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Professionals’ Influence and the Malpractice Problem*: Promoting

Accountability in a Culture of Safety Gerald B. Hickson, MD

Sr. Vice President for Quality, Safety and Risk Prevention Assistant Vice Chancellor for Health Affairs

Joseph C. Ross Chair in Medical Education & Administration Vanderbilt University Medical Center

Center for Patient & Professional Advocacy,

Vanderbilt University School of Medicine

*Hickson & Entman. Obstet Gynecol. 2010; 115:682-6.

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Requires: • Vision/goals/core values • Leadership/authority (modeled) • A safety culture

– Willingness to report and address • Psychological safety • Trust

Pursuing Reliability*

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001; Nolan, et al. Improving the Reliability of Health Care. IHI Innovation Series. Boston: Institute for Healthcare Improvement; 2004. Hickson et al. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

“Failure free operation over time…effective, efficient, timely, patient-centered, equitable”

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• Professionals commit to: • Technical and cognitive competence

• Professionals also commit to: • Clear and effective communication • Being available • Modeling respect • “Self awareness”

• Professionalism promotes teamwork • Professionalism demands self and group regulation

Professionalism and Self-Regulation

Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

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• Ms. X: G1 at 39 weeks, and arrives in L&D at 8 am • Reports regular contractions every 3-5 min for last 2

hr…on exam 2-3 cm/80%/-1…admitted in term labor • 10 am: 3cm/90%/-1. • 1 pm: no change…AROM…Dr. OB orders pitocin

augmentation. • 3 pm: 4-5 cm/90%/0 • 5 pm: no further change.

Case: “Let’s Go”

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• Dr OB expresses concern about progress, says, “Ms. X, it looks like we’ll need to do a C-Section.”

• Ms. X says okay. • Nursing professional takes Dr. OB aside, asks whether

immediate C-Section is necessary… “could we put in an IUPC (to determine labor adequacy)?”

• Dr. OB: “Looks like FTP. Let’s go ahead with Section.” • How might your team member (Nurse __) respond?

Case: “Let’s Go”

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• From Reason’s “Unsafe Acts” algorithm (1997): – Did the team member intend to cause harm? – Did the team member come to work impaired? – Did the team member knowingly and

unreasonably increase risk? – Would another team member (you) in the same

situation act in a similar manner?

A Few Questions About Dr. OB

Reason J.: Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate, 1997.

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How prepared are you?

Do you have a reliable plan?

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What are behaviors that undermine

a culture of safety? And what can we do about them?

Professional Accountability

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• Prevent or interfere w/an individual’s or group’s work, or ability to achieve intended outcomes (e.g. ignoring questions, not returning phone calls re pt care, publicly criticizing team/institution)

• Create, or have potential to create intimidating, hostile, offensive, or unsafe work environment (e.g. verbal abuse, harassment, words reasonably interpreted as intimidating)

• Threaten safety: aggressive or violent physical actions

• Violate VUMC policies, including conflicts of interest and compliance

It’s About Safety

Definition of Behaviors That Undermine a Culture of Safety

Excepts from Vanderbilt University and Medical Center Policy #HR-027, 2010

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Perhaps Even More Common:

Failure to: – Practice hand hygiene – Complete handoffs/documentation – Observe time outs – Answer pages – Practice EBM (CAUTI, CLABSI, VAP, etc.) – Refrain from jousting – Adhere to safety/quality guidelines – Others?

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What barriers exist?

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The Balance Beam

Do nothing Do something June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy; Hickson GB, Pichert JW. Disclosure and Apology. National Patient Safety Foundation Stand Up for Patient Safety Resource Guide, 2008; Pichert JW, Hickson GB, Vincent C: “Communicating About Unexpected Outcomes and Errors.” In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 2007

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Why Might a Medical Professional Behave in Ways that Undermine A Culture of Safety?

1. 2. 3. 4. 5. 6. 7. 8.

Lawsuits

Non adherence/ noncompliance

Consequences of Unsafe Behavior: Patient Perspective

Drop out

(tip of the iceberg)

Infections/ Errors

Bad-mouthing the hospital/ practice to others

Costs

Felps W, et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups., Research and Organizational Behavior. 2006; 27:175-222.

Harassment suits

Jousting

Consequences of Unsafe Behavior: Healthcare Professional Perspective

Burnout

(tip of the iceberg)

Lack of retention Infections/ Errors

Bad-mouthing the organization in the community 15

Costs

Felps W, et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups., Research and Organizational Behavior. 2006; 27:175-222.

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• Team members may adopt disruptive person’s negative mood/anger (Dimberg & Ohman, 1996)

• Lessened trust among team members can lead to lessened task performance (always monitoring disruptive person)... affects quality and pt safety (Lewicki & Bunker, 1995; Wageman, 2000)

• Withdrawal (Schroeder et al, 2003; Pearson & Porath, 2005)

Failure to Address Behaviors that Undermine a Culture of Safety

Leads To:

Felps W, et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups., Research and Organizational Behavior. 2006; 27:175-222.

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Regression Analysis: Preoperative Risk, Patient Complaints, and NSQIP Overall Surgical Adverse Events*

* Analysis controls for # cases sampled, significant interaction, p < 0.01

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The Balance Beam

Do nothing Do something

Staff satisfaction and retention

Reputation

Patient safety, clinical outcomes

Liability, risk mgmt costs Fear of antagonizing

Leaders “blink”

Not sure how lack tools, training

Competing priorities

“Can’t change…”

June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy; Hickson GB, Pichert JW. Disclosure and Apology. National Patient Safety Foundation Stand Up for Patient Safety Resource Guide, 2008; Pichert JW, Hickson GB, Vincent C: “Communicating About Unexpected Outcomes and Errors.” In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 2007

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Guiding Principles for Action

• Justice – Fairness for all • No conflict of interest • Certainty that the “egregious” event in question

or pattern of “evidence” shows that the physician in this case (or other professional in other cases) stands out from peers

• Insight into causes is the first, short-term goal • “Redemption,” “Restoration” or problem

resolution is the 2nd goal

Reiter CE, Hickson GB, Pichert JW. Addressing behavior and performance issues that threaten quality and patient safety: What your attorneys want you to know. Prog Pediatr Cardio. 2012; 33:37-45.

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1. Leadership commitment (will not blink) 2. Goals, a credo, and supportive policies 3. Surveillance tools to capture observations/data 4. Processes for reviewing observations/data 5. Model to guide graduated interventions 6. Multi-level professional/leader training 7. Resources to address unnecessary variation 8. Resources to help affected staff and patients

Infrastructure for Promoting Reliability & Professional Accountability (PA)

Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Academic Medicine. 2007. Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

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• Leadership commitment – Hold all team members accountable for modeling… – Enforce code of conduct consistently and equitably – Recognize professionalism in action – Employ appropriate measures designed to reduce

unprofessional behaviors. – Focus on behavior and performance.

Infrastructure for Promoting PA

Behaviors that undermine a culture of safety. SEA #40. The Joint Commission, July 2008.

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• Goals, credo, supportive policies – Code of conduct … defines acceptable and

inappropriate behaviors. – Implement policies that address “Zero tolerance”

for most egregious… – Protect those who report or cooperate – Locally defined performance standards…measures…

Infrastructure for Promoting PA

Behaviors that undermine a culture of safety. SEA #40. The Joint Commission, July 2008.

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Policies will not work if behaviors that undermine a culture of safety

go unobserved, unreported and unaddressed

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• Risk Event Reporting System – “Dr. __ entered the room without foaming in…proceeded

to touch area with purulent drainage…I offered a pair of gloves…took them and dropped them in the trash.”

• Patient Relations Department – Record patient/family concerns: “I asked Dr. XX to explain

their plan. Dr. XX said, ‘I drew a picture. If you don't get it, you just don't get it.’“

• Compliance hotline; Equal Opportunity, Affirmative Action, and Disability Services (EAD)

What Are “Surveillance Tools”?

Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

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Level 2 “Guided" Intervention by Authority

Apparent pattern

Single “unprofessional" incidents (merit?)

"Informal" Cup of Coffee

Intervention

Level 1 "Awareness" Intervention

Level 3 "Disciplinary" Intervention

Pattern persists

No ∆

Vast majority of professionals - no issues - provide feedback on progress

Mandated Reviews

Mandated

Ray, Schaffner, Federspiel, 1985. Hickson, Pichert, Webb, Gabbe, 2007. Pichert et al, 2008. Mukherjee et al, 2010. Stimson et al, 2010. Pichert et al, 2011. Hickson & Pichert, 2012. Hickson et al, 2012. Pichert et al, 2013. Talbot et al, 2013. Hickson & Moore, in press.

Adapted from Hickson, Pichert, Webb, Gabbe. Acad Med. 2007. ©2013 Vanderbilt Center for Patient and Professional Advocacy

Promoting Professionalism Pyramid

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But does any of this work?

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Med Mal Research Background Summary

• 1-6%+ hosp. pts injured due to negligence

• ~2% of all pts injured by negligence sue

• ~2-7 x more pts sue w/o valid claims

• Non-$$ factors motivate pts to sue

• Some physicians attract more suits

• High risk today = high risk tomorrow

Sloan et al. JAMA 1989;262:3291-97; Brennan et al. NEJM 1991;324: 371-376; Hickson et al. JAMA 1992;267:1359-63; Bovbjerg & Petronis. JAMA 1994;272:1421-26; Hickson et al. JAMA 1994;272:1583-87.

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Patient Complaints

“Dr. OB was dismissive, said I was okay… said, 'Ms. XX, go home and find something else to worry about…upset me and I cried..”

“Dr. OB’s nurse left answering machine message, ‘Contact our office immediately, you have abnormal results.’ Everyone heard…”

“Dr OB and nurse told me I was faking this labor and discharged me 40 min ago...now I’m having contractions 45 secs apart, 1 min long…”

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Academic vs. Community Medical Center Physicians

35-50% are associated with NO concerns

Hickson GB, et al. JAMA. 2002 Jun 12;287(22):2951-7. Hickson GB, et al. So Med J. 2007;100:791-6.

9-14% of Physicians associated with 50% of concerns

Incurred Expense By Risk Category

Predicted Risk Category

# (%) Physicians

Relative Expense*

% of Total Expense

Score (range)

1 (low) 318 (49) 1 4% 0

2 147 (23) 6 13% 1 - 20

3 76 (12) 4 4% 21 - 40

4 52 (8) 42 29% 41 - 50

5 (high) 51 (8) 73 50% >50

Total 644 (100) 100% * In multiples of lowest risk group

Moore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review, 2006.

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• Risk Score Graph

• Complaint Type Summary

Awareness Intervention on Dr. __

• Letter with standings, assurances prior to & at meeting

National PARS® Risk Score Comparisons 0

20

40

60

80

100

120

140

160

180

200

0% 20% 40% 60% 80% 100%

Risk Score*

Percent of Physicians

All Physicians - National PARS® Data

Orthopedic Surgeons - National PARS® Data

Threshold for Assessment and Review **

__, MD: Risk Score of 144 is within top 0.5% of All Physicians and #4 of 950 Orthopedic Surgeons in the National PARS® Database

Last

Upd

ated

: 6/1

4/20

13La

st U

pdat

ed: 6

/14/

2013

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Total # of high-complaint physicians 970 Departed after initial intervention 76 First follow-up in 2013 or 2014 120 Total with follow-up results 774

Results for those with follow-up data: Successfully completed intervention process 428 55% Good – Anticipate ending visits in 2013/2014 128 17% Some improvement – Still need tracking 42 5% Subtotal 598 77% Unimproved/worse 124 16% Departed unimproved 52 7% Total with follow-up results 774

Does it work? PARS® National Progress Report

32 Peer Review and

Confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272 ; not be disclosed to unauthorized persons.

Pichert JW et al. An intervention that promotes accountability: Peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. Oct 2013;39(10):435-446.

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NSQIP and Pt Complaints

Question: Do Patient Complaints moderate the relationship between Preoperative Risk Factors and Surgical Outcomes?

Preop Risk Factors PARS® Categories Surgical

Occurrences

ASA Class Care & Treatment Intraoperative

Priority Status Communication Wound

Wound Class Concern for Pt/Family Urinary

Accessibility CNS

Billing w/C&T concern Respiratory

Other

Risk

s

Patie

nt C

ompl

aint

s

Out

com

es

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Clear and Effective Communication • “Dr. __ did a very poor job of communicating. He

raced through an explanation of what we should expect, then left without giving us a chance to get clarification.”

Respectful • “I said I had questions. Dr.__ looked up and

asked, ‘Are you illiterate?’ I said, “No.” Dr.__ responded, ‘Oh, I just gave you a pamphlet that explains it. Since you didn’t get it, I thought maybe you could not read.’”

Patient Complaints

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Regression Analysis: Preoperative Risk, Patient Complaints, and NSQIP Overall Surgical Adverse Events*

* Analysis controls for # cases sampled, significant interaction, p < 0.01

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Back to the opening scenario:

“Listen, NURSE, I am Dr. OB. I know what I’m doing…

she’s ready. Let’s go. NOW.”

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Nurse: “Called Dr __ re change in pt status…came 25 min later, looked at pt, publicly yelled at me, ‘you lied…pt okay…don’t call again”…felt threatened.

Staff Professionalism Concerns

Confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272; not be disclosed to unauthorized persons.

“Dr. __ was making personal calls (appt for massage) …had pts…needed orders…I asked Dr. __’s help: ‘they can wait…,’ families overheard”

Nurse: “Dr OB wiped head w/ arms…had contact w/ pt… I asked Dr _ to re-gown, use new gloves … replied: ‘at other hospitals… not required to wear cap, gowns [so] I guess I’ll stay in trouble here.’”

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0

2

4

6

8

10

12

90% 95% 100%

Total Num

ber of Reports

Percent of Physicians

VUMC Professionalism Total Reports

Physicians with > or = 4 Reports (n=21)

Confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272; not be disclosed to unauthorized persons.

Distribution of Staff Professionalism Reports about Physicians – 3 years

These 21 (0.75%) of all VUMC Professionals (n=2800) were associated with 26% of Reports

about Behavior/Conduct.

39 Confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272; not be disclosed to unauthorized persons

5 Codes Account for 60% of Concerns %

of A

ll St

aff P

rofe

ssio

nalis

m C

once

rns

40 Confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272; not be disclosed to unauthorized persons.

Distribution of Physicians and Staff Professionalism Reports

0

2

4

6

8

10

12

14

90% 95% 100%

Total Num

ber of Reports

Percent of Physicians - Thru September 2013

Professionalism Reports

Physicians with > 3 Reports (n=27)

These 27 (1%) of all VUMC Professionals (n=2800) were associated with 27% of Reports

about Behavior/Conduct.

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Staff Professionalism Concerns: Who Observed the Event?

Confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272; not be disclosed to unauthorized persons

21% observed by patients & families

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• Know what represents behaviors/performance that undermine a culture of safety

• Have a plan and a supportive infrastructure • Address (act, report) behaviors/performance

that undermine a culture of safety early and consistently

Your role as a group/team leader

Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

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Comments and Questions Now or Later

www.mc.vanderbilt.edu/cppa

The Center for Patient & Professional Advocacy

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