EP19 - Tackling Incivility in Healthcare: Insights from Dr. William Cooper

In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, Explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power.

Hello, my peaceful warriors. Welcome to the Scalpel and Sword podcast. I am your host, Dr. Lee Sharma, physician and conflict analyst. And I am so excited to have on the podcast today, Dr. William Cooper. Dr. Cooper is a graduate of the Vanderbilt School of Medicine. He did his residency and chief residency in pediatrics at Cincinnati Children's, and then he returned to Vanderbilt to do a general academic pediatrics fellowship. After that, he got a master's in public health and joined the Vanderbilt faculty in 1997, where he currently serves as associate dean for faculty affairs. He's also the president of the Vanderbilt Center for Patient and Professional Advocacy. And with all of this experience, we are going to delve deeply today into healthcare incivility in the workplace, professionalism, how it affects our environment, how it affects our conflict, and how we manage it. Dr. Cooper, welcome to the podcast.

Oh, it's great to be here. It's really exciting to talk about the things that are interesting to you and your listeners today.

I'm so glad you're here. What was the impetus for you guys to start looking at managing incivility and some processes that could lead to addressing it?

Well, we've been doing this for about 25 to 30 years, and our early work was rooted in medical malpractice, recognizing that by specialty, 3 to 5% of physicians account for 50% of the malpractice claims. We just sort of stumbled upon, in having conversations with other leaders, that those same physicians Also accounted for 45 to 50% of unsolicited patient complaints, where someone— we fail to meet or exceed someone's expectations, and they call our offices or our hospitals and mention our clinicians specifically by name. We developed an intervention model to use peers to talk with colleagues and say, gosh, for some reason your practice seems to have more of these, and we know that's associated with malpractice risk, which was our sort of early work. We then learned over time that it wasn't just patient complaints that were sort of had the same distribution. It was also unprofessional behavior towards colleagues, physicians to nurses and physicians to other physicians. And so we learned that again, 2 to 3% of clinicians accounted for about 50% of those unprofessional conduct behaviors towards peers and colleagues. And we further began to recognize through studies that we published that those actual same physicians, their patients are more likely to have certain complications, wrong-site surgeries. They're more likely to have wellbeing concerns like burnout and cognitive impairment and other challenges. And so what we've really tried to do is to identify those individuals early and help them be the best version of themselves.

So one of the things that we talked about off camera is with this research that Vanderbilt had done, that you actually started going to community hospitals and other healthcare centers And training other physicians to intervene because we had this data. And I was actually one of the physicians in this early program in 2001. And I actually remember because I think I was recently postpartum with my second, but I told my husband, it's like, okay, you got to take care of the babies today because I'm going to go do this program. And as we started hearing this data from Vanderbilt that this is this very small percentage of physicians that was generating this very large percentage of complaints and malpractice. And what I loved about this intervention, and this was before I had done any kind of study in conflict resolution, this was before I had done my master's, that we weren't going to these physicians and saying, you're bad, you're terrible, you need to do this, you're generating all of this. Literally, the first intervention I did was with an ER physician. And in accordance with the model, I had a list of all the complaints that he had. And all I did is I paged him and said, hey, can I have 20 minutes of your time after a shift? We went and sat down in the break room and I said, so what I need to show you is a list of all of the complaints that you have had, all of the concerns patients have had, all of the concerns your colleagues have had. I'm going to just go ahead and tell you by comparison, this is about 10 times what most of your colleagues have had. And all I wanna do is make you aware of it. And that's all I did. And I said, is there anything else that you'd like to talk to me about right now? But otherwise I'm gonna leave you with this. And he said, no, I'm good. And I said, okay. And walking out of this, like, you know, oh my gosh, it was kind of scary. To deal with a colleague was really terrifying. And like I said, I hadn't had any training in conflict resolution at that point, so I had nothing to fall back on. But got to circle back 6 months later, and this physician's complaint level had dropped on an order of 50%. 5-0. And I still work with this guy. I still see him fairly regularly. And it's so cool because he definitely had his demeanor changed, the way he talked to people changed. And so one of the things I love about the early work that Vanderbilt did, we weren't pointing fingers. We were raising awareness. And so that— what a great place to sort of start in terms of bringing this problem to light, but also developing a process to work with it. Where did the research go from there?

So the early things we did in malpractice really helped us understand. One of the things we know is that, for instance, your colleague, when you have a bunch of these patient complaints, you are at greater risk to be sued. I took over running the center about 10 years ago, and we've added to that by linking all of these data to surgical outcomes, like with the National Surgical Quality Improvement Program data, to trauma outcomes with the National Trauma Data Bank, to wellbeing concerns, to a study we did of cognitive impairment, to understand that it's not just malpractice, it's patient outcomes. And it's nurse turnover. And having that peer-to-peer conversation is so powerful because if I can say, gosh, colleague, for some reason, and I don't know why this is happening, Your practice seems to have more of these than your peers, just as you did. I also want to make sure you know that this increases your risk for your patients to do worse. And those things that what I've done, I've been a messenger even before I took over for probably 15 years. And when I have that conversation, there's often this light bulb that goes off because people have a natural defensiveness, but a light bulb goes off where you're like, okay, when I compare you, because since those early days in 2000, We have trained people in 300 hospitals around the United States, 300 hospitals in Australia, New Zealand, and Singapore, and other places in Ireland and UK and Canada. And it works the same no matter where you are, whether you're in Opelika or Nashville or the Bronx or in LA. The ability to give our colleagues feedback in a nonjudgmental, respectful way. That appeals to their self-regulation and their commitment to their patients and to their peers. It's such a powerful way to give this feedback and help them learn more about ways that they can improve their performance across this really critical skill.

And I think that's so powerful because I think a lot of physicians don't realize if they have instability on the daily or if they're having difficulty interacting with their colleagues or their other coworkers, They don't really realize that not only it's not just about malpractice, it really is about patient care, but it's also about personal well-being. There's so many things are being impacted by this, and I think as you have the research to back it up, because we are all scientists, we're research-driven, show me the data. And when you can present somebody with, I have solid evidence that shows if we can make positive changes in your professional behavior, it's not even just about you. It is really about your patient's outcome. And even if people are working through issues with instability professionalism. We all want the same thing. We all want our patients to do well. It's why we're here. So as you start to have that data, it makes that interaction and that intervention so much more likely to be successful. You're appealing to other things that they care about.

Yeah, no, I'll tell you, and this was really driven home powerfully too. So since we trained you all those years ago, and I'm so delighted to hear the story about your emergency medicine colleague, it warms my heart. But one of the interesting things is that Early on in COVID, we also learned the power of engaging in respectful ways. So like many hospitals, our health system here at Vanderbilt, in the early days, we began to put in screening to make sure that people coming in didn't have fever or symptoms of COVID We put stickers on you for each day.

Mm-hmm.

And so there were stations set up in front of all of our entrances. And we had a physician who entered our hospital 3 straight days, went past the tables without checking in, got on the elevator and went up. Well, an unprofessional conduct report was entered because we were wanting to make sure to protect everyone from COVID as far as we understood at that time. And when one of our peer messengers who had the courage, just like you did those years ago, pulled him aside in a quiet way and just said, hey, tell me a little bit about what's going on here. I wanted to check in with you and see how things are going. The individual burst into tears and said, I'm a very private person and I've not told anybody, but my spouse is up in the ICU here and is dying of COVID and was still trying to go about his workday and trying to get through. And in that moment, the messenger was able to pivot to say, oh my goodness, what do we need to do to surround you with the help you need right now?

Wow.

And so we modified our training even further based on those learnings, just like that, and during COVID to really root what we do in empathy. So when I have one of these conversations now, I'm going to say, tell me a little bit about how your call night went. Sounds like it was kind of busy. Now tell me, I know a nurse called you, seems like about 10 o'clock or so. Tell me how that went down. And they'll tell me. I'll say, gosh, I see how frustrating that must have been because they had called you 3 times with what seems like a normal blood pressure. Now, the report we got said that you told them to quit calling you with stupid questions. I get that you're frustrated. Is there any way that could go differently next time? 97% of the time, that's all it takes. They won't do it again.

Yep.

And so engaging in an empathetic way that says, I am your peer and I understand what it's like, can be so powerful.

Absolutely. You also use this wonderful term. This is in your bio, but you just used it, the idea of being a peer messenger. That we are not tattletales. We are not turning on our colleagues, that we are somebody who's carrying a message. We are carrying insight. And the other thing I love about your interaction that you talked about, and it's so beautiful, is this idea of you didn't go in there judgmentally. You weren't like, you really can't do that again.

Right.

It wasn't that at all. It was, let me see what space you were coming from. You're seeking to understand. But you also, as a messenger, you are actively participating in the process of having this person perform better. You are actively trying to improve their professionalism. And sometimes that's such a powerful thing. And the reason why I think your program does so well and why so many hospitals benefit from these kind of programs is if we don't have a personal ownership or interest in engaging in a problem and we don't have the skills to do it, we're not likely to engage. And if you look at small hospitals like mine, if you look at most hospitals in general, everybody knows who's causing the incivility and professionalism problems.

We all know.

If you cornered one of my doctors up and said, who are the 3 most disruptive doctors in the hospital? Boom, boom, boom. You would have no problem getting a list. And I think most facilities are that way. But because there's no training involved in actually having somebody engage and be that messenger and then being able to approach them, like you said, with empathy. People don't do it. And so the problem just persists. And unfortunately, it can grow. And worst case scenario, the patients suffer from it. And so this training that you're giving people is so valuable. But I think the approach that you're giving them, the skill set, is what's even bigger. What led you from going from this idea of having a messenger? Because now we also have, with an article that the center published in the British Medical Journal in 2024, Using the concept of a huddle as a system to address these problems?

You know, it's really interesting. We found that for the typical sort of rude behavior like I just described between a physician and a nurse or a physician where the ED calls and they refuse to come in to see the patient when they're on call or any type of interaction, those are sort of typical unprofessional behaviors and those relate. There's a certain subset that organizations are required by law or by regulation or by policy to be handled in a special way. Things like sexual boundary violation, impairment by drugs or alcohol, violence towards a patient, or anything that sort of is that in that special space. What we've learned over the years through our research is that these are often handled in variable ways depending on who finds out about it first. So if somebody observes it, they may not act and follow exactly the pathway. So what we put in place here and now use in our other organizations that partner with us is a process where if one of those reports hits a system here at Vanderbilt, and any, all of our reporting systems talk to each other, within 4 working hours, we have a huddle put together with human resources, legal, risk management, Physician leadership if there's a physician involved. We have nursing leadership if there's a nurse involved. We're a teaching hospital, so graduate medical education if there's a resident involved. Only the people that need to be on the call. And we have a 7-minute huddle. We don't try to decide whether we think it happened or not. We just say, gosh, based on the language in the report as we know it, is anybody here aware of anything else that's happened in this space for this event?

Mm-hmm.

And then who thinks this needs to be investigated? And if so, by what pathway? And who's got point? Because when you look at the really, really challenging and vexing cases of sexual abuse and misconduct that have really been in the headlines lately across so many large organizations, one of the common elements was that an individual leader was made aware of the events, did their own review and determined that there was nothing else further that needed to be done. So the challenge with that is that you don't want a single person making that call. So this huddle has given us a chance to engage in a thoughtful dialogue and to say, okay, who's going to do it? And then making absolutely sure we close the loop. The really cool thing about it though, it is as a leader, it's also given me a chance to increase the trust and collaboration across all those key stakeholder groups that carries forward into other work that we do. So it's been sort of transformational for how we think about things and has really been a really important effort on our part to ensure that these sort of tragic things don't happen to the best of our ability.

This is so powerful. There is so much to unpack and talk about that's so positive with this process. The first one is that there is a process. So often, I think, when these things kind of occur, and inevitably they incur everywhere, that there's not a unified place people can report. You might report to your superior, but that's still only going to one individual. So the reporting itself is standardized. Number one, that's huge. The second thing, as you say, often in places that don't have this kind of system, these things get siloed, they get stuck in one place. And so as they get siloed, they're going one direction, they get stuck with one person, and that one person now has the burden of deciding what the huddle really should be deciding. It's not whether it happened or not. That's not what we're trying to decide. Just, this is the event. These are the stakeholders. What needs to happen now? I think the other thing that's great about having a huddle as opposed to having it siloed with one individual is if there is retribution, if there is concern about headhunting, finger-pointing, You can't really say that if this is a group of people, and you're much more likely to have an appropriate intervention or an appropriate solution because you have a circle and not just one person. You also talked about the fact that this has carried over as a transformational act in institutions because all of a sudden people trusted the process. And when you have a process in place that people trust, It creates safety. And when you create safety, you create an environment that people are more likely to come forward with conflict. Conflict is not bad. Conflict does not mean you're doing anything wrong. And I think that's one of the biggest things I see in my work is that institutions, because they don't have a way to work with it, they wanna brush it under the rug. They don't wanna deal with it. And they don't see that addressing conflict has power.

It actually has the ability to make the system, healthcare, the individual That's really one of the interesting things we learned after our first few huddles were that we had to actually also, we added a section to our huddle, and that is to assess the wellbeing of everybody involved. So if you've got somebody who gets really, really angry and throws something across the room, that may happen in, in some of the space where you sit in the operative space in your careers. Like, that is, there's something happening there. Is that person okay? And are they safe to practice? Do we want them operating on one of our loved ones in the next 20 minutes? So part of our huddle process is if we're not certain that they're doing okay, we go send someone to check on them. The second key player are the people that are in the environment that may be affected. Consider a setting where in a practice setting or an emergency department setting or something, someone shows up to work unfortunately impaired by drugs or alcohol. They are removed from the situation to follow the organization's policies. But everyone who's left behind is traumatized by that. That is so scary to see that happen. And many times they have inadvertently put workarounds around this person until their impairment rose to a level where they actually showed up to work impaired. And so that is a real— so we send people over just to check on the team and make sure that they're doing okay and that the patient cares. But we also think about patients.

Mm-hmm.

So let's say you've got a cardiologist. who becomes really, really, really angry because the green drapes are on the patient instead of the blue drapes, and they want blue drapes, dang it, right?

Yeah.

Yep. And so I know you run across this kind of stuff in your career every once in a while. It's like they do it wrong, and you've seen colleagues who have this. Well, the cardiologist throws the drapes on the floor, walks out past the holding room where the patient's family is sitting, and says, these idiots, we'll cancel this case and get going later on today. Well, we also need to think about what are the needs of the patient there. And so, we've learned through this huddle is that we need to address those regulatory things, but we also have to think, how can we provide the best care for everybody who's sitting and affected by this, including all of those key stakeholders?

There's so much power in seeing this as a systemic issue. We have to address the system. Yes, the prompt may have been an individual's instability or unprofessional behavior, but the system is going to suffer. And so we have to address the system as well. And the fact that you've added that to the huddle, how great is that, that you're actually making sure that everybody involved, because that is a traumatic thing for people to witness, to see an impaired physician that has to leave, that you were actually able to do that. And I've known situations where I know in my institution, and this was years ago, where there were impaired physicians that were let out by security because they were making a ruckus in areas of the hospital. But nobody went back to see how were the people who were there, who witnessed it, how are they doing? That didn't happen. And now we have more wisdom about the systemic nature, the fact that we are part of that system. And I think that's one of those things that doctors sometimes are not good at. We see ourselves like the system is in service to us. We don't really see ourselves as part of the system. And so that's a really big mind shift for us to actually, no, no, no, no, no. We are part and parcel of this symbiotic relationship that we have with our working environment, and we have to approach it that way. Our behavior does affect what goes on in that environment, and being able to raise someone's awareness to that, but also to have a process in place is so powerful. One of the things that when you looked at your study that was in the BMJ last year was the percentage of the different areas of complaint. For incivility and difficulty with professionalism. One of the things I found the most interesting was the most common level of complaint was discrimination. That shocked me because I wasn't expecting that.

We have seen that, and fortunately the behaviors that exist in sort of sexual boundary violation and being impaired by drugs are extraordinarily rare. Like, Extraordinarily rare. But other types of behaviors where there's sort of discriminatory behavior perceived or received by an individual really requires us to make sure that we're following all of the relevant sort of laws and policies regarding that. And this study that was in BMJ was from across places from New York to Nashville, Tennessee, to the Dakotas, to California. And so it's really across—

Mm-hmm.

A wide range of the country. And one of the things that has been important as we've used the huddles to evaluate those types of things, sometimes it is a perception of the behavior, but we have to pay attention to both the person who's reporting and reported. One of our early huddles in this space was a clinician was walking one of their patients out to the front desk to reschedule a follow-up visit and just sort of said with a sweeping arm gesture, These people will schedule your follow-up appointment. Well, these people, the 2 persons sitting behind the desk, were women of color. And the person who was doing that was of the majority population. And in that, they felt that this was sort of an unfair characterization and sort of sweeping generalization. So as a part of our review process, talked with them and said, tell us a little bit about what was going on here. And they said, well, this person, the physician who had this, Is an amazing person and so kind and so fair and inclusive, but this was something that we wanted them to be aware of how we perceived this. And so we were able to help them and say, is there anything else that we can do to support you? And then when we gave feedback, the person was obviously very bothered by the fact that they had been perceived this way, but it gave them a chance to reflect. So that action did that. So many times those Sort of reports of these kind of behaviors allow us to help and support everybody who's involved so that we can ensure that we create a place where everybody wants to come to work and be part of something that is creating the best workplace for our colleagues, but also for our patients, of course, to deliver great patient care.

And you yourself, as part of what you do, you are also a faculty messenger. You also have that role at Vanderbilt. And 85 to 90% of the physicians that you've intervened with have had positive change. And I think that's a testament to the fact that the vast majority of people who are in healthcare practice, if they have incivility or difficulties with professionalism, most of them may be unaware that these are things that are happening. And I think that's huge. The idea that you are giving somebody a space to self-reflect in a very kind way. And then you're seeing positive change from that. I think that also goes back to successful process. I mean, the huddles and the way that you're intervening. But I also wonder, and I think your data really bears this out, that a vast majority of physicians who have incivil or difficulty with professionalism are unaware. They may be modeling behavior that they saw from other people. You know, I saw somebody in residency who got mad and threw an instrument across the room, and therefore I must think that's okay.

Right.

I heard somebody else use this term, and therefore I think it's okay. Okay to use this term, and I don't think it's derogatory because so-and-so did it. I was very blessed. My dad was a general surgeon, and one of the things he said to me— he trained in the '60s, you know, when you were a gentleman in the operating room— and he used to tell me, I may be dead, but if I ever hear that you threw something or yelled in an operating room at somebody, I will come find you and I will haunt you.

Oh.

And that was my model of what professionalism looked like. I looked at my parents who are both physicians and both just phenomenal doctors, but phenomenal humans. And everybody who worked for them said the same thing. They were so good to work with. But I feel like I was very blessed that I had a model of what that behavior looked like. But if you are in a situation where that was not modeled to you and you think it's okay and you act that way, you're going to keep acting that way, making everybody else around you miserable until somebody kindly sits down to you and looks you in the eyes and says, How are you? What's going on? Let's talk about what happened at 10 o'clock when you said, stop calling me with the stupid phone calls. And then all of a sudden the light bulb goes off and that person has an opportunity to actually have that self-reflection and then be better. And then in addition to being better, their patients get better care. They're less likely to get sued. This ripple effect goes on. And then you add to that the fact that you're in an academic medical center. You're helping the faculty act better. There's no question the medical students and residents that are going to be training with those people are going to benefit from that behavior as well. As you have been able to introduce these, you've also said that, of course, the process exists for residents and medical students. Have you been able to see any of this change the level of occurrence with graduate medical education?

Absolutely. One of the really fun things about my job is that Across all these sites here in the state, we have all of their patient complaints and these unprofessional conduct reports. So we have five or six million reports that we can review. I can show you how you compare to other OB/GYN docs, or to other general surgeons, or to other pulmonary docs across country. So that when we can provide that comparison, we have a similar database for our residents and fellows and trainees. And so if we identify an individual in the first year of their residency, and that's the most common time they're identified, and we intervene with them, there's an 87% chance they're going to graduate from residency and not have another report.

Wow.

And you talk about the ripple effect. So, during that time in that residency, they're taking care of patients, but when they graduate, the typical physician is going to provide care for 20,000 to 30,000 patients during the course of their career. And so, you think about that early course correction, What a powerful impact that has on the rest of their career. Because just like your ED colleague, if you get this feedback and you improve, we have shown over 20 years of data, you stay good. People don't typically come back and have a reversion of these behaviors because it is a self-regulation, just as you described, that sort of seems to stick with them.

Do you ever find that there are physicians who don't respond favorably to this kind of intervention?

Yeah. And so we identify 2 to 3% of physicians in our patient complaint work and a different 2 to 3% of physicians in our coworker work. They're different populations, right? So both of those operate in parallel. If 87% of those respond to those interventions once they develop that pattern, that leaves about 0.5%. In that case, what we do is we escalate the intervention by having their Supervisor. So if they're a member of an organized medical staff, like at your hospital, they will go if your bylaws allow focused professional practice evaluation. We might use a peer review process or an employment process to put a corrective action plan, and that's still about 70 to 80% effective. And so, as I think about our work in the coworker side, we've tracked 160,000 docs. 18 finally out of the whole 160,000. were not able to improve and had to undergo formal disciplinary action.

Mm-hmm.

So what that means is 90% never had any unprofessional events ever, ever, ever. 8% get an occasional stub their toe day. 2% get that pattern. And so it's increasingly smaller numbers, but we ratchet up the intensity of the intervention as the needs arise, and we keep it as informal as possible as we can down sort of At the lower levels of intervention.

I think that also keeping it more of the personal informal interaction, I think, does invite people into that process more easily. I think that sometimes people are more comfortable with informal conflict resolution processes. And I think escalating only when you have to is a really, really sound way to approach it because I think most people respond very well to informal processes. A lot of times formal conflict resolution doesn't feel good to people. You know, they don't like how that feels. And so you'd have to be really, really, really unresponsive, I think, to something more informal. If hospitals or a medical institution was trying to start the huddle process, how do you recommend that they kind of go about initiating that?

So one of the things is to understand, first, recognize that you've gotta have the right leadership buy-in to this, like the leadership of your organization and the leaders of all those stakeholder groups. Have to say, yeah, this is something that we're going to do because that has to be. You got to make sure you've got the right policies and procedures. So are you following the bylaws policy or bylaw policy, whatever it is? And then you need data. So you have to understand where are all these things coming in? Is it a compliance hotline call? Is it an integrity hotline call? Is it a patient complaint? Is it a report to supervisor? And it doesn't matter where it comes in. You just have to make sure on the back end that you're Getting those, all those data sources aligned. And then once you've got buy-in of those groups and you've got data and you've got a policy, then having a systematic way to have a key person identified. I remember I told you that we do these within 4 hours of a report hitting. The only way that works is that each of those representatives of those teams makes it a priority. And they know, because we run the huddles, we're not going to let it go longer than 7 minutes. 10 would be tops. So they know they're gonna get in, get out. It's gonna be efficient. We're gonna follow through. So those key themes are essential to make sure that you follow that. And then tracking and recording to make sure that you've documented, we had a huddle, here's where we went, and then handing that off to the appropriate regulatory or investigatory process.

Mm-hmm. There's so much that in terms of not only making it where people can put in the complaint. And I think that's an anonymous process, right? When people are putting those in. So, they, when they put in that complaint, and then after that, they're not waiting months and months. They don't feel like it's been swept under the rug. They don't feel like they've been forgotten about. Because I do think when you set up these kinds of processes for people to report, one of the biggest things that happens, and I think this kind of goes back to the siloed model, it's not a priority for that individual. If it's an OR manager, they've got 80 billion things going on that day. If a surgeon threw something and someone, hey, so-and-so threw an instrument at me in the operating room. Oh, okay. Well, I'll look into it. Well, that may not happen for another month. And all of a sudden the employee feels very frustrated. They might be scared. Like we said, we haven't even addressed the problem, much less the system. So, the fact this is happening within 4 hours is huge. That means that person feels like they're heard. That means that voice actually resonated. And then you have a multidisciplinary team that That's looking at this, you've made it where this is not a huge imposition on their time on a busy clinical day. I'm talking about 7 minutes of your day. I can do this in 7 minutes. They have that assurance that you are not interrupting on their time. Not that this is not important, but they need that. This is logistics of what we do. And then also at that point, we're not trying to decide what, we're trying to decide where does this need to go forward? And all of these things, this process that you have designed It's fluid, it's efficient, it allows people to be heard, and it doesn't let the problem fester. I think one of the things, biggest things that happens in conflict situations when hospitals don't have systems in place is these problems basically grow and grow and grow and grow. And all of a sudden, so-and-so heard that this happened and they're going to put their 2 cents in and how dare you do this to my friend. And all of a sudden, this, it has taken on a life of its own. And it's really hard. It's really hard to manage conflict when it gets to that point, because that's typically when you're calling in somebody to help you with it. And at that point, literally, it has taken on a life of its own. And it's very difficult to get, not even just a resolution, just to get a handle on the stakeholders and the problem, because the stakeholders have also grown when that happens.

Yeah.

So we're actually establishing a very clear delineation For how to manage this. And I think that's one of the many reasons why your huddles are so successful is because of the way this system looks. It's very, very efficient and the way that you have it set up and have it implemented. I think it's something that, as you say, when you get people to buy into the process, and I think your data definitely makes it easier for people to buy in, you have the data to prove it and how successful this is. I think this is going to help so much for so many institutions. Where do you see this process evolving as you're getting more data? There's many places that are using the huddles. How do you see this process evolving, especially as you note that since the pandemic, our instability in professionalism unfortunately has increased?

So one of the interesting things is that we started with physicians. We then added nurse practitioners, our trainees. We now do this work with staff nurses. And so we recognize the same distributions occur. We use peer nurses to talk to peer nurses and peer nurse practitioners. So, one of the things that we are interested in is continuing to see the impact on sort of culture and safety and outcomes across having these interventions across the entire workforce. The other thing that we're really exploring, which I'm fascinated by, is how do we use a same sort of tiered, really gentle feedback, respectful approach when people don't follow our safety and quality processes?

Mm-hmm.

So, whenever you do a procedure and you have a procedural timeout, My guess is that just in the brief time we've talked, you make sure that the room follows the timeout procedure. Quiet, nobody's on their phones, you're following that. Not everybody does that. Or when there are C-section bundles or colorectal surgical bundles or ventilator management bundles, or in my space, vaccine guidelines, 90% of people follow that every single time. 7% occasionally may miss a timeout or miss a vaccine or something. But 2% of people accounts for the misses. And so what we're looking into is, can we use our same peer-driven, data-driven, leadership-supported processes to say, gosh, when we looked at your operative reports for the last week, it looks like that following the bundle for your practice occurred about 60% of the time. Your peers at this place are doing it 98% of the time. We piloted it in colorectal surgery and drove our adherence to the bundle to the high 90s. And guess what happened to our surgical site? Our infections dropped. Precipitously. And so we are exploring, we have national roundtables, so we're holding one later this fall about how do you think through other things that get in the way of what we're trying to accomplish to have the best things happen to our patients when they show up at our doors.

Mm-hmm. That's huge. And it's so true. I think about like robotics at our hospital. So I do robotic surgery. So one of the things that happened at a robotics meeting is they actually started looking at the costs Yes. For each case. So for the other people in your peer group that are doing X case, this person is charging X number of dollars per case, but this person is charging X number of dollars. Let's look at what X person is doing. Are they doing something that's really clinically required? Is what they're doing getting a better outcome? No, it's not. Can we standardize this process and actually get great patient care, but also work on maintaining cost as well? And all you have to do, like you said, you don't have to point a finger. You don't have to be putative. All you have to say is, this person's here, this person's here.

And that's it.

Because the majority of people, once that's up on a screen, will go, oh, well, I'm not going to be the outlier anymore. And then you come back to the next meeting 3 months later, and all of a sudden everybody's doing the same thing. And that's getting great care. But it's also doing good things economically. It's also easier for the hospital in terms of logistics. I mean, there's so many positive things that come from that, but I have definitely seen that in real time. And I do think as you talk about processes and how processes are effective for managing conflict, they're also positive for preventing it as well.

Right.

And the whole goal of programs like yours, and to me, what's made them so successful, Is not only have you found a way to successfully manage conflict as it occurs in very real time, in a very, very, very short window, but you've also made it less likely it will occur with this process in place. And conflict is illuminating. It can be inevitable, but it does not mean it always has to be. And I think your research shows that really beautifully.

Thank you. Really fun and important to do. We come to work to make medicine kinder, safer, and more reliable. And anytime we can do that, it's been a good day for me.

No doubt. Dr. Cooper, if people want to find you or find out more about the center, how would they most easily do that?

So we're easily found on LinkedIn. You can find me or our Center for Patient and Professional Advocacy. We also have a website here that can be the Vanderbilt CPPA is our, our sort of our acronym. Or abbreviation, and they can find us that way. Always glad to talk to anybody that has interest in learning more about what we do. All right.

Thank you so much for your time. I love the work that you're doing. Honestly, it was really exciting when I started reading and I found your research and I found the center and I realized, wait a second, I know these people. I remember this.

Yeah.

I remember this.

I'm so proud of you for doing it so effectively that it had a lasting effect. Way to go.

Thank you.

Well, and that's kudos to you and the work that you guys have done. And I don't know for sure, but I don't know if that was part of what made me go into conflict resolution, because I think it really had such a profound effect on me seeing what I was able to do for my colleague that it's like, is there a way that I can learn more about this? And so I ended up doing a master's while I was practicing. And so I've been working in this space since then.

Yeah.

So I will definitely Take my hat off to you and everybody at Vanderbilt for giving me that experience because I wouldn't have had it without you. So thank you very much.

Well, thank you. And thanks for the work you do in conflict. That's really important. So I loved the invitation. It was a great conversation. I appreciate your talk with me.

Hey, thanks for being here. For all of our peaceful warriors, thank you for joining us today on The Scalpel and Sword. Please join the conversation. And until next time, be at peace.

Every episode is an invitation.

To speak, to negotiate, to choose.

I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.