Uncategorized

Disruptive Physician Behavior: Fact vs. Frenzy

The Joint Commission has recently proposed in its 2009 Accreditation Standards that hospitals develop and implement a Code of Conduct policy and provide appropriate education and processes that address disruptive behaviors.

Many think the decision is long overdue, while others have expressed concern that it was just another way for administration to weed out physicians who are openly vocal in expressing contrary views to administrative policies and decisions.

Disruptive behaviors include any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment. Unfortunately, they’re all too common in the health care arena, and they affect staff morale as well as patient safety.

I have been researching disruptive behaviors for 10 years, starting in the era of growing concerns about the nursing shortage to see if there was a relationship of between physician disruptive behavior and nurse satisfaction and retention.

In one study, more than 90 percent of the 2,500 survey participants (physicians, nurses and senior level administrators) witnessed disruptive behaviors in physicians and more than one-third were aware of a nurse who left the hospital specifically because of physician disruptive behaviors.

What we learned from this research was how serious an issue it really was and more importantly, the impact it had on staff relationships, communication efficiency and patient outcomes of care.

The second phase of our research focused on not only physician disruptive behaviors, but also disruptive behaviors in nurses and other hospital employees. We also assessed the relationship of disruptive behaviors to human factor issues affecting decision making, task fulfillment and performance (stress, frustration, concentration, communication and information transfer) and the linkage between disruptive behaviors and negative outcomes of care (adverse events, errors, compromises in quality or patient safety and mortality).

Once again we were astounded by the frequency and significance of our findings and in particular the acute and downstream negative effect of these incidents on patient care and patient safety.

Our recommendations for action include:

  1. Raise awareness
  2. Conduct an internal assessment
  3. Developing and implement behavioral policies and procedures that outline and reinforce appropriate professional code of conduct standards
  4. Assess potential underlying factors that may precipitate disruptive events and provide appropriate educational courses (diversity training, sensitivity training, conflict management, assertiveness training
  5. Provide tools that improve communication efficiencies and team collaboration (SBAR, team collaboration training, improved language/ linguistic skills
  6. Implement an effective and consistently applied reporting and follow up system that assures that all incidents be addressed with appropriate action and feedback as part of the loop
  7. Have a consistent criteria based system for addressing chronic disruptive behaviors to include multidisciplinary review and follow up recommendations that may include counseling and/ or suspension of privileges
  8. Use a clinical champion to foster the cause
  9. Secure leadership support and endorsement
  10. Reinforce the importance of the end goal which is to improve patient safety and quality as an integral part of the organizational culture and other patient safety, quality and risk management programs.

The historical issue of the reluctance of management and clinicians to address other physicians who bring patients into the hospital and are a major source of revenue makes addressing this issue difficult. Also, traditional monitoring and credentialing activities focus on demonstration of clinical or technical competence. We have not really been trained on the merits of communication competency. If you do nothing, you run the risk of staff dissatisfaction and its associated repercussions on staff recruitment and retention, risks to compromises in patient safety and quality outcomes of care, risks to your reputation, and even financial liability.

So what should you do? First, develop the business case around patient safety. Many physicians are not aware of the downstream effect of many of their actions and their primary goal is always to provide optimal patient outcomes of care. Focus on health care complexity and the opportunity to improve understanding, communication and collaboration as way to improve efficiencies and outcomes of coordinated health care delivery rather than taking a primary punitive confrontational approach.

Make sure you have criteria, guidelines, standards and processes in place that address critical issues of concern to help thwart the potential concerns about a hospital witch hunt. Be up front in addressing and following up on physician complaints and issues brought to your attention. Get a better understanding on what makes people react the way they do. With increasing diversity in the medical marketplace providing educational and training programs on culture and ethnicity, generational issues and ways to improve communication and collaboration skills.

Alan Rosenstein is the medical director and a vice president at VHA West Coast, a health care consulting firm. He reported no conflicts of interest related to this post.

Livongo’s Post Ad Banner 728*90

Categories: Uncategorized

Tagged as:

12
Leave a Reply

12 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
12 Comment authors
Richard WillnerDr GDr. DJim FinleyDebbie Waugh Recent comment authors
newest oldest most voted
Richard Willner
Guest

“Disruptive Behavior”? Yes, we all know that physicians, as well as others, are capable of it. But, is this label SEVERELY ABUSED to get rid of some doc the administrators or other docgtors don’t like? The Center for Peer Review Justice has in it’s files hundreds of such cases where a doc is tagged with that label and then the hospital and others get IMMUNITY and because of the Health Care Quality Improvement Act of 1986, the doc only has PROCEDURAL due process and not substantive ( facts) due process. A lawyer can not change the very limited amount of… Read more »

Dr G
Guest
Dr G

The description of Swantine’s friend above who has been targeted by her HMO is a case study in sham peer review. The is well describe by Lawrence Huntoon, MD on the Association of American Physician and Surgeons website. Don’t be a victim of sham peer review. Protect yourself. Bring a friend to any “emergency” meeting you are called to with administrators. Record the interaction on your dictaphone. If allegations are made against you but you cannot have access to the complaints in writing watch out. You are about to become a victim. Get legal advice early. Demand access to records.… Read more »

Dr. D
Guest
Dr. D

Ms Porto, As this issue becomes more prevailant in hospitals I suspect you will find more and more physicians who are concerned by these new requirements. Comments such as yours saying “I have heard the argument that this will be used against physicians who rail against the system and frankly I am not sympathetic to this” are quite possibly the reson for that. This fear is very real, especially as the arena of healthcare becomes more and more politicized. I’ve been in practice for 6 years and in that time I’ve had one incidence where my behavior was questioned. After… Read more »

Jim Finley
Guest
Jim Finley

I’ve been a psychotherapist for a fair number of years now and my wife is a clinical social worker. We’ve both seen disruptive professionals in all the disciplines – doctors, nurses, psychologists, social workers, therapists, and administrators; in each category, they have been a small minority, thankfully. We do need a way to weed them out, and we also need that mechanism to have safeguards built in so that it isn’t abused to get rid of whistleblowers or staff who stand up to the institution in advocating for patients, clients, and their families. Prevention is always better than damage control,… Read more »

Debbie Waugh
Guest

An excellent commentary on the issues and recommendations for action. This is a real issue that impacts healthcare on many levels. I am glad to know that the Joint Commission included it in its 2009 accreditation standards.

swantine
Guest
swantine

Dr. Rosenstein, My friend is a physician with an exemplary 20 year record and is currently in the midst of a battle with a huge HMO which dismissed her for being such a disruptive physician. She was not disruptive but she had reported some unlawful or otherwise problematic procedures that had slipped into practice had not been corrected. That alone brought her into focus and the culture of backstabbing took over! The past 2 years have been unbelievable. Instead of just calling her disruptive, they altered certain medical records to conform to their allegations, filed complaints with the state medical… Read more »

George  Anderson
Guest

Dr. Rosenstein,
This is an excellent and timely article. Hospital Administrator and Physician Well-Being Committees are moving quickly to address this issue. I will pass along the 10 reccommendations which you make in this artical.
http://www.andersonservices.com

Susan Carr
Guest

For further reading on this topic, I recommend two articles co-authored by Grena Porto, which I published in Patient Safety & Quality Healthcare:
http://www.psqh.com/julaug06/disruptive.html
http://www.psqh.com/novdec08/drawing.html

Grena Porto
Guest
Grena Porto

As a member of the Joint Commission’s SEntinel Event Advisory Group and a champion of its efforts in this area, I would like to add a few comments to Alan Rosenstein’s excellent posting: 1) the requirements in the JC’s standards as well as the guidance in the alert released in July of 2008 clearly state that this applies to everyone, not just physicians. 2) the work of Alan Rosenstein and ISMP clearly show that the behavior in question is not limited to physicians. 3) although physicians are not the most frequent disrupters, their behavior tends to have the largest impact… Read more »

Hope
Guest

Alan,
A very cogent post. But, don’t forget the related topic of medical work-place violence.
Link: http://healthcarefinancials.wordpress.com/2009/01/15/medical-workplace-violence/
Best.
Hope Rachel Hetico; RN, MHA, CMP
Norcross, Georgia 30092
http://www.MedicalBusinessAdvisors.com

bev M.D.
Guest
bev M.D.

HAHAHAAA, as my teenage daughter would say, to “a”!!! You must be a doc – I’ve seen a few of those administrators myself! In fact, they are behind the current hospital building binge (and other things) which is driving healthcare costs even higher!
As for arrogance and ass-hole like behavior, I am afraid administrators don’t have it over (some) doctors on that one. As a pathologist I had to deal with too many of them with both titles! But thanks for the good laugh!

a
Guest
a

how about disruptive administrators
those who destroy clinical departments thru incompetence, inexperience, and just plain egotistical stupidity?
what about arrogance, and general asshole-like behavior?
got a regulation for that?