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When Behavior Undermines Safety

Posted By Administration, Thursday, May 12, 2016

A Breakout Session at the NPSF Patient Safety Congress will detail a systematic method for
addressing colleague reports of unprofessional behavior.

by Patricia McTiernan, MS



Safety protocols are only effective if people follow them. Take hand hygiene, for example. While effective hand hygiene can reduce the spread of certain infections, the Centers for Disease Control and Prevention reports that, on average, health care professionals practice hand hygiene less than half the time that they should.


The difference between an inadvertent slip and an intentional disregard for a safety practice has been discussed before. So what is a health care worker to do if he or she sees a colleague behave in a way that undermines safety?


The Center for Patient and Professional Advocacy (CPPA) at Vanderbilt University Medical Center recently published results of a robust program to address colleague reports of unprofessional behavior. Lynn Webb, PhD, assistant dean for faculty development and lead author of the recent paper documenting the program, will be one of the speakers discussing this work at the NPSF Patient Safety Congress in Scottsdale later this month.


A Nonpunitive System of Change

  "It’s really important to emphasize
that this is not a punitive process."
—Lynn Webb, PhD

The Vanderbilt CPPA team already had experience with patient reports of unprofessional behavior. The Vanderbilt Patient Advocacy Reporting System (PARS) is a method of collecting and aggregating patient complaints of physician behavior. According to Dr. Webb, PARS data have shown that 5% of physicians and advanced practice professionals (APPs) are associated with 35-40% of patient complaints about their medical professionals. The PARS method for graduated interventions has been adapted and put into place at more than 140 hospitals and medical groups nationwide.


Now, the principles behind the PARS program have been utilized to develop the Co-worker Observation Reporting SystemSM (CORS).


“The CORS program was established to provide systematic feedback to professionals associated with reports from co-workers about what appeared to be unsafe or disrespectful behavior,” Dr. Webb says. The system involves a method of capturing, reviewing, coding, and tracking data. Peer “messengers” are trained to share reports with professionals associated with the reports. The time between when a report is received by the system and the peer discussion is usually less than one week.


Dr. Webb emphasizes that the system is designed to address behavior that seems inconsistent with the Vanderbilt “Credo,” a statement of values shared by professionals and staff. “It’s important to share reports as soon as possible, giving professionals an opportunity to reflect on the issues raised in them,” says Dr. Webb.


In analyzing reports over a 3-year period, the CPPA team found that 3% of professionals were associated with 45% of reports. After the CORS intervention process was implemented, 70% of identified professionals have not been associated with another report.


At Vanderbilt, CPPA also compared physicians identified in the CORS program with those identified in the PARS process. “We found little overlap of professionals having high numbers of patient complaints and those having a pattern of coworker concerns,” says Dr. Webb.


The Vanderbilt CPPA team has compiled a “project bundle” for use by other organizations considering the implementation of such a system. The bundle includes elements of the program that organizations should have in place to help ensure successful implementation. These include strong leadership commitment, program champions, and policies that address expectations for professional conduct. Co-presenter Roger Dmochowski, MD, Vanderbilt’s executive medical director for quality, safety, and risk prevention, believes that success of the CORS program at Vanderbilt was linked to the early involvement of physician and nursing leaders in the development phase.


“It’s really important to emphasize that this is not a punitive process,” Dr. Webb says. “By having a colleague share an observation with another colleague, the intent is to be restorative and change unsafe or disrespectful behavior.”

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Lynn Webb, PhD, and Roger Dmochowski, MD, will present details of the CORS program in Breakout Session 202 at the NPSF Patient Safety Congress. Find out more about the Congress agenda at


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Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  2016 NPSF Congress  culture 

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