How to Fix Bullying Culture in Health Care

Image result for physician bullying


When we think of bullying, we’re usually worrying about our school-age kids or remembering bad experiences from high school.

We learn quickly in the health care field that bullies don’t change once they enter the clinical world. Health care, with its incredible differential in knowledge, authority and pay creates large power differentials and easily generates subordinate/superior relationship dynamics.

Bullying occurs within professions between trainees and trainers and faculty, and across clinical areas when there are knowledge differences such as between specialists and primary care. Mistreatment also frequently occurs in an interdisciplinary manner between physicians and non-physicians, supervisors and direct reports, nurses, and technicians.

For many (bully and bullied alike), this has been considered the price of entry into the healthcare arena.

The fears generated by the power differentials are very real:

  • loss of one’s job
  • loss of referrals
  • loss of business to a competitor

Through trial and error, bullies find the right formula to preserve the power dynamics.

These unspoken fears create a culture of silence. It then becomes very difficult to achieve a culture of high reliability, which operates on a framework of deference to everyone’s expertise with an intense preoccupation with avoiding errors and failure.  I have seen this culture of silence lead to OR fires and use of new OR equipment and procedures without adequate training or supervision.

An organization-wide “anti-bullying statement” should stop the problem, right? Not likely.  An organization where I once served in administration had such a statement but also had a “hidden agenda,” i.e., ‘”We need these doctors to bring in business and need these nurses’ experience.”  It led to confusion as to what the organization would stand for.  Staff began accepting physician rounding at 10 p.m. and used equipment in the OR without proper training.

Working with the medical staff leadership, we opened some honest conversations around patient safety. Both groups were surprised. The medical staff thought administration was OK with the unsafe behaviors; the administration team hadn’t even been made aware of them until that point.

Having a policy against disruptive physicians and nurses is a Band-Aid for a much deeper issue. Many physicians rightly resent the implication that a legitimate disagreement with another healthcare professional can immediately and irrevocably label one “disruptive” without a fair hearing.  Stories of false accusations fuel the need for physicians to protect each other, to the detriment of improving the system.

There are more effective ways to address this complex problem. Those on the “wrong side” of the power differential need scripting to defuse the confrontation. For example, a nurse being yelling at by a physician about being paged at 2:00 a.m. regarding “non-urgent orders” could neutralize the situation by calling attention to the behavior, while still allowing an escape route for de-escalation by saying “It sounds like you are having a bad night. Are you yelling at me or simply venting?” Simple lines like these can empower line staff to safely de-escalate these situations and re-train those on the “right side” of the power differential.

Now, a single physician or nurse practicing scripting won’t be able to implement a culture change. It’s up to medical and nursing officers to establish the expectation that physicians and nurses will learn and apply such tools.

Medical staff officers must enlighten clinicians on how a culture of fear leads to more complications and patient harm. Medical errors occur when the safety systems designed to catch an error before it reaches a patient are short-circuited, which is commonplace if physicians give in to the doctor yelling the loudest.

Research from the Vanderbilt Center for Patient and Professional Advocacy in Patient Advocacy Reporting System (PARS) and Co-Worker Observation Reporting System (CORS) databases supports the notion that truly disruptive physicians are the minority and can be identified by staff and patient complaints. It further validates the potentially adverse outcomes and unsafe environment physician bullies perpetuate.

Their research also shows that “what gets measured, matters” as these “disruptive providers” don’t always need to be reported to NPDB. Some physicians simply need to understand that their behavior, though considered acceptable in past generations, needs to change.

With new scripting to manage an increasingly difficult health care environment and clear expectations laid out by medical staff officers, it’s entirely reasonable to expect the same zero tolerance for bullying in health care environments that now exists in our children’s schools.



Should Hospitals Limit the Number of Patients Nurses Can Help?

A male nurse with an elderly patient.


The medical community is divided over a November ballot measure that would make Massachusetts only the second state with such staffing requirements.

Voters this fall could make Massachusetts only the second state in the country to limit the number of patients that hospital nurses can help at one time.

Question 1 would create legal ratios based on the type of patients that nurses are dealing with. Nurses aiding women during birth and up to two hours after, for instance, would be limited to one patient. If they’re working with children, they could see four patients at once. In the psychiatric ward, nurses could help up to five patients.

While nurses unions and progressive political groups back the ballot measure, most medical groups — including the Massachusetts chapter of the American Nurses Association and the state’s Health and Hospital Association — oppose it.

The ballot measure’s supporters argue that not regulating this negatively impacts patient care and overall health outcomes.

“There is overwhelming evidence when you look at studies and talk to nurses that when there are limits, there are better health outcomes,” says Kate Norton, campaign spokewoman for the Committee to Ensure Safe Patient Care, which is the official campaign for the ballot measure.

2011 study in the journal Health Affairs found that nurse-patient ratios in California resulted in decreased mortality rates after surgery and an additional half-hour of care for patients overall.

Seven states have laws that require hospitals to have committees that address staffing issues, but California is the only state with a cap on the number of patients a nurse can see during one shift. Advocates have struggled to gain support for ratio laws elsewhere, in part because the hospital industry doesn’t believe there’s enough evidence to support them.

California’s regulations were drafted by the state’s department of health and have been in effect since 2004. There was some fear at the time that hospitals would be forced to hire more nurses with less education in order to comply with the ratios. But according to the 2011 study, that didn’t happen.

Opponents of Massachusetts’ measure also worry that it would force hospitals “to make deep cuts to critical programs, such as opioid treatment and mental health services. Many community hospitals will not be able to absorb the added cost and will be forced to close.”

In California’s experience, those fears are likely overblown.

Research by the California Healthcare Foundation in 2009 shows that while “leaders reported difficulties in absorbing the costs of the ratios, and many had to reduce budgets, reduce services or employ other cost-saving measures,” the impact of the ratios was not discernible on hospital finances.

Research further shows that hiring levels only increased slightly after the mandate. But California is expected to have a nursing shortage of more than 44,000 by 2030. It’s not clear how big a role, if any, the staffing ratios play in this shortage.

In Massachusetts, opponents of the measure argue that it would worsen the existing nurse shortage there. Right now the vacancy rate for registered nurses in Massachusetts hospitals is 6.4 percent.

“If it passes, the estimates are that hospitals will have to hire 6,000 more nurses [according to a study led by the opposition camp]. Where will they get them?” says Jake Krilovich, director of policy and public affairs for the Home Care Alliance of Massachusetts, which opposes the measure.

But according to data from the U.S. Department of Health and Human Services, the state is projected to have a surplus of nurses by 2030.

Although well-financed organizations like the Massachusetts Business Roundtable, Massachusetts Health and Hospital Association and 11 local chamber of commerces oppose the measure, the supporting campaign has much more cash on hand: $1 million to just over $11,000 in the opposition camp.

There hasn’t been any formal polling done on the measure.


Northwell Health to station armed guards at all 23 hospitals

Image result for armed guards in hospitals


New Hyde Park, N.Y.-based Northwell Health placed armed security guards at two of its hospitals on Long Island as part of a pilot program to help staff prepare for an active shooter situation, according to Newsday.

The pilot program, which placed armed security at Manhasset, N.Y.-based North Shore University Hospital in March and at New Hyde Park-based Long Island Jewish Medical Center July 2, came to fruition after employees called for more security in the wake of an increasing number of violent incidents at hospitals across the nation, the report states.

“Hundreds of our employees have gone through active shooter training and have asked us why we don’t have armed security,” Jon Sendach, deputy executive director at North Shore University Hospital, told Newsday. “The solution here includes having guards who can respond immediately.”

He told the publication Northwell plans to have retired law enforcement officers serving as armed guards at all of its 23 hospitals within one year. He noted that not all guards at every hospital will be armed.

A second Northwell administrator told Newsday Bay Shore, N.Y.-based Southside Hospital will be the next facility to add armed security.

The goal of the program is to ensure the overall safety of patients, their families and employees, a Northwell spokesperson told Becker’s Hospital Review July 10.


Epic President says EHRs are not walled off, integrations are just hard



These 6 healthcare leaders say quality improvement is an organizationwide effort and a cultural imperative

Executive looking out window

Despite recent uncertainty about the government’s commitment to value-based care, healthcare organizations remain focused on efforts to improve quality, patient care and employee engagement.

In 2017 the Centers for Medicare & Medicaid Services cancelled mandatory bundled payment models for hip fractures and cardiac care and also asked providers for feedback on other value-based payment models.

But healthcare organizations seem committed to the initiatives they have already put in place to improve quality. Indeed, last year healthcare leaders shared their successes, challenges and lessons learned as they worked to improve quality and patient outcomes. We’ve rounded up the most memorable quotes from these healthcare thought leaders about quality, the importance of physician engagement and how to achieve a culture of patient safety.

Here are six of our favorite quotes from our interviews and industry news and event coverage over the past 12 months:

1. “We had to challenge our old paradigms. Physicians are instrumental in setting the tone, and unless the physicians believe we’re on the right path we don’t have the kind of alignment that will help us move forward.”

Gary Kaplan, M.D., chairman and CEO of Virginia Mason Health System, explained in a webinar this fall how the Seattle system improved patient safety using a patient-centered approach. Virginia Mason’s safety culture transformation began in 2001, Kaplan said, when system leaders realized that a physician-centered approach alone would not improve patient care.

2. “You need to start with the early adopters. You can’t start with folks who will fight you tooth and nail. You want to start with early successes and then evolve from there.”

Felipe Osorno, an executive administrator at Keck Medicine of the University of Southern California, spoke at the Institute for Healthcare Improvement’s annual quality forum about strategies to engage physicians in improvement initiatives. The secret was designing a program in which physicians were respected for their competency and skills, their opinions were valued, they had good relationships with their medical colleagues, they had a broader sense of meaning in their work and they had a voice in clinical operations and processes, he said.

3. “We really want to attract folks who believe at their core, not just intellectually but in their heart, that kindness can heal. … If we do it right the first time and we assess candidates based on the fit of the organization, ideally we will have more engaged employees who deliver care in a way that is patient-centered.”

Wanda Cole-Frieman, vice president of talent acquisition at Dignity Health, talked to FierceHealthcare this summer after the California system was named by an online job platform as the best place to interview in 2017. Among its techniques: It assesses candidates’ behavioral competencies for human kindness, compassion and the human experience.

4. “To create a true culture of safety and reliability we need to engage everyone, and it can only be driven when we have strong alignment. Everyone can play a role in safety.”

Gary Yates, M.D., a partner in strategic consulting at Press Ganey, explained in an interview that building and promoting a culture of safety at healthcare organizations is important to retain current staff members, but is also an especially effective recruiting tool for millennials, who will make up half of the workforce by the year 2020.

“People talk, and people ask about the culture inside different organizations,” Yates said. Putting the spotlight on safety and quality could “tip the scales” for young people.

5. “Our focus is safety, to fundamentally be a safe hospital. If we start there or if any hospital starts there, patient experience will take care of itself, quality metrics will take care of itself as will employee morale.”

FierceHealthcare caught up with Nicholas “Nico” R. Tejeda, CEO of The Hospitals of Providence Transmountain Campus in El Paso, Texas, at an American College of Healthcare Executives event. He talked about opening a new teaching hospital and establishing the culture of the organization from the beginning and with every hire.

There are no acceptable levels of errors, he said. And while it may be nearly impossible to achieve zero incidents, he still wants the organization he leads to strive for perfection.

6. “We don’t see quality as just a clinical goal. It’s an enterprisewide priority that encompasses customer service, compliance and wellness.”

A few years ago, Anthem decided to make a “rigorous” effort to boost the quality of its plans. And it’s demonstrating results, Anthem’s then-CEO Joseph Swedish said during the 2017 AHIP Institute & Expo. Now, more than half of the insurer’s Medicare Advantage enrollees reside in 4-star plans, compared to just 22% the year before.


50 Essentia Health workers fired for refusing flu vaccine

Dive Brief:

  • Essentia Health terminated 50 employees for refusing to get the flu vaccination, reports the Star Tribune. Hundreds of other workers agreed to be vaccinated after the Duluth, Minnesota-based healthcare system threatened to fire them if they refused.
  • The new policy requires all employees to get vaccinated to protect patients, Dr. Rajesh Prabhu, Essentia’s chief patient safety officer and an infectious disease specialist, told the Tribune. He said severely ill patients are more susceptible to complications and death from the flu, which is why the need to vaccinate employees is greater.
  • The Tribune says three unions oppose the new policy, which covers 15 hospitals in the system and 75 clinics. The United Steelworkers, which represents some employees, failed to get a court injunction to block the terminations.

The American Hospital Association​ (AHA), along with the National Business Group on Health and the American Academy of Family Physicians, strongly supports vaccinations to prevent the spread of the flu. The AHA backs mandatory patient safety policies that require workers to get flu vaccinations or wear hygienic masks when coming in contact with patients during the flu season.

Statistics from the Centers for Disease Control (CDC) show that less than 45.6% of Americans got flu shots during the 2015 to 2016 flu season. According to the CDC, some people don’t think the flu vaccination is effective, while others don’t think they’ll come down with the flu or think the side effects will be worse than the disease. Other workers might be eligible for a medical or religious exemption.

Employees routinely come to work ill, spreading infections to coworkers. Some 80% of employees came to work sick last year based on findings from Staple Business Advantage’s cold and flu survey. The cost of the flu alone is  $10.4 billion in medical expenses and, for employees, $16.3 billion in lost earnings each year.

Healthcare statistics would seem to support the argument for mandatory flu vaccinations. However, legal considerations come into play. States like New York allow employers to have blanket mandatory flu vaccination policies, but the Equal Employment Opportunity Commission (EEOC) is against mandatory policies. Employers will need to pay attention to local and state law before making any such policies of their own.


Investigations about safety issues result in few meaningful consequences for hospitals


Investigations into hospital safety issues rarely result in consequences that spark meaningful improvements, according to USA Today. That can leave patients in the dark and vulnerable to unnecessary infections.

An article in USA Today outlines a system stacked against public admissions of safety issues and potential risks of infection. A recent investigative report on sewage leaking down the walls and floor of an operating room in MedStar Washington Hospital Center represented the first public glimpse of a health department investigation into the matter.

In a statement, the president of MedStar Washington Hospital noted the hospital had corrected its plumbing issues, but Lisa McGiffert, director of the Safe Patient Project run by Consumer Reports, says the system as it stands does little to demonstrate public accountability. She suggests that hospitals must be forced to undertake internal and external audits following safety lapses.

Larry Muscarella, author of the Discussions in Infection Control blog, told the newspaper that penalties or fines issued in such cases rarely provide enough incentive for substantive change. In some cases, he says, hospitals face “little or no consequence” from citations by state agencies.

That leaves patients without information that could be crucial when it comes to deciding where they want to go to seek treatment. This compounds a related issue where, despite a general trend toward increased transparency intended to give patients information to make informed choices about their care, some hospitals have dragged their feet on releasing quality data.

Concentrating on short-term financial incentives that lead hospitals away from more substantive quality improvements actually could end up hurting the bottom line in the long run, according to trauma and emergency surgeon David Kashmer, M.D. He points out that hospitals that implement error-prevention programs see a median savings of $250,000.

“We have advanced quality tools available, but unfortunately we see some centers where, because of the culture or the situation, [they] don’t use them,” he says.

Arbitrator awards fired Swedish Health whistleblower surgeon $17.5M

Legal cases

A substantial payout for a fired whistleblower has Swedish Health crying foul. The organization will now challenge the arbitrator’s award in court.

David Newell, M.D., blew the whistle on a high-profile case involving neurosurgeons who double-booked patients for surgeries at a Swedish Health hospital in Seattle. The fallout from that case was sufficiently brutal for the CEO of Providence St. Joseph, which acquired Swedish, to take out a full-page ad in The Seattle Times apologizing to the organization’s employees and patients.

Now, The Seattle Times reports, an arbitrator has agreed with Newell’s claim that Swedish fired him in retaliation for his whistleblowing activities, and awarded him $17.5 million. The award reportedly includes $15.5 million in lost earnings and another $1 million for emotional distress.

Swedish Health contends it fired Newell after he failed to immediately disclose he had been arrested in a prostitution sting, as required by his employment agreement. The organization also protested the amount of lost earnings requested, noting that the figure represented nearly 10 times his annual compensation in 2014, and that he would have needed to perform more than 3,000 complex brain-aneurysm procedures in a year to reach such an amount.

Guy Hudson, M.D., the CEO of Swedish, blasted the ruling in a statement (PDF). “For this arbitrator to award Dr. Newell $17.5 million—at a time when many people cannot afford healthcare or fear losing their insurance, and when there is an epidemic of sex trafficking and exploitation of women—is unconscionable and outrageous,” he said.

But the newspaper reports that in a recent court filing, Newell’s attorney maintained that evidence presented showed Swedish Health’s actions “were part of a pattern of targeting and interfering with established neurosurgeons’ practices, retaliatory behavior, and a disregard for patient safety.”

In a similar case, a court recently ruled in favor of a Boston-based surgeon who lost his job at an upstate New York hospital after speaking out about concurrent surgeries performed there by another doctor. Lost wages in that case totaled $88,277.

Swedish Health’s Cherry Hill campus at risk of losing Medicare, Medicaid funding

Image result for Swedish Health's Cherry Hill campus at risk of losing Medicare, Medicaid funding

CMS is threatening to cut off Medicare and Medicaid funding to Seattle-based Swedish Health’s Cherry Hill campus in 90 days unless it resolves patient safety issues, according to The Seattle Times.

The Washington Department of Health inspected Swedish’s Cherry Hill campus after a February Seattle Times investigative report exposed troubles, including staff members feeling intimidated, patient care concerns and surgeons performing overlapping surgeries.

The state surveyors identified numerous patient safety issues at the Cherry Hill campus, including failure to outline the roles of medical fellows, failure to address behavioral concerns, failure to document surgical tasks of medical residents, failure to listen to staff concerns and failure to track when the attending physician was in the operating room.

“Staff members feared punishment and retaliation for voicing concerns,” the regulators wrote, according to the Seattle Times. “Staff members stated they were frequently bullied and intimidated for voicing concerns about the working conditions in the neurosurgical operating area.”

To keep federal funding for the Cherry Hill campus, Swedish Health must submit a corrective action plan to CMS. Regulators will conduct another survey to ensure the hospital is in compliance with Medicare and Medicaid rules.

Swedish Health said that many of the deficiencies cited have been addressed, according to the report. The system implemented a new policy to ban overlapping surgeries. Additionally, Swedish Health CEO Guy Hudson, MD, insured that the culture of intimidation will be addressed

“We are sorry for what occurred at Swedish Cherry Hill on our watch,” Swedish Health board members told the Seattle Times. “As volunteers, we continue to be deeply committed to our critical governance role in overseeing patient quality and safety, as well as physician credentialing.”

A new public health crisis: Preventable harm in healthcare

Doctor and nurses wheeling patient in gurney through hospital corridor