sponse, labeling them the “cycle of fear” (see Figure 8-5) (Scherkenbach, 1991, p. 98).

Knowledge of predictable human responses to accountability data is a key factor in the design of an effective patient safety reporting system. It is also an important consideration in deciding how much emphasis to place on accountability versus learning applications because the former applications run a much higher risk of instilling fear than do the latter.

Reaction 1: Kill the Messenger

Accountability data inherently focus on individual health professionals or care delivery organizations. Upon being flagged as an outlier, most humans react defensively. They perceive a negative evaluation as a direct attack. In response, they raise defensive barriers that make positive communications difficult.

Under the philosophy that the best defense is a good offense, they often counterattack (shift the blame). They challenge the measurement system, analytic methods, and accuracy of the evaluation. They question the competence and motives of those conducting the assessment. Most important, they try to block access to data that could contribute to similar criticism in the future. For example, Berwick and Wald conducted a survey of hospital leaders’ reactions to the release of the HCFA mortality data in 1987. They found

FIGURE 8-5 Scherkenbach’s cycle of fear.

SOURCE: Scherkenback, 1991.



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