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

Transcription

1 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 1 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 Objectives 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. 2 Speaker Disclosure Speaker Disclosure: William O, Cooper, MD, MPH has nothing to disclose. Gerald B. Hickson, MD has nothing to disclose. 3 1

2 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. 4 Pursuing the Right Balance Intentionally Designed Systems Professional Accountability Hickson et al., Joint Commission Resources, Professionalism and Self-Regulation Technical & Cognitive Competence Respect Professional Effective Communication Self-awareness Commitment Availability Teamwork Hickson et al., Joint Commission Resources,

3 Let s look at a case 7 We Know Patient complaints are nonrandomly distributed Clinicians with many complaints are at risk for lawsuits Surgeons with many complaints have poorer surgical outcomes 8 Hickson, JAMA, 2002; Moore, So Med J, 2007; Cooper, JAMA Surgery 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? 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. 9 Hickson et al., JAMA, Hickson et al., So Med J.,

4 Promoting Professionalism Pyramid No Pattern persists Level 3 "Disciplinary" Intervention Level 2 Guided Intervention by Authority Apparent pattern Single concern (merit?) Level 1 "Awareness" Intervention Informal Cup of Coffee Mandated Vast majority of professionals - no issues - provide feedback on progress 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, PARS Interventions Nationally PARS Program, National Impact Interventions on 1709 high claims risk physicians in 144 sites 76% Successful Interventions 17% Unimproved/worse 7% Departed organization unimproved Pichert et al., ABIM Foundation Professionalism Prize, Journal on Quality and Patient Safety, Confidential Peer Review Document Privileged Pursuant to North Carolina Statutes. 4

5 Essential Elements to Promote Reliability Hickson et al., Joint Commission Resources, People 14 Leadership Who are the key leaders? How do you engage? How do you decide? 15 5

6 Collaboration of the Willing Decide together Map out a corrective action plan Leader Accountability 16 Process 17 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 18 6

7 Systems 19 Training Training Leaders Informing Clinicians 20 What does it mean, for Authority? What does it mean actually? End Runs Having Your Back Shared Leadership Accountability Clear lines of Authority Follow Through Consistency Resources 21 7

8 sm What is CORS? Co-worker Observation Reporting System CORS sm Vanderbilt-developed process to distribute and track co-worker observations and successfully intervene when patterns are identified 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. Webb et al., The Joint Commission Journal on Quality and Patient Safety, Sometimes you get a wrench What is this? Who do I talk to? What do I need to do next? 23 What does an Authority Intervention look like? What principles apply? 24 8

9 Principles of Authority Conversations Goals Alert to persistent pattern or single significant event Create a corrective action plan 25 EDICTS: Corrective Action Plan Preparation Authority figure and individual co-develop a plan OR Authority figure develops and specifies plan Clearly defined consequences if plan not followed/doesn t work within defined time 26 EDICTS: Elements E D I C T S Expectations Discrepancies from expectations Intervention options Consequences Timeline Surveillance 27 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

10 Having the Authority Conversations Anticipate Pushback But It s Not a Control Contest Stakes are higher Emotional responses may be stronger 28 Types of Pushback Deflection Dismissal Distraction 29 Pushback: Deflection Deflection It s not me, it s the Patients (unique, difficult) System Your failed leadership 30 10

11 Pushback: Dismissal Dismissal Do you know who I am? I don t believe Data Seriousness You want me to spend my time on this? 31 Pushback: Distraction Distraction We should really be focusing on System/other team members Other low performers Morale/Burnout 32 Potential Responses Remind: This is a part of who we are Reflect: on Reinforce: Expectations, majority respond May also experience pushback from local leader 33 11

12 Resources for Authorities 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 34 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. Authority Guiding Principles Strategies for Success: 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 35 Let Us Hear Your Comments and Questions Now or Later