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Consider the following scenario – does this healthcare worker sound like someone in your facility?
“A medical center’s Quality and Safety Department observes higher-than-expected postoperative infection rates for a surgical specialty. An interprofessional team is charged to create a plan to address these infection rates. The team reviews evidence-based best practices and develops a plan based on input from all professional groups whose work might be affected by the changes. The planning team gains leaders’ approval and implements a resulting ‘bundle’ of perioperative procedures to promote standardization and safety. One bundle element includes changing gown and gloves at key points during surgery. Following implementation, a nurse submits a report through the institution’s occurrence reporting system: ‘Dr. X performing [a procedure covered by the bundle]. At the appropriate point in surgery, a team member reminded Dr. X, ‘it’s time to regown and reglove.’ Dr. X replied, ‘I don’t agree. It’s not necessary, and I’m not stopping now.’ Dr. X continued with the procedure.”1
What would do about such a healthcare worker? Vanderbilt University Medical Center in Nashville uses the Co-Worker Observation Reporting System (CORS). Healthcare team members are well positioned to observe disrespectful and unsafe conduct — behaviors known to undermine team function. CORS addresses coworkers’ reported concerns about problem employees, and researchers found that a small percentage of medical and advanced practice professionals were associated with a disproportionate number of reported coworker concerns.
Concerns were reported, primarily by nurse and physician colleagues, about physicians’ and advanced practice professionals’ disrespectful and unsafe conduct. The CORS program includes feedback to the worker in question by peer messengers that discuss the reported behavior.
To conclude the scenario, “Following receipt of the report about the refusal to regown and reglove, a messenger met with Dr. X within 24 hours and shared the reporter’s perception that a safety protocol was disregarded. Dr. X replied by saying he felt the literature on impacts of gown/glove changes was equivocal. The messenger agreed that the evidence for each bundle element may vary, but referred to the consensus-building process that led to agreement to employ them all. The messenger said he regarded Dr. X as a key contributor to the department and a model for others, expressed confidence that Dr. X would reflect on why the concern was reported, and asked him to reconsider his position on regowning and regloving in support of what the messenger knew was Dr. X’s commitment to his patients.”
Overall, the researchers found that 3% of the medical staff were associated with a pattern of CORS reports, but 71% of recipients of pattern-related interventions were not named in any subsequent reports in a one-year follow-up period. Systematic monitoring of documented coworker observations about unprofessional conduct and sharing that information with involved professionals are a feasible way to address work culture problems, they conclude.
“Our experience with the CORS program suggests that well-trained, well-supported peers and leaders will share concerns-related feedback,” the authors note. “Follow-up surveillance to date indicates that the majority of professionals self-regulate after receiving CORS data.”
In an accompanying editorial,2 Richard C. Boothman, JD, executive director of clinical safety and chief risk officer at the University of Michigan Health System in Ann Arbor, wrote that systems like CORS could provide answers to a longstanding problem.
“Producing actual evidence of caregivers engaged in dangerous behavior has been largely the result of a lagging indicator too reliant on a pattern of harm — how many complications does it take before we finally identify a caregiver whose clinical behavior is problematic?” he noted. “How much staff turnover will we tolerate before we acknowledge an individual’s abusive behavior as a root cause? How many injuries do we tally until we realize that a process or a colleague may be to blame?”
Caregivers engaged in dangerous behaviors or who work with personal or clinical competency challenges are never a secret to those with whom they work, Boothman continued.
“The conspiracy of silence, however, is real,” he wrote. “I seriously doubt that there exists an experienced healthcare professional anywhere who has not had concerns about the behavior or competence of a colleague, but unlocking that information has been notoriously problematic, even taboo. There are multiple reasons for this of course. Staff members worry about retribution, fears both real and exaggerated.”
Encouragingly, the Vanderbilt CORS program shows signs of success and may serve as model to continue to address this issue, he concluded.
Financial Disclosure: Senior Staff Writer Gary Evans, Managing Editor Jill Drachenberg, and Consulting Editors/Nurse Planners Kay Ball and MaryAnn Gruden report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.