Elvis Is Dead and I Don’t Feel So Good Myself Gerald B. Hickson, M.D. Associate Dean for Clinical Affairs gerald.hickson@vanderbilt.edu Center for Patient & Professional Advocacy www.mc.vanderbilt.edu/cppa

Why focus on identifying and addressing adverse events and risk?

Principles Errors and harm are not always linked No shortage of patient injuries (whether caused by errors or not) Prudent to give first priority to finding and addressing those situations that actually give rise to injury or risk

So what do we know about the causes of adverse medical outcomes?

Methods Identify RM files for inclusion 1996-2001 116 Risk Management files opened out of 820,000 pediatric visits (<0.02%) Prepare Cause and Effect Diagrams Code the Causes Aggregate the code Hain PD, Pichert JW, Hickson GB, Bledsoe SH, Hamming D, Hathaway J, Nguyen C: Using Risk Management Files to Identify and Address Causative Factors Associated with Adverse Events in Pediatrics. Therapeutic & Clinical Risk Management (in press)

Cause-Effect Diagram People Procedure Equipment Adverse Outcome Environment Policy Other “Ichikawa Diagram”

1996-2001 Pediatrics (n=116) Number of Cases Confidential and privileged pursuant to TCA section 63-6-219

So what kinds of communication failures do we have among members of our team? Let’s review a case…

We can’t stop the Sz KP-16 mo male with sudden onset of fever to 105° Parents call 911, transported to closest ED (40 minutes from children’s hospital) ED at CH called: “Status epilepticus I hr duration…can’t get in line, can you help?”

We can’t stop the Sz CH ED Attending (23:00): Knows CH really busy, hospital and ICU are full Knows “there is always a bed in ICU” (policy) Calls ICU attending to discuss transfer, who responds, “just can’t take pt…we are full.”

We can’t stop the Sz ED attending weighs the pros and cons, transport arranged KP arrives in status (00:30): T - 100.5°, P – 179, R – 33, BP 91/38 Two lines inserted, multiple doses of multiple anticonvulsives administered CT – neg; LP - neg Needs admit to ICU. ICU called for admission.

We can’t stop the Sz Conversation between ICU and ED attending is described as “challenging” ICU attending: “I told you – NO BEDS. Why did you accept pt?…You will just have to arrange transport somewhere else…hangs up” Vitals: T – 101, P – 180, R – 36, BP 78/32

We can’t stop the Sz Air transport arranged Vitals at lift off (04:40): P – 85, R – 30, BP – 59/25 On arrival at 2nd CH (05:00)– pt started on dopamine…no response

We can’t stop the Sz Receiving ICU attending; “I can’t believe…” Hypoxic ischemic brain injury Family filed suit – Allegation; failure to rescue (we paid real $$s)

Cause-Effect Diagram People Procedure Equipment Adverse Outcome Environment Policy Other “Ichikawa Diagram”

Let’s Examine Several “Causes” in Some Detail Coordination of service delivery Chain of command Environment - busy “A policy” – one open bed Ineffective communication “Disruptive behavior” – hanging up on a colleague?

SBAR A standardized format to transfer info: 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.

What constitutes disruptive behavior? INM starts here

What Constitutes Disruptive Behavior? Behavior that interferes with…work…or creates… hostile…environment: verbal abuse, sexual harassment, inappropriate demands; yelling, profanity or vulgarity; unwelcome physical contact; assault/battery threats of harm; behavior reasonably interpreted as threatening (verbal, written or physical); behavior causes stressful or traumatic incidents that interfere with others’ effective functioning. Vanderbilt University and Medical Center Policy #HR-027

How can you forget to do that? You’re a worth-less resi-dent. Hmm. I better give them perfect evals so they don’t kill me!

“I don’t have a problem with anger. I have a problem with idiots.”

“Why do we need to do anything anyway?” “Dr. ____ is technically outstanding (just a bit challenging)…” GBH Starts again here

Spectrum of Disruptive Conduct: Patient Perspective Lawsuits Voiced Complaints (tip of the iceberg) -Some patients that are unhappy may say or do nothing, some may not adhere to recommendations or drop out of the health care system. -And a minority of patients may be so unhappy that they choose to file a complaint with an institutional authority or at the tip of the iceberg of patient dissatisfaction, file a lawsuit in the event of an adverse outcome. Errors Drop out Non adherence

Why Might a Medical Professional Behave in Ways that are Disruptive? JWP Starts here

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

Scientific evidence proves the world does revolve around me

Why Might a Medical Professional Behave in Ways that are Disruptive? The Point If the organization wants to help or “redeem” the professional, the intervention is best done when based on a conceptual framework, sound policies, good assessment tools, strong leadership, and training in the “how to”.

Disruptive Behavior Pyramid Level 3 "Disciplinary" Intervention No ∆ Pattern persists Level 2 "Authority" Intervention Apparent pattern Level 1 "Awareness" Intervention Single “unprofessional" incidents (merit?) "Informal" Intervention Mandated Issues Vast majority of doctors—no issues

Upcoming CPPA Conferences at Vanderbilt: The Why and How of Dealing with “Special” Colleagues: Discouraging Disruptive Behavior June 28-29, 2007; November 8-9, 2007 The How and When of Communicating Adverse Outcomes and Errors August 16-17, 2007; February, 2008 http://www.mc.vanderbilt.edu/CPPA

Questions? Comments? www.mc.vanderbilt.edu/CPPA