex environment, with the subsequent development of subspecialization and advanced practice, it helps to develop a closer relationship between practitioner, organization and professional bodies. This relationship should focus on key quality improvement issues, reduce ambiguity for the practitioner and enable consumers to contribute at both a professional and organizational level.
Berwick [20] provides strategies to improve quality. These are conveniently grouped into clinical practice improvement (CPI) and evidence based practice (EBP) tools. CPI tools include: small scale strategic research, clinical pathways, outcome and performance indicators, clinical audit and peer reviews and community participation in health care planning and evaluation. EBP tools include: systematic appraisal of the best available evidence, clinical practice guidelines, peer reviewed clinical research, Cochrane Collaboration and community values and expectations.
The College's response to the challenge
First and foremost we as psychiatrists must do two things: stop taking responsibility for the behaviour of people with a mental illness, and start taking total responsibility for the quality of what we do. I will not elaborate on the former, having done so elsewhere [21]. I will use the framework from the ‘Quality Chasm’ report [12] to expand on the latter. The multilevel framework as elaborated by Berwick [13] requires us as a College to examine our activities at level D, the health care environment. We need to reflect on the leadership we give in regulation, accreditation and professional education.
The College is central to setting standards of practice: knowledge, technical skills, attitudes and ethical principles. For those entering the profession our bylaws for training and examination set these. Many hours of voluntary input from the Fellowships Board and its committees goes in to scrutinizing these bylaws, accreditation of experience gained against these and reviewing of satisfactory achievement of expected goals.
The recent focus on continuing learning, incorporating skill and knowledge maintenance and development throughout one's life is fundamental to improving quality. The role of the Board of Practice Standards is crucial here. The debate about the correct way to promote quality of practice is healthy as long as it does not excuse us from actual performance. When literature acclaims the boldness of learned colleges that expect continuing education and skill development to be part of Fellowship we would be unwise to do otherwise. I would expect ongoing review of our maintenance of practice standards programme, but would be dismayed if it were dismantled.
The College needs to promulgate its code of ethics and to review what constitutes ethical behaviour. There needs to be accessible, expert opinion for the Fellow and for the patient alike as to what constitutes good practice. Deliberations that result from such reviews need to enter feedback loops and guide appropriate educational material designed to assist improvement. The literature on quality stresses, as previously cited, the ineffectiveness of a ‘blame and shame’ culture. Instead, data from practice reviews should inform desirable changes of practice, reinforce that which produces better outcomes and extinguish that which is inferior.
We must determine when types of practice are inappropriate and take effective steps to protect the public. The College is reviewing the ways it deals with complaints and its relationship with statutory bodies such as medical boards and health commissioners. In the spirit of the ‘Quality Chasm’ challenge, we must promote this process.
The College initiative on boundary violations is a focused attempt to address a practice that is especially prevalent in psychiatry and damaging to patients and their families. This initiative, developed with a strong patient/caregiver/professional partnership, has examined interventions from education (of both practitioner and patient) to disciplinary measures. The project calls for an emphasis on prevention in line with all modern approaches to quality achievement, whereby a range of tools are developed to minimize error.
The delay in applying new research findings to health practice is something a learned College is cognizant of and takes steps to minimize. We achieve some of this by promotion of educational activities such as our Congresses. The Board of Research has this on its agenda but perhaps the College should prioritize its place. Most people are staggered by the time it takes for proven health care benefits to become routine (and, conversely, for practices that are ineffective to cease). With knowledge transmission so much more achievable today, it is hard to accept that application of new findings is so slow.
Initiatives such as clinical practice guidelines and clinical pathways are recent examples of the College providing tools to make it easier for the clinician to provide the right intervention to the right person at the right time. That will make it likely the patient will get the best possible health gains with the fewest untoward effects. It is disappointing that a vocal minority continually attacks guidelines and pathways out of a fear they will lose autonomy and patients will suffer. I suspect this headin-the-sand position leads commentators like Duggan, Luce, Leape and Berwick to exhort the professions to help health services to deliver a better quality product.
The ‘Quality Chasm’ highlights risks and challenges for a learned college. ‘Over-regulation for stability’ is an example. It is easy for regulations, designed to keep the system safe, to work against improvement. When regulations promote the status quo, progress is impeded. This is often confounded by a non-cooperative approach from the bodies charged with defining and policing the regulations which allows the old mistakes to be repeated. Berwick sees the need for a ‘new breed’ of citizenship among health professionals. From early training we must teach an interactive model. We are all familiar with allegations that learned colleges are ivory towers interested only in protecting their members. We must listen to this criticism and promote a cooperative approach.
I have chosen not to focus on the B and C levels of the framework. Though many of us have roles in provision of care, these are not the direct responsibility of the College. Level D activities will, of course, influence operations at other levels.
I wish to reflect on the importance of the changes at level A, the experiences of patients and their families. For those who know me it will come as no surprise that I resonate strongly with the view of ‘Quality Chasm’ that the experiences of patients are the ‘true north’ – the ultimate determiner. What are we doing to recognize their central role?
Most influential here is the Board of Professional and Community Relations. I hope it will continue to flex its muscle in overviewing all College decisions. The Board, given its diversely representative structure, a Community Liaison Committee, an Indigenous Persons Committee and a Professional Liaison Committee for each country as well as a Regional Affairs Committee, should consider all policy. The high proportion of patient and caregiver representatives exhibits the spirit of partnership. Having served on the Board I admire those intrepid people who accept invitations to participate.
We have also had patient and caregiver input in key areas like the curriculum and the complaints process. We are discussing the possible roles of patients and caregivers in other spheres of the College, including governance and the examinations of skills and attitudes. We must move from consultation to involvement by creating an environment where it is not only possible but also expected that professional/patient/caregiver participation occurs.
Conclusion
The data pointing to the risk health services pose for patients cannot be ignored. Exhortation to perform better and punishment of poor performers makes little difference. I hope I have convinced you that the remedy needs a multisystem, multilevel approach. Safety in health care is everyone's business. As a learned College we must accept a central role in improving what we have to offer. We must also enhance the participation of patients and caregivers to guide the process, their experiences are pivotal in defining quality.