addressing behaviors that undermine safety...

Addressing Behaviors that Undermine Safety Culture

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©2015 Vanderbilt Center for Patient and Professional AdvocacyIHI National Forum

December, 2015

December 6, 2015


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

Jay Banerjee, MBBS, MSc, FRCS, FCEM

Emergency Physician/Associate Director Quality Improvement

University Hospitals of Leicester NHS Trust

Kevin Stewart, MB, MPH, FRCP, FRCPI

Clinical Director, Clinical Effectiveness Unit

Royal College of Physicians

Session Code: L10

Presenters have nothing to disclose

27th Annual National Forum on Quality

Improvement in Health Care

1. Appreciate the spectrum of behaviors that

undermine a culture of safety;

2. Articulate an evidence-based approach to

addressing behaviors that undermine a

culture of safety; and

3. Understand how to deliver Cup of Coffee

and Espresso conversations.

Session Objectives


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The content and materials related to the following

presentation are the sole property of Vanderbilt University and

the Vanderbilt Center for Patient and Professional

Advocacy. The presentation shall not be reproduced in any

form, or stored in any format or on any medium (e.g. video,

website, server, etc.) that is available to the general public or

others not attending this conference. The presentation, in any form, may not be used to produce a commercial product for

sale.

Copyright Disclosure 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.


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� Professionals are willing to engage in all aspects of the

job – tedious or otherwise – to the best of their ability.

� Professionals commit to:

• Technical and cognitive competence

AND

• Clear and effective communication

• Being available

• Modeling respect

• Self-awareness

� 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. Reason, James. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries.

Ashgate Publishing Limited 2008

Checklists: The Keys to the Kingdom…


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� Conclusions:

Adjusted risk of death; surgical

complications; SSIs; wound

complications, 30-day mortality…

But wait…

Urbach DR, et al. Introduction of surgical safety checklists in

Ontario, Canada. N Engl J Med. 2014 Mar 13;370(11):1029-38.

Reames BN, et al. A Checklist-Based Intervention to Improve Surgical

Outcomes in Michigan: Evaluation of the Keystone Surgery Program. JAMA

Surg. 2015 Jan 14. doi: 10.1001/jamasurg.2014.2873. [Epub ahead of print].

No Difference…No Difference…

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

Intentionally Designed Systems

Professional Accountability

The Right Balance


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� A safety culture is the overarching goal

� Disruptive behavior is counter to…

� Individuals are accountable to

promote and protect the safety culture

of the organization…

Transition from “Disruptive” to “Behaviors

that Undermine a Culture of Safety”Case: Whistling a Tune

The following event was reported to you through your

electronic event reporting system:

� “Dr. Surgeon was scheduled to perform procedure.

Once in the OR, the team attempted to perform a

‘time out’. Dr. Surgeon asked everyone to ‘listen

carefully,’ then as the process started Dr. Surgeon

began whistling a tune. ‘We believe it was the

Mickey Mouse Club theme song.’”


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Represents a threat to safety?

1. Strongly Agree

2. Agree

3. Uncertain

4. Disagree

5. Strongly Disagree

1. 2. 3. 4. 5.

0% 0% 0%0%0%

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1. 2. 3. 4. 5.

0% 0% 0%0%0%

1. 0%-20%

2. 20%-40%

3. 40%-60%

4. 60%-80%

5. 80%-100%

If this event occurred in your org, what % of the

time would it be reported?

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1. 2. 3. 4. 5.

0% 0% 0%0%0%

1. 0%-20%

2. 20%-40%

3. 40%-60%

4. 60%-80%

5. 80%-100%

If reported, what % of the time would a medical

leader have a conversation with Dr. Surgeon?

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What are behaviors that undermine a culture of safety?

Why are we so hesitant to act?


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Interfere with ability

to achieve intended

outcomes

Definition of Behaviors That Undermine a Culture of Safety

Excerpts from Vanderbilt University and Medical Center Policy #HR-027, 2010

Create intimidating,

hostile, offensive (unsafe)

work environment

Threaten safety

(aggressive or violent

physical actions)

Violate policies (including

conflicts of interest and

compliance)

It’s About Safety


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To “do something” requires more than a commitment to

professionalism and personal courage.

It requires a plan(people, process and systems).

Essential Elements to Promote Reliability


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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

Surgical

Bundle

Compliance

Staff Professionalism ConcernsCalled Dr. __ re: change in pt status…came 25 min later,

looked at pt, publicly yelled at me, “you lied… pt okay…don’t

call again.”…felt threatened.

Called Dr. __ re: change in pt status…came 25 min later,

looked at pt, publicly yelled at me, “you lied… pt okay…don’t

call again.”…felt threatened.

Refused to do a time out before surgery, …. said, “we’re all

on the same page here.”

Refused to do a time out before surgery, …. said, “we’re all

on the same page here.”

Dr. __ refused to re-gown and re-glove during colorectal

surgery. Said, “I don’t agree with that part of the bundle.”

Dr. __ refused to re-gown and re-glove during colorectal

surgery. Said, “I don’t agree with that part of the bundle.”

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.


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Reports of Unprofessional Behavior

RN: One APRN said, “Well, are you going to push the IV med or

are we going to stand around all day?”

RN: One APRN said, “Well, are you going to push the IV med or

are we going to stand around all day?”

RN: [The APRN] gave me an off-protocol order…I tried to speak

up…APRN responded, “I’m driving the treatment plan here, not

you.”

RN: [The APRN] gave me an off-protocol order…I tried to speak

up…APRN responded, “I’m driving the treatment plan here, not

you.”

RN: We paged the APRN four times to come see the patient. She

never came.

RN: We paged the APRN four times to come see the patient. She

never came.


Co-Worker Observation Reporting

System: VUMC Physicians – 3 years

VUMC Attending Physicians and Residents

VUMC Attendings with 3 or more Reports (3.1%)

VUMC Residents with 3 or more Reports (0.4%)

Threshold of Assessment and Review

87% of physicians association

with NO reports in 3 years

3.5% of physicians associated with > 40% of reports


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97% of physicians are associated

with NO reports in 3 years

Co-Worker Observation Reports - National CORS℠ Database (n = 5,721)

Co-Worker Observation Reporting

System: National Comparison

1% of physicians associated with 61% of reports

Promoting Professionalism Pyramid

No ∆Level 3 "Disciplinary" Interv

Pattern persists Level 2 “Guided" Authority Interv

Apparent pattern Level 1 "Awareness" Interv

Single “unprofessional"

incidents (merit?)

Vast majority of professionals - no issues -

provide feedback on progress*includes CMS-defined “condition level” and “immediate jeopardy” safety-related complaints

"Informal" Cup of

Coffee Intervention

Mandated

Ray, Schaffner, Federspiel, 1985.

Hickson, Pichert, Webb, Gabbe, 2007.

Pichert et al, 2008.

Mukherjee et al, 2010.

Stimson et al, 2010.


Hickson & Pichert, 2012.

Hickson et al, 2012.


Talbot et al, 2013.

Mandated

Reviews


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Back to the case: Whistling a tune

So what kind of conversation?

Dr. Surgeon asked everyone to ‘listen

carefully,’ then as the process started Dr.

Surgeon began whistling a tune. ‘We

believe it was the Mickey Mouse Club

theme song.’”

Informal ConversationRegular (Cup of Coffee)

(see handout)

For a single “event”…


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1. Model respect and seek to maintain trust

2. When possible share in a private area

3. Avoid tendency to downplay ‘event’

4. Balance empathy and objectivity

5. Anticipate range of responses (push-backs)

Principles for “Informal” Conversations

See Handout:

6. Your role (even as “the chief”): • To report a single “disturbance”

• To let the colleague know that the behavior/action was noticed

(surveillance)

7. It’s not a control contest

8. Don’t expect thanks

9. Know message and “stay on message”

10. Know your communication style (and your buttons)

Principles for “Informal” Conversations

See Handout:


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� Offer appreciation (if you can): “You’re important, if

you weren't, I wouldn't be here.”

� Use “I” statements: “I heard…,” “I saw…,” “I received…”

� Avoid “you” statements…

� Review incident, provide appropriate specifics

� Ask for colleague’s view…pause…

� Respond to questions, concerns…

Having the “Informal” Conversation

See Handout:

� Appreciation, affirmation

� Empathy: “Now I feel I understand..."

� Accountability: "But we've all got to respond

professionally..."

� Reminder of behavior standards: “incident did not appear

consistent with..."

� If asked what to do use phrases: "reflect on the issues,

think about ways to prevent recurrence."

� If appropriate: conversation confidential, known only to…


Closing:


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� A control contest

� Therapy (for the individual or yourself)

� A hierarchical conversation

� An enabling conversation

� An opportunity to address multiple issues


Conversation is NOT:

Now it’s your turn…


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Essential Elements to Promote Reliability

But wait, does any of this really work?


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1Schaffner 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;329:1271-12732Hickson 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. 3Talbot et al. Infect Control Hosp Epidemiol. 2013; 34: 1129-364Catron et al. Am J Med Qual. 2015 Apr 27; Webb, Dmochowski et al., submitted for publication, 2015

Reduces malpractice

claims & expenses:

By > 70%2

Improves hand hygiene

practices:

From 50% to > 95%

compliance3

Addresses behaviors that undermine a culture of safety4

Improves physicians’

prescribing, clinical

decision making1

PARS® Process- Does it work?

Unimproved/worse

Successfully completed

intervention process

or are improving

Departed organization unimproved

Since FY 2000, PARS® has identified

1368 U.S. physicians as high risk

68 Physicians

158 Physicians

806 Physicians


78%

7%

15%

“An Intervention Model that Promotes Accountability: Peer Messengers and Patient/Family Complaints”by James W. Pichert, Ilene N. Moore, Jan Karrass, Jeffrey S. Jay, Margaret W. Westlake, Thomas F. Catron and Gerald B. Hickson.

Joint Commission Journal article honored with ABIM Foundation Professionalism Article Prize

Departed before follow up = 123 - First follow up next year = 213


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-76%*

-83%*

*N=80 PARS High Risk Physicians with at least one year of follow-up data, p < .001

**No claims for these physicians exceeded the $2MM cap after interventions

Reduce Physician Malpractice Claims

and Costs

Claims Dollars Paid* Per Physician Year Before and After First PARS Interventions

Vanderbilt Medical Malpractice Suits Per 100 Physicians

ID & intervene on high-risk

VUMC physicians (PARS®)

2003 –

Claims

reviews

w/

leaders

2005 – 2007

Standardized

MM&Is; Faculty

Disclosure

Training

2007 - Allocation rebate

program

2012 - Address

unprofessional or

unsafe behavior

VUMC Risk Prevention Initiatives

SVMIC VUMC Tort Reform in TN

2008 – Cert. of Merit w/ Notice 2011 – $750K Cap


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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.Threshold Target Reach VUMC YTD

Hospital Unit Hand Hygiene Compliance

July 1, 2010 – November 30, 2011VUMC Quarterly HH Compliance

June 2009 – June 2015

Reach

Threshold

Period of intensified HH program utilizing shared

accountability

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


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Hand Hygiene Improvement Strongly

Correlates with Low Infection Rates

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

Case: House call

The following event was reported to you through

your electronic event reporting system:

� Nurse reports: Attempted to page Dr. ___ about one of his

patients, 56 y/o with progressive renal failure and BP

elevation…BPs continued to rise so I paged again and called

his office…Office said they would give him a message…After

30 more min we called the RRT...shortly after the team

arrived Dr.___ shows up...clearly...declares "I will fix this

problem"...Returns with a poster with his name and pager

number...pulls out a roll of tape and...


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December, 2015

Promoting Professionalism Pyramid

No ∆Level 3 "Disciplinary" Interv

Pattern persists Level 2 “Guided" Authority Interv

Apparent pattern Level 1 "Awareness" Interv

Single “unprofessional"

incidents (merit?)

Vast majority of professionals - no issues -

provide feedback on progress*includes CMS-defined “condition level” and “immediate jeopardy” safety-related complaints

"Informal" Cup of

Coffee Intervention

Mandated

Ray, Schaffner, Federspiel, 1985.

Hickson, Pichert, Webb, Gabbe, 2007.


Mukherjee et al, 2010.

Stimson et al, 2010.


Hickson & Pichert, 2012.

Hickson et al, 2012.


Talbot et al, 2013.

Mandated

Reviews

Informal Conversation

Espresso(see handouts for each)

For a single “event”…


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� As your leader…let you know that the

behavior/action was noticed

� Documentation – but declare, “I will

drop a note…”

Principles for Espresso Conversations

See Handout:ESPRESSOESPRESSOESPRESSOESPRESSO

Coffee Talk Practice Exercises

Case Pushback Type

Whistling a Tune

Scrub the Hub: let it ride

Those are my Crackers

Standing Around

Third Time Out Report

Shift Report

Hand Washing

Cell Phone

Surprised & Dismissive

Disengaged, mostly silent

Narcissistic, Arrogant

Angry, Waste of Time

System is so Dysfunctional

Had to get home, Family issues

Others do worse than me

Acknowledge event, no big deal


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What can I do?• Model professionalism

• Self-reflect on your own behavior

• Speak up or report when you see/experience

lapses in professionalism

• Commit to engage others in building a culture

of accountability

• Discuss what you’ve learned with your leader

I’m only one person…

What should I do?• Everything on the previous slide, plus

• Review your Gap Analysis

• Write down three things that will move you

closer to your goal

� Complete

� Repeat

I’m a Leader…


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1. Cup of Coffee Handout

2. Espresso Handout

3. Gap Analysis

Takeaways from this Session

Now or Later

www.mc.vanderbilt.edu/cppa

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