Sometimes we find ourselves in circumstances we did not choose, but we learn from them. As a student, I was assigned to work with a surgical resident who had technical skills, but who was disrespectful to all medical team members. It was not a healthy learning environment. Years later, the surgeon took his life. I wondered, What if the disrespectful behaviors directed at students and nurses represented signs of mental illness? And what if I had just spoken up?

Years later, as a Vanderbilt faculty member, I had a second unexpected learning experience. Our Vice Chancellor, Dr. Ike Robinson, invited several of us to dinner but did not tell us why. After dinner, Ike shared about a well-recognized surgeon who harmed a patient. “All of us saw it coming,” he told us. “I talked to him about his behavior, but talking was not enough!” Ike challenged our group to get to work and create an effective approach to identify and address struggling professionals. Today, Ike’s initiative spans a network of 350-plus hospitals staffed by 300,000-plus professionals.

A third learning experience was launched by questions from Dr. Frank Sloan, a Vanderbilt economist. Frank had published a study confirming that only a small subset of physicians (2-8 percent) account for 70-plus percent of all malpractice claims and costs for their specialties. Frank asked, “Why do these physicians stand out, and what can we do to support our struggling colleagues?”

Over the next 20-plus years, our team has sought answers to Frank’s questions. Turns out, high malpractice risk is not related to complexity of care delivered or even to clinical competence but to modeling disrespect to patients, families, and coworkers and disregard for established safety practices like universal time-outs, hand hygiene, and speaking up. Respect builds trust, trust builds teamwork, and teamwork builds safety.

Think about the challenge of speaking up. If you have been disrespectful to me, and I observe what I believe represents a deterioration in a patient’s condition, what is the probability that I take the risk and speak up? Or is it more likely that I remain silent until I am certain? This is one reason patients cared for by high-risk clinicians are 20-30 percent more likely to experience surgical site infection, unplanned returns to the OR, and death when requiring trauma care.

So how can we break the cycle? The key is to address disrespectful behaviors early, before patterns develop. To successfully address early identification, we rely on the experiences of patients and families reported to patient relations offices or to the experiences of coworkers submitted through electronic safety systems. But remember, reporting requires trust.

Based on 30 years of experience, we know the vast majority of team members who experience slips in behavior self-regulate if a trusted peer, not a leader, shares a report and asks them in a respectful way to just reflect…no coaching, no diagnosing.

Approaching 90 percent of reports of disrespectful behavior will be successfully addressed with no more than “sharing coffee.” But don’t share coffee unless you’re willing to escalate as required. If patterns develop, peers are assigned to deliver discipline-specific comparative data, again to promote “awareness” and self-regulation. If there’s still no improvement, a leader steps in with a plan to connect the struggling professional with the right resources. Fewer than 0.3 percent of your professionals will reach that point, and the great news is that at least 60 percent will be able to successfully return to the workplace.

One additional thought: I always talk about professionals rather than providers. Professionals have competence supported by a body of knowledge that they own. Professionals also have a responsibility to self-regulate, as individuals and as members of medical teams. That said, self-regulation is the first step. So, before you walk into an ED, ICU, or OR this week, ask yourself: When I walk in, will my presence make it easier or harder for fellow professionals to do their work?

So, if you are considering building or strengthening your plan to support the pursuit of professional accountability, where do you start? I have made a thousand mistakes over the past 37 years but have learned three things that matter. You must have real leadership commitments supported by the right people, processes, and systems:

• Leadership: Leaders must model professionalism and cannot “blink.” The work must link to your core values and performance evaluations.
• Infrastructure: You need a champion who “owns” and manages the work as well as trained peers who volunteer to serve and policies that support the process. These policies should promote nonjudgmental, respectful sharing of stories and data supports escalating directly to leadership interventions for non-responders. There should be no exceptions for those with perceived “special value.”
• Systems: Provide credible comparative data and bring reports together in one place, so high-risk concerns don’t sit scattered across HR, legal, risk, and leadership.

The good news is the accountability model works. As an example, a recent study involving 200-plus orthopedic surgeons experienced an 83 percent decline in malpractice claims sustained over a 16-year period.

Our work represents a marathon, and pursuit of professional accountability is not for the faint of heart. But, that said, self and group regulation are part of our professional responsibility and duty to those we serve. We can’t help our struggling colleagues if we don’t identify and engage. Build and strengthen your plans and get back to work.

Join Gerald Hickson, MD, at Rewiring Healthcare: Foundation to Future, October 20–21 in Nashville. His October 20 session, Professionalism and Trust in Healthcare, will explore how leaders can reinforce professional standards and accountability. Click here to learn more and register.