The Ethos Program:Re-defining Normal

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Dr Victoria Atkinson Group Chief Medical Officer

Group General Manager Clinical Governance

Cardiothoracic Surgeon

Victoria.Atkinson@svha.org.au

1. Background

Unprofessional behaviours are creating a culture that is

putting staff and patients

at risk.

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Vanderbilt

version

1. Background

• Poor behaviours increase surgical complications, hospital

acquired infections, medication errors and adverse outcomes.

• Poor behaviours affect operational efficiency and revenues

• Evidence indicates that early intervention can prevent minor

inappropriate behaviours from escalating into bullying and

harassment.

• Cultural change is created through conversations

Our aim is a kinder, safer and more reliable healthcare

system4

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The impacts are felt by:

• Patients; linked to safety, errors especially in procedural areas

and patient complaints

• Staff; turnover and retention and associated recruitment costs,

reduced productivity through poor morale and demands on

management time, OH&S, training impact, reset career goals,

suppresses ideas,

• Institutions; stifles potential, significant legal costs and

reputational damage, economic cost, propagation of culture

It’s all about safety

Policies and Processes– Finally the answer…

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Or not…..No Difference

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Where’s the Evidence?

• Studies across NHS, Canada, USA and Germany including a Joint Commission review in 2008

• Worst perpetrators are only 2-3% of staff but their influence casts shroud over entire hospital; directly or through others

• 2/3 of nurses reported being abused by other nurses or physicians in last 3 months

• 44% were dissatisfied at work, with 21% planning to leave within 12 months

So what is normal professional behaviour for the other 98% of staff?

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Prevalence of bullying/harassment in the

health sector

• 49% Fellows, trainees and IMGs report being subjected to BHSD

• 54% trainees and 45% fellows <10 yrs report being bullied

• 71% of hospitals reported BHSD within last 5 years, mostly bullying

• Across all specialities

• Senior surgeons and consultants the primary source problems

• Prevalence of bullying/harassment in the

health sector not conclusively known

• Research suggests it is widespread

• 25% of employees in the health sector have

reported experiencing bullying – the highest

of all Victorian public sector agencies

• 40% of nurses and 39% of surgeons

reported experiencing bullying.

Training Medical Staff

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Psychological GenderDiscrimination

(F)

GenderDiscrimination

(M)

SexualHarrassment

(F)

SexualHarrassment

(M)

Physicalassault

Abuse and Discrimination in Medical Registrars (Canada)

SMS Peers (incl nursing) Patients

Cornelia H.M et al. Discrimination and Abuse in Internal Medicine

Residency (1996). J Gen Intern Med 1996; 11:401-405

Is Gender Important?

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Genders

What about Gender?

Women in healthcare are twice as likely to experience all

types of bullying and harassment as men

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Gender at SVHA; How do we rate?

SVHA Non-Medical Workforce

Gender

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Executive Senior Mx Middle Mx Clinical (ex.Medical)

Admin Other

SVHA Non-Medical Workforce Gender

Male Female Column1

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SVHA Medical Workforce Gender:

Public Division

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SMS Registrars /Fellows

HMO Interns Medical Students

Proportional Medical Staff Gender Distribution: Public Division

Male Female

SMS

31 %

female

SVHA Medical Workforce Gender:

Speciality Breakdown

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General

medicine SVHS

31% female vs

SVHM

47%

Surgery at

SVHS 8%

female vs

SVHM 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Anaethesia EmergencyMedicine

ICU Medicine Radiology Surgery MentalHealth

Pathology

65

55

83

57

6783

72

53

3545

17

43

2317

28

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SMS Gender Breakdown By Speciality Area : Public Division

Male Female

What are the root causes?

VAGO report found that across the health sector:

• poor accountability for inappropriate behaviour

• a ‘double standard’ where some individuals are perceived as ‘untouchable’

• widespread under reporting due to:

• belief that the reported behaviour will not be addressed

• distrust of human resources departments

• fear of repercussions

• normalisation and acceptance of inappropriate behaviour particularly among

junior doctors.

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What are the root causes?

• The health sector has an entrenched clinical hierarchy.

• Environments can be insular; especially procedural areas.

• Tradition plays key role in culture.

• Career still dependent on reputation, references and word of mouth; even as

VMO.

• Clinical prowess still valued much more than behavioural exemplars.

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Promoting Professionalism:

Addressing Behaviours that

Undermine a Culture of Safety,

Reliability and Accountability

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Background

• Vanderbilt program is built on the premise that most staff are good people,

doing the right thing for the right reasons

• Honours people who are behaving well

• Based on peer accountability, peer messaging and peer comparison

• Create micro / macro environments to intervene early & often

• Data and safety driven interventions

• These systems enable the right culture

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• Patient and staff observations gathered through reporting system

• Observations are triaged into a tiered accountability model which

aligns with human resource processes and laws

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Vanderbilt

version

Page 24

The Ethos Program

Redefining Normal

The Ethos Program

We feel safe

We feel valued

We feel welcome

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SVHA has a long legacy of living our values through

professional practice.

The principles of the Ethos Program are:

• All SVHA staff are entitled to a safe workplace

• We will encourage, acknowledge and reward behaviours that

reflect our values.

• Our response to behaviour that undermines patient or staff wellbeing

will be consistent, transparent and equitable.

• Our staff are given an opportunity for reflection and self-regulation

• Particular attention will be paid to vulnerable groups e.g. trainees,

junior staff.

• Diversity and gender balance are central to organisational strength.

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Building Cultural Identity

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Reporting

Electronic reporting app / database

Positive or negative event report

Safe voice; anonymous / confidential

Patient observations

Staff observations

Behavioural and safety events

Accountablility

Equitable, consistent and transparent

Tiered intervention model

Signed behavioural declaration

Aligned with internal HR policies / by laws

Aligned with laws / legislation

Internal Governance

Building Cultural Identity

Cultural Training / communicaton

Orientation

Recruitment

Performance management

Gender diversity / equality

Build external partnerships

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Login and report behaviour

Reports assessed by trained

triage team

Response determined by

Ethos model

Can remain

anonymous

Dependent on

severity of event /

number of related

reports

The SVHA Ethos model

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Building external relationships:

Creating the Web

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Communication – current model

Staff member

Facility

ProfessionalCollege

Regulatory board

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Support services

Communication – Creating a web

Staff member

Facility

Support services

ProfessionalColleges

Regulatory board

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• Working with Jeffrey Braithwaite and Johanna Westbrook from AIHI

Macquarie University on NHMRC partnership proposal

• Work with Vanderbilt University Medical Centre on collaborative research

• Explore partnerships with other health services

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Research and Evaluation

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