Sentinel Event Alert Number 40 - Texas Organization for Associate
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Transcript Sentinel Event Alert Number 40 - Texas Organization for Associate
Presented by
Christopher L. Pate, Ph.D, MPA, CQIA
64th Annual Convention of the Texas Community College Teachers
Association
29 January 2011
San Antonio, Texas
Agenda
• The Joint Commission
• Role
• Sentinel Events
• Sentinel Event Alert #40
• Definitions
• Prevalence
• Incivility in nursing education
• Mitigation through recommendations and steps
described by the Joint Commission
• Implications for higher education
Learning Outcomes
At the conclusion of this presentation, attendees will be able
to:
Identify the critical features of Sentinel Event Alert Number 40
Describe sentinel events in the context of civility
Identify characteristics of the concept of civility in healthcare
settings
Discuss findings of civility-related studies in US healthcare settings
List Joint Commission recommendations for improving the
environment of care and reducing workplace aggression
Discuss causes and consequences of nursing incivility
Understand how organizational activities taken in response to the
Joint Commission’s changes in civility-related accreditation
standards are compatible with collaborative decision making in
institutions of higher education
The Joint Commission
The Joint Commission (TJC)
Seeks to continuously improve health care for the public, in
collaboration with other stakeholders, by evaluating health care
organizations and inspiring them to excel in providing safe and
effective care of the highest quality and value
Evaluates and accredits more than 17,000 health care organizations
and programs in the United States
Independent, not-for-profit organization
Nation's oldest and largest standards-setting and accrediting body
in healthcare (The Joint Commission, 2009).
Focused on all aspects of organizational performance
Particular interest and focus on
Quality
Safety
Processes
Sentinel Events
Sentinel event defined
An unexpected occurrence involving death or serious
physical or psychological injury, or the risk thereof.
Serious injury specifically includes loss of limb or
function. The event is called ‘sentinel’ because it sends a
signal or sounds a warning that requires immediate
attention (The Joint Commission, 2007)
TJC began issuing Sentinel Event alerts in 1998
(McLaughlin, 2008)
Sentinel Event Alert: Issue 40
• Sentinel Event Alert
• “Behaviors that undermine a culture of safety” (Joint
Commission)
• Issued July 2008
• Effective 1 January 2009, as requirement for accreditation
• Specifically linked to domain of organizational leadership
• Elements of performance (EP)
– Hospitals/organizations must have code of conduct that
defines acceptable, disruptive and inappropriate behaviors
– Leaders must create and implement a process for managing
disruptive and inappropriate behaviors
Sentinel Events
Four Key Goals of Sentinel Event Policies
Positive impact on improving patient care, treatment
and services and preventing future occurrences
Focus attention on understanding the causes and on
changing systems and processes to reduce likelihood of
future occurrences
Increase knowledge about sentinel events, their causes
and strategies for prevention
Maintain confidence of the public and accredited
organizations in the accreditation process (The Joint
Commission, 2007)
Undermining Culture of Safety:
Behaviors and Outcomes
Relationship between intimidating and disruptive
behaviors and outcomes
Medical errors
Poor patient satisfaction
Preventable adverse outcomes
Increase in cost of care
Retention; clinicians, administrators, managers engage
in search for jobs external to the organization
Joint Commission, 2011 National Patient Safety Goals
#2: Improve staff communication
Source: Joint Commission,
http://www.jointcommission.org/SentinelEvents/Sentineleventalert/sea_40.htm
Prevalence
Most research on topic conducted outside US (e.g.,
UK, Australia, Canada)
US
American College of Physician Executives (2009)
Survey of 13K physicians and nurses
98% of respondents reported observation of behavioral
problems between physicians and nurses within past year
30% indicated that bad behavior occurs several times year;
30% indicated weekly occurrence; approximately 25%
occurring monthly
Most common: degrading comments, insults
Prevalence
US
Agency for Healthcare Research and Quality (AHRQ, US
Department of Health and Human Services, 2011)
2008 survey (citing work of Rosenstein & O'Daniel); 100
hospitals
77% of respondents reported observation of physicians
engaging in disruptive behavior
65% reported witnessing disruptive behavior by nurses
Prevalence
US
American Association of Critical Care Nurses (AACN),
VitalSmarts (2004 Survey)
Focus group of 1700 physicians, nurses, administrators
(VitalSmarts, 2005)
More than 75% “regularly work with doctors or nurses who are
condescending, insulting or rude” (Grenny, 2009, p. 30)
About 1/3 of the participants reported that behavior includes
name-calling, yelling, and swearing (p. 30)
Definitions
Disruptive behavior
Behavior that interferes with effective communication among
healthcare providers and negatively impacts performance and
outcomes; behavior not supportive of a culture of safety
(Agency for Healthcare Research and Quality, 2011; Center for
American Nurses, 2008)
Culture of safety
“characterized by open and respectful communication among
all members of the healthcare team in order to provide safe
patient care. It is a culture that supports an organizational
commitment to continually seeking to improve safety”
(Institute of Medicine, as cited in Center for American
Nurses, 2008)
Definitions
Incivility
Lack of regard for others; violation of workplace norms that
promote respectful, interpersonal interaction
3 key features
Psychological
Low intensity, inconsiderate
Ambiguous intent to harm target (Felblinger, 2009, p. 14)
Bullying
Goes beyond incivility; aggressive, deliberate, psychological or
physical (Felblinger, 2009)
Behavior that is generally persistent, systematic and ongoing (Task
Force on the Prevention of Workplace Bullying, as cited in Center
for American Nurses, 2008)
Disruptive Behaviors and Incivility
Behaviors associated with incivility
Rude comments
Disrespectful verbal attacks
Offensive, condescending language
Lack of collaboration
Disregard for interdisciplinary input about patient care
Public criticism
Subtle or overt verbal aggression
Name calling
Withholding critical information (Felblinger, 2009)
Disruptive Behaviors and Incivility
Behaviors associated with incivility
Ethnic slurs or jokes
Sexual comments
Yelling
Screaming
Attacking a person’s integrity
Requesting input when decisions are already made
Superficial listening
Lacking empathy
Blaming others in front of family members; blaming team members
when something goes wrong (Felblinger, 2009)
Lateral Violence
Lateral or horizontal violence
Nursing defined as nurse-to-nurse aggression
“aggressive behavior between nurses on the same power level”
(Simons, 2008)
Verbal or nonverbal
Common forms
Lateral Violence: Behaviors
Common forms
Non-verbal innuendo
Verbal affront
Undermining activities
Withholding information
Sabotage
Infighting
Scapegoating
Backstabbing
Failure to respect privacy; broken confidences (Griffin, as cited in
Center for American Nurses, 2008)
Workplace Bullying
Workplace bullying
“repeated inappropriate behavior, direct or indirect,
whether verbal, physical or otherwise, conducted by one
or more persons against another or others, at the place
of work and/or in the course of employment, which
could reasonably be regarded as undermining the
individual’s right to dignity at work” (Task Force on the
Prevention of Workplace Bullying, as cited in Center for
American Nurses, 2008)
Specific Types of Bullying Behaviors
in Healthcare Settings
Verbal abuse
Written abuse
Physical abuse
Intimidation
Displays of offensive material (Edwards, O’Connell,
2007, p. 28)
Verbal Abuse
Verbal abuse
“disruptive form of behavior involving verbal communication that is
associated with horizontal violence” (Center for American Nurses, 2008)
“any communication a nurse perceives to be a harsh, condemnatory attack
upon herself or himself professionally or personally” (Cox, as cited in
Center for American Nurses, 2008)
Examples
Offensive language or innuendo
Language that belittles a person’s abilities
Spreading malicious rumors
Sexist, racist, or patronizing remarks
Inappropriate or intimate questioning (NHS, as cited in Edwards,
O’Connell, p. 28)
Bullying Behaviors in Healthcare
Settings: Written and Physical Abuse
Written
Letters, email, faxes
Physical
Unwanted physical contact
Explicit physical threats or attacks
Unnecessary touching or assault
Stalking that is related to work, may occur at work or
outside of work(NHS, as cited in Edwards, O’Connell, p.
28)
Bullying Behaviors in Healthcare
Settings: Intimidation and Offensive
Material
Intimidation
Slander
Belittling conduct (e.g., being yelled at)
Intrusion by pestering, following
Unnecessary closeness
Apportioning blame wrongly
Offensive material
Flags and emblems
Badges
Graffiti
Unnecessary highlighting of differences (NHS, as cited in
Edwards, O’Connell, p. 28)
How Might this Look in Practice?
http://www.youtube.com/watch?v=mBCRBaLHR1k
Root Causes
Individual factors
Learned behavior, “perpetrators of bullying have been bullied themselves”
(Paterson et al., as cited in Edwards & O’Connell, 2007)
Individual insecurities
Stress
Individuals lack training on appropriate behavior and expectations
Organizational factors
Power imbalances between organizational members (nursing as “oppressed
group,” Hutchinson, Vickers, Jackson, & Wilkes, 2006, p. 119)
Lack of professional training
Lack of leadership
Organizational demands and stress, “do more with less” mentality, focus on
productivity
Organizational change and uncertainty (Randle, Stevenson, & Grayling, 2007)
Effects on Individuals
Nurse-to-nurse hostility
Anxiety, fear, shock, anger, guilt, vulnerability,
humiliation
Loss of self-confidence
Loss of self-esteem
Feeling threatened
Developing stress-related illness
Contemplating suicide (Leiper as cited in Bartholomew,
2006)
Practical Recommendations: An
Individual Perspective with
Organizational Implications
Disclosure
Knowledge of workplace protections
Documentation
Being assertive
Being empathetic
Use open questions
Buying time
Assertiveness training (Randle, Stevenson, & Grayling,
2007)
What and How to Address:
Carefronting
Carefronting (Briles, 2009)
When you ________________
I felt _____________________
Because __________________
Was it your intent to _______
In the future ______________
Are you committed to ______
If there is not a change _____
Incivility in Nursing Education
Defined:
“rude or disruptive behaviors that often result in
psychological or physiological distress for the people
involved and may progress into threatening situations
when left unaddressed” (Clark as cited in Clark &
Springer, 2010, p. 320)
Faculty and student consequences
Disrupted student-faculty relationships
Problematic learning environments
Increased stress levels for faculty and students (Clark &
Springer, 2010)
Creating a Culture of Civility in
Nursing Education
Recognition that both students and faculty have responsibilities
Factors contributing to incivility
Faculty (high stress, negative attitude of superiority, assumption of
“know it all” attitude, arrogance)
Students (consumer mentality, refusal to accept responsibility,
making excuses, high stress)
“faculty and student stress and disparaging attitudes in conjunction
with missed, avoided, or poorly managed opportunities for
meaningful engagement are major contributions to incivility in
nursing education” (Clark as cited in Clark & Springer, 2010, p. 320)
An Organizational Perspective
Strategies
Define the problem
Awareness and accountability
Organizational and leadership commitment
Policies and procedures
Staff education
Communication/team collaboration skills
Reporting policy and follow-through
Disruptive behavior policy
Address barriers
Implement intervention plan (Rosenstein, 2009, p. 332)
Specific Recommendations from the
Joint Commission
Education
Enforce accountability
Consistency in enforcement
Model desirable behaviors
Development of comprehensive approach (policies/procedures)
Zero tolerance for intimidating or disruptive behaviors
Alignment of medical/professional staff policies with those of larger
organization
Reducing fear of retaliation; protecting those who report—make
non-retaliation clauses part of policy on addressing disruptive
behaviors
Responding to patients and families that have witnessed
intimidating or disruptive behaviors
How and when to begin disciplinary actions
Source: Joint Commission,
http://www.jointcommission.org/SentinelEvents/Sentineleventalert/sea_40.htm
Specific Recommendations from the
Joint Commission
Develop process for addressing that uses input from inter-professional
team
Medical staff
Nursing staff
Administrators
Other employees
Provide skills-based training
Assessment
Develop system of reporting and surveillance
Use tiered approach to addressing
Conduct all interventions within context of improving organizational
commitment to the health and well-being of the staff
Document all attempts to address intimidating and disruptive
behaviors
Source: Joint Commission,
http://www.jointcommission.org/SentinelEvents/Sentineleventalert/sea_40.htm
Zero Tolerance
TJC
Good start
Needs follow-up with “strong communication that there
is zero tolerance for these behaviors, and strong actions
when they occur” (Physician Executive, 2009, p. 22)
“Implement a no-tolerance policy and enforce it 100% of
the time” (p. 22)
Empower staff
“I am sorry, but you may not speak to me it that tone of
voice” (p. 22)
Healthcare, Higher Education
Many similarities between higher education and healthcare
Emphasis on costs
Emphasis on output measurement, productivity
Increasing accountability
Organizational power centers
Codes of conduct (faculty, employees, students) necessary but insufficient to
address disruptive behaviors
Collaboration is necessary
Inclusion of groups most likely targeted
Appropriate cultural mix
Accrediting body involvement and standards
Places of rigorous inquiry; health sciences education perfect place to start
Recognition of institutions that adopt a robust plan to address intimidating
and disruptive behavior
Point of Contact
Contact info:
Christopher Pate, Ph.D, MPA, CQIA
Department of Radiology
Brooke Army Medical Center
Fort Sam Houston, TX 78234
210-916-7397
[email protected]
References
Agency for Healthcare Research and Quality. (2011). Disruptive and unprofessional behavior.
Retrieved January 27, 2011 from http://psnet.ahrq.gov/primer.aspx?primerID=15
Bartholomew, K. (2006). Ending nurse-to-nurse hostility: Why nurses eat their young and each other.
Marblehead, MA: HCPro, Inc.
Briles, J. (2009). Are there saboteurs in your midst? Retrieved January 27, 2011 from
http://ezinearticles.com/?Are--There-Saboteurs-in-Your-Midst?&id=2812525
Broome, B.A. (2008). Dealing with sharks and bullies in the workplace. ABNF Journal, 19(1), 28 – 30.
Center for American Nurses (2008). Lateral violence and bullying in the workplace. Retrieved August
15, 2009 from
http://www.mc.vanderbilt.edu/root/pdfs/nursing/center_lateral_violence_and_bullying_position_st
atement_from_center_for_american_nurses.pdf
Clark, C.M., & Springer, P.J. (2010). Academic nurse leaders’ role in fostering a culture of civility in
nursing education. Journal of Nursing Education, 49(6), 319 – 325.
Edwards, S.L., & O’Connell, C.F. (2007). Exploring bullying: Implications for nurse educators. Nurse
Education in Practice, 7(1), 26 – 35.
Felblinger, D.M. (2009). Bullying, incivility, and disruptive behaviors in the healthcare setting:
Identification, impact, and intervention. Frontiers of Health Services Management, 25(4), 13 – 23.
Grenny, J. (2009). Crucial conversations: The most potent force for eliminating disruptive behavior.
Physician-Executive, 35(6), 30 – 33.
Hutchinson, M., Vickers, M., Jackson, D., & Wilkes, L. (2006). Workplace bullying in nursing:
Towards a more critical organizational perspective. Nursing Inquiry, 13(2), 118 – 126.
References
Johnson, C. (2009). Bad blood: Doctor-nurse behavior problems impact patient care. PhysicianExecutive, 35(6), 6 – 11.
McLaughlin, S. (2008). Historical perspective: The joint commission’s growing role in the
environment of care. Health Facilities Management, 21(4), 43 – 45.
Randle, J., Stevenson, K., & Grayling, I. (2007). Reducing workplace bullying in healthcare
organizations. Nursing Standard, 21(22), 49 – 56.
Rosenstein, A.H. (2009). Disruptive behaviour and its impact on communication efficiency and
patient care. Journal of Communication in Healthcare, 2(4), 328 – 340.
Sheridan-Leos, N. (2008). Understanding lateral violence in nursing. Clinical Journal of Oncology
Nursing, 12(3), 399 – 403.
Simon, S.L. (2008). Mission (im)possible? Nurse civility in the NICU. Neonatal Network, 27(2), 141 –
142.
The Joint Commission (2009). Facts about the Joint Commission. Retrieved November 16, 2009 from
http://www.jointcommission.org/AboutUs/Fact_Sheets/joint_commission_facts.htm
The Joint Commission (2008). Sentinel event alert, Issue 40. Retrieved August 15, 2009 from
http://www.jointcommission.org/SentinelEvents/Sentineleventalert/sea_40.htm
The Joint Commission (2007). Sentinel events policies and procedures. Retrieved August 15, 2009
from http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/se_pp.htm
VitalSmarts. (2005). Media advisory: Panel examines harmful communication gaps in healthcare
system and provides prescription for change. Retrieved January 28, 2011 from
http://www.silencekills.com/UPDL/PressKit.pdf