Philadelphia College of Osteopathic MedicineINDP 100G 100M.docx

Philadelphia College of Osteopathic Medicine
INDP 100G/ 100M: Module 3 Professionalism and Leadership
Questions from Reading Assignment for Module 3
Please answer the each of the following questions with at least 4
sentences, and upload your answers into Blackboard.
1. Briefly describe the importance of interprofessional
communication and professionalism in modern healthcare.
2. Briefly describe how poor professionalism can negatively
impact the delivery of patient care.
3. Provide two qualities that you feel would improve your own
professionalism skills within GA-PCOM.

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Page 1 of 1

The Joint Commission Journal on Quality and Patient Safety
Volume 40 Number 4April 2014168
Leaders of medical institutions are responsible for creating
environments in which physicians, scientists, and other
health care professionals are able to sustain their deep capaci-
ty for high-quality, compassionate care. Creating such environ-
ments depends on supporting a culture of trust, which has been
identified as the core of successful leadership.1–3
The mission statements of both academic and communi-
ty-based medical centers and hospitals characteristically reflect
high aspirations for excellence in patient care. Yet, despite sig-
nificant resources directed toward improving the delivery of
health care, the rate of preventable and iatrogenic patient in-
juries has not improved significantly.4,5 Although a number of
reasons have been cited for this lack of progress,6,7 there is
grow-
ing recognition that an environment in which professionalism
is not embraced, or where expectations of acceptable behaviors
are not clear and enforced, can result in medical errors, adverse
events, and unsafe work conditions.7–9
Simultaneously, health care providers are experiencing de-
creased control over their work environment. Clinicians are ex-
pected to increase efficiency by seeing a greater number of pa-
tients with fewer resources, be readily available in person or on-
line, and provide timely and error-free care. This environment
of decreased control and escalating responsibilities in turn can
lead to a self-defeating cycle of clinician stress, depression, and
burnout.10 In addition, these factors are likely to contribute to
an increase in professionalism lapses. An estimated 3% to 5% of
physicians and nurses exhibit “disruptive” (unprofessional) be-
havior, which negatively affects coworker communication; team

dynamics; and, ultimately, patient safety.11
At its best, professionalism fosters what Kirch described as “a
culture that is grounded in the values of collaboration, trust and
shared accountability. . . . that encourages transparency and in-
clusivity, rather than exclusivity. . . . [and] that is driven
equally
by our traditional commitment to excellence, and by service to
others.”12
In this article, we describe the development of the Center
Safety Culture
Article-at-a-Glance
Background: There is growing recognition that an envi-
ronment in which professionalism is not embraced, or where
expectations of acceptable behaviors are not clear and en-
forced, can result in medical errors, adverse events, and un-
safe work conditions.
Methods: The Center for Professionalism and Peer Support
(CPPS) was created in 2008 at Brigham and Women’s Hos-
pital (BWH), Boston, to educate the hospital community
regarding professionalism and manage unprofessional behav-
ior. CPPS includes the professionalism initiative, a disclosure
and apology process, peer and defendant support programs,
and wellness programs. Leadership support, establishing be-
havioral expectations and assessments, emphasizing commu-
nication engagement and skills training, and creating a pro-
cess for intake of professionalism concerns were all critical
in developing and implementing an effective professionalism
program. The process for assessing and responding to con-
cerns includes management of professionalism concerns, an
assessment process, and remediation and monitoring.
Results: Since 2005, thousands of physicians, scientists,

nurse practitioners, and physician assistants have been
trained in educational programs to support the identifica-
tion, prevention, and management of unprofessional behav-
ior. For January 1, 2010, through June 30, 2013, concerns
were raised regarding 201 physicians/scientists and 8 health
care teams.
Conclusions: The results suggest that mandatory educa-
tion sessions on professional development are successful in
engaging physicians and scientists in discussing and partici-
pating in an enhanced professionalism culture, and that the
processes for responding to professionalism concerns have
been able to address, and most often alter, repetitive unpro-
fessional behavior in a substantive and beneficial manner.
Jo Shapiro, MD, FACS; Anthony Whittemore, MD, FACS;
Lawrence C. Tsen, MD
Instituting a Culture of Professionalism: The Establishment of a
Center for Professionalism and Peer Support
Copyright 2014 The Joint Commission
Volume 40 Number 4April 2014 169
Center for Professionalism and Peer Support Programs
Supporting health care professionals in providing the highest
quality compassionate care in a
culture that values and promotes mutual respect, trust, and
teamwork.
Wellness Programs

for Professionalism and Peer Support (CPPS) and the results of
our programmatic initiatives at Brigham and Women’s Hos pital
(BWH), Boston, to educate the hospital community re garding
professionalism, as well as our process for managing
profession-
alism lapses.
Methods
Setting
BWM, a 793-bed tertiary care facility, serves as a major
teaching
hospital of Harvard Medical School. The physician and scien-
tist faculty is composed of 2,738 individuals (1,630 [60%] men
and 1,108 [40%] women), who represent 13 major specialty
departments. The number of faculty at each rank includes in-
structor, 1,434 (52%); assistant professor, 638 (23%); associ ate
professor, 395 (14%); and professor, 271 (10%).
Establishing the Center for Professionalism
and Peer Support
In 2008 we established the CPPS to strengthen and support a
culture of trust explicitly predicated on mutual respect for indi-
viduals, teams, the institution, and patients and their families.
The mission of the CPPS is to encourage a culture that values
and promotes mutual respect, trust, and teamwork. To achieve
this, we established several key programs, including the profes-
sionalism initiative, a disclosure and apology process, peer and
defendant support programs, and wellness programs (Figure 1,
above). We chose to define professionalism as any intent,
action,
or words that foster trustworthy relationships. Inui has stated:
. . . the present intensity of our discourse about professionalism
in
medicine represents both a flight from commercialism, on the

one
hand, and a corresponding need to reaffirm our deeper values
and
reclaim our authenticity as trusted healers, on the other.13(p. 9)
Trust embraces such concepts as integrity, transparency, and
self-awareness, which require an understanding of our own mo-
tivations.14 Over time, trusting relationships throughout an in-
stitutional community encourage and provide support, partic-
ularly during difficult times. According to Drucker, “Organi-
zations are no longer built on force but on trust. . . . Taking
responsibility for relationships is therefore an absolute necessi-
ty.”15(p. 152)
Trust is the unifying concept—trust among health care team
members, as well as between us and our patients and society.
Conversely, unprofessional behaviors are those that diminish or
destroy relational trust. For example, a conflict of interest may
violate the trust between the clinician and society; disrespectful
behavior breaches the trust between the clinician and the pa-
tient; and disruptive behavior erodes the trust between the cli-
nician and other health care providers.
The CPPS initiated its professionalism educational efforts
and handling concerns process with a focus on physicians and
scientists. This choice partially reflected the roles of individu-
als for whom complaints had been received historically, as well
as an understanding of the hierarchical patterns of culture and
behavior inherent in the practice of medicine. Many leader-
ship organizations, including the American Board of Internal
Medicine,16 the American College of Surgeons,17 the Accred-
itation Council for Graduate Medical Education Outcome
Project,18 and The Joint Commission,19*,20 have document-
ed comprehensive definitions of professionalism that include
stated expectations of physician behavior. That said, every-

one in the institution is expected to be accountable for their
behavior. Issues deeply embedded into the medical culture (for
* Leadership (LD) Standard LD.03.01.01. Leaders create and
maintain a culture of
safety and quality throughout the hospital. Element of
Performance (EP) 4: Leaders
develop a code of conduct that defines acceptable behavior and
behaviors that
undermine a culture of safety; EP 5: Leaders create and
implement a process for
managing behaviors that undermine a culture of safety.
Disclosure and Apology Process
Supporting disclosure as a process
that starts before the clinician
discloses an adverse event to the
patient/family and continues after
the patient is discharged
Peer Support
Developing a network of clinicians
trained to help their colleagues
deal with adverse events and other
stressors
Defendant Support
Providing defendant peer outreach
and support when a complaint has
been filed against a clinician in the
institution

Figure 1. Center for Professionalism and Peer Support programs
include the professionalism initiative, a disclosure and apology
process, peer support, and defen-
dant support.
Professional Initiative
Strengthening the institution’s
culture of trust to support
respectful behavior and to protect
against and address
unprofessional behavior
example, a hierarchical, highly competitive, sometimes puni-
tive environment) can undermine the sense of trust and as a
consequence, professionalism. Lesser et al. observed, “profes-
sional behaviors are profoundly influenced by the organization-
al and environmental context of contemporary medical prac-
tice.”21(p. 2733)
To support a culture of professionalism at an institutional
level, organizations must address unprofessional behavior in a
substantive and direct way. In 2008 The Joint Commission sug-
gested that health care organizations “develop and implement
policies and procedures/processes” that address ‘zero tolerance’
for intimidating and/or disruptive behaviors,” which include

“overt actions such as verbal outbursts and physical threats,” as
well as more subtle behavior such as intimidation, “reluctance
or refusal to answer questions” or answer pages/calls, “conde-
scending language or voice intonation,” and “impatience with
questions.”20
CritiCal DimenSionS in Developing anD
implementing an effeCtive profeSSionaliSm program
In our experience, several dimensions are critical in devel-
oping and implementing an effective professionalism program:
leader ship support, establishing behavioral expectations and as-
sessments, emphasizing communication engagement and skills
training, and creating a process for assessing and responding to
concerns.
Leadership Support and the Code of Conduct. In 2003,
following a number of employment lawsuits, BWH leadership
recognized that health care institutions, including ours, lacked
widespread understanding of employ ment law and the princi-
ples of appropriate workplace behavior. In 2006 we partnered
with an employment law educational company to develop a
series of professionally acted videotaped vignettes and a work-
book, which formed the basis of a required educational pro-
gram for all physicians.
During the following several years, various challenges and
opportunities emerged, prompting us to begin the develop-
ment of a broader initiative. We realized that true cultural trans-
formation requires a partnership between institutional champi-
ons and like-minded teammates who are able to deliver and
reinforce the message that these initiatives are key to our funda-
mental mission. Such initiatives also can and should be created
with enough consistency and intentionality that their outcomes
can be measured and their effects sustained.

The founding director of the CPPS [J.S.] is a surgeon who
has worked in that capacity at BWH since 1986. As the As-
sociate Director of Graduate Medical Education for Partners
Healthcare, which includes BWH, Massachusetts General Hos-
pital, and affiliates, she had been involved in some of the na-
scent programs regarding professionalism and peer support that
were initiated by Anthony Whittemore, MD, the then BWH
chief medical officer (CMO). She proposed creating a center
to further the development and leadership of the disparate ini-
tiatives to focus the cultural change mission and to strengthen
each program. Gary Gotlieb, MD, who was then president of
BWH, fully supported the creation of the CPPS. In 2008 the
CPPS director was given responsibility for creating institutional
change through access to key people and support for program-
matic development.
We solicited the ideas of thought leaders within the institu-
tion from various departments, committees, and resources. We
made the physicians and scientists aware of the CPPS by publi-
cizing our mission, logo, and contact information, and indicat-
ing that our physical location in the hospital was staffed daily
during regular business hours. Recognition and acceptance of
our professionalism initiative was driven by the development
of (1) an educational program to clarify expectations and teach
skills in professional behavior and interpersonal communica-
tion, and (2) a process for reporting, assessing, and remediating
individuals with unprofessional behavior.
Under the authority of the CMO to whom she reports, the
director is supported as a 0.7 full-time equivalent. The center
has a manager who assists in the development and evaluation
of programs, as well as an administrative assistant to assist with
scheduling meetings and programs. In 2011 an additional cli-
nician [L.C.T.] with clinical research experience and leadership
was appointed as associate director as the scope and number of

evaluations and programs increased.
We developed an institutional Code of Conduct (Appendix
1, available in online article), which provided an opportunity
for us to restate our commitment to one another and to our
patients, in a multidisciplinary, inclusive, and iterative process.
In addition, we formed a trusted group of advisors that meets
regularly. Each time we gather, this Professionalism Leadership
Group, composed of physicians, nursing administrators, and
other leaders, discusses CPPS updates and issues and then re-
flects on our work, using the principles developed by Palmer in
his work regarding courage and renewal.22–24
Educational Programs. To support the identification, pre-
vention, and management of unprofessional behavior, we rec-
ognized that policies and codes of conduct alone do not change
behavior. The experience of the CPPS director and other BWH
thought leaders, as well as the extensive organizational leader-
ship literature, reinforced our belief that the elements needed
to promote professionalism among individuals and teams in-
clude conflict and stress management, communication and
teamwork, an awareness of systems resources, and the presence
of a supportive community.25 To facilitate such awareness and
skills, we collaborated again with the employment law educa-
tional company to revise our training materials on the basis of
feedback from earlier sessions.26 These materials are used in a
1.5-hour, interactive educational session for which attendance

by every physician (from trainee to senior physician) and scien-
tist is required to maintain institutional credentials. Although
we recognized that professionalism concerns were not limited
to physicians and scientists, we focused our initial training on
those groups, while maintaining a collaborative relationship
with the institution’s leadership, including nursing, adminis-
tration, and human resources. An average of two sessions per
month are scheduled at various times to accommodate different
work schedules. The content of the sessions fulfills the follow-
ing functions:
n Emphasizes the hospital’s commitment to a safe and re-
spectful working environment
n Includes discussions on harassment, bullying, and responses
to work-hour requirements
n Provides an exploratory and learning opportunity for clini-
cians to communicate with colleagues regarding individual and
organizational challenges to professional behavior
n On the basis of a frame-based approach derived from our
work with the Center for Medical Simulation,25,27 provides
spe-
cific strategies for managing conflict and giving feedback to
col-
leagues who have behaved unprofessionally
n Details the institution’s program for addressing concerns
Because the participants represent a diversity of specialties
and experiences, the open discussions provide an opportunity
to share a variety of perspectives that frequently illuminate the
range of unprofessional behaviors and the responsibility of col-
leagues and bystanders to speak up.

In addition to these professionalism training sessions, we
lead a series of voluntary, interactive workshops to enhance
skills in communicating and giving feedback.
Creating a Process for Managing Professionalism Con-
cerns. The process for assessing and responding to concerns in-
cludes (1) intake of professionalism concerns, (2) an
assessment
process, and (3) remediation and monitoring.
1. Intake of Professionalism Concerns. In developing
a system for reporting, evaluating, and responding to pro-
fessionalism lapses, we created a process that is confidential,
centralized, clear, and respectful. Protecting the confidentiality
of the reporting individual is imperative, particularly for those
individuals considered vulnerable to retaliation. The individu-
al cited as being unprofessional—the focus person (FP)—must
also be treated respectfully. Our centralized system, in contrast
to a disseminated model within specialty departments, has sev-
eral advantages in that it allows for a more consistent response,
eliminates favoritism and a sense of futility, facilitates the
aggre-
gation of data so that patterns become evident, and enhances
our ability to recognize and intervene when microcosms of un-
professional behavior are team based.
Reports of interprofessional behavior problems are brought
to the attention of the director or associate director by affect-
ed individuals, as well as by concerned leaders. Our mandatory
professionalism education program is one way in which we raise
awareness of our availability as a resource for handling profes-
sionalism concerns.
For this article, we analyzed all concerns reported to the
CPPS from January 1, 2010, through June 30, 2013. We re-

sponded to all reports, with the nature of the response depen-
dent on variables such as the severity and frequency of the be-
haviors. Decisions about the severity of the behavior were made
on the basis of the perspective of the person reporting the be-
havior, as well as multisource interviews with others who may
have experienced or witnessed the behaviors. We developed a
system for categorizing the types of reported behaviors of the
physicians/scientists (Table 1, page 172). The categories were
developed as an iterative process by the CPPS director and as-
sociate director.
The cases involved individuals from different departments
(Table 2, page 172), including many individuals who served in
senior leadership roles within their laboratory, division, or de-
partment. A few cases involved a limited interpersonal conflict
between two individuals or elements not directly relevant to our
code of conduct (for example, technical competence or knowl-
edge base issues).
The CPPS is not a disciplinary body and thus does not fun-
nel behavior complaints into the ongoing professional practice
evaluation (OPPE) process. We encourage division chiefs to do
so, as many have already done.
Although we primarily focus on interprofessional be havior
concerns, we are also attuned to clinician-patient professional-
ism issues.28 Concerns involving patient complaints are filtered
to us through two routes. The CPPS director sits on the Medical
Staff Credentialing Committee, where patient complaint data
from our electronic database are routinely reviewed. If a phy-
sician has generated repeated patient complaints, the center’s
director facilitates a feedback intervention and monitors subse-
quent patient complaints. In addition, the CPPS meets regular-

ly with the BWH Department of Patient and Family Relations
to review all patient complaints from the database and identify
patterns that require intervention.
2. Assessment Process. In designing the assessment pro-
cess, we felt that an algorithm would be constraining and could
be perceived as unfair if we deviated from it in any way. It is
important to have a process that is consistent but also flexible
enough to deal with the nuances of each case.
The assessment process must discreetly determine the valid-
ity of the reported professionalism lapses and any potentially
exacerbating issues. The first step involves an in-depth conver-
sation with the person voicing the concern (the reporter). If the
concern is not egregious or is an isolated incident and the FP
has not had any other issues, we usually coach the reporter on
how to give the FP direct feedback regarding the incident. If the
person does not feel “safe” in giving direct feedback, we
involve
a more senior colleague to facilitate. If the behavior is severe,
its
severity is unclear, or its validity is in question, the director or
associate director performs multisource interviews. Some cases,
such as those regarding harassment or discrimination, may re-
quire an investigation by Human Resources. If, after the assess-
ment or investigation, the concerns are found to be either repet-
itive or egregious, the director or associate director discusses
the
findings with a physician of meaningful authority in the FP’s
professional life (for example, division chief, department chair,

or CMO). We develop a plan and then, in a feedback inter-
vention, present anonymous findings to the FP in the presence
of his or her supervisory physician—and explicitly define ex-
pectations for corrected behavior, outline a monitoring process,
and state the consequences of not adhering to the professional
behavioral expectations (Table 3, page 173).29 Occasionally, an
outside evaluation or treatment is required. In rare cases, and
pertinent to the nature of the complaint, immediate suspension
may be necessary during the investigation.
Feedback given to the FP regarding his or her perceived
behavior should protect the person(s) who reported or cor-
roborated the concerns. During the feedback intervention, we
explicitly state the institution’s unwillingness to tolerate any
form of retaliation. Feedback conversations in the presence of
the FP’s department chair, division chief, or supervising physi-
cian emphasize the importance of the intervention and add lo-
cal oversight and encouragement.
3. Remediation and Monitoring. Resources for supporting
behavior change include professional behavioral coaching, con-
flict resolution programs, and mental health support for emo-
tional stressors if such stressors are raised by the FP as a
concern.
At this stage, use of these resources is usually encouraged but
not mandated. The intent is to help the FP alter the exhibit-
ed behavior rather than to attempt to diagnose the behavior.
Although physicians almost reflexively try to explain unprofes-
sional behavior as a consequence of mental or physical illness,
that is not our role in these situations. Ultimately, it is the FP’s
choice whether to change the behavior. He or she is more likely
to do so if this choice is internally motivated.30 As part of the
feedback intervention, hearing the FP’s explanation for the be-
Complaint Category N (%)

Demeaning 55 (27)
Angry 51 (25)
Uncollegial 16 (8)
Patient communication 16 (8)
Shirking responsibilities 11 (5)
Hypercritical 8 (4)
Clinical competence 8 (4)
Misconduct 7 (3)
Sexual innuendo 6 (3)
Other (for example, sexual harassment, substance
abuse, boundary issues, leadership competence)
23 (11)
Department Total
Percentage of
Total Concerns
Surgery 51 24.4
Medicine 51 24.4
Anesthesiology 31 14.8
Radiology 11 5.3
Neurosurgery 10 4.8
Orthopedic Surgery 9 4.3
OB/GYN 6 2.9
Newborn Medicine 5 2.4
Radiation Oncology 5 2.4
Emergency Medicine 4 1.9
Psychiatry 3 1.4
Neurology 3 1.4
Dermatology 2 1.0
Pathology 2 1.0
Other (for example, dental, ophthalmology,
nuclear medicine, rehabilitation medicine,
departments from affiliated institutions)

16 7.7
*Reports concerned 201 physicians/scientists and 8 health care
teams. OB/
GYN, obstetrics/gynecology.
Table 2. Department Affiliation of the Reported
Individual or Team, January 1, 2010–
June 30, 2013 (N = 209)*
Table 1. Primary Reported Professionalism Lapses
by Physicians/Scientists, January 1, 2010–June 30, 2013
(N = 201)
havior can be helpful in identifying overlap between the team’s
needs and the FP’s goals. For example, if the discussion reveals
that the FP (Dr. Jones) raises his voice and criticizes his team
because he is trying to advocate for his patients, the feedback
provider can honor that intent and point out that such behav-
ior actually represents a risk to his patients. We recognize that
unprofessional behaviors may be a habitual response to stressful
or conflicted situations, or related to age, culture or ethnicity,
gender, upbringing, or perceptions regarding organizational sys-
tems failures28 or hierarchy.11 We repeatedly highlight that
what
is important is not the intent but rather the impact of one’s be-

havior.
After a period of time (typically, three to six months), anoth-
er series of more limited (in number and duration) interviews
are performed to determine if progress in the FP’s behavior has
been made; additional meetings and consequences may result
from these interviews. If the behavior has improved, the FP is
given positive feedback. If there is insufficient improvement,
there are a series of escalating consequences, modeled after the
accountability pyramid described by Hickson and colleagues.31
Assessments and consequences are meticulously document-
ed. Several other leaders are often involved, including the CMO
and the Office of General Counsel. Depending on the circum-
stances, on some occasions we refer for an occupational health
or neurocognitive evaluation. Issues of misconduct or substance
abuse may trigger other pathways, such as disciplinary action
(in accordance with the hospital bylaws), a required evaluation
by Physician Health Services, or reporting to the Board of Reg-
istration in Medicine. We also formed a Professionalism Advi-
sory Committee to provide regular case review.
Results
partiCipant evaluation of profeSSionaliSm training
SeSSionS
At the conclusion of the mandatory professionalism training
sessions, participants are asked to complete an evaluation indi-
cating their professional role (for example, training level) and
provide an assessment (for example, 1 = “strongly agree”; 5 =
“strongly disagree”) of three elements: (1) whether the objec-
tives of the session were met (for example, accepting their re-
sponsibility in supporting the institution’s professionalism cul-
ture), (2) whether the session improved their understanding of
professionalism, and (3) whether the session enhanced their
professional practice. In addition, participants are asked to pro-
vide written comments on the most important “take-away” les-

sons, the strengths of the session, and improvements that could
be made to the training sessions.
The first training sessions were held in 2005, and since then
thousands of physicians, scientists, nurse practitioners, and
physician assistants have been trained. A total of 1,287 phy-
sicians and scientists completed the session from October 10,
2010, through December 31, 2012. We instituted a session
evaluation in 2011, and 529 individuals completed the evalua-
tion form; although precise response rates are not available, the
estimated rate was more than 90%. The sessions were highly
favorably rated, with mean scores of 1.5, 1.7, and 1.8 for objec-
tives being achieved, awareness being increased, and their sense
that the session will enhance their professional practice, respec-
tively. In 2012, 757 individuals completed the evaluation form,
which indicated mean scores of 1.6, 1.7, and 1.8 for the same
outcomes. The most common written comments indicated an
Steps Features
Step 1: Receive Report of
Concerning Behavior
Conduct confidential conversation with reporter regarding focus
person (FP) to determine next steps. For
example, if the concern is deemed an isolated incident, the FP
has not had any other issues, and the reporter
feels safe to do so, we provide coaching for the person bringing
forward concerns on how to give the FP direct
feedback regarding the incident. If the concerns are more
complex, we proceed to Step 2.
Step 2: Assessing Concerns To validate the concerns and assess
their frequency and severity, multisource interviews are
conducted to pro-
vide comprehensive insight into and corroboration of alleged
behavior.

Step 3: Feedback Intervention Share findings of investigation
with department chair, division chief, or supervising physician
initially without FP,
then again with FP. A summary of specific behaviors, resources
for facilitating behavioral changes, and warnings
regarding retaliation is detailed. Follow-up processes are put
into place.
Step 4: Intervention to address
subsequent lapses
The institutional administration is involved, with legal counsel
present and a plan of action developed. Selected
institutional administrators meet with FP to detail expected
behavioral changes and consequences, including
termination.
Step 5: Communication with
those reporting complaints
Communication with reporter to detail that an intervention has
occurred is made, with encouragement for report-
ing of unchanged behavior or any form of retaliation; respect
for the privacy of the FP is maintained.
* Adapted from Papadakis MA, et al. Perspective: The
education community must develop best practices informed by
evidence-based research to remediate lapses of
professionalism. Acad Med. 2012;87(12):1694–1698 (reference
42, page 177).
Table 3. Center for Professionalism and Peer Support Process
for Handling Repetitive or Egregious Lapses*

acceptance of a personal role in ensuring a culture of
profession-
alism and appreciation that a functional system exists to manage
unprofessional behaviors.
reporteD ConCernS regarDing profeSSional Be-
havior
The number of reports has steadily increased each year, with
45, 51, and 71 submitted in 2010, 2011, and 2012, respective-
ly. From January 1, 2010, through June 30, 2013, the CPPS
received reports of 201 physicians/scientists and 8 health care
teams about whom concerns were raised (for a total of 209 re-
ports). There was excellent interrater agreement (90.3%) be-
tween the two raters for 41 randomly selected scenarios (Co-
hen’s kappa = 0.88; standard error, 0.07; p < .0001).
A number of different interventions were used (Figure 2,
right), depending on multiple factors such as the type, severity,
and frequency of the behaviors. The most common intervention
was a feedback conversation with the FP and his or her supervi-
sory physician, usually facilitated by the CPPS director or
associ-
ate director. Some FPs underwent behavioral coaching.
Career outcomes for the FPs are shown in Figure 3 (right). A
minority of cases required demotion from positions of authority
or having the individual leave the institution.

To assess behavioral outcomes (Figure 4, page 175), the di-
rector and associate director reviewed each case and obtained
as much follow-up information from various sources, includ-
ing those who brought the concerns forward, other health care
team members, and supervisory physicians, as possible. We rec-
ognize that such information is highly subjective but believe
that it is nonetheless worthwhile. This process revealed substan-
tive changes in the behavior of multiple individuals.
Many cases were resolved by the feedback intervention, as
individuals became aware of how other people perceived them
and as they took active steps to mitigate some of the external
stressors. Some FPs, although initially angered or confused at
being identified as unprofessional, were subsequently apprecia-
tive of our process for enabling them to find their “former,”
more professional, selves.
Discussion
Our intention in creating the CPPS was, above all, to cre-
ate a more supportive professional community, one in which
we can, as Walsh stated, “begin to define and experience lead-
ership as a collective project that derives its power and au-
thority from a cooperative attachment to mutually de-
fined commitments and values.”32(p. 24) Our findings indicate
that mandatory education sessions on professional develop-
ment are successful in engaging physicians and scientists in dis-
cussing and participating in an enhanced professionalism
culture,
and that our processes for responding to professionalism
concerns
have been able to address, and most often alter, repetitive
unpro-
fessional behavior in a substantive and beneficial manner.
The recognition that professionalism plays a significant role

in workplace satisfaction and patient safety and malpractice risk
* Involves: CPPS director, CMO, OGC, EAP, Pt Relations, div
chief, dept chair.
103
23 19
11
3
0
20
40
60
80
100
120
Feedback by
CPPS*
Coaching Formal
evaluation
360 Other†
† Residential referral, empathy training, emotional
intelligence.A

Professionalism Initiative Interventions for
Reported Persons or Teams,
January 1, 2010–June 30, 2013 (N = 159)
Career Outcomes for Reported Persons,
January 1, 2010–June 30, 2013 (N = 201)
Figure 2. A number of different interventions were used, with
some reported
persons or teams receiving more than one intervention,
depending on multi-
ple factors such as the type, severity, and frequency of the
behaviors. CPPS,
Center for Professionalism and Peer Support; CMO, chief
medical officer;
OGC, Office of the General Counsel; EAP, Employee
Assistance Program; Pt,
Patient; div, division; dept, department; eval, evaluation.
Figure 3. The reported persons not represented in the figure
include those no
longer at the institution, those who were demoted, and those
who did not
require investigation because of their institutional affiliation or
because their
concerning behavior was deemed minor. Another category,
“Need follow-up
information,” includes persons who were lost to follow-up and
others who are
still involved in ongoing monitoring for whom the extent of
behavior change
could not be determined.

has been highlighted by several investigators.29 The Sentinel
Event
Alert from The Joint Commission,20 the policy (H-225.956) on
“Behaviors That Undermine Safety” from the American Medi-
cal Association,33 the “Code of Professional Conduct” from the
American College of Surgeons’ Task Force on
Professionalism,17
and a similar code from the American Board of Internal Medi-
cine,16 all recognize the necessity of responses to
unprofessional
behavior within health care institutions. The universal applica-
bility of these documents to the practice and science of medi-
cine indicates that all institutions, regardless of size, academic
orientation, or geographical placement, must take steps to en-
hance the culture of professionalism.
We agree with other leaders in the field that any professional-
ism initiative cannot succeed without the commitment of both
the leadership and engaged champions for this process.11 In our
case, the hospital leadership supported the development of a ro-
bust, systematic, and multifactorial process to begin addressing
this foundational issue.
We developed an institutional definition of professional-
ism and an associated code of conduct. Our definition of pro-
fessionalism as that which supports trustworthy relationships
became a focal point toward which a common purpose, lan-
guage, ethos, and code of conduct could develop. To create
awareness of our code of conduct and our expectations for pro-

fessionalism, we developed an interactive educational pro gram.
Many institutions have incorporated similar pro grams, with
content frequently derived from professional sub specialty soci-
eties, and have demonstrated subsequent improvement in pro-
fessionalism awareness among participants. Kumar et al.,using
the American College of Surgeon’s case-based multimedia ma-
terials, improved the ability of residents to define and recognize
components of professionalism and dis cuss unprofessional be-
havior.34 Hultman et al.,who created a 6-week, 12-hour course
within an academic plastic surgery practice, demonstrated a sig-
nificant increase in professionalism knowledge and a decrease
in
sentinel events related to profes sionalism.35
The video vignettes that we use in our mandatory profes-
sionalism training sessions facilitate a mixture of didactic and
interactive education, which fosters greater learning and
concept
retention than either method alone.36 Moreover, the vignettes
enable learners to observe and practice responses to specific be-
haviors and attitudes—and thereby adopt the new skills.37 Mc-
Laren, Lord, and Murray indicated that the use of vignettes,
movie clips, or reflective writings in education programs
focused
on correcting unprofessional behavior make concepts more re-
latable and engender greater self-reflection and awareness.38
The CPPS’s initiation of its work with physicians and scien-
tists partially reflected the roles of individuals for whom com-
plaints had been received historically, as well as an understand-
ing of the hierarchical patterns of culture and behavior inherent
in the practice of medicine. Ultimately, however, profession-
alism is a shared responsibility among all individuals within a
health care institution, and multidisciplinary team training is
an important component. We did expand our required profes-

sionalism training to all nurse practitioners and physician assis-
tants. Although we believe that most other clinical, education-
al, and research personnel would benefit from the interactive
professionalism training sessions, those sessions are
particularly
resource intensive. We have therefore chosen to focus our other
multidisciplinary approaches on specific groups that have asked
for interventions to improve teamwork communication. In re-
cent years, we have begun drawing on the work of Gittell, et
al. on relational coordination to assess and guide team-based
interventions.39
By introducing our professionalism initiative at the orienta-
tion seminar for all new interns, residents, fellows, staff physi-
cians, and scientists, we establish the expectations and boundar-
ies for acceptable behavior, as well as the importance of holding
one another accountable for our behavior. Particularly for new
health care practitioners and scientists, our program sets expec-
tations and highlights our commitment to professional behav-
ior early in their career development, which may be critical to
the formation of lifelong habits and professional identity.40 The
need for early exposure to professionalism expectations is in-
creasingly salient, given the greater mobility and globalization
of our trainee population, for whom cultures, practices, and
behaviors can vary considerably.41
Despite a growing number of programs demonstrating
notable and salutary improvements in professionalism aware-
Behavioral Outcomes for Reported Persons
or Teams, January 1, 2010–June 30, 2013
(N = 149)*
Figure 4. To assess behavioral outcomes, as shown, the director
and associate

director reviewed each case and obtained as much follow-up
information as
possible.
ness, Papadakis et al.observed that we “generally do not have
the knowledge, skills, and methodologies to address unpro-
fessional behavior when we encounter it.”42 (p. 1695) We
believe
that approaching those persons with professionalism lapses in a
compassionate manner with the intent of supporting their in-
trinsic motivation to remediate their behaviors is most likely
to lead to sustained behavioral change. That said, the expec-
tations and consequences of not behaving professionally need
to be clear. Indeed, we strongly believe that educational pro-
grams must be coupled with a robust program for reporting,
assessing, and managing individuals exhibiting unprofessional
behaviors. A central tenet of any process is that it be consistent-
ly applied throughout the institution, with no protected indi-
viduals, teams, or divisions. Our most senior institutional lead-
ership, including the president and CMO, have stood by the
commitment to hold everyone to a high professional standard.
This means that we are each held accountable for our behaviors;
if, after feedback and reiterating expectations, as well as
provid-
ing remediation resources, the unprofessional behavior is either
repetitive or egregious, there need to be consequences for the
individual such as removal from teaching roles, demotion from
leadership positions, or termination.

We face the challenge of how to better measure the success of
the CPPS initiative. Have we indeed positively affected the cul-
ture in our institution? And if so, what is the respective contri-
bution of each of the CPSS programs to such a culture change?
Other institutions have used validated scales of measurement to
assess the impact of professionalism programs on provider be-
havior and the overall work environment. For example, DuPree
et al.6 used the US Agency for Healthcare Research and Quality
Hospital Survey on Patient Safety Culture43 and the Institute
for Safe Medication Practices Survey on Workplace Intimida-
tion44 to measure the impact of their multidisciplinary program
on a labor and delivery suite at Mount Sinai Hospital (New
York City). In addition, we need to improve our follow-up of
FPs’ behavior so that we can better assess the outcomes of our
interventions.
According to the Hickson et al. accountability pyramid, a
greater number of individuals exhibit a single incident of un-
professional behavior that is observed as an anomaly and re-
sponsive to an informal intervention; fewer individuals show an
apparent or persistent pattern of unprofessional behavior, which
is followed up with an “awareness” or “authority” intervention;
and even fewer demonstrate no behavior change, which results
in disciplinary action.28 In contrast, most of our reported con-
cerns have involved patterns of recurrent unprofessional behav-
ior rather than single anomalous incidents. Our program is also
unique in its focus on interprofessional behavior, as well as cli-
nician-patient professionalism.
We view the increasing number of individuals being report-
ed to the CPPS with each subsequent year as a reflection of
trust
in our center and its processes. DuPree et al.6 also reported a
steady increase in the number of reports (during a six-year pe-

riod). We have noticed a trend toward earlier reporting of un-
professional behaviors—when the behaviors are less severe and
have been manifest for less time. This trend decreases the need
for multisource interviews and enables us to do more coaching
of peers to provide difficult feedback regarding interprofession-
alism lapses. In addition, we are increasingly finding lesser se-
verity of unprofessional behavior among team members, even if
patterns of communicating and relating among various groups
within the team are sometimes less than ideal.39
Conclusions
Initiating and sustaining changes in professional relationships
requires a significant and sustained commitment to cultural
change. We have made substantial progress in professionalism
with the creation of our Center for Professionalism and Peer
Support, which includes a code of conduct; mandatory educa-
tional programs; and a robust reporting, assessment, and man-
agement process for handling concerns regarding profession-
alism lapses. Future work is needed to more carefully catego-
rize different types of unprofessional behavior, track the most
appropriate and effective behavior modification strategies, and
identify methods for conflict resolution, team training, and re-
lational coordination between different types of providers. J
The authors gratefully acknowledge the contributions to this
article of Jessica Per-
lo and Sara Nadelman (former managers of the Center for
Professionalism and
Peer Support) and Pamela Galowitz (current manager). The
authors thank Shiphra
Ginsberg, MD, and Jennifer J. Shin, MD, SM, for their
invaluable assistance in
behavioral coding and statistical analysis, respectively. Finally,
the authors extend
their heartfelt thanks to James Pichert, PhD; Thomas Gallagher,
MD; and Daniel

Wolfson, MD, for their excellent suggestions for earlier
versions of this article.
Jo Shapiro, MD, FACS, is Chief, Division of Otolaryngology,
and Di-
rector, Center for Professionalism and Peer Support, Brigham
and
Women’s Hospital (BWH), Boston; and Associate Professor,
Depart-
ment of Otology and Laryngology, Harvard Medical School,
Boston.
Anthony Whittemore, MD, FACS, formerly Chief Medical
Officer,
BWH, is Professor, Department of Surgery, Harvard Medical
School,
Boston. Lawrence C. Tsen, MD, is Vice Chair, Faculty
Development
and Education, Department of Anesthesiology, Perioperative
and
Pain Medicine; and Associate Director, Center for
Professionalism
and Peer Support, BWH; and Associate Professor, Department
of An-
esthesia, Harvard Medical School. Please address
correspondence
to Jo Shapiro, [email protected] Please address requests for
reprints to Pamela Galowitz, [email protected]
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Online Only Content
See the online version of this article for
Appendix 1. Code of Conduct
http://www.ingentaconnect.com/content/jcaho/jcjqs
Volume 40 Number 4April 2014 AP1
Online Only Content
Appendix 1. Code of Conduct
Code of Professional Conduct Policy
Brigham and Women’s Hospital

Brigham and Women’s Physicians Organization
Brigham and Women’s Hospital and the Brigham and Women’s
Physicians Organization are committed to providing the highest
quality health care to patients and their families, to expanding
the boundaries of medicine through research, and to educating
the next generation of health care professionals. We are also
committed to ensuring an ideal work environment for all
employees,
medical staff and trainees whereby our core values of
excellence, compassion, respect, and diversity are embraced by
all. We be-
lieve in and uphold the principles of a fair and just culture and
communicate these beliefs and values throughout the institution.
We expect our employees, medical staff and trainees to:
• Adhere to hospital policies and procedures.
• Maintain a professional demeanor at all times and treat each
person with courtesy, decency, and respect. Use words and
actions that are thoughtful, constructive, tolerant, and
compassionate.
• Be collegial team members and recognize and support each
member’s value in our interactions with them.
• Be accountable for our behavior and avoid retaliation against
those who report concerns.
• Never engage in or tolerate inappropriate, disruptive, or
abusive behavior.
• Never work while impaired by any substance or condition that

compromises ability to function safely and competently.
• Listen and respond to patients, patients’ families, and
community members.
• Respect and value diversity.
• Respect our patients’ confidentiality and privacy.
• Maintain the highest ethical standards and address conflicts of
interest honestly and directly.
• Be honest and forthright in representing information and
ensure accurate attribution for all work.
• Report near misses and errors and disclose and apologize to
patients in order to improve patient care.
• Make wise use of the hospital’s human, financial, and
environmental resources.
• Support quality, safety, and efficiency initiatives in order to
enhance patient care.
• Attempt to resolve differences in a spirit of cooperation and
to create solutions that benefit all parties.
Instituting a Culture of Professionalism: The Establishment of a
Center for Professionalism and Peer Support

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