addressing the untouchables: the case of dr. x - ihi...

Addressing the "Untouchables": The Case of Dr. XGerald B. Hickson, MD and William O. Cooper, MD, MPH

IHIDecember 12, 2017

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©2017 Vanderbilt Center for Patient and Professional Advocacy

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Addressing the "Untouchables": The Case of Dr. X

Gerald B. Hickson, MDSr. Vice President for Quality, Safety and Risk Prevention

Joseph C. Ross Chair in Medical Education & AdministrationProfessor of Pediatrics

Vanderbilt University Medical Center

William O. Cooper, MD, MPHCornelius Vanderbilt Professor of Pediatrics and Health Policy

Associate Dean for Faculty AffairsDirector of Vanderbilt Center for Patient and Professional Advocacy

Vanderbilt University Medical Center

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• Identify the critical infrastructure needed to support sustained accountability for individuals who fail to self-regulate.

• Utilize a toolkit for developing and implementing corrective action plans under authority.

• Develop skills in having conversations with individuals who fail to self-regulate.

Objectives

After participating in this session, participants will be able to:

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Speaker Disclosure

Speaker Disclosure:

William O, Cooper, MD, MPH has nothing to disclose.Gerald B. Hickson, MD has nothing to disclose.



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Copyright Disclosure

The content, slides, materials and images contained in this presentation are the sole property and considered intellectual property ("IP") of Vanderbilt University, Vanderbilt University Medical Center and the Vanderbilt Center for Patient and Professional Advocacy. The IP is intended solely for the use of the contracting organization and its employees participating in this event. The IP 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 for viewing, downloading, printing, etc. by the general public or others not attending this event. The IP, in any form, may not be used to produce a commercial product for sale.

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Intentionally Designed Systems

Professional Accountability

Pursuing the Right Balance

Hickson et al., Joint Commission Resources, 2012.

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Professional

Commitment

RespectEffective

Communication

Technical & CognitiveCompetence

AvailabilitySelf-awareness


Professionalism and Self-Regulation

Teamwork



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Let’s look at a case…

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We Know…

…Patient complaints are nonrandomly distributed

…Clinicians with many complaints are at risk for lawsuits

…Surgeons with many complaints

have poorer surgical outcomes

Hickson, JAMA, 2002; Moore, So Med J, 2007; Cooper, JAMA Surgery 2017.

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Patient Advocacy Reporting System

“Dr. XX was rude the moment I met him...He's

a physician...I am a person with a painful

problem...why be a jerk?”

“Dr. XX is either too busy or scatterbrained to read my files or is dangerously neglectful...I fear for my safety…”

“If he had stressed the adverse effects of the procedure … I WOULD HAVE NEVER GONE THROUGH WITH THE PROCEDURE.”

PARS®

Vanderbilt-developed system to reliably

identify and successfully intervene with high malpractice

risk physicians

Hickson et al., JAMA, 2002.Hickson et al., So Med J., 2007.

What is PARS®?



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Promoting Professionalism Pyramid

Level 2 “Guided“Intervention by Authority

Apparent pattern

Single concern (merit?)

Informal“Cup of Coffee”

Level 1 "Awareness" Intervention

Level 3 "Disciplinary" Intervention

Pattern persists

No

Vast majority of professionals - no issues - provide feedback on progress

Mandated Reviews

Mandated

Webb et al, 2016; Talbot et al, 2013; Pichert et al, 2013; Hickson et al, 2012; Hickson & Pichert, 2012; Pichert et al, 2011;Stimson et al, 2010; Mukherjee et al, 2010; Pichert et al, 2008; Hickson, Pichert, Webb, Gabbe, 2007; Ray, Schaffner, Federspiel, 1985.

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PARS Interventions Nationally | 2002-2017

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PARS® Program, National Impact

Interventions on 1709 high claims risk physicians in 144 sites

Unimproved/worse

SuccessfulInterventions

Departed organizationunimproved

Pichert et al., ABIM Foundation Professionalism Prize, Journal on Quality and Patient Safety, 2014.

Confidential Peer Review Document – Privileged Pursuant to North Carolina Statutes.

76%

7%

17%



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Essential Elements to Promote Reliability


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People

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Leadership

Who are the key leaders?

How do you engage?

How do you decide?



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Collaboration of the Willing

Decide together

Map out a corrective action plan

Leader Accountability

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Process

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Alignment with Values

“This behavior isn’t consistent with…

…the professional I know you to be.”

…our commitment to safety”

…our shared vision for quality health care.”

…our commitment to the respect, dignity and experience of our patients and families.”



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Systems

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Training

Training Leaders

Informing Clinicians

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What does it mean, for Authority?

What does it mean actually?

Having Your Back

Follow Through

Shared Leadership

Accountability

Clear lines of Authority

End Runs

Resources

Consistency



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Co-worker Observation Reporting System

“Dr. __ held the orders in front of my (RN)

face, pointed to what she needed and walked

away. It was incredibly disrespectful.”

“Dr. __ became angry… said ‘you people are mismanaging my patients’ …all this in front of patients and other staff.”

“Paged covering physician Dr. __ to get order … Dr. __ listened, then said, ‘never wake me up for these requests again,’ and hung up without giving the order.”

What is CORS ?

CORSVanderbilt-developed

process to distribute and track co-worker

observations and successfully intervene

when patterns are identified

sm

sm

Webb et al., The Joint Commission Journal on Quality and Patient Safety, 2016.

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• What is this?

• Who do I talk to?

• What do I need to do next?

Sometimes you get a wrench…

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What does an “Authority” Intervention look like?

What principles apply?



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Principles of “Authority” Conversations

Goals

Alert to persistent pattern or single significant event

Create a corrective action plan

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EDICTS: Corrective Action Plan

Preparation Authority figure and individual

co-develop a plan

Authority figure develops and specifies plan

Clearly defined consequences if plan not followed/doesn’t work within defined time

OR

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E

D

I

C

T

Expectations

Discrepancies from expectations

Intervention options

Consequences

Timeline

SurveillanceS

EDICTS: Elements

Hickson GB, Moore IN. Professional accountability and pursuit of a culture of safety. In: Frush KS, Krug S, eds. Pediatric Patient Safety and Quality Improvement. 2014.



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PushbackAnticipate

But It’s Not a Control Contest

Stakes are higher Emotional responses may be stronger

Having the “Authority” Conversations

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Types of Pushback

Deflection

Dismissal

Distraction

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Deflection

It’s not me, it’s the…

Patients (unique, difficult)

System

Your failed leadership

Pushback: Deflection



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“Do you know who I am?”

“I don’t believe…”

Data

Seriousness

You want me to spend my time on this?

Dismissal

Pushback: Dismissal

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Distraction

“We should really be focusing on…

System/other team members

Other low performers

Morale/Burnout

Pushback: Distraction

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Potential Responses

Remind: This is a part of who we are

Reflect: on…

Reinforce: Expectations, majority respond

May also experience pushback from local leader



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Resources for Authorities

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.

EVALUATION/ASSESSMENT

SKILLS-RELATEDASSISTANCE

PRACTICE CHANGES

FINANCIAL

Personnel resources

Physical, mental health

Physician Wellness Program

360° team evaluations

Coaches, counselors

Trainingeducation

Chair review of care, systems

Reduce RVUs, volume

Adjust schedule

Personnel

Adjust incentives

Eligibility for increases

Liability ins. Surcharge

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“Authority” Guiding Principles

Prepare for conversation, also emotionally

Know your message and stick to it (avoid tangents)

Remember your hope to “redeem,” but also your commitment to your organization and patients (fairness)

Connect to appropriate resources

Create effective and realistic plan

Document the conversation

Follow up and follow through

Strategies for Success:

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Now or Later

www.mc.vanderbilt.edu/cppa

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addressing the untouchables: the case of dr. x - ihi...

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