Gerald B. Hickson

A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors.

Vanderbilt University School of Medicine (VUSM) employs several strategies for teaching professionalism. This article, however, reviews VUSM’s alternative, complementary approach: identifying, measuring, and addressing unprofessional behaviors. The key to this alternative approach is a supportive infrastructure that includes VUSM leadership’s commitment to addressing unprofessional/disruptive behaviors, a model to guide intervention, supportive institutional policies, surveillance tools for capturing patients’ and staff members’ allegations, review processes, multilevel training, and resources for addressing disruptive behavior. Our model for addressing disruptive behavior focuses on four graduated interventions: informal conversations for single incidents, nonpunitive “awareness” interventions when data reveal patterns, leader-developed action plans if patterns persist, and imposition of disciplinary processes if the plans fail. Every physician needs skills for conducting informal interventions with peers; therefore, these are taught throughout VUSM’s curriculum. Physician leaders receive skills training for conducting higher-level interventions. No single strategy fits every situation, so we teach a balance beam approach to understanding and weighing the pros and cons of alternative intervention-related communications. Understanding common excuses, rationalizations, denials, and barriers to change prepares physicians to appropriately, consistently, and professionally address the real issues. Failing to address unprofessional behavior simply promotes more of it. Besides being the right thing to do, addressing unprofessional behavior can yield improved staff satisfaction and retention, enhanced reputation, professionals who model the curriculum as taught, improved patient safety and risk-management experience, and better, more productive work environments.

Relationship between patient complaints and surgical complications

Background: Patient complaints are associated with increased malpractice risk but it is unclear if complaints might be associated with medical complications. The purpose of this study was to determine whether an association exists between patient complaints and surgical complications. Methods: A retrospective analysis of 16 713 surgical admissions was conducted over a 54 month period at a single academic medical center. Surgical complications were identified using administrative data. The primary outcome measure was unsolicited patient complaints. Results: During the study period 0.9% of surgical admissions were associated with a patient complaint. 19% of admissions associated with a patient complaint included a postoperative complication compared with 12.5% of admissions without a patient complaint (p = 0.01). After adjusting for surgical specialty, co-morbid illnesses and length of stay, admissions with complications had an odds ratio of 1.74 (95% confidence interval 1.01 to 2.98) of being associated with a complaint compared with admissions without complications. Conclusions: Admissions with surgical complications are more likely to be associated with a complaint than surgical admissions without complications. Further research is necessary to determine if patient complaints might serve as markers for poor clinical outcomes.

Development of an Early Identification and Response Model of Malpractice Prevention

The dramatic rise in the incidence of malpractice claims over the past thirty years has revealed several problems with the U.S. system of medical dispute resolution. First, the sudden and unexpected increase in claims has created an insurance crisis wherein various medical specialists have had difficulty obtaining affordable insurance coverage.1 One such crisis occurred in Florida in the mid-1980s, when an inability of many physicians to procure medical malpractice coverage caused some to limit or curtail their practice. This resulted in access problems for the public. This phenomenon has disproportionately befallen physicians practicing obstetric medicine.2 Second, besides contributing to periodic crises of access, the current medical dispute resolution system is often responsible for long delays in resolving claims and in compensating victims.3

Physician Practice Behavior and Litigation Risk : Evidence and Opportunity

Malpractice risk bedevils obstetricians. Suits can be a nuisance or emotionally and financially devastating. In this chapter, we ask simple questions and provide empiric data to demonstrate that interpersonal factors trigger suits. A supportive relationship between the obstetrician, team members, and the patient can reduce the chance of being sued after an unexpected event. Collaboration between physician colleagues and others to promote teamwork reduces error and increases patient satisfaction. Physicians who disrupt the emotional ecosystem increase liability for themselves and team members. A method of identifying physicians at increased risk and a strategy for intervening to reverse the pattern is described.

Sustained improvement in hand hygiene adherence: utilizing shared accountability and financial incentives.

OBJECTIVE To evaluate the impact of an institutional hand hygiene accountability program on healthcare personnel hand hygiene adherence. DESIGN Time-series design with correlation analysis. SETTING Tertiary care academic medical center, including outpatient clinics and procedural areas. PARTICIPANTS Medical center healthcare personnel. METHODS A comprehensive hand hygiene initiative was implemented in 2 major phases starting in July 2009. Key facets of the initiative included extensive project planning, leadership buy-in and goal setting, financial incentives linked to performance, and use of a system-wide shared accountability model. Adherence was measured by designated hand hygiene observers. Adherence rates were compared between baseline and implementation phases, and monthly hand hygiene adherence rates were correlated with monthly rates of device-associated infection. RESULTS A total of 109,988 observations were completed during the study period, with a sustained increase in hand hygiene adherence throughout each implementation phase (P < .001) as well as from one phase to the next (P < .001), such that adherence greater than 85% has been achieved since January 2011. Medical center departments were able to reclaim some rebate dollars allocated through a self-insurance trust, but during the study period, departments did not achieve full reimbursement. Hand hygiene adherence rates were inversely correlated with device-associated standardized infection ratios (R(@) = 0.70). CONCLUSIONS Implementation of this multifaceted, observational hand hygiene program was associated with sustained improvement in hand hygiene adherence. The principles of this program could be applied to other medical centers pursuing improved hand hygiene adherence among healthcare personnel.

An analysis of risk factors for patient complaints about ambulatory anesthesiology care.

BACKGROUND:Anesthesiology groups continually seek data sources and evaluation metrics for ongoing professional practice evaluation, credentialing, and other quality initiatives. The analysis of patient complaints associated with physicians has been previously shown to be a marker for patient dissatisfaction and a predictor of malpractice claims. Additionally, previous studies in other specialties have revealed a nonuniform distribution of complaints among professionals. In this study, we describe the distribution of complaints among anesthesia providers and identify factors associated with complaint risk in pediatric and adult populations. METHODS:We performed an analysis of a complaint database for an academic medical center. Complaints were recorded as comments during postoperative telephone calls to ambulatory surgery patients regarding the quality of their anesthesiology care. Calls between July 1, 2006 and June 30, 2010 were included. Risk factors were grouped into 3 categories: patient demographics, procedural, and provider characteristics. RESULTS:A total of 22,871 calls placed on behalf of 120 anesthesiologists were evaluated, of which 307 yielded a complaint. There was no evidence of provider-to-provider heterogeneity in complaint risk in the pediatric population. In the adult population, an unadjusted test for the random intercept variance component in the mixed effects model pointed toward significant heterogeneity (P = 0.01); however, after adjusting for a prespecified set of risk factors, provider-to-provider heterogeneity was no longer observed (P = 0.20). Several risk factors exhibited evidence for complaint risk. In the pediatric patient model, risk factors associated with complaint risk included a 10-year change in age, the use of general anesthesia (versus not), and a 1-hour change in the actual minus scheduled start times. Odds ratios were 1.47 (95% confidence interval (CI), 1.04–2.08), 0.22 (95% CI, 0.07–0.62), and 1.27 (95% CI, 1.10–1.47), respectively. In the adult patient model, risk factors associated with complaint risk included male gender, general anesthesia, a 10-year change in provider experience, and speaking with the patient (rather than a family member). Odd ratios were 0.66 (95% CI, 0.47–0.92), 0.67 (95% CI, 0.47–0.95), 1.18 (95% CI, 1.01–1.38), and 1.96 (95% CI, 1.17–3.29), respectively. CONCLUSIONS:There was apparent evidence in adult patients to suggest heterogeneity in provider risk for a patient complaint. However, once patient, procedural, and provider factors were acknowledged in analyses, such evidence for heterogeneity is diminished substantially. Further study into how and why these factors are associated with greater complaint risk may reveal potential interventions to decrease complaints.

Identifying medical center units with disproportionate shares of patient complaints.

BACKGROUND A pilot study was conducted to learn whether an academic medical centers database of patient complaints would reveal particular service units (or clinics) with disproportionate shares of patient complaints, the types of complaints patients have about those units, and the types of personnel about whom the complaints were made. RESULTS During the seven-year (December 1991-November 1998) study period, Office of Patient Affairs staff recorded 6,419 reports containing 15,631 individual complaints. More than 40% of the reports contained a single complaint. One-third of the reports contained three or more complaints. Complaints were associated with negative perceptions of care and treatment (29%), communication (22%), billing and payment (20%), humaneness of staff (13%), access to staff (9%), and cleanliness or safety of the environment (7%). Complaints were not evenly distributed across the medical centers various units, even when the data were corrected for numbers of patient visits to clinics or bed days in the hospital. The greatest proportion of complaints were associated with physicians. DISCUSSION Complaint-based report cards may be used in interventions in which peers share the data with unit managers and seek to learn the nature of the problems, if any, that underlie the complaints. Such interventions should influence behavioral and systems changes in some units. SUMMARY AND CONCLUSIONS Further experience should indicate how different types of complaints lead to different kinds of interventions and improvements in care. Tests of the system are also currently under way in several nonacademic community medical centers.

Role-modeling and medical error disclosure: a national survey of trainees.

Purpose To measure trainees’ exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees’ attitudes and behaviors regarding error disclosure. Method Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error. Results The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P < .001); negative role-modeling had the largest independent, negative effect (standardized effect estimate, −0.26, P < .001). Positive role-modeling had a positive effect on attitudes (standardized effect estimate, 0.26, P < .001). Exposure to negative role-modeling was independently associated with an increased likelihood of trainees’ nontransparent behavior in response to an error (OR 1.37, 95% CI 1.15–1.64; P < .001). Conclusions Exposure to role-modeling predicts trainees’ attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.

Medical Malpractice Claims Risk in Urology: An Empirical Analysis of Patient Complaint Data

PURPOSE Patient complaints are associated with physician risk management experience, including medical malpractice claims risk, and small proportions of physicians account for disproportionate shares of claims. We investigated whether patient complaint experience differs among urologists, and whether urological subspecialists generate distinct quantities and types of complaints. MATERIALS AND METHODS This retrospective study examined 1,516 unsolicited patient complaints filed against 268 urologists. Patient complaint and urological subspecialty data were collected from January 1, 2004 through December 31, 2007 for 15 geographically diverse health systems. The cohort urologists were assigned medical malpractice claims risk scores and complaint type profiles. A weighted sum algorithm produced risk scores from 4 consecutive years of complaint data and complaint type profiles were generated using a standardized coding system. Statistical analyses tested the associations among risk score, complaint type profile and urological subspecialty. Complaint type profile and subspecialty distribution were assessed for urologists in the cohort top decile for risk scores. RESULTS Overall 125 (47%) urologists were associated with 0 patient complaints, while 30 (11%) urologists were associated with 758 (50%) of the patient complaints. Subspecialty and distribution of risk scores were significantly associated (p <0.001). Calculi and oncology subspecialist distributions suggest greater overall risk. Complaint types also varied among subspecialists (p = 0.02). There was no association between top decile urologists and complaint type profile (p = 0.19). CONCLUSIONS Unsolicited patient complaints were nonrandomly distributed among urologists and urological subspecialties. Monitoring patient complaints may allow for early identification of and intervention with high risk urologists before malpractice claims accumulate.

Pursuing Professional Accountability An Evidence-Based Approach to Addressing Residents With Behavioral Problems

OBJECTIVE To develop an evidence-based approach to the identification, prevention, and management of surgical residents with behavioral problems. DESIGN The American College of Surgeons and Southern Illinois University Department of Surgery hosted a 1-day think tank to develop strategies for early identification of problem residents and appropriate interventions. Participants read a selection of relevant literature before the meeting and reviewed case reports. SETTING American College of Surgeons headquarters, Chicago, Illinois. PARTICIPANTS Medical and nursing leaders in the field of resident education; individuals with expertise in dealing with academic law, mental health issues, learning deficiencies, and disruptive physicians; and surgical residents. MAIN OUTCOME MEASURES Evidence-based strategies for the identification, prevention, and management of problem residents. RESULTS Recommendations based on the literature and expert opinions have been made for the identification, remediation, and reassessment of problem residents. CONCLUSIONS It is essential to set clear expectations for professional behavior with faculty and residents. A notice of deficiency should define the expected acceptable behavior, timeline for improvement, and consequences for noncompliance. Faculty should note and address systems problems that unintentionally reinforce and thus enable unprofessional behavior. Complaints, particularly by new residents, should be investigated and addressed promptly through a process that is transparent, fair, and reasonable. The importance of early intervention is emphasized.