Spotlight Case

1. Spotlight Case Difficult Encounters: A CMO and CNO Respond

2. Source and Credits • This presentation is based on the October 2009 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Ernie Ring, MD; Jane Hirsch, RN, MSUCSF Medical Center • Editor, AHRQ WebM&M: Robert Wachter, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Appreciate the risk of disruptive behavior and understand institutional response to such behavior • Describe characteristics of a culture that encourages open communication, respect, and opportunities for interprofessional learning and teamwork

4. Case: Difficult Encounters An 89-year-old man was admitted to the orthopedic service after sustaining a hip fracture. The patient’s family physician requested cardiology evaluation. Surgery was delayed while the consultant evaluated the patient. The cardiologist identified severe aortic stenosis (echocardiogram showed an aortic valve area of 0.9 cm2) and recommended the patient not go to surgery.

5. Case: Difficult Encounters (2) On the afternoon following the cardiologist’s report, the orthopedic resident called the operating room to schedule the patient for surgery later that evening. The nurse on the floor paged the orthopedic resident and read the cardiologist’s conclusions and recommendations over the phone. The resident came to the floor, told the nurse she was “stupid” and confidently explained that the case would be done under spinal anesthesia, so the cardiologist’s concerns were nothing to worry about.

6. Case: Difficult Encounters (3) Spinal anesthesia can cause unexpected and sudden hypotension resulting in hypoperfusion of the coronary arteries and sudden death. At 7:00 PM, the nurse called the hospital’s Chief Medical Officer (CMO), who was getting ready to leave for the day.

7. Case: Difficult Encounters (4) The CMO promptly paged the orthopedic resident, who was meeting with the attending orthopedic surgeon to review x-rays of the case. The CMO went to the x-ray department and talked with two residents and the attending. The CMO patiently explained the risk of perioperative death associated with hypotension in the presence of severe aortic stenosis. The attending then called the operating room to cancel the case.

8. Case: Difficult Encounters (5) The following day, the CMO reviewed the nurse's intervention with the Chief Nursing Officer (CNO). Two days later, the patient suddenly arrested on the floor. Resuscitation efforts were unsuccessful.

9. Unprofessional and Disruptive Behavior: the CMO’s View • Case review • A resident was rude and disrespectful to a nurse for pointing out a consulting cardiologist’s concern about a patient’s high risk for surgery • The resident responded by demeaning the nurse, and ignored her warning by scheduling the surgery • This prompted the nurse to take immediate action by contacting the CMO and asking him to intervene and stop the surgery

10. The CMO’s Responsibility to Protect Patient Safety • The author, a former CMO, would have quickly evaluated the clinical facts • Contact chief of relevant service, involved providers • Must deal with immediate clinical issues first • Once this dealt with, turn to issue of behavior • CMO interviews all witnesses trying to understand both sides of the story • If case involved resident (as here), need to work through department chair, residency program director

11. Written Codes of Conduct • Certain acts never tolerated, dealt withat highest leadership level • Physical contact, throwing equipment, very threatening language • Depending on provider’s past action, might refer to anger management or even firing • If first complaint, work with department leadership to counsel, facilitate apology to nurse

12. If an Attending Physician… • CMO responds to every complaint about physician unprofessional behavior • Sends an email thanking the reporter, assuring follow-up • Meets with physician–subject of complaint • Physicians often wanted to talk about problem that precipitated outburst • Hear them out, but then focus on inappropriate reaction • Letter to credentials file chronicling results of meetings

13. A Problem of Authority • CMO and hospital has limited authority over attending MDs • Medical staff bylaws provide attendings with many rights, including extensive due process • CMO can suspend MD to protect life or imminent danger, but disruptive behavior rarely rises to this level of threat • More commonly, problem is ongoing pattern of unprofessional behavior that persists despite counseling

14. Dealing with Repeat Offenders • At UCSF Medical Center • Written request to president of medical staff • Ad hoc committee of med staff appointed to investigate • Ad hoc committee chair makes recommends to Executive Medical Board (EMB) • EMB decides on action; if recommendation is reduction or suspension of privileges, MD has right to “fair hearing” • Extremely protracted (often years) process

15. The Problem, From CMO’s Perspective • Need incremental punishments that fit crime • Presently, only available punishments (suspension, often with report to state regulators required) too severe/cumbersome to be used • Medical center left with responsibility for protecting staff/patients without real control over MD staff • Most physicians aren’t problematic, leaving CMO the time to focus on the few “bad apples”

16. The CNO’s Perspective • Disrespectful, disruptive, hostile behavior remain significant issues, leading to errors • New Joint Commission leadership standard requires hospitals to have comprehensive approach for addressing behavior problems • In this case, we see unprofessional behavior and poor teamwork • Such behavior can lead to conflict avoidance, silence and poor morale among nurses See Notes for references.

17. In This Case… • Nurse decided, appropriately, to contact CMO • She is to be commended for doing so • Probably jumped several levels in “chain of command” • CMO acted promptly to deal with immediate clinical situation and behavioral issues

18. CMO and CNO Must Work as Team • Must role-model professional collaboration, teamwork • Also need organizational commitment to skills training in conflict resolution and conflict engagement • CNO must support nurses to handle conflict in optimal ways • Interprofessional training can be helpful

19. Things are Getting Better • Unprofessional behavior less likely to be tolerated today than in past • A few senior physicians have lost privileges • Safety innovations (rapid response teams, time outs, etc.) have helped • Teamwork training has helped change culture • But more change is needed • Many nurses still feel complaints aren’t taken seriously, or that a double standard remains