Management StrategiesManagement StrategiesA constructive, proactive, A constructive, proactive,

rehabilitative & effective approachrehabilitative & effective approach

The Credentialing FallacyThe Credentialing Fallacy

• “The credentialing process…usually misses or ignores…those behavioral or emotional factors that, at some point, may be a greater determinant of professional competence than board certification.”

• Daniel A. Lang, M.D.

Competence vs. Performance*Competence vs. Performance*

• Competence– The possession of required skill, knowledge,

qualification, or capacity; adequacy.

• Performance– The execution or accomplishment of work,

acts, feats, etc.

Guiding PrinciplesGuiding Principles

• Respectful at all times

• Completely confidential

• Safe for everyone– Protect anonymity of staff

• Rehabilitation focus

• Timely & prompt: Must report back

• Based on objective, nonjudgmental data

Objective data, Objective data, Presented non-judgmentallyPresented non-judgmentally

• Investigate thoroughly

• Objective, behavioral descriptions– Observable behavior (yelled, said “stupid!)– Times, dates, etc.– No motives– Write down

• Present in nonjudgmental terms– Rehearse

Separate the physician from the Separate the physician from the problemproblem

• Be “hard” on behavior

• Be “soft” on person

• Always refer to behavior

• Assume good intentions of doctor

• Do not impugn motives

Use appropriate consequencesUse appropriate consequences

• Frequently no previous consequences– Even for bullying

• Consequences promote behavior change– Good intentions, insight don’t work

• Examples of consequences

Follow-Up & Monitoring Follow-Up & Monitoring

• Intervention is only first step

• Chronic conditions often present

• Good monitoring & follow-up relapses

• Provide ongoing mentoring & support

Step I: Announce goal of Step I: Announce goal of ““Culture of SafetyCulture of Safety””

Get full support from top Get full support from top Administrative & Medical Administrative & Medical

LeadershipLeadership

Boldness has genius, power and magic in it. Begin it now.

--Goethe(William Hutchinson Murray , MD)

Waste ManagementWaste Management

ca. 56 on the job deaths/ yearca. 56 on the job deaths/ year

Step II: Develop Step II: Develop objectiveobjective Code of BehaviorCode of Behavior

““Principles of PartnershipPrinciples of Partnership””

Step III: Examine Policies, Step III: Examine Policies, Procedures, BylawsProcedures, Bylaws

Make sure they are up to date andMake sure they are up to date and

Support Support rehabilitationrehabilitation of these of these physiciansphysicians

Step IV: Develop Physicians Health Step IV: Develop Physicians Health Committee (non-punitive option)Committee (non-punitive option)

• Group of respected physicians (us. 5-7)– Wisdom, skills, broadly representative– Psychiatrist, if possible– Recovering alcoholic physician, if possible– Long, renewable terms (3-4 years, renewable)

• Ongoing liaison with OK physicians pgm.

• Train PHC

• Ongoing education programs for doctors

V: Develop effective V: Develop effective intervention processintervention process

• Formal meeting with objective goals• Meaningful people (note plural)• Present data in way it can be heard

– Objective, observable data– Nonjudgmental– Respectful

• Do not allow abusive behavior– Terminate meeting if abusive

Engage physician early in a Engage physician early in a process of dialogueprocess of dialogue

• Identify and intervene early; be supportive– “Golden Period”

• Be firm; Use graded responses

• Develop rehabilitation plan together

• Articulate consequences if no change

• Reinforce positive changes

• Follow up, monitor, support, follow up

Intervene to Intervene to assessmentassessment when when appropriateappropriate

• Behavior does not tell us whether physician is safe to practice

• A comprehensive assessment increases likelihood of successful rehabilitation

• Assessment more palatable to doctors

Monitoring is essentialMonitoring is essential

• Monitoring improves prognosis– Often long-term proposition

• Does not make problems go away– Don’t rely on monitoring alone – Expect physician to address problems

• Monitor compliance with treatment team– Expect FULL COMPLIANCE

• Monitor progress in behavior change• Administer appropriate consequences as needed

Give nurses, staff Give nurses, staff permission to speak uppermission to speak up

““I am empowered to tell I am empowered to tell you that your behavior is you that your behavior is

unacceptable.unacceptable.””

R E S P E C T R E S P E C T

• R= Respectful treatment of everyone

• E= Empowerment of all

• S= Written Standard of Behavior

• P= Persistence, persistence, persistence

• E=Education (ongoing)

• C= Culture, Confidentiality, Consequences

• T= Team effort