The document discusses identifying and addressing behaviors that undermine a culture of safety in healthcare. It provides examples of unprofessional behaviors, such as a physician yelling at a radiology technician. It emphasizes the importance of professionalism, communication, and accountability in promoting patient safety. Infrastructure is needed to capture concerns, guide interventions, and promote reliability. Tools like complaint tracking can identify physicians at high risk and show that interventions generally improve behavior or lead to departure.

1. The CPPA: Center for Patient and
Professional Advocacy
Identifying and Intervening When
Behavior/Performance Undermines a
Culture of Safety
Gerald B. Hickson, MD
Assistant Vice Chancellor for Health Affairs
Associate Dean for Faculty Affairs
Joseph C. Ross Chair in Medical Education & Administration
Center for Patient & Professional Advocacy,
Vanderbilt University School of Medicine
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2. Pursuit of Reliability
• Safety Culture
• Willingness to report and address
–Psychological safety
–Trust
• “Behaviors that undermine a culture of
safety” threaten trust, therefore must be
addressed promptly, fairly, and in a
measured way
Hickson, Moore, Pichert, Benegas Jr. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From
Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Jt Comm Resources;2012:1-36.
2

3. A Case: “My Time”
• Radiology tech entered the OR…attempted to
position the fluoro arm.
• Dr. X, “What took you so long?”
• Tech tried to explain…she (Dr. X) began
yelling, “My time is more valuable than
yours…you better come when I call.”
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4. A Case: “My Time”
• Tech continued…attempted to maneuver the
fluoro arm…Dr. X became more agitated…asked
“Do you know what you are doing?” Then
looked at the image and yelled that tech was
incompetent…Ordered tech out of the room…
• Tech explained that her presence was necessary
for safety and image entry into PAX…(Dr. X)
became even more agitated and yelled for tech
to leave…
4

5. Professionalism and Self-Regulation
• Professionals commit to:
• Technical and cognitive competence
• Professionals also commit to:
• Clear and effective communication
• Modeling respect
• Being available
• “Self awareness”
• Professionalism promotes teamwork
• Professionalism demands self and group regulation
• You have a critical role
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
5 Resources;2012:1-36.

6. Definition of Behaviors That
Undermine A Culture of Safety
Include but are not limited to, words or actions that:
• Prevent or interfere w/an individual’s or group’s
work, academic performance, or ability to achieve intended
outcomes (e.g. intentionally ignoring questions or not returning phone
calls or pages related to matters involving patient care, or publicly
criticizing other members of the team or the institution);
• Create, or have the potential to create, an
intimidating, hostile, offensive, or potentially unsafe work or academic
environment (e.g. verbal abuse, sexual or other harassment, threatening
or intimidating words, or words reasonably interpreted as threatening or
intimidating);
• Threaten personal or group safety, aggressive or violent physical actions;
• Violate VUMC policies, including conflicts of interest and compliance.
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It’s About Safety
Vanderbilt University and Medical Center Policy #HR-027, 2010

7. Perhaps More Common
Failure to:
– Practice hand hygiene
– Complete handoffs/documentation
– Observe time outs
– Arrive on time
– Answer pages/cover call
– Practice EBM
– Refrain from “jousting”
– Others?
7

8. The Balance Beam
Competing priorities
Not sure how lack
tools, training
Leaders “blink”
“Can’t change…”
Fear of antagonizing
Do nothing Do something
June 2009, Unprofessional Behavior in Healthcare Study, Studer Group and Vanderbilt Center for Patient and Professional Advocacy; Hickson GB, Pichert
JW. Disclosure and Apology. 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
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9. Why Might a Medical Professional Behave
in Ways that Undermine…?
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
Samenow CP. Swiggart W. Spickard A Jr. A CME course aimed at addressing disruptive physician
behavior. Physician Executive. 34(1):32-40, 2008.
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10. Why Might a Medical Professional Behave
in Ways that Undermine…?
5. Make others look bad - for some advantage
6. Distract from own shortcomings
7. Family of origin issues—guilt and shame
8. Well, it seems to work pretty well (Why? See #9)
9. No one addressed it earlier (Why?)
Samenow CP. Swiggart W. Spickard A Jr. A CME course aimed at addressing disruptive physician
behavior. Physician Executive. 34(1):32-40, 2008.
10

11. Consequences of Unsafe Behavior:
Patient Perspective
Lawsuits (tip of the iceberg)
Non adherence/ Infections/
noncompliance Errors
Drop out
Costs Bad-mouthing the
practice to others 11

12. Consequences of Unsafe Behavior:
Healthcare Professional Perspective
Harassment suits (tip of the iceberg)
Lack of retention Infections/
Errors
Burnout
Costs
Jousting
Bad-mouthing the organization in the community
Felps W, et al. How, when, and why bad apples spoil the barrel: negative group members and 12
dysfunctional groups., Research and Organizational Behavior. 2006; 27:175-222.

13. Infrastructure for Promoting Reliability &
Professional Accountability (PA)
1. Leadership commitment (will not blink)
2. Goals, a credo, and supportive policies
3. Surveillance tools to capture observations/data
4. Process to guide graduated interventions
5. Processes for reviewing observations/data
6. Multi-level professional/leader training
7. Resources to address unnecessary variation
8. Resources to help affected staff and patients
Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and
addressing unprofessional behaviors. Academic Medicine. 2007.
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.
13

14. What Are “Surveillance Tools”?
• Risk Event Reporting System
– “Dr. __ entered the room without foaming in…proceeded
to touch area with purulent drainage…I offered a pair of
gloves…took them and dropped them into the trash.”
• Patient Relations Department
– Record patient/family concerns: Father: “My son had to
have surgery so I asked Dr. XX to explain their plan. Dr. XX
said, ‘I drew a picture. If you don't get it, you just don't
get it.’“
• Compliance hotline; Equal Opportunity, Affirmative
Action, and Disability Services (EAD)
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.
14

15. Promoting Professionalism Pyramid
Mandated Reviews
Adapted from Hickson
GB, Pichert JW, Webb No Level 3 "Disciplinary"
LE, Gabbe SG, Acad ∆ Intervention
Med, Nov, 2007
Pattern Level 2 “Guided"
persists Intervention by Authority
Apparent Level 1 "Awareness"
pattern Intervention
"Informal" Cup
Single of Coffee
“unprofessional" Intervention
incidents (merit?)
Mandated
Vast majority of professionals - no issues -
provide feedback on progress

16. But does any of this work?
16

17. Med Mal Research Background Summary
• 1-6%+ hosp. pts injured due to negligence
• ~2% of all pts injured by negligence sue
• ~2-7 x more pts sue w/o valid claims
• Non-$$ factors motivate pts to sue
• Some MDs attract more suits
• High risk today = high risk tomorrow
Sloan et al, JAMA 1989; Brennan et al, NEJM 1991; Hickson et al, JAMA
1992; Hickson et al, JAMA 1994; Bovjberg & Petronis, JAMA 1994
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18. Patient Complaints
“Dr. __ was rude and uncaring…told me, ‘There’s no amount of
surgery that can fix your problems.’”
Patient reported: “I showed up for my surgery only to find it had
been cancelled by Dr. XX. No one gave me any reason for the
cancellation. They said someone would call to reschedule…been a
week and still haven’t heard anything from Dr. XX’s office.”
“Dr. __ had not looked at my records before my visit. Dr. __ said
she was going to show up the day of the surgery and wing it…”
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19. Academic vs. Community Medical Center
50% of concerns associated with 9-14% of Physicians
(half of risk $)
100
Academic Med Ctr
% of Concerns
75 Community Med Ctr
50
25
0
30 40 50 60 70 80 90 100
% of Physicians
Note: 35-50% are associated with NO concerns (4% of risk $)
19 Hickson GB, et al. So Med J. 2007;100:791-6; Hickson GB, et al. JAMA. 2002 Jun 12;287(22):2951-7.

20. Predictors of Risk Outcomes
(logistic regression)
• Gender
• Physician specialty
• Volume of service
• Unsolicited patient complaints
Predictive concordance of risk models
ranges from 81-92%
Hickson et al, JAMA. 2002 Jun 12;287(22):2951-7.
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21. Incurred Expense By Risk Category
Predicted Risk # (%) Relative % of Total Score
Category Physicians Expense Expense (range)
1 (low) 318 (49) 1 4% 0
2 147 (23) 6 13% 1 - 20
3 76 (12) 4 4% 21 - 40
4 52 (8) 42 29% 41 - 50
5 (high) 51 (8) 73 50% >50
Total 644 (100) 100%
* In multiples of lowest risk group
Moore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review, 2006

22. Promoting Professionalism Pyramid
Mandated Reviews
Adapted from Hickson
GB, Pichert JW, Webb No Level 3 "Disciplinary"
LE, Gabbe SG, Acad ∆ Intervention
Med, Nov, 2007
Pattern Level 2 “Guided"
persists Intervention by Authority
Apparent Level 1 "Awareness"
pattern Intervention
"Informal" Cup
Single of Coffee
“unprofessional" Intervention
incidents (merit?)
Mandated
Vast majority of professionals - no issues -
provide feedback on progress

23. Awareness Intervention on Dr. __
• Letter with standings, assurances prior to & at meeting
• “You are here” graph with
4-yr Risk Scores
• Complaint Type Summary
“Concerns bullet list”
• Redacted narrative reports
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24. Risk Score vs. Percent of Physicians - National PARS® Data
The Risk Score reflects the complaints with which each physician was associated. It is based on an algorithm that
weights complaints recorded in the past year more heavily than those recorded in prior years.
300
250
Risk Score
200
150
100
Risk Score of 114 puts Dr. __
in the top 3% of orthopedists
50
0
0% 20% 40% 60% 80% 100%
Percent of Physicians *Submitted for publication

25. Does it work?
PARS® Overall Progress Report
Total # of high complaint physicians 853
Confidential and privileged
Departed after initial intervention 61 pursuant to the provisions
of State Peer Review
Statutes
First follow-up later in 2012 –2013 157
Total with follow-up results 635
Results for those with follow-up data:
Good – Intervention visits suspended 336 53%
Good – Anticipate suspension in 2012-2013 107 17%
Some improvement – Still need tracking 43 7%
Subtotal 486 77%
Unimproved/worse 110 17%
Departed Unimproved 38 6%
Total follow-up results 635
25 Hickson GB, Pichert JW. Identifying and addressing physicians at high risk for medical malpractice claims. In: Youngberg
25 B, ed. The Patient Safety Handbook, 2nd ed. Burlington, MA: Jones & Bartlett Learning; Chapter 28, 347-368; 2012

26. Malpractice Claims (per 100 MDs) FY1992 – 2012 *
16
14
12
Claims per 100 MDs
10
8 **
6
4
**TN Certificate of Merit
2
0
92-93 94-95 96-97 98-99 00-01 02 03 04 05 06 07 08 09 10 11 12
Fiscal Years
* Data used with permission, State Volunteer Mutual Insurance Company, a mutual insurer of 10,500 TN
26 non-VUMC physicians of all specialties, 29% to 33% who practiced in Middle TN during the target date.
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

27. Professionalism and Self-Regulation
• Professionals commit to:
• Technical and cognitive competence
• Professionals also commit to:
• Clear and effective communication
• Modeling respect
• Being available
• “Self awareness”
• Professionalism promotes teamwork
• Professionalism demands self and group regulation
• You have a critical role
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
27 Resources;2012:1-36.

28. Upcoming CPPA Conferences
• Promoting Professional Accountability: Addressing
Behaviors that Undermine A Culture of Safety
– Spring, 2013
• The How and When of Communicating Adverse
Outcomes and Errors
– October 5th, 2012
For more information
visithttp://www.mc.vanderbilt.edu/centers/cppa/courses.htm
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