1 Addressing Behaviors that Undermine a Culture of Safety, Reliability, and Accountability Gerald B....
61
1 Addressing Behaviors that Undermine a Culture of Safety, Reliability, and Accountability 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 Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine
1 Addressing Behaviors that Undermine a Culture of Safety, Reliability, and Accountability Gerald B. Hickson, MD Sr. Vice President for Quality, Safety
1 Addressing Behaviors that Undermine a Culture of Safety,
Reliability, and Accountability 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 Center for Patient &
Professional Advocacy, Vanderbilt University School of
Medicine
Slide 2
2 Pursuing Reliability* Definition: Failure free operation over
time effective, efficient, timely, pt-centered, equitable Requires:
Vision/goals/core values Leadership/authority (modeled) A safety
culture Willingness to report and address Psychological safety
Trust 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.
Slide 3
3 Consider a Case: No thank you The following event was
reported to you: A nurse observes: Dr. __ entered the room without
foaming in proceeded to touch area with purulent drainageI offered
a pair of glovesDr. __ took them and dropped them into the trash
can. A nurse observes: Dr. __ entered the room without foaming in
proceeded to touch area with purulent drainageI offered a pair of
glovesDr. __ took them and dropped them into the trash can.
Slide 4
4 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.
Slide 5
5 What are behaviors that undermine a culture of safety ?
Professional Accountability
Slide 6
6 Prevent or interfere w/an individuals or groups 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 Its About
Safety Definition of Behaviors That Undermine a Culture of Safety
Excepts from Vanderbilt University and Medical Center Policy
#HR-027, 2010
Slide 7
7 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?
Slide 8
8 What barriers exist? Why are we so hesitant to act?
Slide 9
9 The Balance Beam Do nothingDo something Fear of antagonizing
Leaders blink Not sure how lack tools, training Competing
priorities Cant 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 ?
Slide 10
10 Why Might a Medical Professional Behave in Ways that
Undermine A Culture of Safety? 1. 2. 3. 4. 5. 6. 7. 8.
Slide 11
11 Why Might a Medical Professional Behave in Ways that
Undermine a Culture of Safety? 1. Substance abuse, psych issues 2.
Narcissism, perfectionism 3. Spillover of family/home problems 4.
Poorly controlled anger (2 emotion)/Snaps under heightened stress,
perhaps due to: a. Poor clinical/administrative/systems support b.
Poor mgmt skills, dept out of control c. Back biters create poor
practice environments Samenow CP. Swiggart W. Spickard A Jr. A CME
course aimed at addressing disruptive physician behavior. Physician
Executive. 34(1):32-40, 2008.
Slide 12
12 Why Might a Medical Professional Behave in Ways that
Undermine a Culture of Safety? 5. Lack of awareness of impacts on
others 6. Make others look bad - for some advantage 7. Distract
from own shortcomings 8. Family of origin issuesguilt and shame 9.
Well, it seems to work pretty well (Why? See #10) 10. No one
addressed it earlier (Why?) Samenow CP. Swiggart W. Spickard A Jr.
A CME course aimed at addressing disruptive physician behavior.
Physician Executive. 34(1):32-40, 2008.
Slide 13
Lawsuits Non adherence/ noncompliance Consequences of Unsafe
Behavior: Patient Perspective Drop out (tip of the iceberg)
Infections/ Errors Bad-mouthing the 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.
Slide 14
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 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.
Slide 15
15 Team members may adopt disruptive persons 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.
Slide 16
16 VUMC replaces 12-14% In a 2009 study, 2/3 of respondents
said they considered leaving their job because of
behavior/performance that undermines... and 41% said they actually
did* If our assumptions are correct, what is our yearly cost of
behavior/performance that undermines...? What is the yearly cost of
replacing nursing professionals due to behav? *Studer Group and
Vanderbilt CPPA. Unprofessional Behavior in Healthcare Study, June
2009. In: Modern Healthcare Outsert. October 26, 2009.
Slide 17
17 Lets do a financial calculation Hospital X Total # of RNs:
3,348 3, 348 RNs X 13.4% (turnover rate) = 449 6-12% leave due to
behavior/performance that undermines a culture of safety = 27-54
[27-54] X $43,667* = $1,179,009 $2,358,018 * Estimated direct cost
of turnover per RN; does not include impact of lost knowledge and
experience * Rawon et al. Cost of unprofessional and disruptive
behaviors in health care. Acad Radiol 2013; 20:10741076; Lewin
Group, Inc. Evaluation of the RWJ Wisdom at Work Research
Initiative: Retaining experienced nurses, Final Report. January
2009. http:
//www.issuelab.org/resource/evaluation_of_the_robert_wood_johnson_wisdom_at_work_retaining_experienced_nurses_research_initiative
Slide 18
18 To do something requires more than a commitment to
professionalism and personal courage. We need a plan. (a function
of preparation)
Slide 19
19 Nurse reported: Dr. __ entered the room without foaming in
proceeded to touch area with purulent drainageI offered a pair of
glovesDr. __ took them and dropped them into the trash can. Nurse
reported: Dr. __ entered the room without foaming in proceeded to
touch area with purulent drainageI offered a pair of glovesDr. __
took them and dropped them into the trash can.
Slide 20
20 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.
Slide 21
21 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.
Slide 22
22 Infrastructure for Promoting Reliability and PA Credo I make
those I serve my highest priority I communicate effectively I
conduct myself professionally I respect privacy and confidentiality
I have a sense of ownership I am committed to my colleagues
Supportive institutional policies VUMC Professional Behavior
policy: conveys expectations, reporting lines, pathways, right
things to do. 22
Slide 23
23 Policies will not work if behaviors that undermine a culture
of safety go unreported and unaddressed
Slide 24
24 Risk Event Reporting System Resuscitation run
incorrectlyteam afraid to speak up dismisses those who say
somethingthreatens culture of safety. Patient Relations Department
Record patient/family concerns: didnt listennor was Dr. __
forthcoming when asked for pros & cons of [one treatment
plan]just said, no cons. 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.
Slide 25
25 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 Egregious 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
Slide 26
26 But does any of this work?
Slide 27
27 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.
Slide 28
28 Patient Complaints While asking Dr. __ about my diagnosis,
he responded that my questions were annoyingwouldnt listen and kept
speaking over me we were so rushed that Dr. __ couldn't even
explain why they were recommending this treatment plan for my mom
over other types of treatmentsunacceptable Dr. __ left me, walked
down hall, said to nurse, this pt has completely [fouled] up my
daygo [give him some info], and get him out of here. I heard
everything Dr. __ said.
Slide 29
29 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. 5%
of Physicians associated with 35% of concerns
Slide 30
30 Risk Score Graph Complaint Type Summary Awareness
Intervention on Dr. __ Letter with standings, assurances prior to
& at meeting National PARS Risk Score Comparisons
Slide 31
31 How do you get physician messengers?
Slide 32
32 Nominated (usually by dept chairs and other leaders) based
on several criteria: drawn from various specialties, currently or
recently in practice, respected by colleagues, committed to
confidentiality, and willing to serve in a challenging role
Nominees are sent a letter Messengers
Slide 33
33 Sample Messenger Letter Chairs and leadership asked to
nominate respected physicians, committed to confidentiality and
professionalism and dedicated to improving the quality of health
care servicesyou have been recommended Committee members are
charged to identify and intervene with colleagues whose experiences
suggest they may be at increased risk of malpractice claims. To
introduce you to the work, I am inviting you to a training
session
Slide 34
34 Receive eight hours of training Are just messengers and not
responsible for fixing their colleagues Messengers own Risk Scores
are mostly satisfactory; some high-risk physicians can serve
successfully as messengers Identification of the right committee
chairs and committee members is essential Leadership council
supports, monitors Messengers
Slide 35
35 Does it work? PARS National Progress Report Pichert JW et
al. An intervention that promotes accountability: Peer messengers
and patient/family complaints. Jt Comm J Qual Patient Saf. 2013
Oct;39(10):435-446. Since FY 2000, >970 U.S. physicians
identified by PARS as high-risk Successfully completed intervention
process or are improving Unimproved/worse Departed organization
unimproved
Slide 36
36 Malpractice Suits per 100 Physicians* FY1992 2013
Slide 37
37 But it is not just about individual performance
Slide 38
38 Professional Accountability Who is this man? He had a good
idea
Slide 39
39 57 y/o, bilateral arthritis of knees, bone on bone Bilateral
knee replacement in your system Surgery without difficulty To
post-op room with good pain control Potential Risks?
Slide 40
40 VUMC Hand Hygiene Adherence (%) July 2008 February 2009
Dates
Slide 41
A Call for Clean Hands: Vanderbilt Hand Hygiene Tom Talbot, MD,
MPH Nancye Feistritzer, RN, MSN Titus Daniels, MD, MPH Claudette
Fergus, RN, BA Gerald Hickson, MD, the Hand Hygiene Committee and
the Leadership Review Task Force Talbot TR, et al. Sustained
improvement in hand hygiene adherence: Utilizing shared
accountability and financial incentives. Infect Control Hosp
Epidemiol. 2013; 34(11, Nov): 1129-1136
Slide 42
42 Confidential and privileged information under the provisions
set forth in T.C.A. 63-1-150 and 68-11-272; not to be disclosed to
unauthorized persons. ThresholdTargetReachVUMC YTD VUH Unit Hand
Hygiene Compliance July 1, 2010 November 30, 2011
Slide 43
43 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 Egregious 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
Slide 44
44 Awareness Letter Bold, red font for demonstration only We
are all committed to minimizing the risk of healthcare-associated
infections. Performing hand hygiene is the most important action we
can take to reduce the spread of these infections to our patients
and ourselves. For FY11, VUMCs reach goal for hand hygiene is 95%
compliance. For November 2010, your areas compliance rate was 35%,
and for FY11-to-date, 47%. A member of our Pillar Goal Committee
team will contact you to schedule a time to meet so we may partner
in achieving increased hand hygiene in your area.
Slide 45
The CPPA Process: Other Applications Sharing Hand Hygiene Data
The CPPA Process. Share comparative feedback with tiered
interventions using the Pyramid; Provide follow-up; Promote
accountability 45
Slide 46
46 Period of intensified HH program utilizing shared
accountability* VUMC Quarterly HH Compliance June 2009 Oct 2013
Threshold Talbot TR et al. Sustained improvement in hand hygiene
adherence: Utilizing shared accountability and financial
incentives. Infect Control Hosp Epidemiol. 2013
Nov;34(11):1129-1136. Reach
Slide 47
47 Monthly Standardized Infection Ratio, All Inpatient Units
Combined (CLABSI, CAUTI, VAP combined) Monthly Hand Hygiene
Adherence Rate HIGH LOW LOW Infection Rates Correlate with HIGH
Hand Hygiene Adherence Each data point indicates the VUMC-wide
monthly HH adherence (x-axis) and infection rates (y-axis) between
Jan 2007-Aug 2012 Each data point indicates the VUMC-wide monthly
HH adherence (x-axis) and infection rates (y-axis) between Jan
2007-Aug 2012 HIGH Infection Rates Correlate with LOW Hand Hygiene
Adherence Hand Hygiene Improvement Strongly Correlates with Low
Infection Rates HIGH As adherence goes up, infection rates go down
Talbot TR, et al. Sustained improvement in hand hygiene adherence:
Utilizing shared accountability and financial incentives. Infect
Control Hosp Epidemiol. 2013; 34(11, Nov): 1129-1136
Slide 48
48 What about concerns reported by staff, other professionals?
Apply the same process, principles, infrastructure
Slide 49
49 Nurse: Mom was worried about tube placementDr. XX said to
child, you let me put it in or I will shove it in. Staff
Professionalism Concerns Confidential, privileged information under
provisions in T.C.A. 63-1-150 and 68-11-272; not be disclosed to
unauthorized persons. Dr. ___ sat in hallway > 1hour, playing
Angry Birds... Clinic was in session... Refused to do a time out
before surgery, . said, were all on the same page here. Dr. __ was
making personal calls (appt for massage) I (RN) asked Dr. __s help:
they can wait, families heard.
Slide 50
50 Distribution of Staff Professionalism Reports about
Physicians 3 years
Slide 51
51
Slide 52
52 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. X responded, "Don't you know how to speak
English? When issue required consideration of different opinions,
Dr. XX became offensive and angry." Dr. XX slammed hands down and
began yelling at RNs. Staff Professionalism Concerns: Who was the
Reported Target?
Slide 53
53 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
Slide 54
54 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 Egregious 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
Slide 55
55 But what if all efforts fail?
Slide 56
56 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 Egregious 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
Slide 57
57 Pattern, no improvement Or, singular significant event Plan
developed: Authority figure and individual co-develop a plan; or
Authority figure develops and specifies plan Clearly defined
consequences if plan not followed/doesnt work within defined time
Authority Conversation
59 Know what represents behaviors/performance that undermine a
culture of safety Address behaviors/performance that undermine a
culture of safety early and consistently Your role as the 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.
Slide 60
60 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.
Slide 61
61 The How and When of Communicating About Unexpected Outcomes
and Errors April 18, 2014 Promoting Professionalism: Addressing
Behaviors That Undermine A Culture of Safety, Reliability and
Accountability June 20-21, 2014
http://www.mc.vanderbilt.edu/centers/cppa/courses.htm Upcoming CPPA
Conferences