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September 30, 2019

The Risk and Cost of Limited Clinician and Patient Accountability in Health Care

Author Affiliations
  • 1Dell Medical School, University of Texas, Austin
JAMA. 2019;322(18):1759-1760. doi:10.1001/jama.2019.14832

Personal accountability has been a divisive issue in health care, with positions revealing an ideological chasm between those who see health care as a privilege and those who see it as a right. The discussion is generally limited to accountability for payment regarding whether the health care system should expect individuals to take prudent action to protect themselves from future health care costs, usually by buying insurance. While certainly an important issue, this framing ignores deeper questions that have left accountability only superficially examined in the health care system. Value-based care encourages more accountability for clinicians and health care organizations to achieve better outcomes. It is time to examine the role of the patient in determining these same outcomes so that accountability is appropriately assigned and incented.

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    3 Comments for this article
    Complexity Too Great
    Scott Helmers, MD | Retired family physican
    I would question if the complexities and variabilities can ever be overcome to the point that incentives for value based care will align effectively enough to be worthwhile.
    Collaborative Health Care and Shared Responsibility
    Negin Hajizadeh, MD, MPH | Northwell Health System
    Thank you for this terrific viewpoint which extends medical decision making/collaborative decision making beyond the office visit to accountability after and between visits. Investments in seamless and effective communication after the clinic visit via mHealth and Telehealth technologies is key for the continued collaboration from clinicians, health systems, patients and their families with the common goal of improved health. After all, it does 'take a village'. These methods can also capture real-life barriers to adherence for researchers and policy-makers for more effective interventions.
    Are Healthcare Key Performance Indicators Harmful?
    Robert Gillespie of Blackhall, OBE, BSc, MA, MBA | University of Sussex
    It's possibly not people who stress hospital clinicians, but numbers.

    A list of numeric Key Performance Indicators (KPIs), established by a consulting firm to install Balanced Scorecard reporting in healthcare, places a heavy load of worry on clinicians about mistakes and satisfying others.

    Many of these numbers focus on dysfunction: number of patient complaints filed; percentage of electronic health records completed; discharge time; number of mistake events; patient wait times; patient satisfaction; emergency-code response time; medication errors; post-procedural death rate: the list goes on and on.

    Among 109 indicators in the long list, 42
    survey clinician activity and 30 report purely on clinician dysfunction.

    Among the 70-or-so common complaints which foreground the distress clinicians report, are: I suffer from time pressure; I have scarce resources; different groups at work demand different things from me that are hard to combine; I have little support from my colleagues; I have a feeling of wrongdoing; I’m exhausted; I have to work too fast; I am not recognised for the job I really do, etc. (1)

    Such performance indicators and clinician-stress drivers in healthcare appear correlated: I have discovered such distress among physicians in the USA, France and the UK.

    Once Key Performance Indicators have recoded the DNA of healthcare reporting, they lose personality, and their cold data relentlessly exhibits dysfunction month after month without embarrassment. Is it any surprise that, in such a ‘litigious and punitive climate’, as Van Kooy et al. claim, ‘care providers hesitate to report medical errors’ and ‘peer protection and internal hierarchies tend to prevail’ (2)

    In the case of gross dysfunction, management knows about it and takes action but, in the majority of reporting, action is not taken because not necessary. The question is whether this mountain of unused data merits what it costs to administer, and the cost of clinician exhaustion.

    Excessive focus on clinician error in a Balanced Scorecard appears pernicious: the saying that ‘what gets measured gets done’ no doubt has merit, but if management uses such indicators then management may wish to focus on that word Balanced.

    Much error reporting is claimed necessary to ensure payment by insurance organisations and as a documentary measure providing legal protection against malpractice suits. But who reads the vast bulk of detailed, innocent, reports which clinicians are now bullied to write? The useless part of this work keeps them away from their families, writing in their surgeries until 11 at night, or paying extra staff to type it up? How much of this ocean of paperwork serves patient wellbeing? And, assuming payors do identify slips, what do they do about it except not pay, which helps their cash flow rather than the patient.

    Don’t we need to avoid embarrassing those whose vocation is dedicated to improving and to saving lives? Such pressures on clinicians did not exist just a few decades ago: they have changed the work and destroyed the motivation felt by clinicians in the past. Do we wonder why fewer and fewer young people are entering healthcare?

    Should medicine not be run once more like a learned society, which is what it is, than a business?
    The analytical tools do exist to understand what is essential about their work and to throw out all the ‘portly’ work they do which has no value? We can get rid of the waste in these predatory processes. Good management means focusing on unseating the superfluous and not on poring compulsively over Balanced Scorecards.


    1. Cécile Decroix, 2018; Lancaster & Ward, 2002; Sussex partnership clinical strategy.pdf; Tomei, Ricci, & Fidanza, 2016.

    2. Van Kooy & Pexton, 2018.