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Balancing Systems and Human Accountability: And How We Learned to Wash Our Hands. Gerald B. Hickson, MD Assistant Vice Chancellor for Health Affairs Associate Dean for Faculty Affairs Joseph C. Ross Chair in Medical Education & Administration Center for Patient & Professional Advocacy,

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Balancing Systems and Human Accountability: And How We Learned to Wash Our Hands


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    1. Balancing Systems and Human Accountability: And How We Learned to Wash Our Hands Gerald B. Hickson, MD Assistant Vice Chancellor for Health Affairs Associate Dean for Faculty Affairs Joseph C. Ross Chair in Medical Education & Administration Center for Patient & Professional Advocacy, Vanderbilt University School of Medicine

    2. Pursuit of Reliability • Three Pillars • Vision/goals/core values • Leadership/authority (modeled) • A safety culture Hickson GB, Moore IN, Pichert JW, Benegas Jr M. 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.

    3. Pursuit of Reliability • Safety Culture • Willingness to report • Psychological safety • Trust • “Behaviors that undermine a culture of safety” threaten trust, therefore must be addressed fairly, and in a measured way Hickson, Moore, Pichert, Benegas Jr. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Jt Comm Resources;2012:1-36.

    4. Case: “Got to Go” • Dr. GTG (surgeon) has just walked into the unit to place a central line • Established policy around use of “insertion bundle”

    5. Central Line-Associated Bloodstream Infections • 250,000 infections occur in US every year • Cost $296 million to $2.3 billion • $22K per BSI ($3,592-34,410) • Associated with 2,400-20,000 deaths annually • Increase LOS by 7-21 days • 12 days = most recent estimate • In FY10 we had 172 (x $22K = $3,784,000 of cost) Pronovost P.J., et al.: Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. BMJ 340:c309, Feb. 4, 2010.

    6. CLABSI Prevention Bundle • Hand hygiene • Maximal barrier precautions • Chlorhexidine skin antisepsis • Except very LBW infants (<2 months old) • Optimal catheter site selection • Subclavian vein preferred • Daily review of line necessity, with prompt removal of unnecessary lines Pronovost P.J., et al.: Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. BMJ 340:c309, Feb. 4, 2010.

    7. 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.”

    8. Assertive Statement • Get attention • Express Personal Concern • State the Problem • Propose a Solution • “Dr. XX!” • “I’m concerned.” • “Betadine is not as effective as Chlorhexidine.” • “Let me get the Chlorhexidine.” http://www.cdc.gov/hicpac/BSI/05-bsi-background-info-2011.html

    9. Case: “Got to Go” • Nurse X, using best focused communication technique, suggests…need to get Chlorhexidine… • Dr. GTG, “I don’t have time for that nonsense…I know what I am doing…for 30 years” • Dr. GTG continues • How might your team member (Nurse X) respond?

    10. How might your team member (Nurse X) respond? • Reason…“I’ve done my duty”…assist… • Leave the bedside while reasoning, “I will not be a part…” • Repeat the focused communication… • Declare publicly and loudly, “Does everybody else see what Dr. GTG is doing?” • Something else 10

    11. Case: “Got to Go” • Nurse X, chooses to repeat focused communication… Chlorhexidine… • In response, Dr. GTG declares, “I’m sorry, who are you? I’m Dr. (spells out name)…I’ve got to go…” • How might Nurse X respond?

    12. How might Nurse X respond? • Pleased to meet you Dr. … • Reason…“I’ve tried…proceed to assist…” • Walk away – get help • Try a third time, but with more gusto… • Assist but report later • Something else 10

    13. What % of the time would a nursing professional report the event to either a supervisor or through an event reporting system? Consider the microsystem where you work… • 0 – 20% • 20 – 40 % • 40 – 60% • 60 – 80% • 80 – 100% 10 Countdown

    14. If reported, what % of the time would a medical leader have a conversation with Dr. GTG? • 0%-20% • 20%-40% • 40%-60% • 60%-80% • 80%-100% 10

    15. Case: “Got to Go” • Central line insertion completed using Betadine • The rest of the case… • Third post procedure day…fever… hemodynamicaly unstable…sepsis • Blood culture: MRSA • Progressive deterioration…death

    16. Case: “Got to Go” • EA (RCA) conducted • Event report: Dr. GTG refusal to “pause” • A few questions

    17. A Few Questions About Dr. GTG • From Reason’s “Unsafe Acts” algorithm (1997): • Did the team member intend to cause harm? • Did the team member come to work impaired? • Did the team member knowingly and unreasonably increase risk? • Would another team member in the same situation act in a similar manner? Reason J.T.: Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate Publishing, 1997.

    18. One last question: Concept of causation* What is the probability that Dr. GTG’s refusal to pause is directly related to MRSA, sepsis, and cause of death? • 0%-25% • 26%-50% • 51%-75% • 76%-100% 10 * As a proximate result of the defendant’s negligent act or omission, the plaintiff suffered injuries which would not otherwise have occurred. T.C.A. §29-26-115 (a)(3)

    19. A Trick Question • Nurse X testifies in deposition: “I tried to get him (Dr. GTG) to stop…tried twice…just blew me off…I feel so awful…” • A settlement: $$$$ MM (high lost income) • More importantly…

    20. Professionalism and Self-Regulation • Professionals commit to: • Technical and cognitive competence • Professionals also commit to: • Clear and effective communication • Modeling respect • Being available • “Self awareness” • Professionalism promotes teamwork • Professionalism demands self and group regulation • You have a critical role Hickson GB, Moore IN, Pichert JW, Benegas Jr M. 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.

    21. Definition of Behaviors That Undermine A Culture of Safety Include but are 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 outcomes (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. It’s About Safety Vanderbilt University and Medical Center Policy #HR-027, 2010

    22. Perhaps More Common Failure to: • Practice hand hygiene • Complete handoffs/documentation • Observe time outs • Arrive on time • Answer pages/cover call • Practice EBM • Others?

    23. What barriers exist? Why are we so hesitant to act?

    24. I think the nurses contributed to his frustration. Just talk to him. I’m sure he didn’t mean it. We can’t do anything, we’ll get sued. The nurses are against him.

    25. The Balance Beam Competing priorities Not sure how lack tools, training Leaders “blink” “Can’t change…” Fear of antagonizing Do nothing Do something June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and 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

    26. Why Might a Medical Professional Behave in Ways that are Disruptive? 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.

    27. Why Might a Medical Professional Behave in Ways that are Disruptive? 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.

    28. Consequences of Unsafe Behavior: Patient Perspective (tip of the iceberg) Lawsuits Infections/ Errors Non adherence/ noncompliance Drop out Costs Bad-mouthing the practice to others

    29. Failure to Address Behaviors that Undermine a Culture of Safety Leads To: • Team members may adopt disruptive person’s negative mood/anger (Dimberg & Ohman, 1996) • Lessened trust among team members can lead to 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. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups., Research and Organizational Behavior. 2006; 27:175-222.

    30. Consequences of Unsafe Behavior: Healthcare Professional Perspective (tip of the iceberg) Harassment suits Infections/ Errors Lack of retention Burnout Costs Jousting Bad-mouthing the organization in the community Felps W, et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups., Research and Organizational Behavior. 2006; 27:175-222.

    31. Let’s do a rough calculation • How many nursing professionals do you replace per year? • At VUMC, 12-14% • In a 2009 study, 2/3 of respondents said they considered leaving their job because of disruptive behavior and 41% said they actually did* • If our assumptions are correct, what is our yearly disruptive behavior cost? *Studer Group and Vanderbilt CPPA. Unprofessional Behavior in Healthcare Study, June 2009 . In: Modern Healthcare Outsert. October 26, 2009.

    32. Let’s do a rough calculationHospital X • Total # of RNs: 3,348 • 3, 348 RNs X 13.4% (turnover rate) = 449 • 6-12% leave due to DB = 27-54 • [27-54] X [$55,740 avg. annual salary*] = $1,504,980 – $3,009,960 *Some studies suggest range up to $110,000

    33. The Balance Beam Staff satisfaction and retention Competing priorities Not sure how lack tools, training Reputation Leaders “blink” Patient safety, clinical outcomes “Can’t change…” Liability, risk mgmt costs Fear of antagonizing Do nothing Do something June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and 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

    34. Professionalism and Self-Regulation • Professionals commit to: • Technical and cognitive competence • Professionals also commit to: • Clear and effective communication • Modeling respect • Being available • “Self awareness” • Professionalism promotes teamwork • Professionalism demands self and group regulation • You have a critical role Hickson GB, Moore IN, Pichert JW, Benegas Jr M. 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.

    35. Guiding Principles for Action Reiter CE, Hickson GB, Pichert JW. Addressing behavior and performance issues that threaten quality and patient safety: What your attorneys want you to know. Prog Pediatr Cardio. 2012; in press. Justice– Fairness for all No conflict of interest Certainty that the “egregious” event in question or pattern of “evidence” shows that the physician in this case (or other professional in other cases) stands out from peers Insightinto causes is the first, short-term goal “Redemption,” “Restoration” or problem resolution is the 2nd goal

    36. Infrastructure for Promoting Reliability & Professional Accountability (PA) • Leadership commitment (will not blink) • Goals, a credo, and supportive policies • Surveillance tools to capture observations/data • Process to guide graduated interventions • Processes for reviewing observations/data • Multi-level professional/leader training • Resources to address unnecessary variation • Resources to help affected 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. 2007. Hickson GB, Moore IN, Pichert JW, Benegas Jr M. 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.

    37. Organizational Infrastructure: Next Segment • What do you have? • What do you need?