Kelly Gooch – Becker’s Hospital Review
Amid bullying, rudeness and violence in healthcare, one of the nation’s largest systems is emphasizing professionalism.
St. Louis-based Mercy, which operates more than 50 hospitals, began its partnership with the Vanderbilt Health Center for Patient and Professional Advocacy in 2009 by implementing the Patient Advocacy Reporting System at two of its hospitals. The collaboration expanded to include the Coworker Observation Reporting Systems and eventually evolved into a comprehensive professionalism program across Mercy’s network.
Chad Smith, MD, chief medical officer at Mercy Hospital Oklahoma City and its ministry medical staff leader, told Becker’s the partnership was born out of the correlation between poor professionalism and patient safety.
For example, a study published in JAMA Surgery in 2019 found that patients whose surgeons had higher numbers of reports from co-workers about unprofessional behavior in the three years before the patient’s operation appeared to be at higher risk of surgical and medical complications.
“I think as the healthcare industry continues to mature around patient safety, quality and looking at opportunities to continue to move the needle in a positive direction, [professionalism] is definitely one of those things that should be highly considered,” Dr. Smith said.
“When you look at what it takes for good patient safety programs, you have to have intentionality around it, and I think you have to work really hard to build that culture of safety and situational awareness.”
Before partnering with the Vanderbilt CPPA, Mercy addressed unprofessional behavior, but not in a defined, programmatic process.
Dr. Smith said the standardized and scalable approach, which is specific to about 17,000 physicians and advanced practice professionals across Mercy, is non-punitive and beneficial.
“It’s designed to create clear awareness about behavior and the impact of perceived poor behavior. I think that’s a very critical tenet and cultural aspect of the program,” he said. “We don’t use this as a punitive process; we use it to guide conversations about appropriate behavior. We also don’t take sides in the process — it’s intended to be an awareness process.”
On a day-to-day basis, if a caregiver has what they feel is a negative interaction with a physician or APP, Mercy relies on that caregiver to report and document their perceptions of the interaction.
“If they believe that [interaction] was unprofessional, then we ask them to categorize it as such in our anonymous reporting system,” he added.
The report then gets triaged by Mercy, and if labeled unprofessional, it gets routed to the Vanderbilt CPPA team, which helps collect data and confirms, through a multi-tiered review process, if it is in fact unprofessional.
“We also reserve the right within that process to determine if something is egregious and needs to be escalated to a higher level because it may involve abuse, neglect, or something that requires immediate attention,” Dr. Smith said.
The Vanderbilt CPPA then sends the Mercy team a list of reports, which the health system team reviews. This process — from reporting to when the Mercy team conducts a review — typically occurs within 24 hours, “because we know there’s a high sense of urgency around any of these conversations,” Dr. Smith said.
“For most physician reports, it requires what we call a ‘cup of coffee’ conversation,” he said. “We’ve refined that a little bit at Mercy because we have a strong heritage around the Sisters of Mercy. Our founder, Catherine McAuley, and her original sisters, who led the organization, would often have comfortable cups of tea when they were having conversations where they were discerning issues and making key decisions. We’ve rebranded it to ‘cup of tea conversations.'”
He said the goal is to identify a peer colleague to deliver the “cup of tea” — not a physician leader, not a CMO, not a medical director, not a section chief or department chair. Mercy identifies one of the individual’s colleagues at the bedside, shares the information with that peer, then asks them to have a conversation with the caregiver mentioned in the report for unprofessionalism.
“Essentially, that conversation is meant to be, ‘Hey, Dr. X, we got a report the other day, and I just wanted to share a little bit of the detail,'” Dr. Smith said.
“‘I don’t know what might have been going on in that situation, and there’s nothing that needs to be done in follow-up from this, but we want to make you aware there was an interaction with a caregiver that was perceived unprofessionally. I’m not saying they’re right or wrong; I’m just letting you know that this was reported, and I want you to think about it.'”
While some physicians reported for unprofessionalism may want to provide a reason or bring up something that caused them to be angry or upset, Mercy encourages the reporter to acknowledge their feelings and concerns.
“It’s not about right or wrong; it’s just, ‘Hey, this is the way the interaction was perceived. I just want you to think about it — nothing else to do. But, it sounds like there was a system issue that we might address, so I’m going to escalate that, and we’ll have the team look at whether there’s an opportunity to improve the system so that we remove frustrations from the workflow,'” Dr. Smith said.
“Then that’s it. We document in our system that the conversation was had and feedback received, and we’re done — nothing more to do.”
The majority of staff never have to have that “cup of tea” conversation more than once. Data from the Vanderbilt CPPA shows more than 90% of individuals who receive feedback based on a single event never develop a pattern.
Addressing consistent unprofessionalism
For the small number of clinicians who exhibit an apparent pattern, Vanderbilt’s CPPA team applies a research-based, multivariate algorithm to develop a risk profile that allows for tracking longer-term behavior. Once a certain risk threshold is met, the next level of intervention is initiated: “level one awareness.” This includes a summary of the redacted, collated reports and a comparison of where the clinician lies compared to local and national benchmarks. These rankings include comparisons across Mercy, within a given specialty, and even nationally across the more than 100,000 clinicians within Vanderbilt’s collaborative.
“That’s pretty impactful because physicians are generally competitive by nature. So, if you can share objective information that says, ‘Hey, you’re No. 2 out of 400 urologists across the nation,’ that resonates,” Dr. Smith said. “We’ll then see a significant proportion of providers who, after that level one awareness, get back on track and not have any further issues.”
When a provider does have three or more reports, Mercy asks questions such as, “What stresses might this provider be facing? Is this a symptom of burnout that we just haven’t recognized yet? What resources do we think we can provide? Do they have internal professional stressors? Do they have external personal stressors?’ What can we do to work with those providers to provide assistance?”
“Recognizing that, again, the vast majority aren’t people intentionally being mean — it’s just a manifestation of something they’re dealing with,” Dr. Smith said. “So, how can we help with that? That’s where we start to leverage this information when providers have more than three reports in a short period of time.”
Dr. Smith acknowledged there was some reluctance when the program initially rolled out. He said Mercy still sees pockets of reluctance, which is why education around the program is critical.
“You could definitely roll out a program like this and have a lot of resistance and reluctance because it’s not clearly understood what the intention behind it is,” he said.
“It’s really just all in how you deliver the message behind the program. And when you get them to understand truly this is patient-centric at its core, that’s when you overcome that moment of anxiety associated with it that they may be feeling.”
While the current program is specific to physicians and advanced practice providers, Mercy is exploring rolling the program out to nurses. The Vanderbilt CPPA programs are implemented nationally across physicians, APPs, nurses, residents and nonclinical faculty.
