Unprofessional behaviour and the risks to patient safety
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1 Unprofessional behaviour and the risks to patient safety Kevin Stewart MPH FRCP Clinical Director, Clinical Effectiveness & Evaluation Unit, Royal College of Physicians, London
2 Kevin Stewart 2009/10 Quality Improvement Fellow, Institute for Healthcare Improvement and Harvard School of Public Health, Boston, USA* Consultant Geriatrician, Winchester Medical Director, Winchester & Eastleigh NHS Trust to 2009 Medical Director, QIPP Safe Care Program, Department of Health to 2011 The views expressed here are my own and are not intended to represent those of the Health Foundation, IHI or RCP *Health Foundation QI Fellowship
3 What is unprofessional behaviour? In the North America this is usually referred to as disruptive behaviour so we shall use these terms interchangeably. Although other staff also display unprofessional behaviour* we shall restrict our discussion to doctors. *Francis Report and NHS staff surveys
4 What is it? When the use of inappropriate words, actions or inactions by a physician interferes with teamwork and quality healthcare delivery (College of Physicians and Surgeons of Ontario, 2008)
5 What is it? may in rare circumstances be demonstrated in a single egregious act (e.g. physical assault) but is more often composed of a pattern of behaviour. Its gravity depends on its nature, the context and its consequences. (College of Physicians and Surgeons of Ontario, 2008)
6 What is it? A spectrum of behaviours Passive Inadequate notes Avoiding meetings Doesn t answer pages etc Passive -aggressive Derogatory comments Hostile notes Sexual harassment Non-compliance with policies etc Aggressive Verbal outbursts Assaults Throwing instruments etc Hickson et al; Acad Med Nov;82(11):
7 My list includes Refusal to follow hand-washing or prescribing policies Not responding/aggressive response to bleeps, requests to see patients, medication queries Verbal abuse of admin. and clerical staff Electronic harassment; e mail, incident reports
8 My list includes Instrument throwing Racial abuse Sexual harassment Etc etc
9 How common is it?
10 Sources of information US; 1635 Physician executives (Weber 2004) 2135 physician and nurse executives (ACPE 2009) 4530 nurses & pharmacists (Rosenthein & O Daniel 2008) UK; 1198 cases referred to NCAS 163 Clinical Leaders (unpublished)
11 Recurrent themes Most doctors do not present problems but recurrent incidents involving the same individuals are common Behaviours occur across the spectrum Doctors get reported later and treated more leniently especially high value ones There are rarely systems in place for dealing with this (or else they are rarely used)
12 Clinical Leaders surveys In my organization problems tend to arise Amongst the same small group of individuals Occur in various individuals with no clear pattern Weber et al; US Clinical Leaders Unpublished data. 163 UK Clinical Leaders
13 Hickson et al, JAMA 2002 Figure. Cumulative Distribution of Physician Cohort Members and Unsolicited Complaints The dotted lines illustrate that 9% of cohort members were associated with 50% of patient complaints and 5% were associated with approximately one third of all complaints.
14 Bismark et al BMJ Q&S July
15 Examples. Dr Jones Mr Black Dr Smith Dr Green
16 Why do some people behave like this? Internal (personal) factors External (system) factors
17 Why do some people behave like this? Internal factors Illness (physical, psychiatric) Personality disorder Addiction/dependency Poor communication, influencing and conflict resolution skills
18 Why do some people behave like this? External factors Life cycle events (family, financial etc) High system demands, low system support Poorly developed systems for responding to genuine concerns
19 And... what we permit, we promote It achieves the desired results We have a culture of tolerance and indifference Joint Commission, 2008 Sometimes as far back as Medical School
20 Effects of disruptive behavior There is good evidence that it contributes to; Patient Safety problems Staff turnover Poor team-working Complaints Litigation risk
21 Patient safety and disruptive behaviour
22 Institute for Safer Medication Practice survey (2004) 2095 nurses and pharmacists On at least 3 occasions in the last year 17% felt pressurised to accept a medication order despite concerns about its safety On at least 10 occasions in the last year 13% refrained from contacting a specific prescriber to clarify concerns in the last year 7% have been involved in a medication error where intimidation had been involved
23 Rosenthein and O Daniel (2008) 4530 nurses, doctor and other staff 60% reported being aware of potential adverse events related to disruptive behaviour 14% were aware of a specific adverse event related to it
24 What can be done
25 Common elements of all approaches Action at every level Leadership Board, CEO, clinicians in leadership roles Other clinicians The front line Medical Schools
26 Common elements of all approaches Modeling expected behavior Board commitment Transparency and consistency Code of conduct and supporting policies Recruitment policies Surveillance systems Integration into the quality and safety agenda
27 Common elements of all approaches Screening for health and other issues Graduated responses Dealing with low level aberrant behavior early Appropriate escalation Training and resources
28 Vanderbilt University Hospital, Nashville
29 Does this work? In Vanderbilt, intervention with highest risk group Approx 60% of individuals had reductions in complaints and legal cases over next 2 years 20-40% make little progress
30 Summary (1) This is a patient safety issue A small number of individuals are responsible for a disproportionate percentage of issues Passive and passive/aggressive behaviours are the most common manifestation Individuals can; Model the expected behaviours Challenge peers
31 Summary (2) Organizations can; Acknowledge it as a patient safety issue Use their infrastructure to deal with it The infrastructure which could support this already exists in some places
32 Thanks The Health Foundation Jim Conway, Gerry Healy and Ron Wyatt, IHI Barry Silbaugh, ACPE E mail me for slides and references; Kevin.stewart@rcplondon.ac.uk
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