Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.

This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.

Physicians who behave unprofessionally toward other health care workers compromise both safety culture and patient health. Hostile behavior among surgeons is particularly harmful because surgical care is both teamwork-dependent and has high stakes. Although many have reported anecdotally that disrespectful surgeon behavior has led to patient harm, it is challenging to study systematically. Investigators sought to determine whether patients whose surgeons had coworker reports of unprofessional behavior experienced more harm. Surgeons at two academic medical centers who had coworker reports of unprofessional behavior in the 3 years before a surgery were more likely to have patients experience both medical and surgical complications after the surgery. These findings highlight the importance of empowering team members to report unprofessional behavior so that it can be remediated. Two WebM&M commentaries describe different approaches to addressing unprofessional physician behavior.

When physicians and advanced practice providers behave unprofessionally, they can diminish both individual patient safety and organizational safety culture. Historically, power gradients in health care have led to underreporting of unprofessional provider behavior. Investigators analyzed an anonymous incident reporting system for coworkers, created a taxonomy for unprofessional behavior, and then validated the taxonomy with a group of experts. They classified 120 reports into 4 professionalism domains: competent medical care, clear and respectful communication, responsibility, and integrity. Disrespectful or offensive communication was the most common unprofessional behavior observed. Two previous WebM&M commentaries explored approaches to unprofessional behavior among trainees and attending physicians.

Patient complaints are associated with increased malpractice risk. This retrospective cohort study of more than 1300 ophthalmologists sought to determine whether ophthalmologist age was linked to likelihood of receiving unsolicited patient complaints. The authors found that unsolicited patient complaints occur less frequently among older ophthalmologists.

… as a part of safety culture assessment. … Martinez W, Lehmann LS, Thomas EJ, et al. Speaking up about …

Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.

Disrespectful behavior and lack of speaking up are hallmarks of dysfunctional safety culture, which can be resistant to change. In this pre-post study, investigators implemented a voluntary reporting system called Co-Worker Observation Reporting System (CORS) to allow health care team members to report "disrespectful or unsafe conduct." Designated trained peers had cup-of-coffee conversations to discuss reports with the associated individuals, and after receiving this feedback most providers did not have a repeat report completed about them. Even when there were two or more complaints about a provider, the vast majority of individuals were able to regulate their behavior following receipt of feedback. The number of reports increased during the intervention, suggesting that team members saw a benefit to reporting disrespectful or unsafe behaviors. This comprehensive, system-wide intervention demonstrates that safety culture can improve over time.

This study validated two new surveys (Speaking Up Climate-Safety and Speaking Up Climate- Professionalism) for measuring aspects of safety culture that are associated with resident physicians' likelihood of speaking up about patient safety concerns and unprofessional behavior. Both scales performed well on psychometric testing. These surveys may fill current gaps in widely used assessment tools.

Although physicians generally support disclosing adverse events, they often choose their words carefully when discussing errors with patients. Since few training programs include formal curricula in error disclosure, most residents and medical students learn these skills through direct observation of senior clinicians. This survey of trainees evaluated the effects of negative and positive role models on their attitudes and behaviors regarding error disclosure. Most trainees had observed a harmful medical error, and the majority reported exposure to positive role models. Poor role models were associated with negative trainee attitudes about disclosure and an increased likelihood of trying to evade responsibility for harmful errors. More than one-third of trainees reported nontransparent behavior in response to a harmful medical error they had made. Addressing the importance of role models in shaping clinicians' future behaviors will be important to advancing full disclosure efforts. An AHRQ WebM&M perspective by Dr. Albert Wu discusses the importance of disclosing adverse events.

A recent Australian study showed that a small number of doctors account for a disproportionate share of complaints by patients. These physicians are more likely to engage in disruptive behavior and be the subject of a malpractice lawsuit; however, system-level solutions for addressing poorly performing physicians are lacking. This study reports on the outcomes of a peer feedback and coaching program for physicians who had received multiple patient complaints and were therefore considered at high risk for malpractice lawsuits. This program, which was described in a 2009 AHRQ WebM&M interview, consists of a tiered approach that relies on feedback of patient complaints accompanied by one-on-one counseling by trained peer clinicians. Among more than 370 high-risk physicians who received coaching, nearly all responded professionally to the feedback, and almost two-thirds were considered to have responded appropriately to feedback over an average of 2 years of follow-up. Although disruptive and unprofessional behavior has long been tolerated in health care despite the safety risks, this innovative program demonstrates that this problem can be successfully addressed.

This commentary discusses strategies to address medical errors and preventable adverse events, including checklists, team training, and simulation.

This commentary discusses experts' recommendations for early identification of problem residents as a strategy to prevent poor or disruptive behaviors from being ingrained in their practice.

Efforts to address professionalism and individual accountability remain important in patient safety, even with the role systems play in poor patient outcomes. Past studies have tried to predict poor professional behavior based on medical school performance, and concerns have also been raised as a result of changes in residency training requirements. This article describes the efforts of one academic institution in teaching professionalism. The authors share their approach and model for addressing disruptive behavior, and their related interventions to prevent it. An AHRQ WebM&M conversation and commentary also discuss professionalism and patient safety.

… patient safety from this important resource. … White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Cause and effect …

This study examines the association between physicians’ patient complaint records and their risk management and malpractice experiences. A retrospective review of 645 physicians in a large U.S. medical group was performed. Both patient complaints and risk management events were higher for surgeons than nonsurgeons. Both complaint and risk management data were positively correlated with clinical volume. Risk management file openings, openings with expenditures, and lawsuits were significantly related to total numbers of patient complaints.