Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes.

OBJECTIVE: To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death. SUMMARY BACKGROUND DATA: Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential. METHODS: This retrospective cohort study used data from 9 level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by 1 or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days. RESULTS: Among the 71,046 patients in the cohort, 9553 (13.4%) experienced the primary outcome of complications or death, including 1875 of 16,107 patients (11.6%) with 0 high-risk services, 3788 of 28,085 patients (13.5%) with 1 high-risk service, and 3890 of 26,854 patients (14.5%) with 2+ highrisk services (P < 0.001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from 1 or more high-risk services were at 24.1% (95% confidence interval 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome. CONCLUSIONS: Trauma patients who received care from at least 1 service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

Physician Engagement in Malpractice Risk Reduction: A UPHS Case Study.

BACKGROUND: The University of Pennsylvania Health System (UPHS) implemented a risk reduction strategy in response to high malpractice costs and the broader implications these trends had for patient safety and quality. A key component of this strategy was the Risk Reduction Initiative (RRI), which uses a bottom-up approach to actively engage physicians in risk mitigation and malpractice reduction within their respective departments. METHODS: The value of clinical communities in achieving common goals has been previously recognized in quality improvement efforts. Using a physician-directed approach, the RRI program requires each clinical department to propose and execute an intervention in response to prior malpractice claims data or recognition of an area of high risk. Based on the success of the intervention, clinical departments were eligible to receive a financial rebate for use in future quality improvement projects. RESULTS: Clinical departments have led the development and implementation of interventions that have shown demonstrable improvements in quality and safety and thereby received full financial rebates. On a system level, the inclusion of physicians in risk mitigation efforts has resulted in significant benefits from both quality improvement and financial standpoints. The number of malpractice claims and malpractice cost have decreased since the inception of the program. CONCLUSION: Since the program inception, 250 proposals have been submitted and $14 million in rebates have been awarded. Although it is difficult to directly measure the combined impact of these bottom-up, physician-directed interventions, empowering frontline physicians to become actively involved in risk mitigation is a promising method for reducing malpractice claims and costs.

Tipping the scales: educating surgeons about medical malpractice.

BACKGROUND: In Pennsylvania, medical malpractice premiums are a major cost to surgeons. Yet surgeons often have little if any education in the basics of tort litigation or how to manage their risk. This work describes one approach for educating academic faculty surgeons on current concepts of medical malpractice and provide some guidance on how to "tip the scales of justice"; or minimize the risks of being named in a malpractice claim. MATERIALS AND METHODS: The course had five parts: the basics of medical malpractice, the cost of malpractice insurance, current departmental claims experience, strategies for decreasing the risk of being named in a claim, and an overview of malpractice reforms. An anonymous seven question survey was cast in a five-point Likert scale format. A weighted average of 4.5 or above was considered satisfactory. Two free text questions asked about positive and negative aspects of the course. RESULTS: Eighty of 95 (84%) faculty attended either in person or by reviewing a web-based video. Quantitatively, five of seven questions had a weighted average of more than 4.5 (n = 48, response rate = 60%). Qualitatively, the course was reviewed very favorably. CONCLUSIONS: The high percentage of participation and overall survey results suggest that the course was successful. This course was one facet of an approach to decrease the risk of malpractice claims. Unique aspects of this course include an emphasis on state law, department-specific data, and strategies to minimize risk of future claims. Given the state-specific nature of malpractice claims and litigation, individual departments must particularize similar presentations.

Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center.

BACKGROUND: The Joint Commission Leadership standard on the need to create and maintain a culture of safety and quality and to develop a code of conduct was based on the rationale that unprofessional behavior undermines a culture of safety and can thereby be harmful to patient care. Few reports have described effective and successful approaches to defining and managing unprofessional behavior. The Professionalism Committee (PC)-based approach at the University of Pennsylvania Health System (UPHS) may serve as a model for other hospitals and health systems. METHODS: Each of the three large teaching hospitals within UPHS has a PC that reports to its respective Medical Executive Committee. The PCs serve as a resource for department chairs and hospital administrators to address unprofessional behavior among faculty. Key features of the PC include the PC chair as the first point of contact and the integration of psychiatry into the model by virtue of the Professionalism Committee chair's training and expertise in psychiatry. RESULTS: In the 2009 calendar year, the PC chair received contacts concerning behavior of only 2 physicians, which increased to 42 physicians in 2011 and 39 in 2012. Contacts involved referrals, management consults, interview screening, and the need for general advice. Of 79 resolved cases, 30 involved interpersonal issues, and 2 were associated with poor clinical outcomes. CONCLUSION: One key feature of the UPHS approach is early identification of the role of behavioral health issues in unprofessional behavior (as opposed to physical, cognitive, or systems issues) by virtue of the PC chair's professional training and expertise. Although aspects of the UPHS experience may not be generalizable, the PC structure and approach are replicable.