1 Addressing Behaviors that Undermine a Culture of Safety: It
Starts with a Cup of Coffee 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
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. Chapter 1: 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 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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4 Sometimes you just suspect a disturbance in the force
Slide 5
5 What data exists Post-op infection rates above the national
average
Slide 6
6 Response: We need a plan A multidisciplinary team was charged
to assess and evaluate: Current performance Opportunities for
improvement Plan development
Slide 7
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.SIU
Slide 8
8 The Plan: Colorectal Bundle Standardization of care for the
colon surgery patient: Communication of expectations Evidence-based
optimal bundle 9 elements: bowel prep wound protector change gown
and gloves etc. Education across service lines Ongoing monitoring
and compliance measurement Monthly review and analysis of surgical
site infection Problem Solved
Slide 9
9 So everyone responded in a professional way? Well not
exactly
Slide 10
10 The following event was reported to you (responsible party)
through an event reporting system. Policy defines that you review
and follow up. A nurse reports: Dr. X was performing a transverse
colon resection. At the appropriate point in surgery, Nurse Y
stated, Dr. X, you need to re-gown and glove per our colorectal
bundle. The following event was reported to you (responsible party)
through an event reporting system. Policy defines that you review
and follow up. A nurse reports: Dr. X was performing a transverse
colon resection. At the appropriate point in surgery, Nurse Y
stated, Dr. X, you need to re-gown and glove per our colorectal
bundle. Case: Re-Gown and Glove
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11 Dr. X replied, I dont agree with that element of the bundle
and Im not stopping now to change gowns and gloves. Dr. X continued
with procedure Case: Re-Gown and Glove Threat to safety?
Slide 12
12 Why Might a Medical Professional Behave in Ways that
Undermine a Culture of Safety? 1. Substance abuse, mental health
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.
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13 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 14
Lawsuits Non adherence/ noncompliance Surgical Complication
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.
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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.
Slide 16
FY09 FY10 FY11 FY12 FY13 CLABSI ICU 169 172 65 40 33 FY09 SIR:
3.16 FY13 SIR: 0.62 80% SIR and event reduction CLABSI NonICU 188*
96 65 68 FY10 SIR: 3.09 FY13 SIR: 0.93 70% SIR and 64% event
reduction *Extrapolated from 6 months of data CAUTI ICU 114 111 88
84 76 FY09 SIR: 1.36 FY13 SIR: 1.01 28% SIR and 33% event reduction
CAUTI NonICU 51 24 FY12 SIR: 1.29 FY13 SIR: 0.56 57% SIR and 53%
event reduction SSI 286* 266 263 183 161 FY09 SIR: 1.64 FY13 SIR:
0.98 40% SIR and 44% event reduction *Extrapolated from 6 months of
data Procs = CARD, CSEC, COLO, HYST, CABG, CBGC, CRAN, HIP, KNEE,
Peds CARD, Peds VSHUNT. REC, VHYST VAP** 145 151 76 56 FY09 SIR:
2.86 FY12 SIR: 1.12 61% SIR and event reduction Numbers Noted are
the Number of Specific HAI Events All SIR benchmarked to FY14
benchmarks **VUH and MCJCHV
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17 Infect- ion FY10 Pre HH Interv. (baseline) FY11-13 Expected
# Infectns FY11-13 Actual # Infectns # Fewer Infectns Over 3 Yrs
Mean Attrib Cost/ Infection* Est. 3-Yr Savings
Clabsi172516138378$22K $8.3MM VAP*151302132170$24.5K $4.2MM
SSI298894669225$19K $4.3MM CAUTI- ICU 11133324885$1.5K $0.1MM
Estimated Savings 858 infections $16.9MM Estimated Infection
Control Impacts Following Interventions to Promote Accountability
*VAP Surveillance ended mid-FY13 Estimates based on data in:
Perencevich, et al. SHEA Guideline. Raising standards while
watching the bottom line: Making a business case for infection
control. Infect Control Hosp Epidemiol. 2007;8:1121-1133.
Slide 18
18 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. Adoption of
unprofessional conduct Lessened trust, lessened task performance
(always monitoring disruptive person) Threatened quality and
patient safety Withdrawal
Slide 19
19 The Balance Beam Do nothingDo 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 Cant change
Studer Group and Vanderbilt Center for Patient and Professional
Advocacy, Unprofessional Behavior in Healthcare Study, June 2009;
Hickson GB, Pichert JW. Disclosure and apology. In: 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 20
20 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 21
21 To do something requires more than a commitment to
professionalism and personal courage. It requires a plan (people,
process and technology).
Slide 22
22 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. Acad Med. 2007
Nov;82(11):1040-1048. Hickson GB, Moore IN, Pichert JW, Benegas Jr
M. Chapter 1: 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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23 What are behaviors that undermine a culture of safety?
Accountability
Slide 24
24 Definition of Behaviors That Undermine a Culture of Safety
Excepts from Vanderbilt University and Medical Center Policy
#HR-027, 2010 Create intimidating, hostile, offensive (unsafe) work
environment Interfere with ability to achieve intended outcomes
Threaten safety (aggressive or violent physical actions) Violate
policies (including conflicts of interest and compliance) Its About
Safety
Slide 25
25 Policies will not work if behaviors that undermine a culture
of safety go unobserved, unreported and unaddressed
Slide 26
26 Hand Hygiene Performance What Are Surveillance Tools?
Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Chapter 1:
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. Staff
Concerns Risk Event Reporting System Patient Relations
Department
Slide 27
27 Reports of Unprofessional Behavior RN: Dr. __ entered the
room without foaming inproceeded to touch area with purulent
drainageI offered a pair of gloveshe took them and dropped them
into the trash can RN: Nurse on shift before me didnt assess need
for catheter and I found a kink in the bag Anesth: Dr. __
rushedsaid to team setting up barrier wound protection [per
bundle], Just use standard wound precautions. Lets get going.
Slide 28
28 Academic vs. Community Medical Center Physicians
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29 Co-Worker Observation Reporting System: VUMC Physicians 3
years
Slide 30
30 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. Promoting Professionalism Pyramid *includes
CMS-defined condition level and immediate jeopardy safety-related
complaints
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31 Improves physicians prescribing, clinical decision making 1
Reducing malpractice claims and expenses: By greater than 70% 2
Improving hand hygiene practices: From 50% to greater than 95%
compliance 3 Addressing behaviors that undermine a culture of
safety 4 Does any of this really work? 1 Schaffner W, et al. JAMA
1983;250:1728-1732; Ray WA, et al. Am J Public Health
1987;77:1448-1450; Greco PJ, Eisenberg JM. New Engl J Med
1993;329:1271-1273 2 Hickson et al. JAMA. 2002;287(22):2951-57;
Hickson et al. South Med J. 2007;100(8):791-6; Pichert et al. In:
Henriksen et al, editors. AHRQ; 2008: 421-30; Hickson &
Pichert. In: Youngberg, editor. Jones and Bartlett Publishers;
2012: 347-68; Pichert et al. Jt Comm J Qual Patient Saf.
2013;39(10):435-46. 3 Talbot et al. Infect Control Hosp Epidemiol.
2013; 34: 1129-36 4 Dmochowski et al. Manuscript in preparation,
2014
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32 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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33 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 day
give her some info, and get her out of here. I heard everything Dr.
__ said.
Slide 34
34 Academic vs. Community Medical Center Physicians
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35 Gender Physician specialty Volume of service Unsolicited
patient complaints Predictors of Risk Outcomes Predictive
concordance of risk models ranges from 81-92% Hickson et al. JAMA.
2002 Jun 12;287(22):2951-7. (logistic regression)
Slide 36
36 Incurred Expense By Risk Category Predicted Risk Category* #
(%) Physicians Relative Expense* % of Total Expense Score (range) 1
(low)318 (49) 1 4% 0 2147 (23) 613% 1 - 20 3 76 (12) 4 4%21 - 40 4
52 (8)4229%41 - 50 5 (high) 51 (8)7350%>50 Total644 (100) 100% *
In multiples of lowest risk group Moore, Pichert, Hickson,
Federspiel, Blackford. Vanderbilt Law Review. 2006.
Slide 37
37 Share comparative feedback with tiered interventions using
the Pyramid for Promoting Reliability and Professional
Accountability. Identify and train Peer Messengers Position for
protection from discovery Promote accountability References 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 et al, 2012. Pichert et al,
2013. Talbot et al, 2013. Adapted from Hickson, Pichert, Webb,
& Gabbe. Acad Med. 2007. 2013 Vanderbilt Center for Patient and
Professional Advocacy The PARS Process
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38 Risk Score Graph Complaint Type Summary Awareness
Intervention on Dr. __ Letter with standings, assurances prior to
& at meeting National PARS Risk Score Comparisons
Slide 39
39 Unimproved/worse Successfully completed intervention process
or are improving Departed organization unimproved Since FY 2000,
PARS has identified >1070 U.S. physicians as high risk 64
Physicians 110 Physicians 672 Physicians Total # of high-risk
physicians to date1071 Departed before 12 month follow up(79) First
follow-up will be in 2014 or 2015(149) 846 with follow-up data 80%
7% 13% Pichert JW et al. An intervention model that promotes
accountability: Peer messengers and patient/family complaints. Jt
Comm J Qual Patient Saf. 2013 Oct;39(10):435-446. 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.
Slide 40
Medical Malpractice Suits Per 100 Physicians SVMIC VUMC Tort
Reform in TN 2008 Cert. of Merit w/ Notice2011 $750K Cap
Slide 41
41 Respect, trust and team performance Our latest work: Patient
Complaints & Surgical Outcomes
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42 Patient Complaints 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 didnt get it, I thought maybe
you could not read. Clear and Effective Communication
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43 NSQIP and Pt Complaints Question: Do Periop Risk Factors
moderate the relationship between Patient Complaints and Surgical
Outcomes? Preop Risk Factors PARS Categories Surgical Occurrences
ASA ClassCare & TreatmentIntraoperative Priority
StatusCommunicationWound Wound ClassConcern for Pt/FamilyUrinary
AccessibilityCNS Billing w/C&T concernRespiratory Other
RisksPatient ComplaintsOutcomes
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44 66 surgeons; 10,536 procedures Correlations between pt
complaints and occurrences: Results: Significant relationships
between Occurrences & Complaints Occurrences Correlation with
Patient Complaints Intraoperative0.58, p