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organized medicine (i.e., a nonintegrated collection of physicians) is attempting to organize a boycott against these plans. The result could be an expensive lawsuit which organized medicine would be forced to defend. The second reason is that participation in such a plan does not necessarily force a physician to act unethically. Admittedly, capitation plans which punish a physician financially for referring patients to specialists do provide a financial incentive to withhold care, but the AMA and FMA Councils on Ethical and Judicial Affairs both have stated unequivocally that the physician has a duty to place the well being of the patient before his or her own fiscal concerns. Therefore, a physician may act ethically in such plans if they do not succumb to the temptation of withholding appropriate care. Constructed appropriately, capitation can encourage increased awareness of the broader physician obligation to public health as well as increased attention to efficiency in clinical practice, both of which benefit the health care system and ultimately patients. In an effort to minimize any conflict and to ensure that capitation is applied in a manner consistent with the interests of patients, the AMA and the FMA Councils on Ethical and Judicial Affairs recommend that physicians participating in such plans should adhere to the guidelines set forth below. The Councils acknowledge that, applied inappropriately, capitation can create untenable and potentially harmful conflicts for physicians and patients. Encouraging physicians to consider their obligations to patient populations and to the preservation of health care resources is appropriate only to the extent that the primacy of patient care is not threatened. Plans that are not actuarially sound require physicians to bear excessive financial risk and may place physicians in a position where they are forced to choose between individual patients needs and the needs of other plan patients. The result of this tension may be forms of circumstantial or “bedside” rationing, a sense of competition between patients for plan resources, and a significant deterioration in both the individual and public trust in physicians.To avoid these potential conflicts, the Councils conclude that capitated plans should be constructed carefully to reflect the medical needs of plan patients. In determining capitation rates, plans should rely upon estimates of the cost associated with providing necessary care to individual subscribers rather than upon factors such as market forces or the threat of liability. Furthermore, the financial risk assumed by physicians should be limited by capitating large numbers of physicians and patients rather than individual clinicians or small, isolated groups. This will allow more accurate predictions of plan expenses in addition to reducing the impact any single clinical decision can have on the capitated pool of resources available for care, thus preserving physicians’ objectivity and autonomy. The Councils place a portion of the burden for ensuring that plans are designed appropriately on physicians by requiring them to review plans prior to signing contractual agreements to provide care. Physicians must also be prepared to discuss with patients the financial arrangements under which they work and to appeal to the plan for changes in the amount or structure of capitated payments should design flaws become apparent. Physicians should attempt to promote full disclosure of the limitations of the managed care plan. Many of the other duties, however, fall upon the managed care organizations themselves. Among these duties are the creation of structures allowing physicians to have significant input into the plan's quality assurance, the development of adequate due process appellate mechanisms, and full disclosure to enrollees of the plan's incentives for physicians not to refer to specialists. Those readers familiar with the FMA legislative agenda may recognize these latter duties. Each of them is included and addressed in the FMA's Patient Protection Act, which continues to be a legislative priority of the FMA. The ethics of capitation, therefore, is an issue that not only affects physicians, but managed care organizations as well. While the existence of these plans may facilitate unethical conduct, neither the plan nor its participating providers are inherently unethical. The physician nevertheless has a primary duty to act in the best interests of the patient, even if financial incentives exist to behave otherwise. The managed care organization, however, also has the same obligations to ensure the patient is aware of the plan's contents and receives the requisite level of care, regardless of the cost. TeamSTEPPS has a three-phased process aimed at creating and sustaining a culture of safety with (AHRQ, nd):A pretraining assessment for site readiness. Training for onsite trainers and health care staff. Implementation and sustainment.TeamSTEPPS provides higher quality, safer patient care by producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients (AHRQ, nd).Increasing team awareness and clarifying team roles and responsibilities. Resolving conflicts and improving information sharing.Eliminating barriers to quality and safety. Rapid Response Systems are another important “team” in patient safety. A Rapid Response System (RRS), sometimes referred to as Medical Emergency Team (AHRQ, nd) :Brings teams of critical care expertise to the patient bedside when other resources are lacking. Has a wide range of health care professionals coordinating efforts. Treats patients with early warning signs of acute clinical deterioration, namely cardiac arrest. Has a common goal of patient stabilization. Through implementing RRS initiatives, organizations have found positive results. Some examples include (AHRQ, nd): 50% reduction in non-ICU cardiac arrests (Buist, et al., 2002). Reduced post-operative emergency ICU transfers (58%) and deaths (37%) (Bellomo, et al., 2004). Reduction in cardiac arrest prior to ICU transfer (4% vs. 30%) (Goldhill, et al., 1999).17% decrease in the incidence of cardiopulmonary arrests (6.5 vs. 5.4 per 1,000 admissions) (DeVita, et al., 2004).A free, customizable toolkit called TeamSTEPPS™, provides evidence-based techniques for promoting effective communication and other teamwork skills among staff in various units or as part of rapid response teams. Materials can be tailored to any healthcare setting, from emergency departments to ambulatory clinics. Ordering information for the Team STEPPS Multimedia Resource Kit (AHRQ Publication No. 06-0020-3) and information on the training sessions are available at http://teamstepps.ahrq.gov/index.htm. 10. Insert chest tubes safely.Chest tube insertion is a life-saving procedure used to relieve tension pneumothorax or hemothorax, the accumulation of air or blood (fluid) under pressure in the pleural space, seen most often in trauma patients. If performed incorrectly, patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury or infection (AHRQ, 2006). A series of preventive measures for each type of problem, using an easy-to-remember mnemonic, UWET, was developed from the Joint Commission and stands for: 19 Universal Precautions (achieved by using sterile cap, mask, gown, and gloves). Wider skin prep. Extensive draping. Tray positioning. Remember UWET when inserting chest tubes. A free 11- minute DVD provides video excerpts of 50 actual chest tube insertions to illustrate problems that can occur during the procedure. Ordering information for Problems and Prevention: Chest Tube Insertion (AHRQ Publication No. 06-0069-DVD) is available at http://www.ahrq.gov/qual/chesttubes.htm. For free copies of AHRQ tools, please call the AHRQ Publications Clearinghouse at 1-800-358-9295.Development of the Healthcare Partnership In 2006, the IOM identified a number of strategies to reduce medical errors. Among them was “To develop a professional and practice
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