Promoting Reliability: It takes a Plan

Promoting Reliability Case: Got to go Promoting Reliability: It takes a Plan Gerald B. Hickson, MD Joseph C. Ross Chair in Medical Education and Administration Associate Dean for Clinical Affairs Director, Three preconditions Vision/goals/core values Leadership/authority (modeled) Culture to sustain Dr. GTG (surgeon, proceduralist, internist) has just walked into the unit to place a central line Established policy around use of insertion bundle 1 Center for Patient &, Vanderbilt University School of Medicine Gerald.Hickson@Vanderbilt.edu www.mc.vanderbilt.edu/cppa 2 3 Central Line Associated Bloodstream Infections 250,000 infections occur in US every year Cost $296 million to $2.3 billion $18,432 per BSI ($3,592 34,410) 34,410) Associated with 2,400 20,000 deaths annually Increase LOS by 7 21 days 12 days = most recent estimate CLABSI Prevention Bundle 1. Hand hygiene 2. Maximal barrier precautions 3. Chlorhexidine skin antisepsis Except very LBW infants (<2 months old) 4. Optimal catheter site selection Subclavian vein preferred 5. Daily review of line necessity, with prompt removal of unnecessary lines Crnich CJ, Maki DG CID 2002;34:1232+ Center for Patient &,

MC 2705 (R ev. 06/04) NOTE: Please use either black or blue ink to complete this form. MR #: Monroe Carell Jr. atvanderbilt Date: CCU MICU TICU NSICU SICU BICU PCCU NICU Other Please use military time (i.e. 1:00 pm is 13:00) Time end Type of catheter: (catheter secured): Double lumen Insertion Site: Side: Indications for use: Check if: Triple lume n Internal Jugular Right Pressors Consent obtained Introducer Subclavian Left Hemodynamic monit. Pt/Family teaching done Swan-Ganz Femoral Fluids/blood products Guidewire exchange Vascath Other (specify): Frequent lab draws List all sites where insertion was attempted. RIJ LIJ RSC LSC RF LF Other (specify): The prov ider inse rting this line: a. Handed-off his/her pager before the procedure? Yes No Didn t ask b. Washed hands im mediately prior to procedure? Yes No Didn t ask c. Has previously placed at least five (5) central lines? Yes No * Didn t ask * If No, was this procedure supervised by someone with least five (5) central lines experience? Yes No Didn t ask Barrier precautions (check any used): Sterile gloves Sterile gown Mask Sterile towels Full body drape Describe the level of training of the person who actually inserted the line? Medical Student Intern (PGY-1) Resident (PGY-2+) Fellow Attending Nurse Practitioner How many different needle sticks did the patient receive (number of skin breaks)? 1 2 3 4 5 6+ Unknown Was the sterile field maintained throughout the entire procedure? Yes No Pre-insertion skin prep (check any used): Alcohol Betadine (povidone-iodine) Chlorhexidine Other (specify): Describe the circumstances under which this line was placed: Non-emergent Emergent (life-threatening or code situation) Follow-up CXR: Ordered Not ordered (specify reason): CXR findings (check all that apply): No pneumothorax Catheter in good position Pneumothorax (describe action taken): Catheter position adjusted (describe): Pre-existing infection Type of dressing: Bio-occlusive Gauze Other (specify): Patient tolerated the procedure well? Yes No Comments: Complications? None Placement unsuccessful Other (describe): Please file page 2 in patients chart and return top form to the designated location in the ICU. Signature: Date: Promoting Reliability: It Takes A Plan Vanderbilt University Medical Center OR Nursing Checklist: Central Venous Catheter Insertion Time start (1st needle stick): : Dressing applied by: Nurse Proceduralist Other (specify): / / : Case: Got to go Nurse X to assist with the procedure Dr. GTG grabs Betadine to prep Dr. GTG declares, Let s get started got to go. Stop the Line & Toyota 8 Communicating Concerns Case: Got to go 10 1. Patients always come first 2. Target communications carefully 3. Think about the person you re communicating with 4. Use SBAR: Situation, Background, Assessment, Recommendation. VUMC SBAR Policies: Hand Off Communication, CL 30 08.04; Rapid Response Team, CL 30 08.16; SBAR Literature: Weinger MB, et al: Qual Saf Health Care 2004;13:136; Weinger MB, Slagle J: JAMIA 2002; 9: S58; France D, et al. AORN J 2005; 82: 214; Grogan E, Stiles RA, France DJ et al. J Am Coll Surg 2004; 199: 843. 11 Nurse X, using best focused communication technique, suggests need to wait Chlorhexidine Dr. GTG, I don t have time for that nonsense I know what I am doing Dr. GTG continues How might your team member (Nurse X) respond? What aspects of Dr. GTG s behavior/performance might be considered disruptive? Center for Patient &,

Definition of Disruptive Behavior Perhaps Even More Common: 13 14 Disruptive behavior includes, but is not limited to, words or actions that: Prevent or interfere w/an individual s or group s work, academic performance, or ability to achieve intended doutcomes (e.g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution); Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e.g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating); Threaten personal or group safety, aggressive or violent physical actions; Violate VUMC policies, including conflicts of interest and compliance. Vanderbilt University and Medical Center Policy #HR-027, 2010 15 Failure to: Complete documentation/handovers Wash hands Observe time outs Respond to pages Follow evidence based practice Others Why Might a Medical Professional Behave in Ways that are Disruptive? Why Might a Medical Professional Behave in Ways that are Disruptive? Professionalism and Self Regulation 16 1. Substance abuse, psych issues 2. Narcissism, perfectionism 3. Spillover of family/home problems 4. Poorly controlled anger (2 emotion)/snaps under heightened stress, perhaps due to: a. Poor clinical/administrative/systems support b. Poor mgmt skills, dept out of control c. Back biters create poor practice environments Samenow CP. Swiggart W. Spickard A Jr. A CME course aimed at addressing disruptive physician behavior. Physician Executive. 34(1):32 40, 2008. 17 5. Make others look bad for some advantage 6. Distract from own shortcomings 7. Family of origin issues guilt and shame 8. Well, it seems to work pretty well (Why? See #9) 9. No one addressed it earlier (Why?) Samenow CP. Swiggart W. Spickard A Jr. A CME course aimed at addressing disruptive physician behavior. Physician Executive. 34(1):32 40, 2008. 18 Conceptual Framework Professionalism Professionals commit to: Technical and cognitive excellence Professionals also commit to: Confidentiality Clear and effective communication Modeling respect Being available Professionalism promotes teamwork Center for Patient &,

Professionalism and Self Regulation Professionalism demands self regulation Personal Discipline specific Group Systems focused All require the skills to provide and receive feedback All that sounds nice but 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 21 The Balance Beam Consequences of Disruptive Conduct: Healthcare Professional Perspective Competing priorities Not sure how (no training or policies) Leaders blink Harassment suits Lack of retention (tip of the iceberg) Infections/ Errors Can t change Fear of antagonizing Burnout 22 23 Do nothing June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Do something Jousting Bad mouthing the organization in the community Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175 222. 24 Center for Patient &,

Consequences of Disruptive Conduct: Healthcare Professional Perspective Harassment suits Lack of retention Burnout Jousting (tip of the iceberg) Infections/ Errors Bad mouthing the organization in the community Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175 222. 25 26 Failure to Address Disruptive Conduct Leads To: Team members may adopt disruptive person s negative mood/anger (Dimberg & Ohman, 1996) Lessened dtrust tamong team members can lead dto lessened task performance (always monitoring disruptive person)... affects quality and pt safety (Lewicki & Bunker, 1995; Wageman, 2000) Withdrawal (Schroeder et al, 2003; Pearson & Porath, 2005) Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175 222. 27 Failure to Address Disruptive Conduct Leads To: High turnover Pearson et al, 2000 found that 50% of people who were targets of disruptive behavior thought about leaving their jobs Found that 12% of people actually quit These results indicate a negative effect on return on investment Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175 222. The Balance Beam Infrastructure for Promoting Professional Accountability Accountability Pyramid for Professionals 28 Competing priorities Not sure how lack tools, training Leaders blink Can t change Fear of antagonizing Do nothing Staff satisfaction and retention Reputation Patient safety, clinical outcomes Liability, risk mgmt costs Do something June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Professional Advocacy; Hickson GB, Pichert JW. Disclosure and Apology. National Patient Safety Foundation Stand Up for Patient Safety Resource Guide, 2008; Pichert JW, Hickson GB, Vincent C: Communicating About Unexpected Outcomes and Errors. In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 2007 29 1. Leadership commitment 2. Supportive institutional policies 3. Surveillance tools to capture pt/staff allegations 4. Processes for reviewing allegations 5. Model to guide graduated interventions 6. Multi level professional/leader training 7. Resources to help disruptive colleagues 8. 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. Mandated Issues No Pattern persists Apparent pattern Single or isolated unprofessional event (merit?) Vast majority of professionals no issues Level 3 "Disciplinary" Intervention Level 2 Guided" Intervention by Authority Level 1 "Awareness" Intervention "Informal" Cup of Coffee Intervention (Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. Nov. 2007) Center for Patient &,

3 Critical Conversations: Med Mal Research Background Summary Informal: Cup of Coffee Conversation Informal: Espresso Conversation Awareness: An Awareness Visit Authority: EDICTS Conversation But do Awareness visits actually work? 1 6%+ hosp. pts injured due to negligence ~2% of all pts injured by negligence sue ~2 7 x more pts sue w/o valid claims Non $$ factors motivate pts to sue Some MDs attract more suits High risk today = high risk tomorrow Unsolicited comment/concerns predict claims PARS risk profiles make effective intervention tools 31 33 Patient Complaints Academic vs Community Medical Center 50% of concerns associated with 9 14% of Physicians Predictors of Risk Outcomes 34 never gives me more than 5 minutes. He was terrible with this pregnancy and was even worse (if it s possible) with the next one, but the HMO said I had to stay with him. I kept hoping to get his partner, but never lucked out. I m not getting pregnant any more because of him. % of Concerns 100 75 50 25 0 Academic Med Ctr Community Med Ctr 30 40 50 60 70 80 90 100 % of Physicians Note: 35 50% are associated with NO concerns Hickson, et al., SMJ, 2007; Hickson Cogent et Healthcare al, JAMA. 2002 Jun 12;287(22):2951 7 35 36 Gender Physician specialty Volume of service (logistic regression) Unsolicited patient complaints Predictive concordance of risk models ranges from 81 92% Hickson et al, JAMA. 2002 Jun 12;287(22):2951 7 Center for Patient &,

37 Incurred Expense By Risk Category Predicted Risk Category # (%) Physicians Relative Expense % of Total Expense Score (range) 1 (low) 318 (49) 1 4% 0 2 147 (23) 6 13% 1 20 3 76 (12) 4 4% 21 40 4 52 (8) 42 29% 41 50 5 (high) 51 (8) 73 50% >50 Total 644 (100) 100% * In multiples of lowest risk group Moore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review, 2006 Accountability Pyramid for Professionals Mandated Issues No Pattern persists Apparent pattern Single or isolated unprofessional event (merit?) Vast majority of professionals no issues Level 3 "Disciplinary" Intervention Level 2 Guided" Intervention by Authority Level 1 "Awareness" Intervention "Informal" Cup of Coffee Intervention (Hickson GB, Pichert JW, Webb LE, Gabbe SG. Acad Med. Nov. 2007) 39 Intervention on Dr. Letter with standings, assurances prior to & at meeting You are here graph with 4 yr Risk Scores Complaint Type Summary Dr. Complaint Type Summary Dr. Audit Period: Date 1 Date 2 Complaint Type Number of Complaints Distribution of Complaints Categories Your Average for Your Average Complaints Surgery Complaints for Surgery Care & Treatment 19 4.5 30.2% 39.8% Communication 15 2.9 23.8% 25.7% Humanistic Concern 14 1.3 22.2% 11.5% Access/Availability 9 1.9 14.3% 16.8% Safety of Environment 0 0.0 0.0% 0.0% Money/Payment Issues 6 0.7 9.5% 6.2% Total # of Complaints 63 11.3 Total Number of Reports Note: each report may contain multiple complaints Past 48 months 26 5.9 Past 12 months 6 1.7 Concerns bullet list Redacted narrative reports 40 PARS Progress Report Total # of high complaint physicians 685 Departed after initial intervention 47 First follow up later in 2011 2012 134 Total with follow up results 504 Results for those with follow up data: Good Intervention visits suspended 226 45% Good Anticipate suspension in 2011 2012 110 22% Some improvement Still need tracking 31 6% Subtotal 367 73% Unimproved/worse 95 19% Departed Unimproved 42 8% Total follow up results 504 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. Malpractice Claims (per 100 MDs) FY1992 2009 A Call for Clean Hands: Vanderbilt Hand Hygiene Tom Talbot, MD, MPH Titus Daniels, MD, MPH Claudette Fergus, BA, RN Gerald Hickson, MD, and the Hand Hygiene Committee, a Pillar Goal Committee Center for Patient &,

VUMC Hand Hygiene Compliance Path to Compliance In June, 2009 VUMC Hand Hygiene Compliance was 58% July 2009 marked the beginning of Hand Hygiene Compliance as a metric in the VUMC Allocation Rebate Program with the following goals for March May of 2010: Reach 80% Compliance Rate Target 80% Compliance Rate Threshold 70% Compliance Rate 100% 90% 80% 70% 60% 50% 40% Our data was less than ideal Quarterly Data Jun 09 Sep 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Threshold Target Reach HH Monthly HH YTD HH Accountability Pyramid No Pattern persists Apparent pattern of non compliance Single non compliant incidents (merit?) Majority of professionals/units no issues Level 1 "Awareness" Feedback to Leaders Informal individual "Cup of Coffee" Feedback Egregious response (rare) to Veritas Adapted from Hickson GB, et al, Acad Med, Nov, 2007 December 22, 2010 To: Medical Director, MD Administrative Manager From: Thomas R. Talbot, MD, MPH Chair, Hand Hygiene Pillar Goal Committee Gerald B. Hickson, MD Director, VUMC Clinical Risk and Loss Prevention Nancye Feistritzer, RN, MSN Co Chair, Hand Hygiene Pillar Goal Committee Associate Hospital Director, Perioperative Services CC: Department Chair, MD Quality and Patient Safety Director, MD Associate Hospital Director (units), RN, MSN Administrative Area Manger, RN, MSN Re: Hand Hygiene Compliance Level 1 Awareness We are all committed to minimizing the risk of healthcareassociated infections. Performing hand hygiene is the most important action we can take your area compliance rate was 35%, and for FY11- to-date, 47%. Awareness Letter A member of our Pillar Goal Committee team will contact you to schedule a time to meet so we may partner in achieving increased hand hygiene in your area. We are all committed to minimizing the risk of healthcare associated infections. Performing hand hygiene is the most important action we can take to reduce the spread of these infections to our patients and ourselves. For FY11, VUMC s reach goal for hand hygiene is 95% compliance. A recent audit of hand hygiene observations places your area among those services with a low rate of compliance with hand hygiene. We are writing to share the data with you. 100% 90% 80% 70% 60% 50% 40% 30% 20% 1 st Letter: Dec 2010 Intervention Letter Results as of March 31, 2011 1 st Letter: Jan 2011 1 st Letter: Feb 2010 100% 90% 80% 70% 60% 50% VUMC Hand Hygiene Compliance The average compliance rate for all VUMC units was 80% in November 2010 and 79% for FY11 to date. Many units have achieved compliance rates above the threshold goal of 85%. For November 2010, your area compliance rate was 35%, and for FY11 to date, 47%. A member of our Pillar Goal Committee team will contact you to schedule a time to meet so we may partner in achieving increased hand hygiene in your area. In the interim, a copy of the hand hygiene expectations for all Vanderbilt employees is attached so that you may review with your staff. Information on how to improve hand hygiene compliance may also be found at www.mc.vanderbilt.edu/handhygiene. Thank you in advance for your team s active participation and efforts to improve your area s hand hygiene compliance rate to help us reduce the risk of infection for VUMC patients. As this is an ongoing quality improvement program, we will continue to provide you with regular reports regarding the compliance rate within your area. If you have questions or need more information, please do not hesitate to contact either of us. This material is confidential and privileged information under the provisions set forth in T.C.A. 63 6 219 and shall not be disclosed to unauthorized persons. 10% 0% A B C D E F G H I J K L M N VUMC Compliance March 2011 VUMC Compliance YTD Compliance Pre Letter (YTD) Compliance Post Letter (YTD) Compliance Post Letter (March 11) This material is confidential and privileged information under the provisions set forth in T.C.A. 63 6 219 and shall not be disclosed to unauthorized persons 40% Quarterly Data Jun 09 Sep 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Threshold Target Reach HH Monthly HH YTD Center for Patient &,

Central Line Associated BSI Infrastructure for Promoting Professional Accountability Upcoming CPPA Conferences y SIR Monthl 3 2.5 2 1.5 1 0.5 0 CLABSI ICU SIR CDC Benchmark Intensified HH Program Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 1. Leadership commitment 2. Supportive institutional policies 3. Surveillance tools to capture pt/staff allegations 4. Processes for reviewing allegations 5. Model to guide graduated interventions 6. Multi level professional/leader training 7. Resources to help disruptive colleagues 8. Resources to help disrupted staff and patients The Why and How of Dealing with Special Colleagues: Discouraging Disruptive Behavior June 2 3, 2011; November 3 4, 2011 The How and When of Communicating Adverse Outcomes and Errors October 14, 2011 http://www.mc.vanderbilt.edu/centers/cppa/courses.htm This material is confidential and privileged information under the provisions set forth in T.C.A. 63-6-219 and shall not be disclosed to unauthorized persons. 50 Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring and Addressing Unprofessional Behaviors. Academic Medicine. November, 2007. 51 Center for Patient &,