Bill Klaproth (Host): Welcome to the ASHRM podcast, made possible by the American Society for Healthcare Risk Management to support efforts to advance, safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. I'm Bill Klaproth. And with me is Josh Hyatt, Director of Consulting Healthcare at Presidium as we talk about rethinking abuse prevention. Josh, welcome.

Dr. Josh Hyatt: Hi, Bill. Thanks for having me. I really appreciate being here.

Host: You bet, Josh. This is such an important topic. Happy to have this discussion with you today. So Josh, why is professional sexual misconduct still such a significant concern in healthcare?

Dr. Josh Hyatt: In reality, it will probably always be a concern in healthcare. Whenever you have vulnerable people, you will have situations in which vulnerable people are taken advantage of. And it could be intentional, it could be unintentional. But anytime that we have people in those situations where there is a particular vulnerability, and it could be patients, it could be children, it could be elderly people, that situation's always going to occur. And what we at Presidium look at is hoping to find a way to build prevention of abuse. In our case, specifically, we are looking at sexual abuse, building that into the DNA of the organization and its culture so that abuse prevention is a consideration amongst the many considerations that healthcare organizations have and in order to reduce that likelihood.

The reality is abuse, sexual abuse, in healthcare is very expensive. The average lawsuit for a sexual abuse case, the average amount is about $59 million. On top of that, there's reputational harm to the organization. There's individual harm that happens to our staff. And then, there are allegations sometimes where they may not be true, and they can be either fake, they can be false allegations or they could be allegations where you have a patient that's got some kind of perceptual disorder, they're on pain medications, things like that, where they perceive something that may not have occurred, and it can really impact the livelihood and professionalism of that provider that's been accused.

So with all of these kind of factors in play, what we want to do is to really look at how organizations can do abuse prevention in a way that is effective, efficient, safe for both the patients and the employees.

Host: That is the goal. As you said, Josh, organizations should try to build that abuse prevention right into the DNA or culture of their organizations. That sounds easier said than done though. So, what are some of the blind spots? What are we missing? What are you seeing that's happening in the policies or the leadership responses to sexual abuse?

Dr. Josh Hyatt: I think one of the major things that I see in healthcare as a big blind spot is complacency. We don't want to believe that the people we work with that go into healthcare would even consider harming a person in this way. And when I go into organizations or I talk to people especially in tight-knit community or units, what I hear is, "Oh, that would never happen here. I know these people, they're not like that. Our patients are protected by our staff. They're not taken advantage of by our staff. It wouldn't happen here. It happens other places, but not here" or "What we do here is not high risk. We're not an adolescent psychiatric unit. So, we're not the same kind of risk. We're not an OB-GYN. We're not the same kind of risk." And in reality, what we see is this is a broad spectrum problem that hits everybody. And we've seen allegations that involved dentists, that involved rheumatologists, that involved, you know, dermatologists, different people of different levels. So, it really all depends on the situation at hand.

Host: So, Josh, you just said people think, "Hey, this is not going to happen here." So then, what do you say to someone who says that to you, Josh, you know, "Nah, it's not going to happen here. You don't have to worry about us"? What do you say to that person?

Dr. Josh Hyatt: Unfortunately, I say it doesn't happen until it happens. So, there are different kinds of people that offend. There are the predators out there. Those are like the Larry Nassars of the world where you see them, and you would never guess that this kind of person would be predatory. Those are people that have the intent to cause harm to individuals.

Then, there are other types, which is the bigger bucket of individuals which are situational, where people make decisions that lead down bad paths. And when that happens, they often will get down to this place where you start seeing things like boundary violations, professional boundary violations. They start having red flag behaviors. There may be some mild grooming behaviors that start occurring. But the intent is really not to cause harm. It's just that there's a series of bad decisions that end them up in this particular place. And then, often, when you ask somebody, "Well, how did you go from here to there?" And they go, "You know what? I really just don't know how this happened, but it just happened." And those are people that generally are not intentional abusers or intend to have any cause any kind of harm.

So, we need to be hypervigilant and hyperaware so that we can, A, catch those people who are actual predators that are intending to cause harm. And, B, we want to help safeguard our colleagues who might be going down a path that's not really necessarily good for them or for the patient, where you can intercede and say, "Hey, you know what? When you're providing care to that patient, you may not want to close the door. This person has had a history of sexual abuse, so you may want to bring somebody in the room with you just as a backup, just as somebody so that we can mitigate out potential allegations." Or if you're dealing with, for example, hypersexual adolescence in a behavioral health program, you know, make sure you don't go into the room alone with patients. Stay within visual sight of the cameras so that if there is an allegation made against you, we can easily identify whether or not there is validity to that.

Part of it is really about protecting the patients, but yourself as well. And so, if you kind of do those steps, if you're mindful of how you can prevent abuse and then also, on the other side, manage those allegations if they do come to you, I think that applies to any situation. So, it's not about do you have bad actors on your unit? It's really about what are you doing to protect your patients and to protect your staff. And so, that's kind of how I often will frame those kinds of questions. Like, "Well, this doesn't happen here." Okay, well, maybe it doesn't happen here, but that doesn't mean that allegations still may not happen or they may not still not come. So, what are those preventative measures you have in place to protect both parties?

Host: Which is ultimately what you want. It sounds like education really is important in these instances just to make sure people are always aware of their actions and be cognizant of things like, "I better leave the door open. I better not shut the door. I better have somebody in there with me while I'm doing an examination," things like that. So, education, seems like this is really, really important.

Dr. Josh Hyatt: That's exactly right. And that's when we start talking about things like what do boundary violations look like? Because if I ask five different providers what boundary violations look like when it comes to abuse prevention, I get five different answers. It's very interesting because people have different boundaries, they have different sense of professional boundaries and what's acceptable.

And the other part of this, people sometimes they don't want to report their friends or their colleagues because they don't want to believe that those boundary violations may or may not be intentional. So when we talk about this and we provide coaching around what these things look like, it's really using those opportunities to pinpoint and identify things that just make your stomach turn a little bit. The big stuff you know is wrong. It's the little stuff that people really need to be more attentive to so that they can intervene earlier to protect both the patients and the staff.

Host: Earlier is always better. So if you see something right away, best to address it right then and not let these little things grow and grow and grow and grow until it really becomes a big problem. So then, Josh, how do you talk about this topic with healthcare leaders who get uncomfortable or defensive that don't want to talk about these things?

Dr. Josh Hyatt: Well, it depends on my audience, right? So, nobody-- and I mean, absolutely nobody likes to talk about this topic. It is uncomfortable for everybody. I work in this professionally and it's uncomfortable for me sometimes. I hear things, I hear stories. I hear events that occur that make me want to go take a shower. It is uncomfortable, but it's a reality. So if I'm talking to clinical leaders, I may frame my conversation in protecting your team members and your patients. If I'm talking to administrative or CFO types, I will talk maybe more about these are the ramifications, you know, financial ramifications, reputational ramifications of not having good thought-out programming.

And so, I always kick off presentations with, "This is a really, really, really tough conversation. It's an uncomfortable conversation. We don't like it. There's nothing about it that's fun." But you can go onto Netflix and in about five minutes, find 10 different Netflix specials on this particular topic. And if you watch them, each one will make you more and more uncomfortable.

And so, it's that awareness. You don't want to get to the point where everything you see is a predatory behavior. Because they're not. But at the same time, you want to have an awareness that something doesn't seem right. And if it doesn't seem right, let me figure out why that doesn't seem right and let me pull this forward. And maybe other people have thoughts or maybe other people have seen similar kinds of behaviors. And that gives the leadership an opportunity to say, "Let's do some coaching, let's do some intervention before this gets out of hand."

And if it's truly a predator, most predators from my experience is if they are confronted, if people like draw the line in the sand and say, "This kind of behavior isn't tolerated, we watch for it, we know about it," they're going to leave. And they may go to other places, but they will self-select out so that they can get into a place where they're not being so monitored or scrutinized, because grooming behaviors happen in a lot of different ways. Grooming happens to patients, but it also happens to coworkers, family members, parents of children. So if you look at like depositions of maybe somebody that has sexually abused-- and there's one particular case that I know of where they sexually abused young women in the presence of a parent who was in the exam room at the time, but they had groomed both of them to make them feel like what was happening was normal. And it wasn't until later where the normalization of that deviance was identified and became an issue.

Host: So again, if something doesn't feel right, report it.

Dr. Josh Hyatt: Yes. And I would say do that without judgment, right, as best as you can depending on obviously the level of severity of the event. But if it's something that this is a boundary violation, you should not be sharing your cell phone number and texting patients that have left the unit, that's not okay.

I have this conversation with physicians. A lot of physicians will give their personal cell phone numbers out to patients. And they see that in many cases as good customer service. I want my patients to be able to reach out to me. But it also sets up a condition in a circumstance in which abuse can happen. And when we look back at some of these events, those are the kind of things that end up happening, where those may be professional texts in the beginning, maybe start getting more personal, and then boundaries start getting crossed and things start happening.

And so, what we encourage people to do is to really be conscious of those boundary violations. You see this in social media as well. People start connecting through social media and then boundary violations start happening. So when we look at the conditions that have to exist for almost any kind of abuse to occur, but especially sexual abuse, you have three different conditions that have to exist for this to happen. You have to have access to people. So, that could be one-on-one. It could be, you know, cell phone, texting people, right? It could be even virtual medicine. There's many ways to access people.

The second condition you have to have is privacy. So, you have to be able to engage in conversations or do boundary violation behaviors, things along those features in, which nobody else knows about it. And that's where you start hearing about keeping secrets. This is where you start seeing grooming behaviors occurring. So, grooming behaviors are really those testing of limits with a patient or anybody. You test limits to see how far you can go. A true predator will keep testing limits and keep testing limits. And if the person keeps letting them go, they will keep testing until they get to where they want to be. And then, all of a sudden, you're in this particular place that you don't want to be as a victim, right? But if they get a barrier, they often will stop, back off, and go find another way.

And then, the third condition you have to have is control. And in healthcare, we have control. I had a case one time where we had a substance abuse physician who was withholding pain medication from patients or prescribing pain medication for patients, but would only do so under the condition of pictures on his cell phone. So, he was inserting control around the care in those cases.

So when you have those three things, those three elements set up and they kind of Venn diagram together, you created a perfect storm for abuse potential. And so, part of looking at how we mitigate abuse is to say, where are we at in this continuum and where can we break out of that and put in some guardrails and some mitigating factors.

Host: So, access to people, privacy and control. That's the path that these abusers go down. So. Let me ask you about this. One of the ways to stop that path would be to mitigate it. So, could you talk about chaperones and chaperone policies, what they are, and if they're effective, or are they just symbolic?

Dr. Josh Hyatt: I would say yes and no to both to most of that question. Yes and no, both. So, chaperone policies in general is having somebody in the room when you're providing some sort of care, right? Generally, what we're talking about are sensitive exams or intimate care, so things that involve breasts, groin, rectum, those sorts of things where you are exposing patients in a very vulnerable way. And chaperone would be somebody that's in the room to assist. So, for example, if a male OB-GYN is doing a Pap smear, he may have a medical assistant in the office with him, during that time as a chaperone, intent being that it's kind of two-sided, right?

So, the first side is that the patient hopefully would feel comfortable that there's a person there in case something goes wrong or happens, or just has somebody there to feel safe with. And generally, that chaperone would be of the same gender. That's not really necessarily a big thing, I mean, it is still considered same gender. And it's for the protection of the provider so that, if the patient makes allegations that the provider did something inappropriate, that there's somebody to witness what was happening.

Chaperone policies in general are good and bad. The good part of a chaperone policy is that if it's executed well, and there's lots of conditions under what well means, it can do those two things: protect the patient and protect the provider. If it's not done well, it can actually cause more risk. And unfortunately, when I have interviewed victims or have talked to providers about chaperoning, especially in like medical offices, when abuse has occurred, in many cases, there's a chaperone in the room. And if the chaperone isn't trained to know that they're not just a warm body, they actually have a function and purpose, and their function and purpose is to provide comfort to the patient and to ensure that what is happening in the room is appropriate. Now, obviously, we're not expecting them to know clinical appropriateness. But within their scope, if something seems wrong, they're there as a support and can intercede, and say, "Hey, look, we need to stop. The patient's uncomfortable." I don't know of any chaperones in like a physician's office that have the sense of power and entitlement to be able to do that because we don't give them that authority. We don't give them that kind of training. So, it's like you're not a warm body. You're not just standing there. You actually really do have a purpose.

And I think people overrely on bad chaperone policies to protect themselves without really going through the work of having a really good chaperone policy that's well thought out, and it is accepted by both the providers and the support staff and understanding what's going on. In hospital settings, you may have a little bit of difference, right? Where you have nurses who go in and they're providing Foley catheter care to patients who may be on pain medications or have something that's affecting their perceptions, right? And so, I've seen a lot of allegations made against nurses during this kind of care. And in some cases, it's appropriate to have a chaperone in the room. In other cases, it may not be in all reality.

So, it depends kind of on the environment and the patient. So, I always encourage organizations to look at the patient first. Is this a person who you're concerned about from multiple perspectives? Is this a vulnerable person, like for example, a minor or somebody that has perceptual disorders or has had a history of sexual abuse or rape, or has made allegations of sexual misconduct in the past? Those are kind of those big red flags to start with and say, "If I have one of these kind of patients and I'm going to be providing care, I'm probably want somebody in the room with me."

But it's kind of that thought process of really working through it. So if chaperone policy is well done, well thought out, there's training, and it's part of the DNA of the organization, I think you're really good. I spoke with an OB-GYN chair at an organization and she said, "Look, this is the rule I have. If you are a female physician, you go in the room. And if the patient wants a chaperone, you always offer a chaperone no matter what you're doing. If they want a chaperone, great, we'll bring a chaperone in. There'll be somebody in the room. We'll do our thing." And then, you would document that the chaperone was in the room and who it was and all that sort of stuff. If it's a male OB-GYN, there's no choice. You have to have a chaperone. And if the patient doesn't want a chaperone, which happens actually quite a bit, then you say, "Well, then either need to have a female OB-GYN or you need to seek care elsewhere." That was the rule she established in her particular practice. And that was well thought out for her and it worked for their practice

Host: And that's good protection for patient and staff. And as you said earlier, predators don't like to be monitored. So, having that chaperone in there, really important. So, Josh, how can risk professionals and frontline staff-- how can they shift from check box compliance, "Yep. We do this once a year and we're all good" to real prevention?"

Dr. Josh Hyatt: So when we look at the continuum, right? So, we first start at this place of complacency and we hope that we don't find people there. When we kind of move to the next level, which is the checkbox compliance, it's like, "Okay, well, we acknowledge this is a real thing, fine. So, we're going to have a policy, we're going to have training, we're going to do all of these things. And that's when we start to rely on, "Okay, well we've done this, we've done these little checkbox things, and now we're all good to go and there's no more consideration about it."

When you get kind of stuck in the compliance phase, you are really kind of thinking to yourself, well, we've done it, we've beat it, we've dealt with it, and we can just move on to the next thing. And what we really want people to get to is to a place in which it becomes part of the thought process and patient safety is part of that. And you are thinking about the patient, you're thinking about your staff in all of the things that you are doing. And so if you are passing policies, if it becomes a commitment to your organization, you say as an organization, "We are committed to protecting our patients and making sure that abuse in any form does not occur, and these are the things that we do." So, every time we build a new policy or every time that we engage in an initiative or protocols or stuff, those are the things that are kind of brought forth first. Like, are we making sure that what we're doing really protects our patients? Are we leaving an open gap that can endanger our patients or our staff? So, we hoped people kind of get out of checkbox because, yeah, you can do your check box compliance and say, "Yeah, we did all these things and we're good," but you're really not because people that, test boundaries-- well, just people in general-- because everybody tests boundaries, right? We figure out ways around things. And so, if you are doing a compliance education every year online, that's not really helping a lot. When we ask organizations about training, for example, around sexual abuse, we say, "Do you get sexual abuse training where you're talking about preventing abuse against patients?" And we pretty much always unanimously get, "Yes, we get that training every year through our compliance department." And then I say, "Well, is that training really about sexual harassment, which is staff to staff?" Right? "Is it really about that or is it more about abuse where we're talking about staff-to-patient or even patient-to-patient abuse?" That's where we're concerned. And then, they go, "You know, no, no, it's not covered there. We don't really talk about that. We talk about harassment." And I'm like, "Even though they're two different things, they are a Venn diagram. If somebody sexually harasses coworkers, they might often sexually abuse patients." So, I said, that's certainly a red flag that needs to be managed, but that's not what we're talking about.

Host: So, as you said, the theme is working this into the DNA, the fabric of your organization. This is an everyday thing, not just a "we're going to have a meeting once a year" kind of a thing.

Dr. Josh Hyatt: That is exactly right. And there are different ways in which you can do that. One really powerful way that I don't see very often that I think would be really good is making sure that patients understand that they can even request a chaperone. And what a chaperone is, it's something minor. You could put signs up and have those discussions with patients. Some providers are really good about it. They'll come in and they'll say, "Hey, you know, we're going to be doing a Pap smear. It's very invasive. It's a little embarrassing. I'm happy to bring somebody in as a chaperone who will be here as support for you if you would like that." Some organizations, they make it mandatory. So, there's different ways of engaging in that kind of behavior. But it really is building that in to the fabric of what you're doing.

Host: So, it seems like that proactive approach is the way to go, "Hey, would you like me to bring a chaperone in?"

Dr. Josh Hyatt: Exactly. And the other thing that I wanted to add in there is too, is when we talk to providers, we talk about what's called care narration. And care narration is when you are doing something to talk through it as you are doing it so that the patient understands what's happening. So in a procedure, you know, if a provider and it can be a nurse or a doctor or anything, they could say, "Look, I'm going to be touching you here. You're going to feel this. If you're uncomfortable, let me know. I will stop." And just narrating that care, especially when there is a chaperone in the room, makes it very clear what's happening. And so, everybody's on the same page and people feel safe when you're doing that. If you just go in and you start doing stuff, I had to tell so many nurses, especially around the Me Too movement, we started getting allegations of sexual assault in my hospital, like lots. And a lot of it was nurses that were going in and doing Foley catheter care on patients who were sedated or coming in and out of sedation or on pain medications.

They were vulnerable because they had impaired cognitive status. And so, they didn't maybe even know what was happening. And so then, they would say, "Somebody raped me." And so, these nurses would be like, "Why would somebody say that?" And I would say to them, "Look, for you doing Foley catheter care is a Tuesday. But for this person, it may be different." There are going to be mitigating circumstances per person. There could be trauma history. There could be other things. And so, sometimes that narrative care that you are doing, "Hey, I'm going to be doing this. I'm going to pull this. You're going to probably feel a little pressure here," if you engage with them to the best of your ability, and narrate what you are doing, that will help to mitigate these kind of allegations because they'll trust you more if they understand what is happening in the moment.

Host: I know I really appreciate narrative care, even when I'm in the dentist and they're like, "Okay, here's what's going to happen and I'm going to put the Novocaine in and you're going to feel a little pinch." And I always appreciate that, and I would imagine pretty much everyone else would as well. Josh, what a fascinating conversation. You've really dropped the knowledge on us in this podcast. I want to thank you so much. Before we wrap up, is there anything you want to add?

Dr. Josh Hyatt: I guess to highlight the big bullet points, right, is to first understand that complacency exists in every setting. There may be some areas that are maybe more hypersensitive to this, like behavioral health and stuff, but the risk exists everywhere. There is no place in which this particular risk doesn't exist, and working through that complacency with your team is really important, even if it is uncomfortable.

And next, I would say understand that though these types of events are low frequency, but they are incredibly high impact. And when they hit, they hit, and they change the culture of where you are, what you are doing, because people lose trust. Your patients lose trust. When you have a large event, your staff lose trust. Your physicians get mad because they've put their name to this organization and now you have sullied their reputation. And there are financial and regulatory consequences.

And third, really think through where your high risk areas are. And what are those mitigating steps you can take to reduce them substantially and avoid drift, avoid slipping back, which is where compliance puts you. Really bake it in to your DNA and be thoughtful about it. Those would be like my big three major takeaways.

Host: Very well said, Josh. Understand complacency exists and that these events are low frequency. But when they hit, as you said, they hit with big impacts. So, make sure you understand where the friction points are, where the high risk points are, and avoid drift. Really great advice. Josh, thank you so much for your time today. This has really been educational and informative for all of us. Thank you again.

Dr. Josh Hyatt: My pleasure, and thank you again for inviting me. I really appreciate the opportunity.

Host: You bet. And once again, that is Josh Hyatt. And to access more great content, please consider joining ASHRM. Just go to ashrm.org/join-ashrm where you'll get more great education just like this podcast today with Josh. And the ASHRM podcast is made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ASHRM.org/membership to learn more and to become a member. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. Thanks for listening.