Study shows early, structured intervention when spotting disrespect for patients can reduce malpractice claims risk.

For the healthcare system to function at peak effectiveness, two things above all are required: well-designed systems and professional accountability.

Yet, for a myriad of reasons – including bias, personal challenges, physical or mental health problems – a small percentage of clinicians exhibit disrespectful, unprofessional behaviors in front of patients, colleagues and trainees. And these events can create ripple effects throughout the system.

“Individuals in medicine, from nursing to neurosurgery and everywhere in between, understand that disrespectful behavior threatens team performance and delivery of safe, reliable and effective medical care,” said Gerald Hickson, M.D., founder of Vanderbilt Health Center for Patient and Professional Advocacy (CPPA).

“Clinical team members modeling disrespect can disrupt collaboration, threaten patient outcomes, impact staff retention and increase malpractice claims.”

“Clinical team members modeling disrespect can disrupt collaboration, threaten patient outcomes, impact staff retention and increase malpractice claims.”

In 2003, Hickson and colleagues established CPPA programs capable of reliable identification and support for individuals who demonstrate unprofessional behaviors that impact patient care.

Hickson’s Patient Advocacy Reporting system (PARS) and Coworker Observation Reporting System (CORS) use the observations and experiences of patients, families, and fellow medical team members to identify at-risk colleagues, at which point they provide discipline-specific information to the offender about the risks of displaying unprofessional behavior.

Over the last two decades, CPPA leaders have used the PARS and CORS systems to assist health care institutions nationally and internationally to improve surgical outcomes, strengthen nurse retention efforts, reduce medical malpractice claims and address allegations of sexual boundary violations.

In a new retrospective study published in the Journal of Bone and Joint Surgery, a CPPA research team in partnership with OrthoCarolina and its insurer, Curi, assessed the impact of the PARS program on malpractice claims and costs in a southeastern orthopaedic group between 2004 and 2020.

Although not necessarily causal, the 12 years following implementation of PARS was associated with a sustained 83 percent reduction in the cost of malpractice claims per high-risk clinician after an intervention. Additionally, the group saw an 87 percent reduction in annual claims cost for the practice overall, resulting in over $18 million in savings.

“Our goal is to identify as early as possible team members who for whatever reason are disrespectful and share this information with them before patterns develop,” Hickson said.

The ‘Why’ of Malpractice

Research into malpractice claims initially sparked development and establishment of the PARS program.

In 1989, a Vanderbilt team published a study concluding that a small subset of physicians – between 2 and 8 percent, by specialty – accounted for more than 70 percent of claims and payouts by those specialties. These results prompted follow-up studies by that probed the question of why a large share of malpractice claims were tied to a relatively small number of physicians.

“Our goal is to identify as early as possible team members who are for whatever reasons disrespectful and share before patterns develop.”

These Vanderbilt findings showed that physicians identified as high risk for malpractice claims were characterized by patients and families as being disrespectful and that a high-risk physician today will continue to be a high risk tomorrow unless their behavior is appropriately addressed.

To provide a structured approach to broaching the subject with high-risk colleagues, CPPA launched the advocacy program PARS. Later, in 2013, the coworker observation program rolled out. Today, the center supports more than 200,000 professionals seeking assistance.

In both of these programs, peers meet with the potentially disrespectful individual, usually in an informal setting, to deliver feedback from a standardized assessment – then allows time for reflection. The second step is to share comparative data, including local and national benchmarking metrics.

Finally, if the high-risk individual cannot or will not respond, leader-directed corrective action plans connect the individual to resources that support their health and wellbeing, including coaching, physical and mental health screenings and treatment.

Building Successful Teams

In the orthopaedic group study, successful adoption required a champion for the process, an infrastructure to capture patients’ unsolicited stories, and peers trained to meet and share the data.

“It’s a very small percentage who are unwilling or unable to self-regulate,” Hickson noted. “However, when the individual is perceived to have extraordinary value, sometimes leaders may want to look the other way. In failing to act, they may miss the opportunity to support a colleague with possibly significant needs.”

Whether it is disrespect for patients or disrespect for co-workers, addressing unprofessional behavior is essential for well-functioning healthcare teams.

“We want to help individuals be the best version of themselves they can be and in doing that, model respect for the patients they serve, contribute to team performance and support the delivery of safe and highly reliable care,” Hickson said.

About the Expert

Gerald B. Hickson, M.D.

Gerald B. Hickson, M.D. is senior vice president of quality, safety and risk prevention and Joseph C. Ross Chair of Medical Education and Administration at Vanderbilt University Medical Center. His work includes the development of PARS® and CORSsm programs that use unsolicited patient and coworker complaint data as the basis for tiered interventions for high-risk providers.