More “Skin in the Game” – Is This Where We Are Going?

The name of this blog, Educate the Young–and on occasion Regulate the Old, originated from the somewhat disheartening realization that education alone wasn’t going to create the complete adoption of cultural change–the collective mindfulness of high reliability organizations, and the personal commitment of every caregiver to do all the extra little things it takes to ensure our patients are as safe as possible. To be fully patient-centered, not self-centered. Unfortunately, regulations, carrots and sticks, and negative reinforcements may also appear to be necessary to create the behavior change needed to get us to zero preventable harm events. These rules can sometimes be painful and appear to oppose a just culture approach, but they have also been shown to work when other behavior change methods do not. While the debate over the value of extrinsic versus intrinsic motivators to change continues, so does the harm to our patients.

In Bob Wachter’s post this summer, The New and Improved “Understanding Patient Safety” and Evolution of the Safety Field, he states that the greatest change in his thinking over the past 5 years is the need to balance:

…a “no blame” approach (for the innocent slips and mistakes for which it is appropriate) with an accountability approach (including blame and penalties as needed) for caregivers who are habitually careless, disruptive, unmotivated, or fail to heed reasonable quality and safety rules. Fine-tuning this balance may well be the most challenging and important issue facing our field over the next 5-10 years.

And in November of this year, Peter Pronovost commented in his blog (here) on the leadership it will take, not only to turn Parkland Hospital around, but others as well:

…doctors, nurses and administrators care deeply about patients; they do not want to harm them. They work with broken, underresourced systems. The next CEO must recognize this and seek to understand rather than judge, to learn and improve rather than blame and shame…This won’t be easy. The public wants accountability. Parkland is under scrutiny from federal and state regulators. Yet real improvements will come from internal rather than external motivation…The CEO will need to help the staff see shortcomings in safety as their problem and believe they are capable of solving it. The CEO will need to inspire with lofty oratory, and then drop down, roll up her sleeves, and get things done.

Financial penalties based on safety and quality measures are now prevalent in healthcare. Value-based purchasing, quality care indicators, and readmissions are now tied to revenue deductions, and more measures tied to reimbursement are on the way. Will continuing to increase these type of quality-base incentives be what it finally takes to get us to where quality and safety should be? Or are there more severe penalties on the horizon for not following evidenced-based safe practices?

People are now speculating on what would happen if physicians had more “skin in the game” — a Warren Buffet-ism suggesting that people who feel the hurt financially when something goes wrong will take a more vested interest in the outcome of their efforts. This risk-taking behavior change is seen in business and other areas, including healthcare. In a recent post on his blog, A proposed exception to malpractice coverage, Paul Levy posed a “what if”:

…Any surgeon who has carried out a wrong-site surgery who did not follow the universal protocol for a time-out would not be covered for malpractice claims on that procedure.  Any anesthesiologist who was attending such a surgery likewise would not be covered for malpractice claims on that procedure…

There is possible history behind this proposal. Obtaining informed consent to do a procedure on one part of the body and then (after knowingly violating safe policies and procedures like universal protocol) “harming” another part of the body without gaining informed consent could be classified as battery and a criminal offense. Some in the legal community believe this approach could be used to negate malpractice coverage as wrong-sided surgeries and procedures continue to occur.

The response Paul received provided a good look into just how complex this behavior change is, and in a follow-up post, Let’s go for autonomy, mastery and purpose, he responded by sharing that in his experience, it takes a balance of attention to the needs of the systems in tandem with personal accountability, referring to Dan Pink, a motivation expert, author and TED Talk alumni that carrots and sticks detract from, rather than build up, a workforce.

So would more skin in the game, and a hit to one’s financial well-being (e.g. home, automobile and other personal assets), be what is necessary to help create the culture change we now need to put our patients first and show the last safety “hold-outs” that people are fed up with non-compliance to policies and procedures that have been shown to reduce risk?  I for one would like to believe this is not true–that the vast majority of us still embody our oath to do no harm first and foremost, and that financial or personal gain is not the driving force behind our efforts in healthcare. But I have also watched improvements in care occur at a much slower pace than hoped, and sometimes only after CMS required it–despite all educational energy and effort put into those improvements prior to the mandates. The conversation continues…


2 Comments on “More “Skin in the Game” – Is This Where We Are Going?”

  1. A missing piece of this whole discussion is that the doctors are toast. Surveys consistently show 1 in 3 doctors suffering from symptomatic burnout on any given office day, worldwide regardless of specialty.

    We have these discussions about important issues such as safety and patient satisfaction with no regard for the state of the physician’s well being or awareness as they go about their duties. That state is NOT GOOD.

    You can’t squeeze blood out of a turnip.

    A doctor will not give you optimal performance if they are fried.

    You will not be able to enroll your doctors in change or innovation if you give them no reason to believe that you care about them as an organization.

    If you were to take the medical error research and add in one additional independent factor … like the physician’s perceived stress or fatigue level on the day of the error … you would find one of the big culprits … a smoking gun that I would hope motivates organizations to stop treating doctors like production units and begin to support their health and well being as equal if not more important than anything else … including patient satisfaction.

    My two penny rant,

    Dike Drummond MD
    TheHappyMD (dot) com

    • Dike,
      Thanks for your two penny rant. Fully agree. Burnout is at an all time high. Plus many others acknowledge if they had to do it all over again, they would pick a different profession. The same can be said for nursing and some of the other health disciplines. Lucian Leape and Paul ONeill’s work on bringing joy and meaning back to the workplace is vital to any success in safety and quality.
      That said, patients want results and are tired of being hurt…burn-out or not, they want measures that help ensure their safety. And third party payers and medmal insurance companies are getting tired of paying for bad care especially when caregivers are knowingly violating safe policies and procedures their colleagues have endorsed and are complying with.
      Happy holidays.

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