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
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
2
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.
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
drainage…I offered a pair of gloves…Dr. __
took them and dropped them into the trash
can.”
3
Professionalism and Self-Regulation
 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
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.
4
Professional Accountability
What are
behaviors that undermine
a culture of safety ?
5
Definition of Behaviors That
Undermine a Culture of Safety
• 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
6
Excepts from Vanderbilt University and Medical Center Policy #HR-027, 2010
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?
7
Why are we so hesitant to act?
What barriers exist?
8
The Balance Beam
Competing priorities
Not sure how lack
tools, training
Leaders “blink”
“Can’t change…”
?
Fear of antagonizing
Do nothing
9
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
Why Might a Medical Professional Behave in
Ways that Undermine A Culture of Safety?
1.
2.
3.
4.
5.
6.
7.
8.
10
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
11
Samenow CP. Swiggart W. Spickard A Jr. A CME course aimed at addressing disruptive physician behavior. Physician
Executive. 34(1):32-40, 2008.
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 issues—guilt 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.
12
Consequences of Unsafe Behavior:
Patient Perspective
Lawsuits
(tip of the iceberg)
Infections/
Errors
Non adherence/
noncompliance
Drop out
Costs
Bad-mouthing the
practice to others
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.
Consequences of Unsafe Behavior:
Healthcare Professional Perspective
Harassment suits
Lack of retention
(tip of the iceberg)
Infections/
Errors
Burnout
Costs
Jousting
Bad-mouthing the organization in the community
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.
Failure to Address Behaviors that
Undermine a Culture of Safety
Leads To:
• 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)
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.
15
What is the yearly cost of replacing
nursing professionals due to behav…?
• 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...?
*Studer Group and Vanderbilt CPPA. Unprofessional Behavior in Healthcare Study,
June 2009 . In: Modern Healthcare Outsert. October 26, 2009.
16
Let’s 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;
20:1074–1076; 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
17
To “do something”
requires more than a commitment
to professionalism and personal
courage. We need a plan.
(a function of preparation)
18
Nurse reported:
“Dr. __ entered the room without foaming in
…proceeded to touch area with purulent
drainage…I offered a pair of gloves…Dr. __
took them and dropped them into the trash can.”
19
Infrastructure for Promoting Reliability &
Professional Accountability (PA)
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
20
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.
Infrastructure for Promoting PA
• 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.
Behaviors that undermine a culture of safety. SEA #40. The Joint Commission, July 2008.
21
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
22
Policies will not work if behaviors
that undermine a culture of safety
go unreported and unaddressed
23
What Are “Surveillance Tools”?
• Risk Event Reporting System
– “Resuscitation run incorrectly…team afraid to speak up…
dismisses those who say something…threatens culture of
safety.”
• Patient Relations Department
– Record patient/family concerns: “…didn’t listen…nor was
Dr. __ forthcoming when asked for pros & cons of [one
treatment plan]…just said, “no cons.”
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.
24
Promoting Professionalism Pyramid
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.
No
∆
Level 3 "Disciplinary"
Intervention
Pattern
persists
Apparent
pattern
Single
“unprofessional"
incidents (merit?)
Level 2 “Guided"
Intervention by Authority
Level 1 "Awareness"
Intervention
"Informal" Cup
of Coffee
Intervention
Mandated
Vast majority of professionals - no issues provide feedback on progress
25
Mandated
Reviews
Adapted from Hickson, Pichert, Webb, Gabbe. Acad Med. 2007. ©2013 Vanderbilt Center for Patient and Professional Advocacy
But does any of this work?
26
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
27
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.
Patient Complaints
“While asking Dr. __ about my diagnosis, he responded that
my questions were annoying…wouldn’t 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 treatments…unacceptable…”
“Dr. __ left me, walked down hall, said to nurse, ‘this pt has
completely [fouled] up my day…go [give him some info], and
get him out of here.’ I heard everything Dr. __ said.”
28
Academic vs. Community Medical
Center Physicians
5% of Physicians associated with 35% of concerns
35-50% are associated with NO concerns
29
Hickson GB, et al. JAMA. 2002 Jun 12;287(22):2951-7. Hickson GB, et al. So Med J. 2007;100:791-6.
Awareness Intervention on Dr. __
• Letter with standings, assurances prior to & at meeting
• Risk Score Graph
• Complaint Type Summary
200
All Physicians - National PARS® Data
180
Orthopedic Surgeons - National PARS® Data
160
140
120
100
__, MD: Risk Score of 144 is within top 0.5%
of All Physicians and #4 of 950 Orthopedic
Surgeons in the National PARS® Database
80
Risk Score*
Threshold for Assessment and Review **
60
20
0
0%
20%
40%
60%
Percent of Physicians
30
80%
100%
Last Updated: 6/14/2013
40
National PARS®
Risk Score Comparisons
How do you get physician
messengers?
31
Messengers
• 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…
32
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 services…you 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…
33
Messengers
• 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
34
Does it work?
PARS® National Progress Report
Since FY 2000, >970 U.S. physicians
identified by PARS® as high-risk
Departed organization unimproved
Unimproved/worse
35
Successfully completed
intervention process or
are improving
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.
Malpractice Suits per 100 Physicians*
FY1992 – 2013
36
But it is not just about
individual performance…
37
Professional Accountability
Who is this man?
He had a good idea…
38
• 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?
39
VUMC Hand Hygiene Adherence (%)
July 2008 – February 2009
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
7.08
40
8.08
9.08
10.08
11.08
Dates
12.08
1.09
2.09
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
VUH Unit Hand Hygiene Compliance
July 1, 2010 – November 30, 2011
Threshold
42
Target
Reach
VUMC YTD
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.
Promoting Professionalism Pyramid
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.
No
∆
Level 3 "Disciplinary"
Intervention
Pattern
persists
Level 2 “Guided"
Intervention by Authority
Apparent
pattern
Level 1 "Awareness"
Intervention
Single
“unprofessional"
incidents (merit?)
"Informal" Cup
of Coffee
Intervention
Mandated
Vast majority of professionals - no issues provide feedback on progress
43
Mandated
Reviews
Adapted from Hickson, Pichert, Webb, Gabbe. Acad Med. 2007. ©2013 Vanderbilt Center for Patient and Professional Advocacy
Awareness Letter
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, VUMC’s reach goal for hand hygiene is
95% compliance.
For November 2010, your area’s
compliance rate was 35%, and for
FY11-to-date, 47%.
Bold, red font for demonstration only
44
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.
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
VUMC Quarterly HH Compliance
June 2009 – Oct 2013
Reach
Threshold
Period of intensified HH program utilizing shared
accountability*
46
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.
Hand Hygiene Improvement Strongly
Correlates with Low Infection Rates
HIGH Infection Rates
Correlate with LOW Hand
Hygiene Adherence
HIGH
Each data point indicates the
VUMC-wide monthly HH
adherence (x-axis) and infection
rates (y-axis) between
Jan 2007-Aug 2012
Monthly
Standardized
Infection Ratio,
All Inpatient
Units Combined
(CLABSI,
CAUTI, VAP
combined)
As adherence goes up,
infection rates go down
LOW
LOW
47
Monthly Hand Hygiene Adherence Rate
LOW Infection Rates
Correlate with HIGH
Hand Hygiene
Adherence
HIGH
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
What about concerns reported
by staff, other professionals?
Apply the same process,
principles, infrastructure
48
Staff Professionalism Concerns
Nurse: “Mom was worried about tube placement…Dr. XX
said to child, ‘you let me put it in or I will shove it in.’”
“Dr. ___ sat in hallway > 1hour, playing ‘Angry Birds’... Clinic
was in session ...”
“Refused to do a time out before surgery, …. said, ‘we’re 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.”
49
Confidential, privileged information under provisions 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
50
50
51
51
Staff Professionalism Concerns:
Who was the Reported Target?
“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.”
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
Staff Professionalism Concerns:
Who Observed the Event?
21% observed by
patients & families
53
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
Promoting Professionalism Pyramid
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.
No
∆
Level 3 "Disciplinary"
Intervention
Pattern
persists
Apparent
pattern
Single
“unprofessional"
incidents (merit?)
Level 2 “Guided"
Intervention by Authority
Level 1 "Awareness"
Intervention
"Informal" Cup
of Coffee
Intervention
Mandated
Vast majority of professionals - no issues provide feedback on progress
54
Mandated
Reviews
Adapted from Hickson, Pichert, Webb, Gabbe. Acad Med. 2007. ©2013 Vanderbilt Center for Patient and Professional Advocacy
But what if all efforts fail?
55
Promoting Professionalism Pyramid
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.
No
∆
Level 3 "Disciplinary"
Intervention
Pattern
persists
Level 2 “Guided"
Intervention by Authority
Apparent
pattern
Level 1 "Awareness"
Intervention
Single
“unprofessional"
incidents (merit?)
"Informal" Cup
of Coffee
Intervention
Mandated
Vast majority of professionals - no issues provide feedback on progress
56
Mandated
Reviews
Adapted from Hickson, Pichert, Webb, Gabbe. Acad Med. 2007. ©2013 Vanderbilt Center for Patient and Professional Advocacy
Authority Conversation
• 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/doesn’t work within defined time
57
“EDICTS”
• Expectations
• Deficiencies
• Intervention
• Consequences
• Timeline
• Surveillance
58
Your role as the leader
• Know what represents behaviors/performance
that undermine a culture of safety
• Address behaviors/performance that undermine
a culture of safety early and consistently
59
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.
Professionalism and Self-Regulation
 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
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.
60
Upcoming CPPA Conferences
• 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
61