Introduction: Why Accountability Matters in Health Care

Today, it’s not unusual for patients who face a particular diagnosis to spend time researching physicians and hospitals in their area to find out who has the most experience in treating it. It’s also not unusual for a patient to arrive at a medical appointment with reams of information in hand and specific questions about his or her diagnosis. When a patient is informed in this way, the physician becomes more partner than director in the relationship.

But it’s important to remember that this will never be an equal relationship. Even the most informed consumers need to place a certain amount of trust in the hospitals and health professionals who care for them. For example, they have to trust that the anesthesiologist knows how to give the right medications in the right dosages. They have to trust that the nurses have been well-trained in caring for people with their condition. They also have to trust that there are safeguards in place to minimize the possibility of their contracting an infection, getting the wrong medication, or having the wrong surgical procedure.

At Crozer-Keystone Health System, we value the level of trust placed in us by the thousands of Delaware County residents who seek care at our hospitals every year. We view this trust as our mandate for holding ourselves accountable for delivering quality care. Whether patients are coming to us for services ranging from a routine mammogram or bloodwork to physical therapy, chemotherapy, or burn care, they are in a vulnerable position—a position best characterized by Charles Dougherty, Ph.D., of the Center for Health Policy and Ethics at Creighton University, more than ten years ago:

Compared with the expertise and authority of a contemporary physician, the average patient and family have little ability to diagnose injuries or illnesses, cannot easily project their course, and cannot access directly needed drugs and procedures.

Thus, patients and  families enter therapeutic relationships in a highly vulnerable position and rely on the protection of the stance of caring that lies at the heart of medicine. (“Ethical Values at Stake in Health Care Reform,” Journal of the American Medical Association, November 4, 1992)

This stance of caring is unique to the medical profession. Even as patients are more and more frequently being characterized as “healthcare consumers” and physicians as “service providers,” the hospital is and always will be fundamentally different from the retail marketplace. “Caveat emptor!” (Buyer beware!) may be acceptable in the latter environment, where the burden falls on consumers to do their homework before entering into any business relationship or contract. But hospitals have a special responsibility to make sure that all patients receive safe, timely, compassionate care that is grounded in the latest medical evidence.

A significant part of this responsibility involves having systems in place that enable hospitals to check on the care they are delivering, to know when that care is not meeting certain standards, and then to make changes in direct response to that information.

This is the essence of accountability—not only as we define it today, but also as it was first conceived of by pioneer physicians such as Ignaz Semelweiss and Ernest Amory Codman in the mid-nineteenth and early-twentieth centuries. These physicians shared a vision that accountability mattered, even as concepts such as quality care and standardization of practice were yet to evolve.

More than 150 years ago, the Austrian physician Ignaz Semmelweiss realized that new mothers attended by midwives had a much lower rate of infection than those treated by medical students.

He discovered that medical students were going straight from the pathology laboratory or autopsy rooms to delivering babies without washing their hands. After Semmelweiss instituted a policy requiring physicians to wash their hands between activities, the mortality rate for new mothers declined significantly.

According to many of his biographers, Semmelweiss took it upon himself to make sure that his fellow physicians were following the hand-washing policy: he reportedly would stand next to the sink and reprimand anyone who failed to scrub his hands.

Because the germ theory of disease had not been established, Semmelweiss’s policy was ridiculed by the medical establishment in general and did not become standard practice. It even lost him his job. However, his ideas would gain credibility later in the 19th century, when the English surgeon Joseph Lister demonstrated that washing the hands in a sterile solution, phenol, prevented the transmission of infection and disease during surgery.

This notion that there were standard best practices in medicine inspired the work of another pioneer, Ernest Amory Codman. As a surgeon practicing at Massachusetts General Hospital in the early 1900s, Codman called on hospitals to track their surgical successes and failures, and then make those results public as a way of motivating improvement. His “End Result Idea” proposed that hospitals follow their patients for a year to determine whether or not the treatment was successful, and then use this information to improve care.

When Massachusetts General refused to adopt this practice, Codman started his own hospital and kept track of patient outcomes for as long as five years, a radically new idea at the time. 

Although these two physicians met with resistance and skepticism from their colleagues, their ideas are now accepted as part of routine practice. They paved the way for the fundamental tenet that the medical profession should do what is needed to hold itself accountable for quality and safety. Certainly the healthcare system has become much more complex, making the one-on-one checking done by Semmelweiss and Codman impracticable, but the rationale behind their practices remains the basis for our efforts today.

As you will learn in this seventh Annual Report on Quality, Crozer-Keystone Health System has a number of systems in place to ensure that we are continuously monitoring and improving the quality of care we deliver. Some of these efforts are driven from within—that is, they are steps we take not because we have to, but because we feel they are essential.

 Other efforts are driven primarily by the requirements of government agencies, accrediting bodies, and other outside organizations that assess the quality of care we provide. But they all are grounded in a firm conviction that we must always do the best for patients who put their trust in us.

Gerald Miller
President and Chief Executive Officer

Crozer-Keystone Health System

Joan K. Richards
Chief Operating Officer, Crozer-Keystone Health System

President, Crozer-Keystone Hospitals

Joseph R. Stock, MD
Chairman, Quality of Care Committee
Crozer-Keystone Health System