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

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.

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.

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.

5 What are behaviors that undermine a culture of safety ? Professional Accountability

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

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?

8 What barriers exist? Why are we so hesitant to act?

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 ?

10 Why Might a Medical Professional Behave in Ways that Undermine A Culture of Safety? 1. 2. 3. 4. 5. 6. 7. 8.

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.

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.

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.

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.

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.

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.

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

18 To do something requires more than a commitment to professionalism and personal courage. We need a plan. (a function of preparation)

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.

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.

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.

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

23 Policies will not work if behaviors that undermine a culture of safety go unreported and unaddressed

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.

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

26 But does any of this work?

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.

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.

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

30 Risk Score Graph Complaint Type Summary Awareness Intervention on Dr. __ Letter with standings, assurances prior to & at meeting National PARS Risk Score Comparisons

31 How do you get physician messengers?

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

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

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

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

36 Malpractice Suits per 100 Physicians* FY1992 2013

37 But it is not just about individual performance

38 Professional Accountability Who is this man? He had a good idea

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?

40 VUMC Hand Hygiene Adherence (%) July 2008 February 2009 Dates

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

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

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.

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

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

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

48 What about concerns reported by staff, other professionals? Apply the same process, principles, infrastructure

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.

50 Distribution of Staff Professionalism Reports about Physicians 3 years

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?

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

55 But what if all efforts fail?

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

58 Expectations Deficiencies Intervention Consequences Timeline Surveillance EDICTS

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.

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.

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

Documents

1 Addressing Behaviors that Undermine a Culture of Safety, Reliability, and Accountability Gerald B. Hickson, MD Sr. Vice President for Quality, Safety