Samaritan Pacific Communities Hospital Stephen Hale M.D., Verda Hale R.N.,M.S.N.

June 25, 2013

About Us

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Samaritan Pacific Communities Hospital provides health care for residents and tourists throughout a 27-square-mile area in Lincoln County. This area includes the communities of Newport,

Waldport, Toledo, Depoe Bay and Yachats.

The hospital was built in 1952 as a 17 bed acute care facility. Since then, it has been remodeled and expanded to meet the growing needs of the community. Currently, the hospital is a 25 bed

critical access hospital, with 380 employees, 110 of whom are nurses, and 120 volunteers.

How We Got Started

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• Why did your hospital want to do this?

We acknowledged an organizational problem. Committed to take an active approach to disruptive behavior knowing the growing concerns about workforce shortages, staff satisfaction and retention, hospital reputation, liability and patient safety.

• How did you engage staff and get ownership?

Spreading the word through staff, manager and medical staff meetings

Expert education/training- Dr. Alan Rosenstein

Developed a reporting tool with a closed-loop feedback mechanism

Zero-tolerance and persistence

Top management commitment

• To what extent was your hospital’s administration involved?

Senior management/CEO highly committed

Timeline of Events

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Dates Event Description

Spring 2009 First Team STEPPS Master Trainers

Fall 2010 5 more trainers and a physician leader is born

Fall 2010 Employee training begins

Spring & Summer 2011 Master Team STEPPS instructors spend time “walking the talk” on unit rounds, team debriefings, case reviews, RCAs.

Winter 2012 First multidisciplinary RCA using Team STEPPS as the framework.

October 2012 Disruptive Behavior survey distributed to all employees through survey monkey. Formal disruptive behavior training is embedded in Team STEPPS training.

December 2012 Disruptive Behavior Task Form is born and a reporting system implemented.

Present Spread and sustain Team STEPPS and Disruptive Behavior initiatives.

Definition: “Disruptive behavior” is defined as any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment that can potentially negatively impact patient care.

0 20 40 60 80 100

Other

Physical abuse

Berating in private

Berating in front of patients

Abusive anger

Insults

Condescension

Berating in front of peers

Abusive language

Disrespecful interaction

Yelling/ Raising voice

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Joint Commission Journal on Quality & Patient Safety August 2008

Have You Ever Witnessed Disruptive Behavior?

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Linkage Between Disruptive Behavior and Undesirable Behavioral Factors Occurring Sometimes, Frequent and Constant

95 95

85 92 89

95

0

20

40

60

80

100

Str

ess

Fru

str

ation

Loss o

fC

oncentr

ation

Reduced R

N/M

DC

olla

bora

tion

Reduced

Info

rmation

Tra

nsfe

r

Re

duced

Co

mm

un

ication

Perc

en

t

…

92% 90%

83% 77% 82% 88%

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Linkage of Disruptive Behavior to Undesirable Clinical Outcomes Occurring

Sometimes, Frequent, and Constant

…

68% 74% 67%

57%

78%

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Are You Aware of Any Specific Adverse Event That Occurred as a Result of Disruptive Behavior

18%

…

10

Could These Specific Adverse Events Have Been Prevented?

75%

…

Intervention Process

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• Organizational Culture Assessment – Recruitment behavior & personality/leadership commitment/structure

and process – Types of physicians; environment

• Clinical Champions – Peer mentoring; trust; collaboration

• Recognition and Awareness – Early identification by incident reporting, following rules – Education: responsibility and accountability

• Structured Education/Training – Diversity, sensitivity, conflict management, assertiveness

• Collaboration/Communication Tools – Intent, barriers, exchange, outcomes

• Policies and Procedures • Reporting Mechanism • Intervention

– Prevention, real-time, post-event, long-term • Reinforcement of Patient Safety Initiatives • Prevention

Intervention Strategies • Prevention

– Raise awareness

– Education/training/accountability

• Pre-event early intervention

– Empathy and assistance/support services

– Coaching and counseling (HR/Wellness Committees)

• Real-time intervention

– Assertiveness/assistance/support

– Discussion “cup of coffee”

– Cause/effect analysis; probe for other issues

• Organization based intervention

– Gather data with follow-up.

– Options (bad day)

– Pattern Vanderbilt (algorithm)

– Develop action plan (1,3 and 6 mos-HR, EAP)

– Other resources (dyad model)

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Disruptive Behavior

witnessed

Attempt Resolution and/or

Team STEPPS Tools

Utilized

Resolution

Successful?

Yes No

Inform Supervisor and Manager

DISRUPTIVE BEHAVIOR REPORTING ALGORITHM

Last revised: August 20, 2012

DBTF will report Performance

Improvement measures quarterly to the

Administrative Team

If further attention is necessary, information

will be passed to appropriate department

administrator for follow-up

The Disruptive Behavior Task Force (DBTF)

will evaluate reported incidences to

determine if the incident should be referred

on (either in addition to or instead of) as an

Incident Security Report or an Unusual

occurrence Report.

A response letter ( opportunities for

improvement) and the attached copy of

the reporting form will be sent to the

reporting individual/manager for review if

appropriate.

Complete Disruptive Behavior Report Form

Barriers and Solutions

Barriers Solutions

• Culture

• Lack of institutional integrity

• Lack of definition

• Fear of reporting

• No process for reporting

• Poor adherence to practice guidelines

• Resistance to physician ownership/”witch hunt”

• Civility

• Zero Tolerance

• Educate

• Breakdown hierarchy

• Reporting tool

• Low Emotional Intelligence

• Patient safety/reputation/external/ part of design

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Advice for Others & Lessons Learned

• Awareness (covert vs overt)

• Committed senior management (CEO, CNO, Physician champion)

• Consistent reporting (timely feedback)

• Zero-tolerance (Rationalization/Justification)

• How to: Effective intervention (engagement vs enforcement), Action plan-carrot/stick

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Plan for Spread/Sustainment

• Conflict management training

• EAP

• Periodic Employee Wellness Assessment (MBI, ProQual)

• Staff Retreats

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Next Steps

• Post survey

• Annual competency

• Employee wellness- a missing quality indicator

• Patient/staff satisfaction

• Recognize and reward

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Contact Info

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• Stephen Hale M.D. Director Hospitalist Program

Office: 541-574-4961

Pager: 541-265-1849

• Verda Hale M.S.N. Director Quality Management

Office: 541-574-4748