Every year during our “Incoming Residents’ Week” we do an introduction to patient safety session for several hundred residents. As you’ve heard us in the past, we like “stories, not statistics” so we usually begin with a video that is hard to forget. For several years we have begun with Sue Sheridan’s heart-wrenching testimonial and plea from the TeamSTEPPS™ program. That’s a hard one to beat. But this year we are using a new video “Lucian Leape on Key Lessons in Patient Safety” in which he highlights what he considers to be the number one problem in patient safety today: we have a culture of disrespect.
Fortuitously, a recent ISMP Newsletter (ISMP 2012) highlights and summarizes Dr. Leape’s recent 2-part series on the culture of disrespect (Leape 2012a, Leape 2012b). Read the ISMP summary if you’re short on time but at some point read the full articles by Leape et al. He really hits the nail on the head! On many occasions you’ve heard us say that the biggest reason we have failed to move the bar in patient safety is that we have failed to change the culture to one of safety. But Leape’s argument is that our pervasive culture of disrespect is what is blocking our ability to move to a culture of safety.
He and his colleagues describe disrespectful behavior in 6 categories. While we all easily recognize the first category – the disruptive physician – such account for a relatively small proportion of the problem. Moreover, the disruptive physician is easiest to recognize and probably easiest to take action on. Since the Joint Commission’s Sentinel Event Alert #40 “Behaviors That Undermine a Culture of Safety”, issued in 2008, most hospitals have taken steps to identify egregious behaviors and deal with them appropriately.
But Leape’s main point is that the behaviors in the other categories are the more subtle parts of the continuum of disrespect and collectively the far bigger problem. Most of the culture of disrespect is rooted more deeply in the highly hierarchical environment in medicine where the physician has been traditionally accorded a stature at a different level than everyone else. Leape notes that remains a huge barrier in a time when we have to rely on growing multidisciplinary teams to manage increasingly complex medical conditons.
Importantly, while some aspects of disrespect are due to characteristics of individuals, Leape emphasizes that disrespectful behavior is also learned, tolerated and reinforced by the hierarchical hospital culture.
The second category in part 1 of the Leape papers (Leape 2012a) is humiliating or demeaning treatment of nurses, residents and students. (This is also one of situations where people begin to “learn” disrespectful behaviors and perpetuate the problem.) A third category is passive-aggressive behavior, characterized by negative attitudes, criticizing authority, blaming others, etc. The fourth category, passive disprespect, differs from passive-aggressive behavior in that the latter is often done with with anger and intent to cause psychological harm whereas passive disrespect is not malevolent or rooted in anger. Passive disrespect is much more common. It includes things like chronically being late for meetings, responding slowly to calls, not dictating charts in a timely fashion, and generally being poor team players. Resistance to good practices like hand hygiene, timeouts and use of checklists are common examples. The fifth category is dismissive treatment of patients. They include behavior like interrupting the patient while the patient is trying to explain symptoms, talking “about” the patient on rounds rather than “to” the patient, etc. The last category, systemic disrespect, includes all the system nuances that are disrespectful of patients, physicians, nurses, and all other personnel. Making patients “wait” has become an ingrained fact of life. Productivity and time pressures abound for providers of all disciplines. And minor forms are common: failure to address patients or staff appropriately, lack of “please” and “thank you”, etc. Leape et al. go on to describe the consequences of these behaviors and the many endogenous and exogenous factors involved in producing disrespectful behaviors.
In part 2 (Leape 2012b) the authors discuss what we must do to create a culture of respect. Modeling respectful conduct and leadership are critical and this must be begun in medical school or other professional schools (another of our frequent themes: we preach “teams” yet all of our education is done in silos). In addition, they recommend that part of the evaluation process for all staff (including physicians) should include an assessment of respectful behavior (perhaps in a “360 degree” review where personnel at all levels have input into the assessment). Adopting a code of conduct is another first step. But the most important piece is responding appropriately and in a timely fashion when disrespectful behavior occurs. Developing a learning environment (eg. where everyone has equal input into root cause analyses, etc.) is another key to creating a culture of respect.
Interestingly, another new article from the hospitalist literature (Reddy 2012) demonstrates how often “unprofessional” behaviors occur amongst hospitalists. Many of these behaviors noted were really expressions of disrespect for either colleagues or patients. They include things like: making fun of other physicians, having personal conversations in patient corridors, texting during conferences, “celebrating” blocked admissions, signing out work early, doing handoffs over the phone when a face-to-face handoff could have been done, etc.
Our January 2011 What’s New in the Patient Safety World column “No Improvement in Patient Safety: Why Not?” and our March 29, 2011 Patient Safety Tip of the Week “The Silent Treatment: A Dose of Reality” also discuss failure to change the culture as barriers to patient safety and good healthcare. Turning a blind eye or deaf ear to such problems just continues to make the working environment worse for all parties involved. We’ve seen numerous occasions where staff had previously stepped forward to report such behaviors, only to be ignored or, worse yet, suffer retribution for their actions. So the organization as a whole needs to ensure a supportive environment is present so that staff do not feel uncomfortable in confronting such individuals or in addressing such threats to patient safety. You can have all the policies and procedures in the world but if your culture is not conducive to eliminating these hazards we will never move patient safety to that next level.
You’ve often heard the phrase “culture trumps ________” (fill in the blank with words like policy, procedure, strategy, tactics, vision, etc). In fact, “Culture trumps…Everything!” So until we can get at that true root cause – the culture of disrespect – all the great patient safety interventions developed over the years will continue to have a limited impact.
On second thought, don’t just read the short version of the Leape papers and don’t just watch the video. Failing to take the time to really understand the systemic nature of the problem would be an act of disrespect itself! Read the full versions along with the summary and the video. And do it over and over. We’ve got to get this one right.
"Lucian Leape on Key Lessons in Patient Safety"
ISMP. Dr. Leape and colleagues present a compelling call to action to establish a culture of respect. ISMP Medication Safety Alert! Acute Care Edition. June 14, 2012
Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. [Epub ahead of print, May 22, 2012] 2012; 87: 1-8.
Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. [Epub ahead of print, May 22, 2012] Acad Med. 2012; 87: 1-6.
The Joint Commission. Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety. July 9, 2008
Reddy ST, Iwaz JA, Didwania AK, et al. Participation in unprofessional behaviors among hospitalists: A multicenter study. Journal of Hospital Medicine 2012; Article first published online: 16 MAY 2012 | DOI: 10.1002/jhm.1946