Patient Safety Tip of the Week
July 7, 2015 Medical Staff Risk
Issues
We haven’t done many columns on pure medical staff issues.
But several recent articles have appeared that illustrate medical staff issues
impacting patient safety. Disruptive physicians, aging physicians, low-volume
physicians, and too-early adopters all bring issues that impact patient safety and
create problems for staff morale, patient satisfaction, and hospital image.
The disruptive
physician
The disruptive
physician, of course, is typically the most difficult medical staff
problem. You all know them. They bully and intimidate staff. The cut corners.
They violate rules. They show up late for cases. They throw things. But when
you try to take corrective action no one will testify against them. When
confronted about their behavior they almost always blame someone else as having
been incompetent or doing something wrong.
A very interesting viewpoint on the disruptive physician was
recently published (Gewertz
2015). Gewertz begins by describing bad
behaviors of physicians. Then he describes an episode where he, himself, flies
off the handle when the attendant at his local gym tells him he cannot use his
cell phone. (I chuckled when I read this because the previous day I, too, had
reacted similarly when a store had double-billed me for a small electronic part
and was unable to immediately reverse the error.) Gewertz’s
point is that we all have the capability of reacting boorishly at times. But
the disruptive physician is not a one-time offender. Despite counseling and
anger management techniques the behaviors continue. Gewertz’s
suggested solution is two-fold: (1) ratchet up the peer pressure and (2) treat
each instance the same way you would treat a serious adverse event. He suggests
that the event should be reviewed in a confidential interdisciplinary session
where the nature and consequences of the interaction(s) would be discussed
openly. So you are really treating this
as a “near miss” and looking to prevent such events from leading to real
adverse events in the future. He is really linking the bad behavior to threats
to patient safety. Indeed, as most medical directors will attest to, sooner or
later the disruptive physician is involved in an incident with an untoward
patient outcome. And very often those who might have been able to intervene and
prevent the incident failed to do so, whereas they would have intervened with
physicians not exhibiting disruptive traits and behaviors. Gewertz’s
suggested process gets the problem out in the open and he hopes it would increase
peer pressure to stop the disruptive behaviors and also dampen the support,
overt or otherwise, that some other medical staff members provide for the
disruptive physician.
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 just as bad as the disruptive physician are those
described by Lucian Leape in what he considers to be
the number one problem in patient safety today: we have a culture of disrespect (see our July 2012 What’s New in the Patient Safety World column “A
Culture of Disrespect”). Leape’s 2-part
series on the culture of disrespect (Leape
2012a, Leape 2012b) and the video “Lucian Leape on Key Lessons in Patient Safety” describe
disrespectful behavior in 6 categories. The first category is the disruptive
physician as already noted. But the other categories demonstrate disrespect in
more subtle ways.
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
disrespect, 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. 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.
In our March 29,
2011 Patient Safety Tip of the Week “The
Silent Treatment: A Dose of Reality”) we noted a study (DesRoches
2010) which showed many physicians fail to report or confront their
colleagues who are either impaired or incompetent. A third of physicians who
knew that a colleague was incompetent or impaired failed to report that
physician. The most common reasons cited were belief that someone else would
take care of reporting, belief that nothing would happen as a result of
reporting, and fear of retribution. The same applies to addressing the
disruptive physician. In that column we also highlighted the 2007 American
College of Physician Executives (ACPE) Quality of Care Survey (Steiger
2007) which revealed numerous examples of failure of the system as a
whole to deal with incompetent, impaired or disruptive physicians.
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!”
Patient complaints
The physician with patient
complaints is often a related issue. A new study developed an algorithm to
predict physician risk of formal patient complaints using routinely collected
administrative data (Spittal
2015). The PRONE (Predicted Risk Of
New Event) score is based
upon 4 variables: (1) physician specialty (2) physician gender (3) number of
previous complaints (4) time since last complaint. While most patient
complaints (60%) were related to clinical issues, about a fifth were related to
communication issues (13% related to physician attitude or manner). The
algorithm led to a possible total score of 22. Those with scores of 0-2 had a
14% risk of a complaint in the next 2 years, whereas those with scores of 15-17
had an 88% risk of a complaint in the next 2 years. The authors suggest the
PRONE score could be used to flag physicians needing deeper review. They also
suggest one might “tier” interventions based upon the PRONE score. This is
interesting and likely to be especially of interest to risk managers. But
review of patient complaint patterns should be part of the credentialing
process for all healthcare providers.
In our July 2013 What’s New in the Patient Safety World column “"Bad
Apples" Back In?” we noted a study by Bismark
et al. (Bismark 2013)
which found that 3% of Australia’s medical workforce accounted for 49% of all
complaints by patients and 1% accounted for 25% of the complaints. Moreover,
there was a striking dose-response relationship, i.e. the more complaints about
a physician the higher the likelihood that there would be yet further
complaints. A doctor with a third complaint had a 38% chance of a further
complaint within a year and 57% chance of another complaint within 2 years. For
one with a fifth complaint, the chance of another complaint within 1 and 2
years, respectively, was 59% and 79%. The authors point out that we are often
too late to respond to physicians who have attracted multiple complaints and
that we should really look at complaints as sentinel events. The hope is that
early response may result in changes in physician behaviors. An accompanying
editorial (Paterson
2013) noted that patient complaints are the “canaries in the coal mine”
that should alert us to deeper problems and should not be ignored. Another
accompanying editorial (Gallagher
2013) focuses on the need to end our silence and speak up and tell our
colleagues about ways they can improve their care and communicate better. They
argue we need to do a much better job acting locally (at the departmental,
medical staff, academic unit, and clinical unit levels) to address these
behaviors before they need to go to higher levels. They also note the need to
develop better metrics for incorporating measures of patient satisfaction. And yet
a third accompanying editorial (Shojania
2013) argues there is a systems problem and that we need to focus
our resources on identifying such individuals and dealing with them. They also
note that, in some cases, there may be multiple system problems that lead to a
physician attracting multiple complaints (eg.
understaffing in a clinical area).
We, of course, would point out that staff complaints about physicians are just as important as patient
complaints. Sometimes the patient complaints go elsewhere (eg.
to state health departments, professional disciplinary bodies, medical
societies, etc.) and you may not be aware of these for some time. Staff
complaints are more often available to you immediately. It would be interesting
to see how the PRONE score algorithm would work using staff complaints rather
than patient complaints.
The aging physician
The other big problem is the aging physician. This is often even more difficult a problem to
deal with than the disruptive physician. This physician is usually a very well liked and respected physician who has practiced at the
hospital and community for many years. But now his skill levels and perhaps
cognitive capabilities have begun to decline. But he/she may not be aware of
this decline and everyone is afraid to confront him/her about it. Most of
his/her patients still love him/her and the board members are his/her friends
or have long interacted with him/her in community activities.
In a few cases he/she wants to continue practicing because
they need the income. More commonly they want to continue practicing because
they love what they are doing and that is their whole life. They feel obligated
to their patients and communities. Some don’t have outside interests and would
not know how to exist without coming to the hospital.
In the “old days” these physicians would hang out in the
medical staff lounge and be asked to serve as “assistant surgeons” (they didn’t
have to actually be surgeons) on surgical cases. But third party payors have now largely eliminated fees for assistant
surgeons in all but a few select surgical procedures. So that route for staying
active in the hospital has disappeared.
You begin to hear whispers amongst staff about their
concerns regarding this physician. They all know that sooner or later he/she is
going to do something that might result in patient harm. But they are not
willing to come forward with specific examples.
There is a good chance your hospital bylaws have not
included any verbiage about physician age since they don’t want to appear
discriminatory. And it is extremely difficult to specify an age at which some
sort of mandatory evaluation should be done. There are many physicians well in
their 70’s who practice just fine and some in their 50’s whose skills have
already deteriorated. At a recent AMA meeting the AMA voted to approve a report saying it is time to have a system for
assessing the competence of older physicians but there was considerable
sentiment expressed that screening physicians at a certain age “is
inappropriate and smacks of ageism” (Frellick 2015).
However, the AMA has not yet developed criteria or processes for such
assessments.
Some times it is a specific
physical skill or attribute that declines. We recall one physician who most
staff thought was “blind as a bat” who would every year find an ophthalmologist
who would certify that his vision was good enough for him to perform surgery.
Having access to truly independent
evaluations is critical.
Physicians on your own hospital staff are often uncomfortable evaluating a
medical staff colleague, knowing that their assessment may result in that
physician losing privileges. Equally important in our litiginous
society is the threat of a lawsuit by a physician who might lose his/her
privileges. We’ve seen instances where such physicians have sued for restraint
of trade when a colleague in the same specialty has made an adverse
determination about a physician. Because of that latter threat it is often
impossible to get such an assessment within the same city or geographic region.
NPR recently did a short segment on a program for evaluating
aging surgeons (Whitehead
2015). They highlighted the Aging
Surgeon Program at Sinai Hospital/LifeBridge
Health in Baltimore and Stanford’s Late
Career Practitioner Policy. It’s pointed out that there is a dearth of
literature to demonstrate that patient outcomes are any worse for older
physicians than younger ones.
There, of course, is precedent in other professions where
the safety for others is involved (eg. airline
pilots, air traffic controllers, firefighters, etc.) for either mandatory retirement
or mandatory competency screening at certain ages.
So while you are waiting for the AMA to come forward with
some specific guidelines (it could be a long wait!) you should probably develop
general criteria, irrespective of age, that would trigger some sort of
independent competency evaluation for your physicians and consider developing
an arrangement with one of the programs like the Aging
Surgeon Program.
Physicians returning
to the workforce
Physicians returning
to practice after a gap during which they did not practice is another
issue. There are numerous reasons a physician may have had a gap in practice.
The gap may have been to raise a family. Or it might have been due to illness.
A few years ago we saw a period when the stock market crash depleted retirement
resources for many retired physicians, who then sought to re-enter practice.
Ensuring that such physicians re-entering practice are competent and up-to-date
is therefore very important. In New York State we had a program at Albany
Medical College for preparing physicians to reenter practice. A list of
physician re-entry programs is also available at PhysicianReentry.org.
And the AMA has physician re-entry resources (AMA
Physician Re-Entry). A recent article in the southern California press (Gorman
2015) noted physician re-entry programs at Texas A&M Health Science
Center and Cedars-Sinai Medical Center and an online program in San Diego that
includes several months of course work followed by a written exam and
evaluation during mock visits with actors playing the role of patients.
Risks associated with
low-volume physicians and hospitals
For many years we have known that there is a relationship
between less-than-desirable outcomes and certain procedures performed by
surgeons or hospitals who are “low-volume” (i.e. they have performed a
relatively low number of such procedures). The list of procedures subject to
the low-volume effect keeps growing. Yet low-volume surgeons and low-volume
hospitals persist at doing these cases.
Three recent articles in US News & World Report made the
issue much more apparent to the general public. The first (Sternberg
2015a) highlighted the significant differences in mortality rates for
Medicare patients undergoing certain procedures in hospitals in the lowest
quintile of volume (for that procedure) compared to the highest volume quintile
over the 3-year period 2010 to 2012. For example, at the low-volume hospitals
the mortality rate for knee replacements was double that of the high-volume
ones and for hip replacement surgery the mortality rate was 77% higher in the
low-volume hospitals. Readmission rates for both procedures were also about 25%
higher in the low-volume hospitals.
The second article (Sternberg
2015b) noted that 3 healthcare systems (Dartmouth-Hitchcock, Johns Hopkins,
and University of Michigan) have adopted (or will shortly) voluntary
limitations of low-volume surgery. The recommended minimum number of procedures
per year for 10 procedures are list in a third article (Sternberg
2015c). For example, for knee replacement the recommended annual minimums
are 25 per surgeon and 50 per hospital. For hip replacement the recommended
annual minimums are also 25 per surgeon and 50 per hospital.
Quite frankly, we don’t think some of these recommendations
are rigorous enough. We wouldn’t even consider having a hip replacement from a
surgeon who has only done 25 cases per year or a hospital only doing 50 per
year.
This issue is a dilemma particularly for rural hospitals.
Rural hospitals look to surgical procedures as potential revenue sources,
particularly since profit margins are low or negative on the nonsurgical patients
they provide care for. The communities and hospital boards also like the idea
of providing services locally so patients don’t have to travel long distances
for these services. We’ve cautioned such hospitals against setting up programs
that cannot be reasonably supported by the volumes coming from their
“catchment” area, keeping in mind that many of the potential patients in their
geographic area are going to go elsewhere for the surgery anyway. Sometimes the
counter argument is using a surgeon who has substantial volume of the procedure
at another hospital who will now do surgery at both (or more) hospitals. That
is not enough. There is far more to surgery than the surgeon. The rest of the
surgical team and those providing the postoperative care must also have
extensive experience with the procedure. That is why the newly proposed
voluntary standards include case numbers for both surgeons and hospitals.
The “too early
adopter”
One of the subthemes related to low-volume surgeons is the “too-early adopter”. This is the physician
(often entrepreneurial) who is pushing for a new piece of equipment or pursuing
privileges to do a new procedure that has only been done in a few places. Often
there is also a hidden conflict of interest (love how those device manufacturers
know just who to approach to get their foot in the door!). This is the
physician who threatens to “take my business” to your hospital’s competitors if
you don’t let him/her do this new procedure at your hospital. Over the last
decade we saw hospital after hospital purchase robotic surgical systems based
on such threats. They’ll usually also get a patient or two to contact the
hospital administration to angrily ask “why aren’t you letting Dr. X do this
procedure?”
A recent viewpoint identified this issue as a potential
safety “blind spot” (Pradarelli
2015). That article discusses a court case in which a patient sued
multiple parties after suffering complications of a robotic-assisted
prostatectomy performed by a surgeon who had performed a very low number of
such procedures. While the plaintiff failed to prove that the device
manufacturer was responsible for damages, the case reiterates that
credentialing and privileging are responsibilities of the hospital and medical
staff. And you need to be especially aware that new devices have a way of
popping up in places like the OR with little advance notice to relevant
parties. It is extremely important that your organization have in place
policies and procedures that specify if and when a “vendor” may be present in
an OR (or other patient care area). If you do allow them access you need to
clarify what they may do and you also need to ensure they meet all the other
criteria you require for anyone else going into the OR (eg.
infection control training, health status screening, etc.) and that the patient
is informed of and agrees to their presence. Similarly, when booking surgical
or procedural cases you need to make sure staff are on the lookout for “red
flags” when unfamiliar pieces of equipment are included or when vendor presence
is requested.
Your organization needs to carefully review privilege
requests for “new” procedures and determine what the appropriate training
requirements are for such. And don’t rely on device manufacturers for the
training recommendations. Back in the ‘90’s when laparoscopic surgery was just
being developed we saw all sorts of surgeons get a few days of training on pigs
by device vendors and then a few proctored cases on real patients followed by
issuance of a certificate declaring their competence in the procedure. We all
recall that there was then a significant “learning curve” during which patient
complication rates were quite high. Better to look at training recommendations
from specialty societies, though even these may have some conflicts of
interest. But it is pretty clear that your organization is at risk if one of
your surgeons has adverse patient outcomes during surgeries that he/she has had
little experience with. And don’t forget that you need to consider what
training is necessary for the rest of your surgical teams when new procedures
are introduced.
Dealing with medical staff issues is always very political
and often generates lots of controversy. But those issues that impact on
patient safety need to be addressed and with the increased attention in both the
media and the medical literature now is a good time to get started.
References:
Gewertz BL. Disrupting Disruptive
Physicians. JAMA Surg 2015; 150(5): 385-386
http://archsurg.jamanetwork.com/article.aspx?articleid=2193713
The Joint Commission. Sentinel Event Alert, Issue 40:
Behaviors that undermine a culture of safety. July 9, 2008
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
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Leape LL, Shore MF, Dienstag JL, et al. Perspective: a
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ahead of print, May 22, 2012] Acad Med. 2012; 87:
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"Lucian Leape on Key Lessons
in Patient Safety"
http://www.youtube.com/watch?v=oSoklPmHCkg&feature=relmfu
DesRoches CM, Rao SR, Fromson JA, et al. Physicians' Perceptions, Preparedness
for Reporting, and Experiences Related to Impaired and Incompetent Colleagues. JAMA 2010; 304(2): 187-193
http://jama.ama-assn.org/content/304/2/187.abstract
Steiger B. Doctors Say Many
Obstacles Block Paths to Patient Safety. The Physician Executive 2007; 6-14 May
• June 2007
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MM, Studdert DM. The PRONE score: an algorithm for
predicting doctors’ risks of formal patient complaints using routinely
collected administrative data. BMJ Qual Saf 2015; Published Online First 8 April 2015
http://qualitysafety.bmj.com/content/early/2015/04/08/bmjqs-2014-003834.short?g=w_qs_ahead_tab
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MJ, Gurrin LC, et al. Identification of doctors at
risk of recurrent complaints: a national study of healthcare complaints in
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10 April 2013 doi:10.1136/bmjqs-2012-001691
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Paterson R. Not so random: patient complaints and ‘frequent
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http://qualitysafety.bmj.com/content/22/7/525.full.pdf+html
Gallagher TH, Levinson W. Physicians with multiple patient
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Published Online First: 10 April 2013 doi:10.1136/bmjqs-2013-001880
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Physicians for Competency, Report Asks. Medscape Medical News June 15, 2015
http://www.medscape.com/viewarticle/846497
Whitehead N. When Should Surgeons Stop Operating? NPR News June
18, 2015
http://www.npr.org/sections/health-shots/2015/06/18/414912417/when-should-surgeons-stop-operating
LifeBridge Health. Aging Surgeon
Program
http://www.agingsurgeonprogram.com/AgingSurgeon/AgingSurgeon.aspx
Weinacher A. Medical Staff Update.
Stanford to Implement a Late Career Practitioner Policy.
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http://physician-reentry.org/program-profiles/reentry-program-links/
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Gorman A. For doctors who take a break from practice, coming
back can be tough. Los Angeles Daily News 2015; June 18, 2015
Sternberg S, Dougherty G. Risks Are
High at Low-Volume Hospitals. Patients at thousands of hospitals face greater
risks from common operations, simply because the surgical teams don't get
enough practice. US News & World Report 2015; May 18, 2015
http://www.usnews.com/news/articles/2015/05/18/risks-are-high-at-low-volume-hospitals
Sternberg S. Hospitals Move to Limit Low-Volume Surgeries.
Three of nation's leading hospital systems say they will limit low-volume surgeries.
US News & World Report 2015; May 19, 2015
http://www.usnews.com/news/articles/2015/05/19/hospitals-move-to-limit-low-volume-surgeries
Sternberg S. Low Volume Hospitals: What to Ask. Asking these
questions can improve your odds of staying safe during and after surgery. US
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Pradarelli JC, Campbell DA, Dimick JB. Hospital Credentialing and Privileging of
Surgeons. A Potential Safety Blind Spot. JAMA 2015; 313(13): 1313-1314
http://jama.jamanetwork.com/article.aspx?articleid=2214093
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