Introduction

A desirable health-care performance measure is one that reliably and accurately reflects the quality of care provided by individuals, teams and organizations (Pringle et al. 2002). The means of attributing causality for observed outcomes, or responsibility for departures from accepted standards of care, is critical for continuous improvement in service delivery. When quality measures do not reflect the quality of care provided then accountability for deficiencies is directed unfairly and improvement interventions are targeted inappropriately. It is both unethical and counterproductive to penalize individuals, teams or organizations for outcomes or processes outside their control.

In addressing attribution in health-care performance measurement, assessors must first face their own imperfections – specifically the likelihood that fundamental attribution error may influence quality assessments. Identified through social psychology research, fundamental attribution error occurs as a result of inherent human bias that arises when viewing another person's actions (Kelley 1967; Ross 1977). Specifically, causality is attributed to their behaviour by overemphasizing an individual's disposition and under-emphasizing situational factors. This bias reflects a widespread cultural norm focusing on individual responsibility and free will that is reinforced by some legal frameworks.

When medical errors occur, it may be easier to recognize the active error that transpires rather than the multiple system-level errors that underlie it (Reason 2000). These latent errors may be more subtle and therefore more difficult to uncover and understand, especially in complex health-care environments.