1. Professionalism: does it affect patient safety?
H Yang
Professor & Chair
Department of Anesthesia

2. Conflict of Interest
No payment by industry
No shares in industry

3. Objectives Understand progression of Professionalism
Review risks and successes in organizational professionalism & patient safety
Discuss next steps

4. Progression of professionalism model

5. Progression of Professionalism
Medical profession provides service; society appreciates & respects the medical profession
Social contract – self regulation, oversight of medical education, disciplining of “bad” physicians, attaining & maintaining certificate (special knowledge); in exchange is the placement of patient needs above all else
Lindenauer et al. NEJM 2005; 353:

6. Individual doctor code of conduct
Morals & Ethics
Physician society, National or Provincial authorities
Hospitals, Institutions, Clinics, Depts
Individual doctor code of conduct

7. Professionalism & patient safety successes

8. IOM Report 1999
“Health care organizations [to] develop a ‘culture of safety’ such that their workforce and processes are focused on improving the reliability and safety of care for patients.”

9. Organizational types
Hudson, 2001

10. Collaboration & Communications
Essential for professionalism
American Board of Internal Medicine, European Federation of Internal Medicine, American College of Physicians, & American Society of Internal Medicine (Lancet 2002)
Personal responsibilities: collaborate respectfully
Canmeds 2005 – Communicator

11. Collaboration & Communications
CMA Medical Professionalism 2005 – “The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality.”

12. Surgical Misadventures
38 surgeons in 146 incidents
Incident types
Permanent disability 33%
Patient death 13%
77% involved Sx or other interventions
67% intraop; 27% preop; 10% unnecessary advancement of disease
Surgery 2003; 133(6):614-21

13. Surgical Misadventures
inexperience/lack of competence in a surgical task (53%)
communication breakdowns among personnel (43%)
fatigue or excessive workload (33%)
Surgery 2003; 133(6):614-21

14. JAMA 2002; 287(22):2951-7

15. Physicians with law suits
Correlated with number of patient complaints
Adjusted for clinical activity level
No clear correlation with complaint types
JAMA 2002; 287(22):2951-7

16. Professionalism Model
Formal: investigated by a committee, a proscribed process, and potential for interventions or reprimands

17. Communications & Outcomes
Kaiser Foundation Health Plan
293 cases, Mar – Aug 2005
Trained observers
Behavioral Marker Risk Index (BMRI)
single number calculated
a higher score indicating fewer instances of teamwork behaviour
Am J Surg 2009; 197(5):

18. Briefing, Information sharing, Inquiry, Vigilance & awareness
Am J Surg 2009; 197(5):

19. Adjusted = adjusted for ASA
Am J Surg 2009; 197(5):

20. Infect Control Hosp Epidemiol. 2013 Nov;34(11):1129-36.
Hand Hygiene
Tertiary care center, including outpatient clinics & procedural areas
Use of a system-wide shared accountability model
Adherence was measured by designated hand hygiene observers
monthly hand hygiene adherence rates were correlated with monthly rates of device-associated infection
Infect Control Hosp Epidemiol Nov;34(11):

21. Infect Control Hosp Epidemiol. 2013 Nov;34(11):1129-36.
Hand Hygiene
adherence greater than 85% has been achieved since January 2011 and sustained
Social accountability worked
Infect Control Hosp Epidemiol Nov;34(11):

24. Next steps

25. Professional Identity
Professional Identity – “shape the novice into the effective practitioner of medicine, to give him the best available knowledge and skills, and to provide him with a professional identity so that he comes to think, act, and feel like a physician.”
Merton “The Student Physician. Harvard University Press 1957:3-79

26. Organizational Professionalism
Leaders articulated clear values
Leaders emphasized aligning organizational systems and structures to support desired behaviours
Cultivating strong interpersonal relationships to reinforce and disseminate organizational values
BMJ Qual Saf 2011; 20(4):351-8

27. Professionalism is the culture to create safety
Professional identity
Organizational professionalism
Without engaging individual physicians and surgeons
Only change one goal post at a time; hard to get a sea-change
“Doughy boy” syndrome
Be prepared for the 0.06% or 4%