Accreditation's role in reducing medical errors

Accreditors can provide some leadership, but they can't do it on their own

The admonition “First, do no harm,” paraphrased from the Hippocratic oath,1 has long been a guiding principle for the practice of medicine and the delivery of healthcare services around the world. But harm is done every day in health care. This has been well documented in the medical literature.2 Now public awareness of medical errors and unexpected adverse patient outcomes is growing.3 We have a serious problem, and it cries for timely, effective solutions. No one feels this more keenly than practising physicians, healthcare executives, and the overseers of healthcare quality. Effective solutions, however, are proving to be a daunting challenge.

The oversight of healthcare quality in the United States is accomplished both through professionally based, private sector accrediting bodies and through federal and state regulatory agencies. Many variations of this framework are now increasingly in evidence throughout the world. The initial model for external quality oversight in the United States was created by physicians in 1917. The resulting hospital standardisation programme of the American College of Surgeons was the forerunner in the US of both the national Joint Commission on Accreditation of Healthcare Organizations and the federal and state regulatory framework now in place for all types of healthcare organisations.4 While these parallel oversight mechanisms are potentially duplicative, regulatory agencies commonly defer to accrediting bodies that meet their performance criteria.

Although couched in the language of continuous quality improvement, the accreditation process is, at its core, a risk reduction activity. It begins with the setting of contemporary standards that address important organisational functions—for example, patient assessment, medication usage—and then encourages organisations, through the awarding of accreditation, to comply with these standards. The operating thesis is that if organisations are doing the “right things right,” as reflected in the standards, then errors and adverse outcomes are less likely to happen than if there were no such standards. Notwithstanding the continued high frequency of errors, this thesis is almost certainly correct.5

We are simply at a more primitive stage than we would like to be in our knowledge of why what happens happens in healthcare organisations. It has become too easy to accept some (undefined) degree of medical errors as the inevitable byproduct of today's increasingly complex patient care and simply to blame and punish individual caregivers when things go seriously wrong. Leaders of the medical profession and of healthcare organisations do not include reducing medical errors among their top priorities. Because of this, the level of commitment to analysing relationships between errors and adverse outcomes on the one hand and organisational systems and processes on the other has so far been modest. There is now a growing urgency that such analyses should be undertaken and that the knowledge gleaned should be assimilated, shared, and used in designing and redesigning safer organisational infrastructures that minimise the potential impact of human factors in the delivery of care.6

Changing existing attitudes, behaviours, and priorities towards the identification and management of medical errors lies well beyond the “control” of accrediting bodies or regulatory agencies. Nevertheless, because of their roles as agents of public accountability, such external quality oversight bodies do have the ability to foster constructive change in healthcare organisations.

For example, largely through a voluntary self reporting system, the Joint Commission on Accreditation of Healthcare Organizations has developed a database of serious adverse events and of the results of organisational analyses of these events. We periodically share the lessons learnt with all accredited organisations.7 This simple effort to translate negative results into useful information that can prevent errors in multiple settings is easily replicable anywhere in the world. Mandatory reporting of these occurrences and related analyses would rapidly produce an even richer database, but without the guarantee of confidentiality for the analyses (which does not currently exist) the evidence suggests8 that the analyses would probably not be performed with the desired degree of thoroughness.

The joint commission has also recently introduced the requirement that each accredited organisation should establish reporting channels for unexpected adverse occurrences, perform an in depth analysis of each such occurrence, implement improvements, and assess the impact of the improvements on internal systems and processes. This should move error and adverse event management up leaders' priority lists and help accredited organisations begin to learn more about themselves.

In the end, however, what we most need is a characteristic not described by Hippocrates—the ability of care givers to admit and accept fallibility. Furthermore, the organisations in which care is provided must create environments in which it is “safe” to admit error and safe as well to explore why the error occurred. In a sense, we need to extend the peer review collegiality inherent in the classic morbidity and mortality conference to the context of the entire organisation. Simply stated, if we truly expect to improve the safety of patient care, those who directly provide the care must engage in the improvement process and feel safe in doing so.