If one accepts the notion that effective teamwork is a necessary element to the delivery of safe care in the complex hospital environment, then it’s clear that behaviors that diminish or threaten teamwork can compromise patient safety. However, how can an organization systemically identify such behaviors when they occur, and intervene in a way that can be sustained?
Physician leaders at Vanderbilt University Medical Center (VUMC) in Nashville, TN, decided to take on this problem with the development of what they call the Coworker Observation Reporting System (CORS). Three years into the implementation of CORS, investigators found that when effective safeguards are in place, not only are staff members willing to report unprofessional or disrespectful behaviors among providers, but when these behaviors are pointed out to the individuals involved, they self-correct their behaviors in the vast majority of cases.1
Program developers acknowledge that putting such a system in place requires high-level support and commitment, but they suggest it is a system that can improve culture and patient safety.
Establish Safeguards for Staff Reporting
The idea for CORS grew out of earlier work at VUMC that focused on identifying physicians at risk for medical malpractice.
“We found that a small number of physicians accounted for more than their fair share of patient complaints, which we know increases the risk for malpractice, so we set out to see if there might be parallel differences in physicians who generate more than their fair share of staff concerns,” explains William Cooper, MD, MPH, director of Vanderbilt’s Center for Patient and Professional Advocacy, and vice chair of the department of pediatrics. “It turns out that 3% of our physicians accounted for a large proportion of our staff concerns, and we know if we intervene with physicians to reduce patient complaints, we can be effective. We wanted to set out to see if a similar approach would be effective for staff complaints.”
How are staff complaints about a provider’s behavior relevant to patient safety? Cooper explains that when providers fail to model respect or effective teamwork, it threatens the right thing from happening for the patient.
“If a staff nurse is more worried about how a physician is going to behave when he or she enters the ICU, he or she may fail to attend to the tasks at hand,” he says. “We know that those slips and lapses are among the common sources of medical errors.”
Similarly, disrespect can manifest in providers failing to adhere to accepted best practices, safety checklists, and other issues that can directly affect patient care.
However, training hospital staff to report behavioral concerns about providers is challenging, Cooper acknowledges. “What we have found over the years is that a couple of things have to be present to encourage the sharing of these observations,” he says. “One is that the [reporting] individuals have to trust that the organization is going to respond, and they also have to feel that they have a certain element of psychological safety.”
For example, Cooper notes that if a nurse or tech enters a concern about a provider’s behavior into VUMC’s online occurrence reporting system, that person has to feel that it is going to be worth their time, that someone is actually going to do something with the information, and that there will be no retribution for entering the report.
Always Provide Feedback
To address these issues, staff members who enter reports always receive feedback from the CORS program.
“We don’t tell them the specifics, but we just let them know that we appreciate their willingness to share their concerns, and that we are committed to sharing their observations with the involved professionals, with the intent of giving them the opportunity to self-reflect on how their behavior wasn’t consistent with our culture,” Cooper explains.
Also, the “messengers” who are trained to deliver the information to the providers in question make it clear that any sort of retribution is out of the question.
“We include in [the messenger] training specific messages just to remind the team member receiving the report that if they were to have any conversation that could be interpreted as retaliation, that would require us to escalate, because in a safety culture you can’t tolerate retaliation against safety reporters,” Cooper says.
Providers who serve as messengers are most often nominated by their department chairs or their divisional leaders to serve in the role, Cooper notes.
“We generally look for messengers who are respected physicians who are committed to discretion and confidentiality, and who are themselves models of professionalism,” he says. “They undergo training in how to have these conversations in a non-judgmental way that increases the likelihood that the individual receiving the report will reflect and then hopefully modify [his or her] behavior when put in the same situation again.”
Weed Out Petty Concerns
The initial interactions between a messenger and a provider who has received a negative report from a staff member are referred to as single-report sharing.
“We make people aware that their behavior or something that they have done or said has upset another member of the team, and this is presented as an observation that they can react to and internalize,” explains Roger Dmochowski, MD, the physician leader of CORS, a professor of urology, and associate director of risk prevention in the Vanderbilt Health System.
Dmochowski allows that perceptions often differ between the two sides.
“It may be that the provider has a very reasonable, in their mind, explanation of what occurred and would like that heard, and we provide that venue,” he says. “You have to have a willingness to understand that these are the perceptions of one human about the interactions with another human or an interaction with humans as a group, so there is some necessity to realize that there may be alternative explanations, which allow the individual to at least in their own mind explain what is perceived.”
Also, if a report is deemed to be petty or not substantial, a supervisor has the option not to deliver the message, Dmochowski observes.
“There is that necessity to be aware of pettiness, and there are some individuals who rather than directly addressing an issue will actually revert to writing something or using innuendo,” he explains.
However, Dmochowski notes that in many instances, the reports are actually consistent with other issues that have arisen involving individual providers, and the staff reports help to guide interventions that may be necessary, such as coaching or anger management, for example.
Cooper concurs, noting that some providers who have been reported have been known for years to treat members with disrespect, but once they hear about their behaviors from a messenger, the complaints often cease. Through the CORS program, VUMC now has data to back up this claim.
“So far, we are seeing that 70% [of the providers] get no subsequent complaints in a one-year follow-up period,” he says.
A process is in place in CORS for what is called level 1 “awareness” interventions, level 2 “guided” interventions, and level 3 “disciplinary” interventions if providers continue to receive reports about their behavior after one or two single-report sharing episodes.
Flatten the Hierarchy
As far as effect on culture is concerned, Cooper notes there are anecdotal reports that certain provider behaviors that have been consistently problematic for a long time have improved since implementation of the CORS program. He stresses that the CORS reports, as well as the messenger awareness sessions, are confidential. As a result, staff do not necessarily attribute such improvements to the CORS program, but they have noticed a change.
Would it be better if team members simply reported their concerns directly to the providers they have issues with? Perhaps, but that isn’t always realistic in the current healthcare environment, Dmochowski observes.
“One of the things we have still in modern medicine is a relative hierarchy such that there is a perception of hierarchal dominance, and people are hesitant to go around the hierarchy,” he says. “This allows that flattening of hierarchy.”
Currently, the CORS program is designed exclusively for reports regarding physicians, advance practice nurses, and physician assistants. However, administrators are working with VUMC’s human resources team to see whether there are appropriate parallel processes that could be used to address the behaviors of other team members, Cooper explains.
In addition, VUMC is expanding its work to include several other sites around the country that have expressed an interest in adapting the CORS program to their own settings.
“That will give us a national comparison database so we can not only show a physician how [he or she] compares locally, but also nationally to several partner organizations,” Cooper says.
Get Support From Top Brass
While he is a big believer in CORS, Dmochowski explains there are several pieces that must be in place for the system to work.
“First and foremost, you have to have leadership commitment to this,” he explains. “You can’t do it without the very top, c-suite leadership saying, ‘yes, [we] believe in this, and [we] want to try to remediate bad behavioral patterns.’ That is key.”
Second, Dmochowski says the system requires a stable process that will allow reporting, the aggregation of data, and the delivery of data in a manner that is repetitive and reproducible.
“Third, you’ve got to have trained peers who are willing to basically sit down with their colleagues ... and have discussions regarding whatever has been reported, realizing that it is by and large an awareness intervention,” Dmochowski explains. “It is just a very small group of people who have repetitive sorts of behavioral issues, but repetitive behavioral patterns then point to other issues.”
For example, VUMC has discovered issues with physicians or providers who have experienced cognitive declines, and others who have been under the influence of various exogenous agents that have affected their behaviors at work, Dmochowski notes.
“This has allowed us to have direct intervention in a very timely fashion, which obviously serves patient safety,” he says.
Cooper advises hospitals interested in taking on the issue of unprofessional behaviors to plan carefully and assess whether they have the infrastructure in place to launch an effective program.
“You have to have the right people in place, you have to have the right process, and you have to have the right data systems,” he says. “Really be thoughtful and careful in ensuring that you are able to measure whether physicians have been associated with more than their fair share of reports.”
Cooper adds that leaders must be committed to treating everyone the same and making sure everyone receives interventions regardless of their positions within the organization.
“At the end of the day, this is about culture change, so if you are going to have culture change, you have to be intentional about it,” he says. “You have to ensure that [the program] aligns with your values and that you are willing to step up to the plate when you want to make a change.”
- Webb LE, Dmochowski RR, More IN, et al. Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals. Jt Comm J Qual Patient Saf 2016;42:149-161.
- William Cooper, MD, MPH, Director, Center for Patient and Professional Advocacy; Vice Chair, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN. Email: .
- Roger Dmochowski, MD, Professor of Urology, Associate Director of Risk Prevention, Vanderbilt Health System, Nashville, TN. Email: roger..