Saturday, August 28, 2010

"Compliance: It's Not Just for Patients Anymore."

I'm in a patient safety workshop in Boston today, about engaging minorities in safer care. We just saw a video about safety awareness, encouraging patients to realize what a good role they can play in helping clinicians (doctors and nurses) get everything right. (Long story short, there are many many ways that things can and do go wrong - some complicated, some simple.)

When people talk about making healthcare more effective, "compliance" often comes up. It's usually about whether you and I take our pills, improve our diet, etc. Patient compliance is a hot topic on blogs: Google shows 93,000 blog posts, and 9,000 in the past year.

But the video made a thought come up: holy cow, a lot of healthcare quality issues are because clinicians forget to fulfill their part of the plan. Ironic! But fault-finding finger-pointing doesn't produce behavior change as well as inspiration does - calling forth what people know to be the best in themselves. Here's a draft of a message we might want to spread - feel free to share:

"Compliance: It's Not Just for Patients Anymore."

We all know about patient compliance: whether patients follow our instructions to accomplish good care. When compliance falls short, our profession is undermined. Care suffers, and our efforts are frustrated.

The same is true when we don't comply with our part. Whether it's hand washing or the Five Rights of administering medications, any shortfall cheats the profession as well as the patient. And perhaps our diligence - or lack of it - even rubs off on patients.

Compliance isn't just for patients anymore. Let's not cut corners. Let's set a great example for every patient, and stick to the plan.

This text authored by "e-Patient Dave" deBronkart. May be posted & shared freely with this attribution intact (Creative Commons Share-Alike 3.0)

Additional resources:
  • The safety awareness video is in this post.
  • MITSS, the sponsor of this workshop, is here.
  • The "five rights of medication administration" are:
    • The right patient (this is why they constantly ask your name and date of birth)
    • The right drug (medications too often get mixed up)
    • The right dose (Dennis Quaid's newborn twins famously almost died because two bottles of medication looked too similar though one was 1,000 times stronger)
    • The right time (4x/day, before meals, etc)
    • The right route (pill vs IV, etc)


  1. Dave,

    What do you think about the word "compliance?" Some have suggested that "adherence" is a better word because it does not imply the idea of following orders.

    I'm not sure it matters a lot, but would welcome your take.

  2. Yes, it's an ongoing question; I chose not to delve into it here.

    But since you asked, let's turn it around. How would hospital employees feel if shortfalls in hand washing etc. appeared on performance reviews under "Compliance"?

    Ugh. It just doesn't inspire.

    The Wikipedia compliance page begins
    "In medicine, compliance (also adherence or concordance) describes the degree to which a patient correctly follows medical advice....Non-compliance is a major obstacle to the effective delivery of health care." [emphasis added]

    Then it has a long discussion of the terminology.

    The Wikipedia search page for that word isn't so one-sided: "Compliance (medicine), a patient's (or doctor's) adherence to a recommended course of treatment..." [emphasis addeed]

    If we shift from the paternal view ("we the professionals tell you the unknowing what to do") toward personal responsibility ("I'm responsible for my health, and professionals are my experts"), how does the issue look?

    If your financial advisor says to invest in derivatives and you don't, does s/he talk to management about your compliance? If you don't get oil changes on schedule, does your car dealer talk about your compliance?

    More to the point, what if your dealership complained on its blog about compliance, ignoring that when its staff did ITS work, half the time they didn't follow proven standards for quality and customer safety?

    I don't have an answer, but I'm pretty sure it's off-target to just talk about whether *I* stick to the plan. Treatment plans based on research are smart, but whatever we call it, we ought to track both sides of the care plan.

    [Discosure: my view reflects the thinking of Participatory Medicine, whose society I co-chair: "a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners." Compliance makes no sense in a partnership - and imagine what costs would look like if half your patients thought that way, and if we all stuck to the plan.]

  3. Yeah, I have to agree that the problem with noun pairs "patient compliance," "patient adherence," and "patient concordance" isn't the second half. The problem is using "patient" as a noun adjunct. The patients aren't the entire problem, but these terms assume that we are.

    Well, I need to blog about this, but we're on the same track, I think. The patient is not the whole problem.

  4. BillDog,

    The challenge IMO is that while there are a thousand ways to cast blame, it has little impact, so as in my CaringBridge, the question is: what could be said that would make any difference?

    I think an awakening is needed - if good-hearted people have a paternal view ("We have the knowledge, please do as we say") then all responsibility for getting it right sits on their head, we have no power (and thus no responsibility, if you think about it), and the focus goes to "We need to make those people do as we recommend." The patient becomes a mule subject to carrot and stick.

    If we can get folks to shift the view to shared responsibility and shared decision making on shared treatment plans, both in hospital and out, and if we can all accept that this is not easy/automatic and yet small things make a big difference, then maybe we can shift to a perspective of helping each other, reminding each other, even nagging each other at times.

    I sent a note the other day to the people at the Connected Health conference about this, after their email on the "compliance" topic. It was handy that I had this post to send them.:) Perhaps it's a coincidence, perhaps not, but last night they invited me to be on the discussion panel right after their opening keynote by B.J. Fogg.

  5. p.s. Happily, this week the CDC released a great new video quickly teaching hospita patients that hand washing is important and *showing* how to speak up to a staffer who forgets. Nice of them to hear this discussion and respond so quickly, eh? :)

  6. Okay, Dave, my analysis of the problem is up at Thanks for helping me put this matter in perspective.

  7. Sorry, Dave, I just noticed your posting from this morning. I see we came to the same conclusion, in a way. As you say,

    "The challenge IMO is that while there are a thousand ways to cast blame, it has little impact, so as in my CaringBridge, the question is: what could be said that would make any difference?"

    That was my position, too. Fixing blame--no matter where--doesn't fix the problem. We need a new paradigm. I've suggested one. Let me know what you think.


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