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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., Competing Interests: Disclosure: No external funding was received for this study. The Article Processing Charge for open access publication was funded by the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H981 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

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.

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., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

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., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., Competing Interests: Conflict of interest and disclosure R.C. Boothman, JD, is Owner and Principal of Boothman Consulting, which assists health systems in transitioning to communication and resolutions programs, conducting programmatic and personal peer review, and designing peer review approaches. Dr G.B. Hickson is an employee of Vanderbilt University Medical Center and is a member of Medtronic’s speakers bureau. He receives royalties from Cognitive Institute; and has received payment for the development of educational presentations from numerous health care institutions. Dr G.B. Hickson is also a member of the USC Health System Board and Vice Chair of the Institute for Healthcare Improvement (IHI) Board. No other authors have disclosures relevant to this publication., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

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., (© 2021 American Medical Association. All Rights Reserved.)

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., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)