CME Disclosure Accreditation Statement Studer Group is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Designation of Credit Studer Group designates this educational event for a maximum of 12 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the educational event. Disclosure Policy Dr. Gerald Hickson has disclosed that he does not have any relevant financial relationships with any commercial interests related to the content of this educational event.
Discouraging Disruptive Behavior: It starts with a Cup of Coffee! Gerald B. Hickson, MD Associate Dean for Clinical Affairs Director, Clinical Risk Reduction and Loss Prevention Director, Center for Patient and Professional Advocacy Center for Patient & Professional Advocacy Vanderbilt University Medical Center, Nashville, TN
Presentation Objectives Recognize disruptive behavior Understand the benefits of addressing disruptive behavior Skills training in the Cup of Coffee conversation model for addressing disruptive behavior
About Vanderbilt and other Nashville hospitals: You take your kids there or go if you ve got some rare disease or if you are about to die otherwise, you should go to 4
Consumer Hospital Preference* Davidson County, TN 1996: Vanderbilt University Medical Center 4 th at 7.8%, just above uncertain Since 2006: VUMC #1 and the gap between VUMC and others is growing *Based on a survey of 1,900 households 5
So, why did the transformation occur? 6
Things We Did Right Invested in biomedical informatics Set goals for the clinical/academic enterprise Committed to service renewal - ELEVATE Studer Group Committed to a culture of non - tolerance for special colleagues 7
Case: I wish you would You are a who observes (Special Colleague) walking out of a patient s room and hears him/her say to the patient and family, I wish you would get your act together and quit using resources that we could use for others. How might a member of your team react/respond if they witnessed this event? 8
So, such events are just going to happen, right? Yes, but 9
What constitutes disruptive behavior? 10
Definition of Disruptive Behavior Behavior that interferes with work or creates a hostile environment, e.g.: verbal abuse, sexual harassment, yelling, profanity, vulgarity, threatening words/actions; unwelcome physical contact; threats of harm; behavior reasonably interpreted as intimidating; passive aggressive behaviors: e.g., sabotage and bad-mouthing colleagues or organization behavior that creates stressful environments and interferes with others effective functioning Vanderbilt University and Medical Center Policy #HR-027 11
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Why bother dealing with disruptive behavior? 13
Consequences of Disruptive Conduct: Patient Perspective Lawsuits (tip of the iceberg) Drop out, leaving AMA Errors Voiced Complaints Non adherence/ noncompliance Bad-mouthing the practice to others 14
Consequences of Disruptive Conduct: Nursing Perspective Harassment suits (tip of the iceberg) Lack of retention Errors Burnout Jousting 15
If the case in question occurred in your hospital, how often would a member of your team: Offer service recovery to the patient or family? Speak to the colleague? 16
Why are we so hesitant to act? 17
HR Officer: Why didn't you address their disruptive behavior? Nurse Manager: If she leaves, I lose my most senior nurse. 18
I think the nurses contributed to his frustration. We can t do anything, we ll get sued. Just talk to him. I m sure he didn t mean it. The nurses are against him. 19
Infrastructure for Addressing Unprofessional Behavior (UB) 20 Leadership commitment Supportive institutional policies Surveillance tools to capture pt/staff allegations Model to guide graduated interventions Processes for reviewing allegations Multi-level professional/leader training Resources to help disruptive colleagues Resources to help disrupted staff and patients Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring and Addressing Unprofessional Behaviors. Academic Medicine. November, 2007.
Disruptive Behavior Pyramid Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 No Pattern persists Apparent pattern Level 3 "Disciplinary" Intervention Level 2 "Authority" Intervention Level 1 "Awareness" Intervention Single unprofessional" incidents (merit?) Vast majority of professionals-no issues "Informal" Cup of Coffee Intervention Mandated Issues
The Why and How of Dealing with Special Colleagues: Discouraging Disruptive Behavior Training: 3 Critical Conversations: Informal: Cup of Coffee Conversation Awareness: An Awareness Visit Authority: EDICTS Conversation 22
If such an event occurred, how might a member of your team respond? Have a cup of coffee 23
What might an informal intervention - a cup of coffee conversation - sound/look like? Can anyone have these conversations with anyone? 24
Principles for Informal Conversations Your role is to report an event. It s not a control contest ( I am coming to you as a colleague ) Approach using same principles as for sharing bad news to patients You are letting the colleague know that the institution has eyes and ears (surveillance) Beware of tendency to downplay seriousness. Balance empathy and objectivity. Know message and stay on message Know your natural default 25
Opening the Conversation Offer appreciation (if you can): You re important, if you weren't, I wouldn't... I heard, I saw, I received Briefly review incident in as much detail as appropriate Wait/ask for colleague's view Respond to questions, concerns 26
Ending the Discussion Appreciation, affirmation Empathy: Now I feel I understand...but " Accountability: "But we've all got to respond professionally..." Reminder: incident did not appear consistent with..." If asked, coach: "reflect on the issues, think about ways to prevent recurrence." Assure: conversation confidential, known only to Follow-up: I am confident it won t be necessary, but..." 27
Anticipate Various Reactions Rationalizations, explanations of behavior Acceptance, professionalism Denial, anger, Narcissistic hurt End-around the chain of command Requests for help with change Many others 28
A Cup of Coffee Conversation Is Not: A control contest Therapy (for the individual or yourself) A hierarchical conversation An enabling conversation An opportunity to address multiple other issues
Now it s your turn 30
One Role Play Scenario Divide yourselves into groups of three Each group of three is given a packet of handouts A professional who has behaved badly A messenger An observer 31
What did you experience? Observe?
What if the behavior recurs?
Disruptive Behavior Pyramid Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 No Pattern persists Apparent pattern Level 3 "Disciplinary" Intervention Level 2 "Authority" Intervention Level 1 "Awareness" Intervention Single unprofessional" incidents (merit?) Vast majority of professionals-no issues "Informal" Cup of Coffee Intervention Mandated Issues
And if you bump it up a notch, does any of this really work?
PARS Progress Report Results for those with follow-up data: Improved 228 (58%) Unimproved/worse 79 (20%) Departed the medical group 89 (22%) Total follow-up results 396 Pichert JW, Hickson GB, Moore IN: Using Patient Complaints to Promote Patient Safety. In: AHRQ (Eds). Advances in Patient Safety: New Directions and Alternative Approaches, 2008.
If we act, is there a return on investment? 37
PARS Outcomes Summary 60% of physicians receiving interventions reduce risk scores by median of 78% Vanderbilt pilot study showed 49% reductions in risk management payouts for physicians intervened upon vs. no change for those give no intervention (ROI at Vanderbilt has been at least 5-1) Pichert JW, Hickson GB, Moore IN: Using Patient Complaints to Promote Patient Safety. In: AHRQ (Eds). Advances in Patient Safety: New Directions and Alternative Approaches, 2008. 38
Tom Magliozzi Ray Magliozzi 39
Upcoming CPPA Conferences The Why and How of Dealing with Special Colleagues: Discouraging Disruptive Behavior June 18-19, 2009; October 29-30, 2009 The How and When of Communicating Adverse Outcomes and Errors August 6-7, 2009; March 4-5, 2010 40