Director’s Corner: Crisis Recognition and Management

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Dear Director,

My CEO lit into me for a patient complaint about a missed diagnosis and I just didn’t see this coming.  Now he’s questioning our overall quality of care and I feel like this went from a routine case review to a potential crisis that puts our contract at risk.  How did I miss how serious this issue was and what can I do to manage it?


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Hardly a week goes by without a celebrity from politics, Hollywood or sports facing a crisis.  The individuals are able to hire crisis control experts to advise them and spin their message.  Businesses such as the airline industry are not immune either.  Just consider the video we all saw when a physician was dragged off of a United Airlines flight in 2017. As leaders in a high profile department, we also find ourselves facing challenging situations that require expert leadership.

What’s a crisis?

A crisis is a situation or event that puts you or your organization at risk.  This could be a risk to you, your ED group or to your hospital.  These are usually high profile events, such as something that ends up on the news, but it also may be an event that’s high profile within the hospital because it reached the hospital’s board, the CEO or a committee where minutes get reported to someone in the C-suite.  Whether it’s a patient removed from the ED by security, an intoxicated provider, a sexual harassment complaint, or an unexpected or high profile death that occurred in the ED, as a department leader, it’s critical to recognize a potential crisis, to evaluate it and to successfully manage it.


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Most organizations have done extensive crisis response planning, thus mitigating the impact of a potential crisis.  We’re still doing Ebola drills even though the likelihood of getting an Ebola patient is extremely low, but the consequence for being unprepared is immense.  And we don’t call the patient who is dropped off at the ambulance entrance with multiple gun shot wounds a crisis, because we are prepared for this type of emergency.  As physician administrators and leaders, we need to anticipate the types of potential situations that could lead to a crisis response and develop plans to manage them.  Therefore, perhaps as a leader, a crisis is something we didn’t expect and aren’t prepared for.

 

Is this a crisis?

I got a text from the president of our medical staff with the simple question “are you here right now?”  He’s an anesthesiologist and doesn’t text me very often so this certainly got my attention. I believe that part of effective crisis management is being a bit paranoid, trusting your gut and recognizing the red flags.  I chose to cut to the chase by calling him to ask what’s going on, as I was concerned that a text exchange may delay getting to the issue.  And while there was a potential crisis for the anesthesiologist, I was able to investigate the issue and provide an answer within minutes, before his stress potentially escalated the issue to other departments.


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While one would usually think of an unexpected death in the ED or a bounceback death as triggering a crisis response, there are many other potential issues that can arise.  Many of my colleagues have dealt with an impaired physician and had to have them stop working during a shift.

Sexual harassment or disruptive physician complaints are other high-risk events that may need immediate action to prevent a crisis.  It’s possible for chronic metric underperformance to also hit crisis mode.  I’ve certainly been on the receiving end of CEO conversations where I was told to “Fix it!”  Additional high-risk events could be anything related to the hospital’s inability to bill/collect payment, such as significant charting deficiencies.

Ultimately, there are many factors to consider that go into evaluating a situation or incident before declaring a crisis.

  • One factor to consider in evaluating a potential crisis is to determine the stakeholders and any potential biases.  For example, a misread x-ray in the ER may be a minor issue or can be a big deal – depending on the potential bias of the other parties affected by the miss. A missed fracture is much worse if the orthopedist on call that day already thinks we have too many bogus consults and we misread images on a regular basis compared to an orthopedist who thinks we do a great job and might defend the misread to the quality group by saying “although it was a miss, the ER does a great job.”  High levels of bias may mean the difference between the whole group going through additional mandatory CME or just reviewing the case with the individual provider.
  • The source of the complaint is also important. Although every situation has the potential to blow up to a crisis, certainly an event will get more attention if the CEO hears about it from a board member or a respected physician on the medical staff.  On the flip side, I’ve actually had members of the c-suite tell me that certain docs are such hotheads that complaints about hospital issues typically get ignored.
  • Every hospital has certain sensitivities so the institutional history matters. Part of why I was recruited for my current job was to work on the STEMI program.  While the program had excellent data, STEMI management was perceived as having “issues” and was a very sensitive issue for hospital leadership.  While few people know this, in my second orientation shift, I misread a triage EKG that was a STEMI.  Fortunately, the patient was in a room within minutes, seen by another doc who diagnosed the STEMI and got the patient to the cath lab quickly.  I’m not sure I’ve ever missed another STEMI on EKG, but the STEMI issue was such a hot button issue at my hospital, had that patient been a miss, I think I would have lost all credibility and would have been gone within a week.  The severity of the issue matters, too. While a complaint about wait time from a board member versus a routine patient, may generate more discussion, an unanticipated bad outcome should always be treated as a significant event.
  • Finally, I consider what staff member(s) are involved. Although we’ll get into this more later, the board ultimately grants our privileges and can remove them.  Although bad outcomes are typically reviewed by the medical staff, minutes make their way to the board oversight committees.  In a perfect world, any case is reviewed on its merits, but doctors who have a long body of work to stand on may be treated differently than either a new physician or one who has had a series of minor issues reach the board level.

Reviewing a Potential Crisis

Apollo 13 astronaut John Swigert tells NASA Mission Control of the explosion that occurred in his spacecraft with a famous quote: “Houston, we have a problem.”  Except that he didn’t actually say that.  In the movie, that line adds drama and suspense.  In reality, Swigert said, “uh, Houston, we’ve had a problem,” indicating that this is just another problem to face, but let’s move on to the solution. When told of a potential troubling event, the first thing I want to do is review the event, but my actual first move is likely communication to the person bringing me the complaint.

It’s important to acknowledge the perspective and emotions of the person bringing  the complaint to you.  This conversation can set the tone as you are a leader and in control of the situation or add an increase to the drama of the situation.  We’ve been trained in this with our bedside manner.  Being calm and reassuring by saying something to the extent of, “I can see you’re very concerned/frustrated by what’s going on.” Then reassuring the person that you will review the event in a professional manner and get back to them quickly will show them that you have this covered and can help prevent the incident from reaching crisis level.

After receiving the complaint, it’s time to review the event from all angles and to consider the personnel involved.  Are there other red flags, extenuating circumstances, or institutional history in play?

It’s now time to find someone you trust who can provide an outside opinion.  Everyone should have a mentor internal to your organization who can help you navigate the storm, but also someone outside the organization who can provide a more objective response to the issue at hand.

Concluding your review and gathering the outside recommendations, leads to the moment of truth.  Was there a bad outcome?  Was it preventable?  Was the outcome the inevitable progression of disease?  Did the provider act unprofessional?  Was this sexual harassment?  I’ve been involved in numerous event reviews and while the overwhelming majority of the time, the care or behavior in question was appropriate, sometimes I’ve had to admit that there was an issue.  It’s at this point that your role as a leader is judged not just on the incident, but also on your response.

 

The Response

The first step in responding to a potential crisis will always be communication with an honest, professional opinion that will contain recommendations for next steps.  If you’re facing a systemic problem (i.e. metric performance), you may need to lay out a variety of steps over a given time period to correct the metrics.  If an individual’s performance is responsible for the situation, the actions may range from a focused professional practice evaluation (FPPE), chart reviews, CME recommendations, increased supervision (i.e. bad airway case leads to having someone supervise the individual’s next 10 RSI patients), suspension, or termination.  It is also important to understand what the full spectrum of possible remedies the hospital might request.

Keep in mind that if you are a contracted group, your contract with the hospital likely has a clause that allows the hospital to determine who works at the site, which makes it much easier for them to remove someone from the hospital than if they were an independent member of the medical staff.  If you are a group that works in more than one site, moving the provider to another site might be one option you need to consider. Our privileges are granted and revoked by the hospital’s board of directors.  Fifteen years ago, it would have been extraordinarily rare for a board to terminate a doctor for performance.

Although physician issues at the hospital go through multiple committees, including the MEC, they ultimately go to the hospital board. The board is made up of business people who usually take a very black and white view of a problem and live in a world where people routinely get fired for mistakes.   And over the last few years, I’ve seen (or heard of) numerous physicians resigning after an event to prevent termination by the board (a potential databank reportable event).

Your job as the leader, after reviewing the situation and consulting with mentors, is to read the tea leaves and make the right recommendation that protects the organization while also trying to protect the physician.  And, yes, sometimes recommending the physician resign, to prevent the board from removing privileges is the best outcome for the doc. Finally, when it’s all over, do your own critical review and figure out what you learned.  Would you handle the situation the same way again or did you miss a warning flag?

Conclusion

The bleeding man who walks into the lobby creates a crisis if he’s in a bank.  But in the ED, it’s business as usual because we are trained and have a plan on how to respond.  We need to bring this same approach to our administrative job.  Communication, thorough review and developing an appropriate response are the critical components of a difficult situation.  We are trained in managing all of these components and should seek advice as we work through the process.

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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