“First, Do No Harm” Part II: Know the “How” and Manage Access

The second piece in a 3-part series on what healthcare systems need to consider related to sexual abuse of patients in the care of physicians and other healthcare providers.

The Institute of Medicine report “To Err is Human” placed a spotlight on patient safety in the 1990s. This report estimated that nearly 44,000-98,000 patients die from preventable errors in American hospitals each year. While patient safety and medical errors have been discussed at the federal level over the last few decades, sexual misconduct (which ranges from sexual harassment to sexual abuse) in healthcare is often not included due to the lack of reporting or documented disciplinary actions.¹

In May 2023, Praesidium published “First Do No Harm,” an article discussing both the history of sexual misconduct in medicine as well as an analysis of 100 recent cases of sexual abuse in medicine. The analysis supports the observations of many researchers who have seen physicians and other healthcare workers perpetrate abuse in a variety of healthcare settings. The research also highlights how the liability of these incidents is often shared by the offender and the healthcare organization (private practices, clinics, hospitals, healthcare systems and academic-based medical institutions) and is both patient safety and an underdeveloped organizational culture of safety.

In a 2019 article by the Agency for Healthcare Research and Quality (AHRQ), the authors pointed out that “while most patient safety problems are attributable to underlying systems issues, disruptive behaviors are primarily due to individual actions.” Sexual harassment and sexual abuse by a healthcare provider (physician, nurse, radiology technician, or other health worker) and a patient, not only “impedes the delivery of patient care” but subverts the ability of the healthcare organization to have a culture of patient safety. ² This warrants a closer look at how offenders operate and how this awareness can leverage lessons learned from patient safety work over the last 25 years.

Knowing how Offenders operate & patient safety

Research shows that offenders need three things to abuse: 1) access to a vulnerable individual; 2) privacy to be able to offend without detection; and 3) control to manipulate the individual and the community. Awareness of this 3-part framework allows organizations to create a safe environment and prevent abuse. This safe environment requires many of the same components found to be critical in a culture of patient safety including elements such as teamwork training and structured communication as well as confidential incident reporting, conflict resolution, collaborative practice, internal and external regulation and transparency. ³

In this, the second of a three-part series, Praesidium will examine opportunities healthcare systems have to prevent abuse by managing the Access that a potential offender may have to vulnerable populations through a patient safety lens.

Leveraging policies to protect vulnerable populations

The relationship between healthcare providers and patients is necessarily built on trust due to the underlying vulnerability that exists for the patient.  This vulnerability can arise because of a mismatch between the characteristics of patients’ needs and knowledge and the physicians’ reactions to them; or it can be simply due to the very real power differential that exists in a relationship built on a need and a threat of not having that need met. Increasingly the literature suggests a common recognition that most if not all patients are vulnerable but the administration of care they receive should not be impacted by a provider’s own biases or motives.

Policies are an integral aspect of ensuring standards of care for patients. Typically, organizational policies include legal and safety regulations set at a state or federal level, or protocols related to the delivery of care in a specific healthcare setting. However, organizational policies can also be instrumental in improving safety culture by communicating zero tolerance for abuse, defining boundaries, and setting expectations for all interactions. Organizations and employees can effectively prevent abuse by monitoring individuals to ensure they are following policies – and responding swiftly when they are not.

Policies around patient care interactions are not a new concept for healthcare; however, not all policies are without challenges. One of the most debated policies for preventing abuse is the requirement of a medical chaperone when conducting certain types of examinations. This concept will be explored further in our next article in this series on managing Privacy.

Challenges aside, clearly written policies are the foundation of sexual abuse prevention in all settings, including healthcare. Examples of Praesidium recommendations for policies to be part of a patient safety framework include:

• Policies that clearly define appropriate vs inappropriate interactions between all healthcare employees and their patients.
• Policies for monitoring and supervision of provider-patient interactions to ensure accountability and implementation of all policies and procedures including administrative surveillance.
• Policies for clear responding and reporting channels for inappropriate behaviors, policy violations, and suspected abuse.

Elevating the hiring process for physicians and other healthcare professionals

Although most healthcare systems have robust Human Resource departments that are responsible for all elements of screening and selection of employees, these services are rarely employed at the same level when hiring physicians and providers through staffing services. Credentialing practices to become part of the medical staff may even occur without the rigors of reference checks, interviews with behavioral-based questions, or an updated criminal background check. The emphasis tends to be on sanction checks (disciplinary actions) and professional, educational, and licensing verifications.⁴

When reviewing civil cases against healthcare organizations or medical groups associated with a provider accused of sexual abuse, a key liability question is whether they were aware of anything in the practitioner’s past that could have predicted this behavior. Thus, elevating the hiring process for physicians and other healthcare professionals to include a more comprehensive screening and selection process can both potentially prevent abuse and reduce employer liability. ⁵

Further complications exist due to the reality that most medical training programs and licensing boards do not have requirements for sharing complaints, disciplinary actions, or references with employers. This leaves healthcare organizations without adequate ways of determining if a new hire is at risk of engaging in sexual misconduct.

Although there have been several peer-reviewed journal articles that have proposed mandates for healthcare providers to report concerns of boundary crossings and inappropriate conduct, these do not currently exist; therefore, sanction checks by medical staff rarely uncover any issues. ⁶ This means that the best way for organizations to deny potential offenders access to their patients is to leverage the best screening and selection practices and ensure they are consistently deployed for hiring all employees. ⁶

Recommendations for an effective screening and selection process for all healthcare employees include:

• A standard application including questions related to previous experiences including all patient care and clinical training sites .
• Authorization to contact the applicant’s training programs (for applicants that are newly licensed or credentialed), previous employers, state licensing boards, or medical specialty certification boards.
• Reference checks with former supervisors as well as at least one personal reference using standard questions that assess for risk of abuse.

Final thought: Managing access to prevent harm

The complexities of managing access of potential offenders to patients in healthcare settings can seem daunting when considering the vulnerability of patients each day. However, by understanding how offenders operate and leveraging best practices under the Praesidium Safety Equation hospitals and healthcare systems better position themselves to prevent and respond to incidents of sexual harassment and abuse between staff and patients. Specifically, starting with the implementation of effective Policies and Screening and Selection practices, healthcare organizations can minimize the risk of abuse and hire the safest individuals possible.

In the next installment of our healthcare series, we will examine the second requirement offenders need to operate – Privacy – and explore best practices that can assist healthcare systems in eliminating unnecessary privacy.

REFERENCES

¹ Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000. Available from: https://www.ncbi.nlm.nih.gov/books/NBK225182/ doi: 10.17226/9728

² PSNet/AHQR (Sept 2019) Disruptive and Unprofessional Behavior | PSNet (ahrq.gov)

³ Kachalia A, Mello MM, Nallamothu BK, Studdert DM. Legal and Policy Interventions to Improve Patient Safety. Circulation. 2016 Feb 16;133(7):661-71. doi: 10.1161/CIRCULATIONAHA.115.015880. PMID: 26884621.

⁴ What Is Medical Credentialing? – HG.org

⁵ How hospitals can help prevent, deal with sexual assault cases | Healthcare Dive

⁶ AbuDagga A, Carome M, Wolfe SM. Time to End Physician Sexual Abuse of Patients: Calling the U.S. Medical Community to Action. J Gen Intern Med. 2019 Jul;34(7):1330-1333. doi: 10.1007/s11606-019-05014-6. Epub 2019 May 1. PMID: 31044409; PMCID: PMC6614523.