The Year of the Scientist: Balancing Health and Science “Promoting Professional Accountability: It Starts with a Cup of Coffee” Lynn E. Webb, PhD Assistant Dean for Faculty Development Center for Patient and Professional Advocacy

Objectives Participants attending this session will be able to: Describe how the VUMC Credo applies to their work environment Provide examples of behaviors that undermine a culture of respect and a professional work environment Demonstrate skills in having a cup of coffee conversation with a colleague

Professionalism and Self-Regulation Technical & Cognitive Competence Modeling Respect Professional Effective Communication Self-awareness Being Available Commitment Teamwork 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.

Vanderbilt Credo

Professionalism concerns reported by colleagues “ Dr. X constantly criticizes the team during our lab meetings. He accused me of mishandling the last batch [of specimens] even though I had nothing do with it. Very disruptive.” “I followed her back to her office to look for a file I needed. After just a minute of looking, she said ‘this is ridiculous, I don’t have time for this sh_t’. I walked out. This is not credo like behavior.” “Dr. X has not been easy to work with. He is short tempered and he ignores my questions. It is very stressful. There are days when he is pleasant, but those are few..”.

Professional Accountability What are behaviors that undermine a culture of respect and a professional environment ?

Definition of Behaviors That Undermine a Professional Environment Create intimidating, hostile, offensive (unsafe), biased work environment Interfere with ability to achieve intended outcomes Disruptive behavior is best defined in bullet one: Behavior that creates stressful work environments and interferes with others’ effective functioning. Disruptive behavior represents any behavior that adversely affects the ability of the team to achieve its intended outcome (using James Reason’s definition of a medical error). James Reason – well published in the work of ‘why errors happen’; human errors; This slide mirrors the language and definitions used in TJC’s Alert and in many institutional policies, such as Vanderbilt’s. What is your organization’s definition, if they have one? Violate policies (including conflicts of interest and compliance) Threaten safety (aggressive or violent physical actions) It’s About Safety Excerpts from Vanderbilt University and Medical Center Policy #HR-027, 2010

What barriers exist? vs. Why bother acting? Why are we so hesitant to act? What barriers exist? vs. Why bother acting?

The Balance Beam Do Something Do Nothing Competing Priorities Staff Satisfaction Not sure how Reputation Leaders “blink” Patient Safety Fear of antagonizing Liability Can’t change… Risk Management costs Do Nothing Do Something Studer Group and Vanderbilt Center for Patient and Professional Advocacy, Unprofessional Behavior in Healthcare Study, June 2009; Hickson GB, Pichert JW.  Disclosure and apology. In: 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.

Failure to Address Behaviors… Leads To: Adoption of unprofessional conduct Lessened trust, lessened task performance (always monitoring disruptive person) Threatened quality and patient safety Withdrawal 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.

Co-Worker Observation Reporting System VUMC Physicians UTMC PARS® Program: Identifying and Intervening with Physicians at High Risk for Claims Co-Worker Observation Reporting System VUMC Physicians UTMC New Messenger Training; Nov 2013

Co-Worker Observation Reporting System: National Comparisons UTMC PARS® Program: Identifying and Intervening with Physicians at High Risk for Claims Co-Worker Observation Reporting System: National Comparisons 89% of physicians are associated with NO reports in 3 years 1% of physicians are associated with 29% of reports Co-Worker Observation Reports - National CORS℠ Database (n = 6,659) Percent of Physicians Webb et al. Jt Comm J Qual Patient Safety., 2016. This material is confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272 and shall not be disclosed to unauthorized persons UTMC New Messenger Training; Nov 2013

Promoting Professionalism Pyramid Level 2 “Guided“ Intervention by Authority Apparent pattern Single concern (merit?) Informal “Cup of Coffee” Level 1 "Awareness" Intervention Level 3 "Disciplinary" Intervention Pattern persists No Vast majority of professionals - no issues - provide feedback on progress Egregious Mandated Reviews Mandated https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_q_immedjeopardy.pdf http://www.compass-clinical.com/hospital-accreditation/2011/05/19/deciphering-tjc-condition-level-findings/ 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, 1985.

Informal Conversation For a single “event”… Informal Conversation Regular (Cup of Coffee)

If you were on the receiving end… You would want the colleague to be: Non-judgmental Confidential Respectful Non-directive Non-defensive Collegial What else?

Principles for “Informal” Conversations Goal Deliver a single story/observation, and let the recipient know the behavior/performance was observed.

Principles for “Informal” Conversations Overview Opening Share or Deliver Observation (data) Respond Close

Having the “Informal” Conversation Opening I am here as ____ (peer, safety committee, or leader, etc.) You are an important team member… I observed/received a report… We are committed to sharing…

Having the “Informal” Conversation Review Data Review story with sufficient specifics “I know there are two sides…” Avoid seeming judgmental Avoid “you” word Pause

Having the “Informal” Conversation Respond Pushbacks – “I hear you but…” Questions Connect to values, shared goals. “…didn’t seem consistent with…”

Having the “Informal” Conversation Pushback Anticipate But It’s Not a Control Contest

Types of Pushback Deflection Dismissal Distraction

Deflection Pushback: Deflection It’s not me, it’s the… Patients (unique, difficult) System Reporter’s mistaken perception Report – “that just didn’t happen”

Dismissal Pushback: Dismissal “Do you know who I am?” “I don’t believe…” Data Seriousness Messenger’s (Committee’s) Authority or process

Pushback: Distraction “We should really be focusing on… System / other team members Data analysis/homework Fix or Help me Body language/Emotional response

Having the “Informal” Conversation Close Appreciation Ask to reflect “…and trust you to do the right thing.”

Principles for “Informal” Conversations Strategies for Success: Who – Anyone What – Single, non-egregious report When – As soon as possible Where – Private space/neutral area How – Respectful, nonjudgmental Know the mission and stay on mission Don’t Expect Thanks

VUMC CORS Progress Report UTMC PARS® Program: Identifying and Intervening with Physicians at High Risk for Claims VUMC CORS Progress Report sm Interventions on 62 clinicians with high numbers of coworker concerns 0 to 1 Subsequent Reports 2 or more Subsequent Reports 81% 19% Per LEW 50 Physicians/APPs 12 Physicians/APPs Attending physicians, residents, fellows, and advanced practice professionals Confidential and privileged information under the provisions set forth in T.C.A. §§ 63-1-150 and 68-11-272; not be disclosed to unauthorized persons. UTMC New Messenger Training; Nov 2013

Now or Later www.mc.vanderbilt.edu/cppa Let Us Hear Your Comments and Questions Now or Later www.mc.vanderbilt.edu/cppa

Summary Describe how the VUMC Credo applies to your work environment As a result of participating you should be able to: Describe how the VUMC Credo applies to your work environment Provide examples of behaviors that undermine a culture of respect and a professional work environment Demonstrate skills in having a cup of coffee conversation with a colleague