The Blogosphere: We Are the Ones We’ve Been Waiting For


May / June 2008

The Blogosphere

We Are the Ones We’ve Been Waiting For

Blogs. They provide commentary or news on a particular subject, can serve as a personal online diary and allow readers to leave comments in an interactive format. So what do blogs have to do with healthcare and patient safety?

According to Dr. Robert Wachter, everything.

Dr. Robert Wachter, professor and chief of the division of hospital medicine at the University of California, San Francisco, is generally regarded as a key academic leader of hospital medicine. He coined the term ‘hospitalist’ in a 1996 New England Journal of Medicine article and is a past president of the Society of Hospital Medicine (SHM).

“Even an old guy like me realized that blogs are incredibly hot,” Wachter says. “And as I read more of them, and began relying on them more for information and insights, I started looking for one in our field (hospital medicine) that was lively, engaging, and informative. I couldn’t find anything, so I thought I should start one.”

That’s how Wachter’s World ( was born.

Wachter focuses on healthcare issues that effect “real doctors and nurses — and real patients — in real hospitals and clinics.” Popular topics so far have included quality improvement, pay-for-performance, and health policy. His opinions on these and other topics have made Wachter’s World one of widest read and frequently quoted blogs in healthcare.

Not only has Wachter’s World been a portal for healthcare news and information, it has also been a platform urging readers to take action on controversial healthcare issues.

This recently was the case when a highly publicized Michigan hospital-based quality improvement program was shut down by the Office for Human Research Protections (OHRP), citing the need for informed consent from all patients.

The decision from OHRP to shut down the program, which was a checklist devised to reduce the rate of catheter-related infections in intensive care unit settings, rocked the healthcare community.

Naturally, Wachter took this opportunity to express his concerns for this project and the future of others and urged fellow colleagues and readers to take action in the form of contacting their government representatives and the OHRP.

The following excerpt was taken from a post on January 13, 2008:

Let’s say I now want to put an alcohol hand gel dispenser in every patient’s room and encourage people to use it — with checklists, teamwork training… heck, I’ll drink the stuff if that’s what it takes. Do I need to obtain IRB approval before I install the dispensers? Or before I measure my infection rates after installation? Do I need the consent of the docs and nurses to “participate” in this “intervention”? How about the patients?

I think you can see where this takes us.

Having written about the unanticipated consequences of quality and safety practices and critiqued (along with Pronovost) some aspects of the IHI’s 100,000 Lives Campaign for vigorously promoting practices with weak evidence, I recognize that these are not easy questions. Even commonsensical practices can backfire, and Pronovost believes, as do I, that serious quality improvement interventions — when accompanied by a hypothesis and data collection — are research. The question here is one of balance and feasibility. If the OHRP ruling stands, then what we’ve ostensibly done is place a huge bureaucratic tax on quality improvement work — a tax extracted in money, time, hassles, and frustration. The results will be predictable: less good QI work, fewer participating providers and institutions, fewer smart young people drawn to careers in quality and safety, and ultimately more harm and deaths.

In the end, the question is this: will more patients benefit from the protections afforded by extra bureaucratic obstacles to QI work or by wider dissemination of rigorous quality improvement projects and studies? If you want to see a close race, look to Huckabee vs. McCain, or Obama vs. Clinton. But don’t look here: this contest is a landslide.

Because of blog postings from people such as Wachter, and the efforts of numerous influential healthcare organizations such as the Society of Hospital Medicine; the American Thoracic Society, the Society for Critical Care Medicine, the American Association of Critical-Care Nurses, and the American College of Chest Physicians, OHRP was forced to take a second look at the important quality improvement project they shut down.

This second look resulted in a reversed ruling, which now enables Michigan hospitals to continue to implement their checklist without falling under regulations governing human subjects.

Wachter celebrated this victory and commended all his colleagues who had worked so hard to reverse this decision on February 16, 2008:

This is a seminal moment for quality improvement in the United States. The prior OHRP decision, if left standing, could have mandated regulatory approval and the need to obtain patient and provider consent every time one wanted to improve a process and measure its impact. Today’s decision recognizes the need to balance traditional “research” regulations against the harm that will result if good people are forced to leap over unnecessary bureaucratic hurdles every time they seek to implement a safety or quality practice and see if it worked.

Moreover, as more and more regulations — many sensible but some asinine — are promulgated in the name of safety and quality, I hope the OHRP story kickstarts a process in which the regulators and the regulated collaborate to ensure that the ultimate goal of better patient care is being served.

Finally, it shows that we — when we put our minds to it — have the power to make change happen. We, it seems, are the ones we’ve been waiting for.

As more of these controversial healthcare issues rear their ugly heads, Wachter will be sure to urge all those devoted to quality improvement and patient safety to take action.

You can visit Wachter’s World online at

Heather Abdel-Salam is coordinator of public relations and marketing for the Society of Hospital Medicine in Philadelphia, Pennsylvania. She may be contacted at