PARS is Employed by Dr. Uro’s Organization
PARS was launched at Celestial Medical Center (the organization with which Dr. Uro’s Department is affiliated) only after Vanderbilt’s Center for Patient and Professional Advocacy (CPPA) had established Celestial’s readiness. We assess organization readiness for launching PARS (or any safety/quality improvement or risk reduction project) using a “Project Bundle” tool [9]. In brief, Celestial initiated the PARS program after key Celestial stakeholders/leaders and CPPA mutually judged that Celestial had sufficient (1) commitment from its people, and, (2) adequate organization-related supports, and (3) learning systems in place. Judgments were based on the following considerations:
1.
Commitment from People
(a)
Celestial’s leadership made public commitments to address the patient experience and address unnecessary variation demonstrated by Celestial-affiliated professionals with high PARS Risk Scores;
(b)
Two well-regarded Celestial-affiliated physicians agreed to Co-chair a PARS Messenger Subcommittee and become project champions, i.e., people who have the ability to motivate and hold others accountable to accomplish goals;
(c)
Celestial had an existing dedicated Patient Relations team to hear, address and document patient complaints. Celestial section leaders and department chairs nominated and the Co-chairs recruited peer physicians willing to receive training and deliver the data to high risk colleagues.
2.
Organizational Supports
(a)
Alignment with goals: Celestial management set and disseminated goals to increase capture of patient complaints and provide prompt service recovery;
(b)
Policies and procedures: Celestial reviewed and updated its professional conduct policy. Celestial also created and charged the Co-chairs and members of the PARS Messenger Subcommittee to implement the PARS program under the auspices of the Medical Executive Committee (to be consistent with state peer review statutes);
(c)
Model for Planning and Interventions: Celestial Medical Center adopted the CPPA graduated intervention model for planning and for addressing high-complaint physicians (Fig. 12.1) (see [3, 105, 106] for details). At the pyramid’s base and first level up, unless an allegation or incident is “egregious” or subject to mandated reviews (e.g., inappropriate touch, substance abuse), most professionals simply need encouragement or informal feedback to sustain professional conduct. But some physicians are associated with sufficient numbers of complaints that a pattern appears to have emerged. Consistent with individual and group self-regulation, high risk physicians deserve to be made “aware” of their standing (a Level 1 “Awareness Intervention”) [3, 55, 105, 106, 108]. In this model, the well-trained peer-messengers share the data, encouraging high-risk physicians to consider etiologies for patient complaints, but not provide directive or corrective advice. Anticipating that some high risk physicians would be unable or unwilling to respond to peer-delivered messages, a Level 2 “Authority Intervention” provides the appropriate leader (chairman, chief medical officer, vice president of medical affairs) an opportunity to review the high risk physician’s data, reflect upon other performance data, and then define an improvement plan (elements of which might range from coaching, a practice assessment, or a comprehensive mental and physical health screening). Level 2 interventions include ongoing tracking of complaint data with periodic updates provided to designated leaders. Level 3 interventions are reserved for individuals who fail to respond at Level 2 or who violate policy or legal boundaries (the small, colored triangle in Fig. 12.1, those complaints/events considered “most egregious”) [116]. These persons are referred for appropriate investigative, corrective, or disciplinary action.
Fig. 12.1
Promoting reliability pyramid: a graduated intervention model for addressing behavior/performance that undermines a culture of safety (Adapted from Hickson et al. [105], with permission)
(d)
Resources for teams: Celestial provided funding to support upgrades to an electronic complaint capture software program for use by Risk Management and the Office of Patient Relations.
3.
Learning Systems
(a)
Measurement and surveillance tools: Celestial’s upgraded software program enabled improved tracking of complaints and their resolution, and it provided safe, secure, easy routine transfer of complaint data for coding and aggregated analysis;
(b)
Process to review data: CPPA provides regular feedback regarding quantity and quality of patient complaint reports vs. agreed-upon benchmarks to Celestial’s Office of Patient Relations. CPPA provides multiple reviews of complaint data for quality and consistency. The PARS Messenger Subcommittee Co-Chairs perform their own detailed review of the data prior to asking a Committee member to share the data with a particular colleague, and each Committee member performs reviews prior to agreeing to share the data with a colleague;
(c)
Multi-level training: The PARS tool and process were presented to Celestial’s senior leaders for vetting and final approval, then described to the medical staff at group meetings and in Celestial’s print and online communications. All Office of Patient Relations (OPR) staff were taught about their important role in PARS, and OPR staff participated in a course on best practices in service recovery and documentation [47]. All Messenger Subcommittee members engaged in 8 h of PARS messenger training. Finally, Celestial’s senior leaders received coaching on how to address any high risk physician who attempted an “end around” in an attempt to be exempted from monitoring or interventions.
An Infrastructure for Ongoing Promotion of Reliability and Professional Accountability
The results of the Project Bundle planning assessment indicated that Celestial was ready to launch the PARS program, but actual, ongoing maintenance of any improvement project requires a fair, just, robust, and functioning organizational infrastructure to actually promote reliability and accountability. Ongoing tests of the infrastructure’s functionality include the leadership’s meaningful commitment and actions to address “unnecessary variation” in systems or individual behavior/performance, dissemination and enforcement of relevant institutional policies, use of relevant surveillance tools for obtaining observations or data (e.g., for PARS, complaint recording and delivery of complaint data), routine data reviews by leaders positioned to take action, post-training willingness of essential team members and Co-Chairs to perform “messenger” roles (for PARS, with high fidelity to PARS program training), and accountability to one another [9, 104, 105, 117, 118]. Again, we emphasize that the infrastructure’s existence and ongoing reliability are driven by the organization’s leadership and willingness to listen and take full advantage of their patients’ experiences and stories of how they perceived their care.
Dr. Uro Qualified for a PARS “Awareness” Intervention
Dr. Uro’s Risk Score was in the top 5 % of all Celestial-affiliated physicians and top 3 % of the 399 urologists in the national PARS database. A peer messenger (a surgeon practicing in a different surgical subspecialty) shared the data with Dr. Uro. The peer messenger completed a post-intervention debriefing report which included the messenger’s perception that Dr. Uro was frustrated by the data and felt the complaints reflected systems and leadership issues, not his shortcomings. The messenger reported that Dr. Uro’s specific comments included the following:
Our area—our group—is terribly managed. You should be taking these complaints to Dr. ____ (Chair of Urology).
I’m seeing increasing numbers of patients. It gets hectic because I don’t have enough administrative support. None of us do in this department.
The Chair gets all over me to produce…and see more patients and do more procedures. It’s not me…it’s the poor support.
The system for turning over patients in the OR is especially poor. It would be more helpful for you to talk with the supervisor there.
You could talk to our Department Chair, but frankly the problem is the lack of support we get in this department.
And some of the patients are just unreasonable.
Dr. Uro’s messenger reported to the Committee Co-Chairs her impression that Dr. Uro’s systems-related explanations might have been rationalizations, but also might have merit. She had agreed to pass along the systems-related issues, but, consistent with her training, she had urged Dr. Uro to not only report any concerns up the chain of command, but help address them as well.
The Committee Chair notes that, in fact, several Celestial Medical Center urologists had Risk Scores above the PARS threshold that qualified them for initial awareness interventions (Fig. 12.2). According to several messengers’ debriefing reports of their meetings, other urologists receiving awareness interventions cited similar system/management issues, although several of these messengers added that the physicians they visited took ownership: “some of these are my own doing…I will address these…” The Committee Chair also notes that no other Celestial Medical Center departments or physician “families” had a distribution similar to the one in Fig. 12.2; even in the largest departments, only 0–2 physicians qualified for awareness interventions.
Fig. 12.2
Urology Department Physicians’ Pre-Intervention PARS Risk Scores (diamonds) plotted over all physicians (dashed line) and all other urologists (solid line) in the PARS database. The horizontal line at the Risk Score of 50 indicates the PARS threshold for intervention pending assessment and review of an individual physician’s underlying complaint data (*[112]; **[107])
The Co-Chairs de-identified the data presented in Fig. 12.2 and shared it at a messenger committee meeting a few weeks following initial interventions. The group recommended that the data (with the department identified) be shared with the Chief of Surgical Sciences and appropriate Celestial Medical Center leadership.
When the data were shared, the Medical Leadership:
Were “not surprised” that Urology Department members are disproportionately associated with patient/family complaints;
Expressed concerns that the group “does not appear to be functioning well.” Observations included the following:
Patient and staff complaints appear to revolve around long waits, short visits, not listening/not answering patient questions, problems with timely follow-up
Access and communication complaints could be volume-related
Colleagues from other departments have mentioned a “tense environment”
Suggestions of jousting [69] with other departments and services
The Chair of Urology had been appointed from the ‘ranks,’ several department members were long-time colleagues, and the Chair appeared reluctant to hold them accountable. For example, the Chair was either unable or unwilling to address a long-time department colleague who exhibited abusive behavior towards junior staff and had three malpractice claims in the past 30 months
The newest department members voiced concerns about what they perceived to be the Chair’s lack of action in support of their work, and complained about the “unfair compensation package” that they believed sent “too much of our income” to the Chair and to the Department.
What was done? The leadership agreed that the Urology Department “family” of physicians stood out; no other departments exhibited a similar distribution of Risk Scores. Together the leadership reached consensus that, were it their department, they would want to know and have an opportunity to address the data. The Chief of Surgical Sciences agreed to meet with the Chair of Urology, express that the Chair was a valued member of the leadership team, share the data and leadership’s concerns, and give the Chair the opportunity to “turn things around.”
The Chair of Urology took several actions over the next 6–8 months:
Enrolled in Celestial’s leadership training on promoting reliability and accountability
Added two advanced practice nurses to better manage volume
Assigned the group manager to partner with Patient Relations and assist with internal service recovery
In addition, the Chief of Surgical Sciences did the following:
Met over the course of the year with every department; shared quality, volume and complaint-related data; laid out clear expectations and goals; and described the plan for monitoring and feedback
Adjusted all Surgical Department Chairs’ incentives to more heavily weight Celestial’s quality goals, and put less weight on service volumes.
Over the next year, total numbers of recorded patient complaints at Celestial Medical Center increased as a function of renewed efforts to let patients know “we want to hear from you.” Complaints about urology began dropping, however, so several PARS messengers were able to deliver “good” news to their previously identified high risk urologists. Dr. Uro’s Risk Score, however, was unchanged, and Dr. Uro’s messenger reported that Dr. Uro responded with nothing except irritation about the process.
Urology Department 2 Years Later
Two years following the initial awareness interventions, the Risk Scores for all Department of Urology members except Dr. Uro fell below the intervention threshold (Fig. 12.3). Interventions were suspended for those below the threshold. Unfortunately, Dr. Uro had accumulated additional complaints. Consistent with Celestial Health System policies, Dr. Uro’s messenger and the Messenger Committee Co-Chairs reviewed the data and agreed that Dr. Uro should progress to a Level 2 Authority intervention by the Department Chair.
Fig. 12.3
Urology Department Physicians’ PARS Risk Scores 2 years post initial awareness interventions. Diamonds represent individual urologists’ Risk Scores, and Dr. Uro’s high Risk Score is highlighted. The dashed line represents all physicians and the solid line all other urologists in the PARS database. The horizontal line at the Risk Score of 50 indicates the PARS threshold for intervention pending assessment and review of an individual physician’s underlying complaint data (*[112]; **[107])
The Department Chair agreed to meet with Dr. Uro, to affirm Dr. Uro’s value to the department, review previous awareness interventions and new complaint reports, and mandate an improvement plan. In this case, the Chair directed Dr. Uro to undergo screening by a physician affiliated with a recognized Physician Wellness Program. Dr. Uro underwent individual assessment at a Health Professional Assessment Program. Deficits in team management skills and self awareness/personal insight regarding impacts of interactions with others were identified. Dr. Uro was mandated to participate in a program for “distressed” physicians [68, 119]. Dr. Uro grudgingly attended and grudgingly reported that the program had been “eye opening, helpful.” Dr. Uro’s complaints have since fallen.
Summary and Conclusions
We conclude, like the colleagues cited at the beginning of this chapter that patients can indeed play an important role in promoting safe medical care. Their unsolicited patient complaints provide a means for identifying high-claims physicians, making them aware (not to punish, at least initially), and offer them an opportunity to reduce their risk of claims. After all, it was patient complaints that, because Celestial medical center had an infrastructure to receive and address them, brought Dr. Uro to the attention of leadership. This increased safety and very likely saved his career. We believe the vast majority of physicians at high risk signaled by patient complaints are not aware that they stand out from their physician peers. Consider, if you were at high risk and could get a non-punitive “heads up,” wouldn’t you want to know? If physician colleagues are unaware, they are not likely to address risky or unsafe technical and interpersonal behaviors. Most physicians respond positively if those complaints are captured, reliably processed, and regularly communicated through a physician-driven feedback process.
Patient observations have limitations in promoting safety. Some leaders and colleagues may want to quibble with the evidence in support of these concepts that do not come from randomized controlled trials [120]. Some may cite studies that show patient engagement levels make no difference to outcomes, or the handful of studies that appear to link higher standardized patient experience survey scores to increased hospitalizations, higher costs, or mortality (none of which was methodologically superior to the majority with positive associations) (see the review by Doyle et al. [10]). Others may believe that engaged patients receive elective or unnecessary procedures and check a survey’s “satisfied” boxes for the wrong reasons [90, 121, 122].
Of course, many patient complaints do not signal safety lapses. After all, many might seem to reflect mere annoyances (e.g., “The doctor never apologized for being 30 min late to my appointment.” “The surgeon showed disrespect by using my first name.”) rather than specific, valid observations of negligence or unsafe practices (e.g., “The doctor flew through my diagnosis and what it meant, she didn’t listen to us, did not order some tests I later learned I needed, and wrote confusing discharge orders.”). Nevertheless, we know that patients define medical errors more broadly than clinical mistakes, extending the concept to communication problems, lack of compassion, and responsiveness failures [77, 123], and these are associated with surgical complications and other adverse patient outcomes [103, 124, 125].
A related limitation is that the PARS process does not examine complaint validity. As we have argued previously [106], evaluating the validity of allegations requires exhaustive review beyond the resources available to most healthcare professionals and medical centers. Even when such evaluations occur, professional reviewers do not always agree [126, 127]. Nevertheless, aggregated complaints (allegations) are associated with risk management activity and identify a small proportion of physicians who stand out. There may be “noise” and “faulty perceptions” that contribute to Dr. Uro’s high Risk Scores, but these patient/family expressions of concern drive lawsuits.
Implications and Reflections for Practice
1.
Conduct Project Bundle and Infrastructure Assessments. If your organization is considering using (unsolicited) patient complaints to identify and systematically address service units and professionals associated with disproportionate numbers, the elements described above in the project bundle (people, organization supports, learning organization) can help establish readiness for successful implementation. If your organization already uses unsolicited complaints to promote safety and reduce unnecessary variation, what elements of the infrastructure described above might make their use more efficient and effective?
2.
Employ proactive service recovery. Our work with more than 50 healthcare organizations reveals best practices for service recovery [47], some of which are summarized using the “HEARD” mnemonic:
Hear the person’s concern(s)
Empathize with the person raising the issue
Acknowledge, express Appreciation to the person for sharing, and Apologize when warranted
Respond to the problem, setting timelines and expectations for follow-up
Document expressed concerns and responses/resolutions (or Delegate documentation of to an appropriate person).
Note that the HEARD mnemonic emphasizes the importance of documenting patient complaints for purposes of tracking and trending in support of safety. In our experience documentation practices vary widely. Best practices in documentation should be part of standard orientation and training of Patient Relations professionals [47]. While proactive service recovery activity is important, it is not just about placating patients. Regular audits and feedback can help keep patients from becoming dissatisfied in the first place which, for many patients and families, signals concerns about their and others’ safety. Therefore, attention to both individual and aggregated patient complaints is consistent with our collective commitments to professionalism and patient engagement, both of which help promote safety and improved outcomes.
3.
Be prepared to promote patient activation, empowerment and engagement in support of patients as safety promoters/evaluators and the overall patient experience. Advocate for patients as the organization’s eyes and ears on the basis of a commitment to professionalism, strong humanistic and moral reasons, strong theoretical backing (compelling logic model), and the impressive weight of evidence from the many studies that show patient engagement to be effective [10].
4.
Make it easy and safe for patients/families to share concerns. Organizational characteristics influence patient willingness and ability to be safety promoters. Hospitals, physician practices, Accountable Care Organizations, and healthcare systems encourage engagement by (1) asserting and demonstrating that patients’ participation is critical to achieving mutually beneficial goals; (2) having supportive organizational policies [128–130]; and (3) promoting receptive patient–professional interactions around expressions of concern [19, 131]. When concerns are invited, taken seriously and acted upon, patients are reassured, but are otherwise discouraged from the safety promoter role [35, 132–137]. Finally, patients perceive more involvement when “we want to hear from you” is presented early and often, and the response is prompt and professional [40].
5.
Patient engagement-related skills training may be necessary but not sufficient. Given the previous implications for practice, professionals need to be educated about and appreciate that involving patients in improving healthcare safety and quality outweigh any perceived disadvantages [138]. While training on patient engagement skills may help, it is hardly a cure-all [52, 131, 139, 140]. Creating and sustaining a safety culture that fosters improvement rather than retribution requires supportive systems and infrastructure [9].
6.
Promote skills for managing patients’ and professionals’ expectations. Many patients bring expectations and make specific requests (demands) of physicians, and overall patient satisfaction correlates with fulfillment [141–146]. Some medical professionals may be tempted to “cave in,” fearing patient retribution via low survey scores, especially if survey results impact compensation [144]. If true, such behavior would not always be consistent with evidence-based care and a commitment to professionalism. Physicians therefore need skills for educating patients and “agreeing to disagree agreeably” [90, 117, 147–149]. Without those skills, overemphasis on standardized assessments of patient satisfaction could have unintended adverse effects on healthcare utilization, costs of care, and outcomes [90]. Finally, managing patient expectations may require more time, at least in the short term [150], and some physicians may be reluctant or unwilling to give up a more authoritarian style [25]
7.
Don’t wait to see it in social media. Growing numbers of patients post online comments about their healthcare experiences. The availability of web-based, Yelp-like accounts offer another opportunity to obtain impressions of care quality data in the “cloud of patient experience” [50]. But wouldn’t it be better to hear from dissatisfied patients directly, before they leave your facility, rather than from Angie’s List, Consumer Reports, Health Grades or many other websites where you have little or no opportunity to use the postings to address individual patients’ issues or demonstrate a pattern in carefully recorded aggregated data?
8.
References
1.
< div class='tao-gold-member'>
Only gold members can continue reading. Log In or Register to continue
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
