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.

Developing an Implementation Strategy for Systematic Measurement of Patient-Reported Outcomes at an Academic Health Center.

EXECUTIVE SUMMARY: Patient-reported outcome measures (PROMs) are used in research and have the potential to improve clinical care. We sought to develop a strategy for integrating PROMs into routine clinical care at an academic health center. The implementation strategy consisted of three phases. The first, exploratory phase, focused on engaging leadership and conducting an inventory of current efforts to collect PROMs. The inventory revealed 87 patient-reported outcome efforts, 47 of which used validated PROMs (62% for research, 21% for clinical care, 17% for quality). In the second, preparatory phase, we identified three pilot implementation sites chosen with facilitators determined in the exploratory phase. Using data from local needs assessments at the pilot sites, we constructed a timeline for inclusion of PROM efforts across the clinical enterprise. In the third phase, we adapted a technology platform for capturing PROMs using the electronic health record and began implementing this platform at the pilot sites. We found that integrating PROMs into routine clinical practice is highly complex. This complexity necessitates change management at the enterprise level.

Unsolicited Patient Complaints Identify Physicians with Evidence of Neurocognitive Disorders.

OBJECTIVES: Determine whether words contained in unsolicited patient complaints differentiate physicians with and without neurocognitive disorders (NCD). METHODS: We conducted a nested case-control study using data from 144 healthcare organizations that participate in the Patient Advocacy Reporting System program. Cases (physicians with probable or possible NCD) and two comparison groups of 60 physicians each (matched for age/sex and site/number of unsolicited patient complaints) were identified from 33,814 physicians practicing at study sites. We compared the frequency of words in patient complaints related to an NCD diagnostic domain between cases and our two comparison groups. RESULTS: Individual words were all statistically more likely to appear in patient complaints for cases (73% of cases had at least one such word) compared to age/sex matched (8%, p < 0.001 using Pearson's χ2 test, χ2 = 30.21, df = 1) and site/complaint matched comparisons (18%, p < 0.001 using Pearson's χ2 test, χ2 = 17.51, df = 1). Cases were significantly more likely to have at least one complaint with any word describing NCD than the two comparison groups combined (conditional logistic model adjusted odds ratio 20.0 [95% confidence interval 4.9-81.7]). CONCLUSIONS: Analysis of words in unsolicited patient complaints found that descriptions of interactions with physicians with NCD were significantly more likely to include words from one of the diagnostic domains for NCD than were two different comparison groups. Further research is needed to understand whether patients might provide information for healthcare organizations interested in identifying professionals with evidence of cognitive impairment.

Using Coworker Observations to Promote Accountability for Disrespectful and Unsafe Behaviors by Physicians and Advanced Practice Professionals.

BACKGROUND: Health care team members are well positioned to observe disrespectful and unsafe conduct-behaviors known to undermine team function. Based on experience in sharing patient complaints with physicians who subsequently achieved decreased complaints and malpractice risk, Vanderbilt University Medical Center developed and assessed the feasibility of the Co-Worker Observation Reporting System(SM) (CORS (SM)) for addressing coworkers' reported concerns. METHODS: VUMC leaders used a "Project Bundle" readiness assessment, which entailed identification and development of key people, organizational supports, and systems. Methods involved gaining leadership buy-in, recruiting and training key individuals, aligning the project with organizational values and policies, promoting reporting, monitoring reports, and employing a tiered intervention process to address reported coworker concerns. RESULTS: Peer messengers shared coworker reports with the physicians and advanced practice professionals associated with at least one report 84% of the time. Since CORS inception, 3% of the medical staff was associated with a pattern of CORS reports, and 71% of recipients of pattern-related interventions were not named in any subsequent reports in a one-year follow-up period. CONCLUSIONS: Systematic monitoring of documented co-worker observations about unprofessional conduct and sharing that information with involved professionals are feasible. Feasibility requires organizationwide implementation; co-workers willing and able to share respectful, nonjudgmental, timely feedback designed initially to encourage self-reflection; and leadership committed to be more directive if needed. Follow-up surveillance indicates that the majority of professionals "self-regulate" after receiving CORS data.

Stuck in a moment: an ex ante analysis of patient complaints in plastic surgery, used to predict malpractice risk profiles, from a large cohort of physicians in the patient advocacy reporting system.

INTRODUCTION: Unsolicited patient complaints (UPCs) serve as a powerful predictor of increased risk of malpractice claims, and reductions in UPCs, through targeted physician interventions, lower incidence of lawsuits and decrease cost of risk management. We analyzed UPCs, verified by trained counselors in patient relations, to determine the malpractice risk of plastic surgeons, compared to dermatologists, all surgeons, and all physicians, from a national patient complaint registry. METHODS: We examined the patient complaint profiles and risk scores of 31,077 physicians (3935 surgeons, 338 plastic and reconstructive surgeons, and 519 dermatologists), who participated in the Patient Advocacy Reporting System, a national registry of UPCs. Patient complaint data were collected from 70 community and academic hospitals across 29 states, from 2009 to 2012. In addition to determining the specific complaint mix for plastic surgery compared to all physicians, each physician was assigned a patient complaint risk score, based on a proprietary weighted-sum algorithm, with a score higher than 70, indicative of high risk for malpractice claims. Patient complaint profiles and risk scores were compared between all groups, using Wilcoxon rank and χ analysis. P values less than 0.05 were assigned statistical significance. RESULTS: Over this 4-year period, the majority of plastic surgeons (50.8%) did not generate any patient complaints, but those who did received an average of 9.8 complaints from 4.8 patients. The percentage of physicians at high risk for malpractice claims, based upon the Patient Advocacy Reporting System index score of patient complaints, was as follows: all physicians, 2.0%; all surgeons, 4.1%; plastic and reconstructive surgeons, 2.4%; dermatologists, 1.4%. Physicians (from 2012 only) who were identified by their sponsoring institutions as "reconstructive" plastic surgeons (n = 41) were 5 times as likely to have a high risk score, compared to physicians who were identified as "plastic" surgeons (n = 233), and were more likely to practice within an academic health care system that had a level 1 trauma center and a plastic surgery residency program. The overall mix of patient complaints from plastic and reconstructive surgeons was nearly the same as the national cohort of all physicians: care and treatment, 49%; communication, 19%; accessibility and availability, 14%; money or payment issues, 9%; and concern for patient/family, 9%. CONCLUSIONS: "Reconstructive" plastic surgeons are at increased risk for UPCs, compared to most physicians, especially dermatologists. Because UPCs are a robust proxy for malpractice risk, targeted interventions to decrease patient complaints may improve patient satisfaction and reduce malpractice claims and risk management activity. Monitoring UPCs may permit early identification of high-risk surgeons before malpractice claims accumulate.

An Effective Program to Reduce Malpractice Claims and Payments in a Large Orthopaedic Practice.

BACKGROUND: High reliability in health care requires a balance between intentionally designed systems and individual professional accountability. One element of accountability includes a process for addressing clinicians whose practices are associated with a disproportionate share of patient complaints. This study aimed to evaluate the impact of the Patient Advocacy Reporting System (PARS), a tiered intervention model to reduce patient complaints about clinicians. METHODS: A retrospective cohort study was conducted involving a southeastern U.S. orthopaedic group practice. The study assessed the implementation of the PARS program and subsequent malpractice claims from 2004 to 2020. RESULTS: The implementation of PARS was associated with an 83% reduction in malpractice claims cost per high-risk clinician after intervention (p = 0.05; Wilcoxon rank sum test). The overall practice group experienced an 87% reduction in mean annual claims cost per clinician (p = 0.007; segmented regression). The successful adoption required essential elements such as PARS champions, peer messengers, an Office of Patient Affairs, and a clear statement of practice values and professionalism expectations at the time of onboarding. CONCLUSIONS: The PARS program was successfully adopted within a surgical specialty group as a part of ongoing risk prevention and management efforts. The period following PARS was associated with a retrospectively measured reduction in malpractice claim costs. The PARS program can be effectively implemented in a large, single-specialty orthopaedic practice setting and, although not necessarily causal, was, in our case, associated with a period of reduced malpractice claim costs. CLINICAL RELEVANCE: We have learned in previous research that there are clear links between professionalism and patient outcomes (e.g., surgical complications), but agree that the focus here on medical malpractice is not directly clinical.

Physician Specialty Differences in Unprofessional Behaviors Observed and Reported by Coworkers.

Importance: Because unprofessional behaviors are associated with patient complications, malpractice claims, and well-being concerns, monitoring concerns requiring investigation and individuals identified in multiple reports may provide important opportunities for health care leaders to support all team members. Objective: To examine the distribution of physicians by specialty who demonstrate unprofessional behaviors measured through safety reports submitted by coworkers. Design, Setting, and Participants: This retrospective cohort study was conducted among physicians who practiced at the 193 hospitals in the Coworker Concern Observation Reporting System (CORS), administered by the Vanderbilt Center for Patient and Professional Advocacy. Data were collected from January 2018 to December 2022. Exposure: Submitted reports concerning communication, professional responsibility, medical care, and professional integrity. Main Outcomes and Measures: Physicians' total number and categories of CORS reports. The proportion of physicians in each specialty (nonsurgeon nonproceduralists, emergency medicine physicians, nonsurgeon proceduralists, and surgeons) who received at least 1 report and who qualified for intervention were calculated; logistic regression was used to calculate the odds of any CORS report. Results: The cohort included 35 120 physicians: 18 288 (52.1%) nonsurgeon nonproceduralists, 1876 (5.3%) emergency medicine physicians, 6743 (19.2%) nonsurgeon proceduralists, and 8213 (23.4%) surgeons. There were 3179 physicians (9.1%) with at least 1 CORS report. Nonsurgeon nonproceduralists had the lowest percentage of physicians with at least 1 report (1032 [5.6%]), followed by emergency medicine (204 [10.9%]), nonsurgeon proceduralists (809 [12.0%]), and surgeons (1134 [13.8%]). Nonsurgeon nonproceduralists were less likely to be named in a CORS report than other specialties (5.6% vs 12.8% for other specialties combined; difference in percentages, -7.1 percentage points; 95% CI, -7.7 to -6.5 percentage points; P < .001). Pediatric-focused nonsurgeon nonproceduralists (2897 physicians) were significantly less likely to be associated with a CORS report than nonpediatric nonsurgeon nonproceduralists (15 391 physicians) (105 [3.6%] vs 927 [6.0%]; difference in percentages, -2.4 percentage points, 95% CI, -3.2 to -1.6 percentage points; P < .001). Pediatric-focused emergency medicine physicians, nonsurgeon proceduralists, and surgeons had no significant differences in reporting compared with nonpediatric-focused physicians. Conclusions and Relevance: In this cohort study, less than 10% of physicians ever received a coworker report with a concern about unprofessional behavior. Monitoring reports of unprofessional behaviors provides important opportunities for health care organizations to identify and intervene as needed to support team members.

An analysis of risk factors for patient complaints about ambulatory anesthesiology care.

BACKGROUND: Anesthesiology groups continually seek data sources and evaluation metrics for ongoing professional practice evaluation, credentialing, and other quality initiatives. The analysis of patient complaints associated with physicians has been previously shown to be a marker for patient dissatisfaction and a predictor of malpractice claims. Additionally, previous studies in other specialties have revealed a nonuniform distribution of complaints among professionals. In this study, we describe the distribution of complaints among anesthesia providers and identify factors associated with complaint risk in pediatric and adult populations. METHODS: We performed an analysis of a complaint database for an academic medical center. Complaints were recorded as comments during postoperative telephone calls to ambulatory surgery patients regarding the quality of their anesthesiology care. Calls between July 1, 2006 and June 30, 2010 were included. Risk factors were grouped into 3 categories: patient demographics, procedural, and provider characteristics. RESULTS: A total of 22,871 calls placed on behalf of 120 anesthesiologists were evaluated, of which 307 yielded a complaint. There was no evidence of provider-to-provider heterogeneity in complaint risk in the pediatric population. In the adult population, an unadjusted test for the random intercept variance component in the mixed effects model pointed toward significant heterogeneity (P = 0.01); however, after adjusting for a prespecified set of risk factors, provider-to-provider heterogeneity was no longer observed (P = 0.20). Several risk factors exhibited evidence for complaint risk. In the pediatric patient model, risk factors associated with complaint risk included a 10-year change in age, the use of general anesthesia (versus not), and a 1-hour change in the actual minus scheduled start times. Odds ratios were 1.47 (95% confidence interval (CI), 1.04-2.08), 0.22 (95% CI, 0.07-0.62), and 1.27 (95% CI, 1.10-1.47), respectively. In the adult patient model, risk factors associated with complaint risk included male gender, general anesthesia, a 10-year change in provider experience, and speaking with the patient (rather than a family member). Odd ratios were 0.66 (95% CI, 0.47-0.92), 0.67 (95% CI, 0.47-0.95), 1.18 (95% CI, 1.01-1.38), and 1.96 (95% CI, 1.17-3.29), respectively. CONCLUSIONS: There was apparent evidence in adult patients to suggest heterogeneity in provider risk for a patient complaint. However, once patient, procedural, and provider factors were acknowledged in analyses, such evidence for heterogeneity is diminished substantially. Further study into how and why these factors are associated with greater complaint risk may reveal potential interventions to decrease complaints.

An intervention model that promotes accountability: peer messengers and patient/family complaints.

BACKGROUND: Patients and their families are well positioned to partner with health care organizations to help identify unsafe and dissatisfying behaviors and performance. A peer messenger process was designed by the Center for Professional and Patient Advocacy at Vanderbilt University Medical Center (Nashville, Tennessee) to address "high-risk" physicians identified through analysis of unsolicited patient complaints, a proxy for risk of lawsuits. METHODS: This retrospective, descriptive study used peer messenger debriefing results from data-driven interventions at 16 geographically disparate community (n = 7) and academic (n = 9) medical centers in the United States. Some 178 physicians served as peer messengers, conducting interventions from 2005, through 2009 on 373 physicians identified as high risk. RESULTS: Most (97%) of the high-risk physicians received the feedback professionally, and 64% were "Responders." Responders' risk scores improved at least 15%, where Nonresponders' scores worsened (17%) or remained unchanged (19%) (p < or = .001). Responders were more often physicians practicing in medicine and surgery than emergency medicine physicians, had longer organizational tenures, and engaged in lengthier first-time intervention meetings with messengers. Years to achieve responder status correlated positively with initial communication-related complaints (r = .32, p < .001), but all complaint categories were equally likely to change over time. CONCLUSIONS: Peer messengers, recognized by leaders and appropriately supported with ongoing training, high-quality data, and evidence of positive outcomes, are willing to intervene with colleagues over an extended period of time. The physician peer messenger process reduces patient complaints and is adaptable to addressing unnecessary variation in other quality/safety metrics.

A Proposed Approach to Allegations of Sexual Boundary Violation in Health Care.

BACKGROUND: Sexual boundary violations in the health care setting cause harm for victims, threaten an organization's culture, and create extraordinary organizational risk. The inherent complexities of health care organizations present unique challenges for the initial triage and response to reports of alleged violations. METHODS: A group of experts with experience in law, leadership, human resources, medicine, and health care operations identified processes for organizations to triage and implement an early response to allegations of sexual boundary violations. The group reviewed a series of 100 reports of alleged violations described by patients and coworkers from a 200-hospital professional accountability collaborative to identify the elements of an ideal initial triage and management approach. RESULTS: The group identified three domains to guide early triage and response to reports of boundary violations: (1) severity and acuity of the alleged violation; (2) roles and relationship(s) of the complainant, respondent, and other affected individuals; and (3) contextual information such as prior activity or other mitigating factors. The group identified leadership engagement; coordinated responses; clear articulation of values, policies, and procedures; aligned data reporting; thoughtful reviews; and securing appropriate resources as essential elements of an organization's response. CONCLUSION: A structured systematic approach to classify and respond to allegations of sexual boundary violation is described. The initial response should be guided by assessment of the severity and timing of the reported behavior, followed by assessment of roles and responsibilities with involvement of all relevant stakeholders. Contextual issues and special circumstances of relevance should be identified and incorporated into the response. Systems to identify, store, and retrieve behavior of concern should be improved and integrated.

Balancing Rights and Responsibilities of Key Stakeholders in Addressing Reports of Disrespect Experienced by Patients.

Professionalism in health care occurs in environments that present complex ethical dilemmas that demand ideal individual and team performance. Clinicians who behave unprofessionally toward patients and family members create a disproportionate share of risk for adverse patient outcomes and malpractice claims. However, when made aware, the vast majority will self-regulate. Several options exist for a clinician who observes or hears about an interaction between a colleague and a patient or family member that does not seem to be consistent with the organization's commitment to treat individuals with respect and dignity. Responses to unprofessional behavior need to recognize and balance the rights and responsibilities of key stakeholders, including patients, clinicians, coworkers, and the organization. In one approach, the clinician would speak directly with the colleague to make them aware of the event and encourage them to consider alternative approaches in future similar interactions. Alternatively, the clinician could ensure that the story is reported, reviewed, and shared through the organization's professional accountability program. Professional accountability programs must be supported by appropriate infrastructure elements. Sharing the observation helps to address the concerns and fears of patients and family members, offers a colleague the chance to reflect and reduce the likelihood of future unprofessional behavior, and seeks to fulfill one's individual responsibility to support colleagues as professionals, while striking the right balance of dignity, respect, and pursuit of trust for all key stakeholders.

Honesty and Transparency, Indispensable to the Clinical Mission-Part I: How Tiered Professionalism Interventions Support Teamwork and Prevent Adverse Events.

At the foundation of clinical medicine is the relationship among patients, families, and health care professionals. Implicit to that social contract, professionals pledge to bring clinical excellence to advance their patients' wellness and healing-and to prevent harm. Patients trust that those privileged to deliver care will do so unwaveringly in service of patients' best interests; however, the incentives and infrastructure surrounding health care delivery can promote or undermine individual performance, teamwork, and patient safety. Modeling professionalism and identifying slips and lapses supports pursuit of high reliability. Part 1, Promoting Professionalism, introduces the first of 3 pillars of advancing the clinical mission.

Honesty and Transparency, Indispensable to the Clinical Mission-Part III: How Leaders Can Prevent Burnout, Foster Wellness and Recovery, and Instill Resilience.

The hidden epidemic of burnout exacts a staggering toll on professionals and patients, reflected in increased risk of medical errors, complications, and staff turnover. For surgeons, nurses, and other team members working at the sharp end of care, adverse events can amplify work exhaustion, interpersonal disengagement, and risk of moral adversity. Visionary leaders are not content to mitigate burnout and moral injury; they elevate the human experience throughout health care by modeling wellness, fostering moral courage, promoting safety of professionals, and restoring joy in work. Part 3, Health Professional Wellness and Resilience, introduces the final pillar for advancing the clinical mission.

Honesty and Transparency, Indispensable to the Clinical Mission-Part II: How Communication and Resolution Programs Promote Patient Safety and Trust.

When patients are harmed by health care, concerns fan out in all directions. Patients and families confront a sea of uncertainty, contending with injuries that drain them physically, emotionally, and financially. Health care professionals experience a powerful mix of emotions, but are seldom afforded the time to process what happened or the resources to relieve suffering and prevent harm. Honesty, transparency, and empathy are indispensable to a comprehensive approach that prioritizes patient and family-centered response to unintended harm, clinical improvement, and redemptive peer review. Part 2 introduces the second of three pillars for advancing the clinical mission: communication and transparency.

Supporting the pursuit of professionalism during a crisis.

BACKGROUND: Crisis plans for healthcare organisations most often focus on operational needs including staffing, supplies and physical plant needs. Less attention is focused on how leaders can support and encourage individual clinical team members to conduct themselves as professionals during a crisis. METHODS: This qualitative study analysed observations from 79 leaders at 160 hospitals that participate in two national professionalism programmes who shared their observations in focus group discussions about what they believed were the essential elements of leading and addressing professional accountability during a crisis. RESULTS: Analysis of focus group responses identified six leadership practices adopted by healthcare organisations, which were felt to be essential for organisations to navigate the crisis successfully. Unique aspects of maintaining professionalism during each phase of the pandemic were identified and described. CONCLUSIONS: Leaders need a plan to support an organiation's pursuit of professionalism during a crisis. Leaders participating in this study identified practices that should be carefully woven into efforts to support the ongoing safety and quality of the care delivered by healthcare organisations before, during and after a crisis. The lessons learnt from the COVID-19 pandemic may be useful during subsequent crises and challenges that a healthcare organisation might experience.

Whose Responsibility Is It to Address Bullying in Health Care?

Bullying has significant, far-reaching consequences for all health professionals, students, trainees, patients, their families, and organizations. Bullying is antithetical to healthy organizational culture, patient safety, and professionalism. A culture of safety and respect in sites of health care education and work is foundational to the well-being of everyone in health care. This commentary on a case recommends individual and collective responses to bullying that express fundamental clinical and ethical values and what it means to be a professional.

Evaluation of the My Diabetes Care Patient Portal Intervention: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: My Diabetes Care (MDC) is a multi-faceted intervention embedded within an established patient portal, My Health at Vanderbilt. MDC is designed to help patients better understand their diabetes health data and support self-care. MDC uses infographics to visualize and summarize patients' diabetes health data, incorporates motivational strategies, provides literacy-level appropriate educational resources, and links to a diabetes online patient support community and diabetes news feeds. OBJECTIVE: This study aims to evaluate the effects of MDC on patient activation in adult patients with type 2 diabetes mellitus. Moreover, we plan to assess secondary outcomes, including system use and usability, and the effects of MDC on cognitive and behavioral outcomes (eg, self-care and self-efficacy). METHODS: We are conducting a 6-month, 2-arm, parallel-design, pragmatic pilot randomized controlled trial of the effect of MDC on patient activation. Adult patients with type 2 diabetes mellitus are recruited from primary care clinics affiliated with Vanderbilt University Medical Center. Participants are eligible for the study if they are currently being treated with at least one diabetes medication, are able to speak and read in English, are 21 years or older, and have an existing My Health at Vanderbilt account and reliable access to a desktop or laptop computer with internet access. We exclude patients living in long-term care facilities, patients with known cognitive deficits or severe visual impairment, and patients currently participating in any other diabetes-related research study. Participants are randomly assigned to MDC or usual care. We collect self-reported survey data, including the Patient Activation Measure (R) at baseline, 3 months, and 6 months. We will use mixed-effects regression models to estimate potentially time-varying intervention effects while adjusting for the baseline measure of the outcome. The mixed-effects model will use fixed effects for patient-level characteristics and random effects for health care provider variables (eg, primary care physicians). RESULTS: This study is ongoing. Recruitment was closed in May 2020; 270 patients were randomized. Of those randomized, most (214/267, 80.1%) were non-Hispanic White, and 13.1% (35/267) were non-Hispanic Black, 43.7% (118/270) reported being 65 years or older, and 33.6% (90/268) reported limited health literacy. We obtained at least 95.6% (258/270) completion among participants through the 3-month follow-up assessment. CONCLUSIONS: This randomized controlled trial will be one of the first to evaluate a patient-facing diabetes digital health intervention delivered via a patient portal. By embedding MDC into Epic's MyChart platform with more than 127 million patient records, our intervention is directly integrated into routine care, highly scalable, and sustainable. Our findings and evolving patient portal functionality will inform the continued development of MDC to best meet users' needs and a larger trial focused on the impact of MDC on clinical end points. TRIAL REGISTRATION: ClinicalTrials.gov NCT03947333; https://clinicaltrials.gov/ct2/show/NCT03947333. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/25955.

Characteristics of Inpatient Units Associated With Sustained Hand Hygiene Compliance.

OBJECTIVES: Following institution of a hand hygiene (HH) program at an academic medical center, HH compliance increased from 58% to 92% for 3 years. Some inpatient units modeled early, sustained increases, and others exhibited protracted improvement rates. We examined the association between patterns of HH compliance improvement and unit characteristics. METHODS: Adult inpatient units (N = 35) were categorized into the following three tiers based on their pattern of HH compliance: early adopters, nonsustained and late adopters, and laggards. Unit-based culture measures were collected, including nursing practice environment scores (National Database of Nursing Quality Indicators [NDNQI]), patient rated quality and teamwork (Hospital Consumer Assessment of Healthcare Provider and Systems), patient complaint rates, case mix index, staff turnover rates, and patient volume. Associations between variables and the binary outcome of laggard (n = 18) versus nonlaggard (n = 17) were tested using a Mann-Whitney U test. Multivariate analysis was performed using an ordinal regression model. RESULTS: In direct comparison, laggard units had clinically relevant differences in NDNQI scores, Hospital Consumer Assessment of Healthcare Provider and Systems scores, case mix index, patient complaints, patient volume, and staff turnover. The results were not statistically significant. In the multivariate model, the predictor variables explained a significant proportion of the variability associated with laggard status, (R2 = 0.35, P = 0.0481) and identified NDNQI scores and patient complaints as statistically significant. CONCLUSIONS: Uptake of an HH program was associated with factors related to a unit's safety culture. In particular, NDNQI scores and patient complaint rates might be used to assist in identifying units that may require additional attention during implementation of an HH quality improvement program.

The My Diabetes Care Patient Portal Intervention: Usability and Pre-Post Assessment.

BACKGROUND: My Diabetes Care (MDC) is a novel, multifaceted patient portal intervention designed to help patients better understand their diabetes health data and support self-management. MDC uses infographics to visualize and summarize patients' diabetes health data, incorporates motivational strategies, and provides literacy level-appropriate educational resources. OBJECTIVES: We aimed to assess the usability, acceptability, perceptions, and potential impact of MDC. METHODS: We recruited 69 participants from four clinics affiliated with Vanderbilt University Medical Center. Participants were given 1 month of access to MDC and completed pre- and post-questionnaires including validated measures of usability and patient activation, and questions about user experience. RESULTS: Sixty participants completed the study. Participants' mean age was 58, 55% were females, 68% were Caucasians, and 48% had limited health literacy (HL). Most participants (80%) visited MDC three or more times and 50% spent a total of ≥15 minutes on MDC. Participants' median System Usability Scale (SUS) score was 78.8 [Q1, Q3: 72.5, 87.5] and significantly greater than the threshold value of 68 indicative of "above average" usability (p < 0.001). The median SUS score of patients with limited HL was similar to those with adequate HL (77.5 [72.5, 85.0] vs. 82.5 [72.5, 92.5]; p = 0.41). Participants most commonly reported the literacy level-appropriate educational links and health data infographics as features that helped them better understand their diabetes health data (65%). All participants (100%) intended to continue to use MDC. Median Patient Activation Measure® scores increased postintervention (64.3 [55.6, 72.5] vs. 67.8 [60.6, 75.0]; p = 0.01). CONCLUSION: Participants, including those with limited HL, rated the usability of MDC above average, anticipated continued use, and identified key features that improved their understanding of diabetes health data. Patient activation improved over the study period. Our findings suggest MDC may be a beneficial addition to existing patient portals.

Qualitative Content Analysis of Coworkers' Safety Reports of Unprofessional Behavior by Physicians and Advanced Practice Professionals.

OBJECTIVES: The aims of the study were to develop a valid and reliable taxonomy of coworker reports of alleged unprofessional behavior by physicians and advanced practice professionals and determine the prevalence of reports describing particular types of unprofessional conduct. METHODS: We conducted qualitative content analysis of coworker reports of alleged unprofessional behavior by physicians and advanced practice professionals to create a standardized taxonomy. We conducted a focus group of experts in medical professionalism to assess the taxonomy's face validity. We randomly selected 120 reports (20%) of the 590 total reports submitted through the medical center's safety event reporting system between June 2015 and September 2016 to measure interrater reliability of taxonomy codes and estimate the prevalence of reports describing particular types of conduct. RESULTS: The initial taxonomy contained 22 codes organized into the following four domains: competent medical care, clear and respectful communication, integrity, and responsibility. All 10 experts agreed that the four domains reflected essential elements of medical professionalism. Interrater reliabilities for all codes and domains had a κ value greater than the 0.60 threshold for good reliability. Most reports (60%, 95% confidence interval = 51%-69%) described disrespectful or offensive communication. Nine codes had a prevalence of less than 1% and were folded into their respective domains resulting in a final taxonomy composed of 13 codes. CONCLUSIONS: The final taxonomy represents a useful tool with demonstrated validity and reliability, opening the door for reliable analysis and systems to promote accountability and behavior change. Given the safety implications of unprofessional behavior, understanding the typology of coworker observations of unprofessional behavior may inform organization strategies to address this threat to patient safety.