Professionalism: does it affect patient safety? H Yang Professor & Chair Department of Anesthesia

Conflict of Interest No payment by industry No shares in industry

Objectives Understand progression of Professionalism Review risks and successes in organizational professionalism & patient safety Discuss next steps

Progression of professionalism model

Progression of Professionalism Medical profession provides service; society appreciates & respects the medical profession Social contract – self regulation, oversight of medical education, disciplining of “bad” physicians, attaining & maintaining certificate (special knowledge); in exchange is the placement of patient needs above all else Lindenauer et al. NEJM 2005; 353:349 - 61

Individual doctor code of conduct Morals & Ethics Physician society, National or Provincial authorities Hospitals, Institutions, Clinics, Depts Individual doctor code of conduct

Professionalism & patient safety successes

IOM Report 1999 “Health care organizations [to] develop a ‘culture of safety’ such that their workforce and processes are focused on improving the reliability and safety of care for patients.”

Organizational types Hudson, 2001

Collaboration & Communications Essential for professionalism American Board of Internal Medicine, European Federation of Internal Medicine, American College of Physicians, & American Society of Internal Medicine (Lancet 2002) Personal responsibilities: collaborate respectfully Canmeds 2005 – Communicator

Collaboration & Communications CMA Medical Professionalism 2005 – “The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality.”

Surgical Misadventures 38 surgeons in 146 incidents Incident types Permanent disability 33% Patient death 13% 77% involved Sx or other interventions 67% intraop; 27% preop; 10% unnecessary advancement of disease Surgery 2003; 133(6):614-21

Surgical Misadventures inexperience/lack of competence in a surgical task (53%) communication breakdowns among personnel (43%) fatigue or excessive workload (33%) Surgery 2003; 133(6):614-21

JAMA 2002; 287(22):2951-7

Physicians with law suits Correlated with number of patient complaints Adjusted for clinical activity level No clear correlation with complaint types JAMA 2002; 287(22):2951-7

Professionalism Model Formal: investigated by a committee, a proscribed process, and potential for interventions or reprimands

Communications & Outcomes Kaiser Foundation Health Plan 293 cases, Mar – Aug 2005 Trained observers Behavioral Marker Risk Index (BMRI) single number calculated a higher score indicating fewer instances of teamwork behaviour Am J Surg 2009; 197(5): 678-85

Briefing, Information sharing, Inquiry, Vigilance & awareness Am J Surg 2009; 197(5): 678-85

Adjusted = adjusted for ASA Am J Surg 2009; 197(5): 678-85

Infect Control Hosp Epidemiol. 2013 Nov;34(11):1129-36. Hand Hygiene Tertiary care center, including outpatient clinics & procedural areas Use of a system-wide shared accountability model Adherence was measured by designated hand hygiene observers monthly hand hygiene adherence rates were correlated with monthly rates of device-associated infection Infect Control Hosp Epidemiol. 2013 Nov;34(11):1129-36.

Infect Control Hosp Epidemiol. 2013 Nov;34(11):1129-36. Hand Hygiene adherence greater than 85% has been achieved since January 2011 and sustained Social accountability worked Infect Control Hosp Epidemiol. 2013 Nov;34(11):1129-36.

Next steps

Professional Identity Professional Identity – “shape the novice into the effective practitioner of medicine, to give him the best available knowledge and skills, and to provide him with a professional identity so that he comes to think, act, and feel like a physician.” Merton “The Student Physician. Harvard University Press 1957:3-79

Organizational Professionalism Leaders articulated clear values Leaders emphasized aligning organizational systems and structures to support desired behaviours Cultivating strong interpersonal relationships to reinforce and disseminate organizational values BMJ Qual Saf 2011; 20(4):351-8

Professionalism is the culture to create safety Professional identity Organizational professionalism Without engaging individual physicians and surgeons Only change one goal post at a time; hard to get a sea-change “Doughy boy” syndrome Be prepared for the 0.06% or 4%