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Patient Safety

Out Of Sight, Out Of Mind: Why Doesn’t Widespread Clinical Quality Failure Command Our Attention?

Abstract

 
This paper examines the tolerance by all stakeholders of increasingly well documented evidence of serious and widespread clinical quality failure in the United States. Using research evidence from psychology, it describes specific cognitive and motivational impediments to the perception of quality failure—those shared by all stakeholders and those particularly relevant to patients and their families and to health care professionals. The authors endorse efforts by the National Quality Forum and others to make quality failure more publicly visible. They also point to the pivotal role of health care industry leaders in sustaining focus on a problem that inherently resists visibility.

Such passivity is striking. Americans generally insist on rapid corrective action when operational failures in major industries lead to high rates of injury or death. Operational failures in the transportation, food, and nuclear energy industries have motivated substantial improvements. Why don’t widespread clinical quality problems in health care elicit a similar response?

Scientific understanding of the forces that shape which problems individuals and societies choose for vigilant attention and robust corrective action is limited. Applicable theory and empirical research can be garnered from multiple social sciences: psychology, sociology, anthropology, economics, political science, public policy, marketing, and health services research. This paper applies concepts and empirical findings from research on cognitive and motivational psychology. Using signal detection theory as a conceptual framework, we outline a set of impediments to the perception of clinical quality failure. While perception of a serious problem is not sufficient to assure robust corrective action, it is an essential first step. Since some impediments to perception are shared by most stakeholders while others are more significant for patients or health care professionals, our discussion organizes the impediments in these three categories.

Perceiving Quality Failure: An Example Of Signal Detection

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Perceiving whether clinical quality failure is likely to occur in general or has occurred in a specific instance represents the general task of distinguishing when a "signal" represents a true event. Signal detection theory is derived from research in perception and psychophysics and has been used to study decisions under uncertainty in labeling an event. The medical field has used it to understand problems of diagnosis (for example, determining whether a tumor is malignant or benign).⁵ Correct signal detection is either a "hit" (that is, labeling a clinical quality failure as present when it has occurred) or correct rejection (labeling it as absent when it has not occurred). Incorrect signal detection is either a miss (not identifying it when it occurs) or a false alarm (labeling it a hit when it has not occurred).

Signal detection theory is organized around three primary elements: signal, criterion, and observer. Characteristics of each of these will affect the likelihood that an event is properly identified. In the health care context, many of these characteristics work against correct signal detection and foster a relatively high proportion of misses. Some of the characteristics that increase the likelihood of misses derive from cognitive factors, some from motivational forces, and some from non-psychological barriers to perception. They influence the accuracy of global perceptions, such as whether hospitalizations or medication administration are generally safe and free of defects. They also influence the accuracy of perception and interpretation of specific, personally relevant events, such as an intravenous bag label containing a misspelling of a patient’s name. They may operate before, during, or after health care experiences.

Signal characteristics. It is more difficult to label an event as a hit if there is "noise" surrounding it. Concurrent circumstances or attributes of an event may distract from perceiving or correctly labeling it. Incompletely documented, illegible, or inaccessible paper medical records are common forms of external noise that impede clinicians’ and quality improvement staff’s perception of process failures or suboptimal outcomes. Even when external noise is low, internal noise may block correct perception and interpretation. Internal noise can derive from factors such as fatigue, pain, or worry about the underlying disease.

Criteria. Identification of a "signal" requires some criterion for deciding if it is present or not. Establishing a criterion for identifying quality failures is problematic for reasons unrelated to psychological factors. Because of low investment in outcomes research and the limits of our bioscience knowledge, we often lack the ability to specify confidently the best clinical interventions or expected outcome trajectories. Outcomes ranging from slow or incomplete symptom reduction to death may be the inevitable consequences of perfect clinical processes and therefore difficult to differentiate from the consequences of quality failure. Underdeveloped criteria are a formidable nonpsychological barrier to detecting clinical quality failure.

Observer characteristics. People vary in their natural inclination to detect signals and regard them as important. While transient conditions such as fatigue or pain serve as noise in specific situations, these operate in combination with more enduring observer characteristics. "Yea-sayers" are relatively more likely to say that a signal is present and will have more hits and more false alarms; "nay-sayers" will have fewer. As described below, in health care settings, cognitive and motivational factors induce a propensity toward more "nay-saying" than "yea-saying."

We now turn to cognitive and motivational impediments that contribute to failure to detect quality failures and to undertake preventive action. Some impediments primarily inhibit global perception of danger, while others primarily inhibit perception of specific instances of defect. After identifying impediments that are applicable to everyone, we examine those that are of particular relevance to patients and to clinicians.

Cognitive And Motivational Impediments

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Inaccurate judgment heuristics. The human brain has a limited capacity to process information in short-term memory. This makes it burdensome to interpret events in health care environments, where a great deal of relevant information needs to be processed simultaneously. A well-documented automatic response to high burden is the use of judgment heuristics, which are shortcuts used to simplify decision making. These shortcuts may grossly impede the accuracy of signal detection. Prevalent heuristics in the health care context tilt observers toward underdetection.

Availability heuristic. The availability heuristic leads people to overestimate the likelihood of occurrence of relatively dramatic or vivid events.⁶ Such events are more salient and more easily called up from memory. For example, because aviation deaths are more vivid in memory than automobile deaths are, many people fear flying more than driving, although the per mile risk of death is much lower for flying. This bias toward overestimation of vivid events has been shown in relation to multiple types of health threats. For example, although death from disease is sixteen times more frequent than death from accidents, people view their likelihood to be roughly equal.⁷

If most quality failures in health care were unambiguous, dramatic, and widely reported, the availability heuristic would induce overestimation of danger and heighten vigilance. However, the opposite is the case: Most failures are subtle and not reported by the media. Underestimation of the likelihood of preventable harm and detection of quality problems results from an "unavailability heuristic."

Equating familiarity with trustworthiness. Another heuristic that undermines accurate signal detection is the equation of familiarity with trustworthiness.⁸ One may be less vigilant for quality failures at a local hospital where one works or has previously visited or been treated. This may help to explain national surveys that show that consumers estimate the likelihood of failure by physicians and hospitals they have used to be much lower than by other providers.⁹ This bias may also contribute to the frequency with which organ transplant patients, who are at high risk of death and serious complications, decline recommendations from case managers to switch their transplant site from a familiar provider to an unfamiliar center of excellence, despite credible evidence of much lower mortality risk.¹⁰

Optimistic bias. Empirical research has documented widespread "optimistic bias," with the average person viewing him- or herself as being at lower-than-average risk of bad outcomes.¹¹ Optimistic bias results, in part, from estimating future likelihood based on personal experience. It causes a systematic underestimation of the risk of unfavorable events that one has not yet experienced. It also reduces the likelihood of taking preventive actions.¹²

The tendency toward optimistic bias is especially great for outcomes that are believed to be preventable and under one’s control, even when this is not the case.¹³ For example, people are more likely to underestimate the chances that they will experience drug addiction or suicide than they are to underestimate experiencing stroke or cancer. Both patients and providers may feel that many quality problems are mostly under their control. Patients may feel that they exercise this control via their choice of a physician or a hospital, and most health care professionals feel that they control their own performance. Many stakeholders’ belief that they can individually prevent clinical failure increases optimistic bias and, as a consequence, reduces their vigilance in detecting and preventing failure.

Dissonance reduction and the role of the health care provider. Cognitive dissonance is an aversive state that results when a person holds two conflicting ideas. In response, most people tend to modify one of the ideas. Awareness of widespread clinical failure is dissonant with all stakeholders’ views of the role of the health care system as a place that helps, not hurts, patients. Very few wish to change their view of clinicians as people on whom sick patients can safely rely. Instead, most suppress the idea that clinical failure is widespread. Unfortunately, this reduces vigilance in detection and prevention of quality failure.

The discounting principle. Attributing an adverse clinical outcome to quality failure requires confidently connecting it to a preceding process flaw. Psychological research has examined how people make causal attributions for events. A relevant finding is that the greater the number of possible causes for an event, the less confident people will be in making a casual attribution to any one cause; this has been labeled the "discounting principle."¹⁴ Adverse clinical outcomes often occur in the context of multiple providers, multiple preceding clinical interventions, and the possibility of an external or unknown cause. This is particularly true in hospital care. For example, in a recently published analysis of an adverse hospital outcome, dozens of correct processes and nine process failures preceded an unambiguously suboptimal outcome.¹⁵ A context of multiple simultaneous health care processes and potential external causes will induce observers to discount the actual contribution of process flaws to suboptimal outcomes.

Fundamental attribution error. This error refers to an inherent human bias when attributing cause for another person’s behavior. Most people are biased in favor of individual, rather than situational or system-caused, attributions.¹⁶ This tendency reflects a widespread cultural norm of individual responsibility and autonomy. In addition, it is much easier to grasp how an individual could have erred than to understand more complex and subtle situational determinants.

Overrating the causal importance of individual characteristics and shortcomings is especially misleading in health care, where complex work environments shape individual actions and consequences. While the fundamental attribution error will not block perception of process flaws, it is likely to block accurate perception of their cause. This, in turn, will often drive mistargeted and therefore inadequate remedies, such as disciplinary actions, rather than reforming defective methods of work that account for most quality failures.¹⁷

Perceptual Impediments Primarily Facing Patients

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For patients, a state of illness accentuates many of the universal cognitive and motivational impediments to detection of quality failure discussed above. Additional impediments may be especially handicapping for patients and families.

Bias toward simplicity. Herbert Simon demonstrated that people do not operate as maximally rational decisionmakers but rather show a "bounded rationality." If identifying an optimal option requires great effort and analysis, they are likely to opt for a satisfactory option even if it is not optimal.¹⁸ When making decisions about health care, patients face a large amount of unfamiliar information about illness and its treatment. This may exhaust their ability to pursue the level of detail needed to assess quality accurately. Information relevant to judging quality is more complex, of uncertain credibility, and less easily obtained than is information about other aspects of care (such as the attractiveness of a hospital). Bias toward simplicity will accentuate several other biases such as bias toward familiarity and further impede patients’ detection of quality failure.

Bias toward authority. Bias toward trust of authority conferred by job, specialized education, or governmental licensure has also been demonstrated by psychological research.¹⁹ This bias facilitates more efficient social interactions and is critical to effective functioning of institutions. It also makes it more difficult for even the most self-confident patients to reject apparently flawed treatments. It may also reduce motivation to be vigilant, since it implicitly challenges authority.

Reduced critical faculties. Many illnesses and their symptoms depress cognitive functioning. In addition, a health crisis may elicit stress responses among patients and their family members, which may further impair their cognitive functioning. Psychological research demonstrates that people under stress narrow their attention to the most observable threat(s), which for patients is typically the symptoms of illness and issues of prognosis. In addition, a common way of coping with disturbing circumstances is use of avoidance and denial.²⁰ Denial of the seriousness of one’s illness can be functional, in part through reducing physiologic stress responses that themselves can impair health.²¹ However, these benefits may come at a cost of inadequate attention to imminent, real quality failures (such as being offered an unfamiliar, incorrect medication). A patient or family member may fail to accurately perceive quality failure during stressful moments not only because it requires an expanded frame of attention and information processing, but also because thoughts about poor quality further increase stress.

Impediments Primarily Facing Clinicians

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Michael Cabana and others have reviewed why physicians frequently fail to ensure that treatment plans align with clinical guidelines.²² Some of these reasons derive from the impediments to perception of failure described above. Less has been written about why, beyond the obvious barriers of time and money, health care professionals do not more assiduously seek out and implement structural improvements in quality, such as computerized clinical decision support systems or surgical team training. Psychological research suggests several impediments that particularly affect health care professionals.

Wishful thinking. Clinicians may be vulnerable to "wishful thinking" about avoiding bad outcomes, whether attributable to quality failure or other causes. For example, house officers in one study responded to patients with possible bacteremia by vastly underestimating the impact of bacteremia on patient survival. The more likely they thought it was that patients had bacteremia, the lower their estimates of the probability that such patients would die.²³ Wishful thinking may reduce clinicians’ likelihood of perceiving imminent and past quality failure, in specific instances and in general.

Defensiveness. It is painful for anyone to acknowledge that his or her actions have caused harm to others. This is accentuated in a health care system based on the premise that well-trained, expert, and conscientious physicians will not make mistakes. This may make it harder for doctors to acknowledge quality failure by themselves and others, as well as to accept appropriate responsibility for their contribution to failure. There are successful provider efforts to identify quality flaws and prevent their reoccurrence. However, Marcia Millman documented that the psychological burden of acknowledging personal errors causing death or suffering in others induced a strong bias among health care professionals to avoid objective critical analysis of their own performance.²⁴ The malpractice legal environment exacerbates these natural barriers to perception of failure. Concerns about financial liability and notoriety, particularly arising from suits that may not be justified, can create pressure on professionals to avoid "false positives" in detecting quality failure, especially when attributing a suboptimal outcome to quality failure.

Policy Implications

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The array and strength of both universal and role-specific impediments to detection of quality failure are sobering. Most physicians and consumers estimate error-mediated health care deaths at less than one-tenth of the mid-point of the IOM’s estimated range.²⁵ When considered together with the large magnitude of quality failure and our collective tepid response to the IOM’s unambiguous alarms, these impediments constitute a strong rationale for vigorous policy intervention to strengthen detection and correction of health care quality failure. Cognitive and motivational impediments to accurately detecting quality failure make it highly unlikely that appropriately vigorous corrective action will naturally occur.

Knowledge of these impediments can guide specific remedies to reduce their impact. The National Quality Forum Strategic Framework Board’s recommended approach to engaging consumers in quality-based decision making and implementation tools from the Foundation for Accountability constitute thoughtful guidance on how to expand public awareness.²⁶ Health care professionals, the media, accreditation groups, and government are likely to be sensitive to consumer pressure for quality reform. Exhibit 1 summarizes current approaches addressing each impediment; it also suggests associated gaps that require new policy solutions.

Editor's Notes

 
Arnie Milstein is the medical director of the Pacific Business Group on Health in San Francisco. He is also the cofounder of the Leapfrog Group and a principal at Mercer Human Resource Consulting in San Francisco. Nancy Adler is professor of medical psychology in the Departments of Psychiatry and Pediatrics at the University of California, San Francisco, and director of its Center for Health and Community.

The authors gratefully acknowledge Lucian Leape and Judith Hibbard, whose insights stimulated portions of this paper.

NOTES

Top Perceiving Quality Failure: An... Cognitive And Motivational... Perceptual Impediments Primarily... Impediments Primarily Facing... Policy Implications NOTES

 

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