Objectives. Speaker Disclosure: Copyright Disclosure. Addressing the "Untouchables": The Case of Dr. X

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1 Objectives Addressing the "Untouchables": The Case of Dr. X William O. Cooper, MD, MPH Cornelius Vanderbilt Professor of Pediatrics and Health Policy Associate Dean for Faculty Affairs Director of Vanderbilt Center for Patient and Professional Advocacy Vanderbilt University Medical Center Gerald B. Hickson, MD Sr. Vice President for Quality, Safety and Risk Prevention Joseph C. Ross Chair in Medical Education & Administration Professor of Pediatrics Vanderbilt University Medical Center After participating in this session, participants will be able to: Identify the critical infrastructure needed to support sustained accountability for individuals who fail to selfregulate. Utilize a toolkit for developing and implementing corrective action plans under authority. Develop skills in having conversations with individuals who fail to self regulate. 1 2 Speaker Disclosure Copyright Disclosure Speaker Disclosure: William O, Cooper, MD, MPH has nothing to disclose. Gerald B. Hickson, MD has nothing to disclose. 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

2 Pursuing the Right Balance Professionalism and Self Regulation Technical & Cognitive Competence Intentionally Designed Systems Professional Accountability Respect Professional Effective Communication Self awareness Commitment Availability Teamwork Hickson et al., Joint Commission Resources, Hickson et al., Joint Commission Resources, We Know Let s review a case Patient complaints are nonrandomly distributed Surgeons with complaints have poorer surgical outcomes Clinicians with many complaints are at risk for lawsuits 7 8 Hickson, JAMA, 2002; Moore, So Med J, 2007; Cooper, JAMA Surgery

3 9 What is PARS? Patient Advocacy Reporting System PARS Vanderbilt developed system to reliably identify and successfully intervene with high malpractice risk physicians 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? I had several questions about different treatment options. Dr. XX just shrugged and said, Well, do you want the surgery or not? Dr. XX spent five minutes with me and I waited 5 weeks for an appointment Hickson et al., JAMA, Hickson et al., So Med J., Promoting Professionalism Pyramid No Pattern persists Apparent pattern Single concern (merit?) Level 3 "Disciplinary" Intervention Vast majority of professionals no issues provide feedback on progress Level 2 "Guided" Intervention by Authority Level 1 "Awareness" Intervention Mandated Informal "Cup of Coffee" Mandated Reviews 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, Let s put this in perspective 66,000+ 2,000 (2.5%) 256 (0.4%) How about all physicians? PARS PARS & CORS Program, National CORS Impact Interventions on 1726 high claims risk physicians in 144 sites 76% 7% Successful Interventions 17% Unimproved/worse Departed organization/unimproved Interventions on 204 professionals * with high coworker index 25% 3% 72% (0.1%) 12 Webb et al, Jt Comm Jl Qlty Pt Sfty, *Attending physicians, residents, fellows, and advanced practice professionals Pichert et al., ABIM Foundation Professionalism Prize, Journal on Quality and Patient Safety,

4 Essential Elements to Promote Reliability People 13 Hickson et al., Joint Commission Resources, Leadership Collaboration of the Willing Who are the key leaders? How do you engage? How do you decide? Identify Lines of Authority Decide together Map out a corrective action plan Promote Leader Accountability

5 Process Alignment with Values This behavior isn t consistent with our commitment to the respect, dignity and experience of our patients and families. the professional I know you to be. our shared vision for quality health care. our commitment to safety Systems Training Training Leaders Training Messengers Informing Clinicians

6 What does it mean, for Authority? Sometimes you get a wrench What does it mean actually? Engage and prepare leaders (all levels) Create an End Run Strategy Know your policies and procedures Identify wellness evaluation/treatment resources Create a corrective action plan template Access & review system/individual data Prepare/Huddle/Debrief with fellow leaders What is this? Who do I talk to? What do I need to do next? Promoting Professionalism Pyramid No Pattern persists Level 3 "Disciplinary" Intervention Level 2 "Guided" Intervention by Authority What does an Authority Intervention look like? Apparent pattern Level 1 "Awareness" Intervention Single concern (merit?) Mandated Vast majority of professionals no issues provide feedback on progress Informal "Cup of Coffee" Mandated Reviews What principles apply? 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,

7 EDICTS: Elements Having the Authority Conversations E D I C T S Expectations Discrepancies from expectations Intervention options Consequences Timeline Surveillance Anticipate Pushback But It s Not a Control Contest Stakes are higher Emotional responses may be stronger 25 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 Types of Pushback Resources for Authorities Deflection Dismissal Distraction EVALUATION/ ASSESSMENT Personnel resources Physical, mental health Physician Wellness Program 360 team evaluations SKILLS RELATED ASSISTANCE Coaches, counselors Training education Chair review of care, systems PRACTICE CHANGES Reduce RVUs, volume Adjust schedule Personnel FINANCIAL Adjust incentives Eligibility for increases Liability ins. Surcharge 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:

8 Selected Best Practices Let Us Hear Your Comments and Questions Engage and prepare leaders (all levels) Create an End Run Strategy Know your policies and procedures Identify wellness evaluation/treatment resources Now or Later Create a corrective action plan template Access & review system/individual data Prepare/Huddle/Debrief with fellow leaders