Diffusing disruptive physician behavior
Work with med staff to set clear expectations for a safer care environment
Disruptive behavior can come in a variety of forms, from yelling and inappropriate language to physical altercations in the worst-case scenario.
A report released in May by QuantiaMD indicated that disruptive physician behavior is still an issue in hospitals around the country. The report surveyed more than 840 physicians and physician leaders at QuantiaMD and the American College of Physician Executives. Survey results showed that 70% of those physicians said disruptive physician behavior occurs at least once per month and 11% said it occurs daily. An overwhelming 90% of respondents also indicated that disruptive physicians ultimately affect patient care, and 21% reported experiencing adverse clinical events that could be attributed to disruptive physician behavior.
Although patient safety is the primary concern in any healthcare facility, disruptive behavior must be dealt with regardless of who it affects, says Dean White, DDS, MS, a medical staff consultant in Granbury, TX.
"Disruptive behavior, particularly repetitive disruptive behavior, doesn't necessarily have to be tied to patient safety or quality," White says. "In other words, it's just unacceptable. You don't have to have a bad outcome because of the behavior to make it wrong. It's not the outcomes we're looking at here, it's the behavior."
The ultimate decision on how best to deal with or punish a disruptive physician usually falls to medical staff leaders and hospital administrators.
Defining a disruptive physician
The AMA's ethics policy, outlined in Opinion E-9.045, "Physicians with Disruptive Behavior," defines disruptivebehavior as "conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care." However, the AMA definition also notes that "criticism that is offered in good faith with the aim of improving patient care should not be construed as disruptive behavior."
"The common thing that you see is any inappropriate touching, screaming, or inappropriate behavior that is just abnormal," says Carol S. Cairns, CPMSM, CPCS, president of PRO-CON, a consulting firm in Plainfield, IL, and senior consultant at The Greeley Company, a division of HCPro in Danvers, MA. "You can disagree, but you don't have to be disagreeable."
The trick is defining that fine line between a physician who is merely critical and one who acts out inappropriately. For instance, if a physician raises his or her voice because a patient transporter is unsafely handling a patient, that may be an example of urgency and patient safety rather than a disruption.
Examples of disruptive behavior listed in the QuantiaMD report that most concerned physicians and physician leaders include:
- Degrading comments or insults
- Inappropriate joking
- Refusal to cooperate with other providers
- Refusal to follow established protocols
- Discriminatory behavior
Distinguishing these key behaviors from urgent outbursts during patient care is the first step in developing a sound disruptive physician policy.
Creating a policy to fall back on
In 2009, The Joint Commission established a standard (LD.03.01.01) that addressed disruptive physicians in the healthcare environment:
- EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors
- EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors
From a legal perspective, a clear, concise policy also protects a facility from accusations of unfairness or mistreatment. "You are always on solid ground when you have a clear policy that is consistently enforced; that is what lawyers will tell you," Cairns says.
Medical staff leaders should be heavily involved in writing that policy and should look to other colleagues and resources to ensure that the language covers every situation.
Important points that should be addressed in any disruptive physician policy include a definition of disruptive behavior, appropriate repercussions, and sanctions for multiple offenses.
Unfortunately, some hospital administrators have atricky relationship with physicians who are not employed by the organization. These physicians are often viewed as customers by the hospital, says Carlotta Rinke, MD, FACP, MBA, chief quality officer at Alexian Brothers Medical Center in Elk Grove Village, IL. If administrators are too lenient because the hospital is afraid to lose market share in the community, it can create issues.
"If there's not a strong safety culture in those organizations, sometimes the staff get mixed messages from the administrators about holding physicians accountable to things like the rules and regulations of the medical staff, respecting The Joint Commission's national patient safety goals, hand washing, etc.," says Rinke.
The fact that hospitals need physicians isn't going to change, so Rinke advises having a clear strategy.
"You want to hold [physicians] accountable, but they're your customer, you want to make them happy. How do you do that in a balanced sense?" asks Rinke. "Some of that takes some artfully crafted leadership."
With hospital-employed physicians, creating incentives for good behavior is a bit easier-you can provide bonuses or penalties based on behavior. But regardless of whether physicians are employed by your organization, they should be held accountable for their actions, says Rinke.
She advises hospitals to ensure that clear expectations for following protocols and behaving appropriately are written into policies with the help of medical leadership to ensure that a team of physicians are holding other physicians accountable.
"Holding the physicians to some of those rules requires strong leadership that feel empowered, that are backed by the medical executive committee, the department of medicine, the department of surgery, steering committees, etc.," says Rinke.
After the policy is written and reviewed, perhaps the most challenging aspect is consistently adhering to that policy, White says.
"The culture of the hospital can vary 180 degrees," he explains. "You can have one hospital that says they have zero tolerance for disruption, and at the same time they will have the favorite son that has been there for a long time and they will say, ‘Oh, he's just a surgeon and he's a good guy, so we'll overlook it.' That happens every day, I hate to say it."
With the right culture, medical staff leadership should take responsibility as the regulator in this situation, identifying instances in which a physician is being treated unfairly or being let off the hook for legitimately disruptive behavior.
Physicians who fail to follow proper protocol might need to be reminded that the hospital must follow a number of outside regulations and guidelines.
"But now we're in a data-driven culture where we have quality metrics, we have publicly reported information, we have Joint Commission, we have the National Quality Forum, and we have Leapfrog. You have state-level reporting-quality is a different animal now," Rinke says, noting that in years past, quality often became a tool to go after a physician for other reasons, such as a power move, financial gain, or personal vendettas.
In many cases, repeated behavior occurs over the course of many years, and existing medical staff leaders may forget about past incidences or new medical staff leaders may be unaware of reoccurring instances.
"The medical staff professional can and should be in the role of making sure there is clear documentation every time an incident occurs and then that there is clear documentation on the incident, what the action was, discussions with the physician, expectations laid down, and consequences," Cairns says. "Then when it reoccurs, that documentation is there and available for the next incident and for leaders that are involved at that time."
Getting support from medical staff leadership
On paper, your hospital may take a very hardened stance against disruptive physicians, but when push comes to shove, medical staff leaders are often uncomfortable confronting disruptive physicians or enforcing disciplinary actions.
Cairns suggests seeking support from HR to help guide medical staff leaders who might be unwilling to approach a disruptive physician.
"Sometimes medical staff leaders are not trained to do that type of intervention," she says. "HR people very often are. Maybe the chief of a department or the credentials chair might be counseled by a vice president of HR who understands how to do that process; someone who does this more commonly with employees and they know how to do it effectively."
Continuous educational opportunities also help keep leaders informed of the issues and ways to approach a sometimes volatile situation, White says.
Getting the physician help
One thing medical staff offices want to avoid when dealing with disruptive physicians is taking a "whack-a-mole" approach, in which physicians are disciplined without any attempt to uncover the root of the problem, White says.
"It shouldn't be about punishing the physician, it should be about getting him or her help," he says. "A lot of times disruptive physicians are a sign of impairment. They are burned out, stressed, depressed, alcoholics, on drugs, or they may have aging issues. So this approach should be ‘How can we help you with your behavior?' "
Interventions include anger management courses, communication seminars, or referrals to a psychologist.
There may also be glitches in the system or certain procedures that are inviting disruptive behavior, White says. For example, doctors are often called throughout the night if there are issues with a patient. White says there should be a procedure in place so that a nurse who has to call at 2 a.m. is having a very concise conversation with all the important information on hand.
Rapid response teams can be another useful tool to help reduce physician stress, says Rinke. "I can't say whether it definitively decreases disruptive behavior, but it helps the patient," she says, noting that without the teams, physicians would be the sole party called.
"If you have a system that's not working and the physician is being disruptive because he's not getting what he needs, then you also need to look at the system," White says.
An increasingly complex healthcare system suffering from lower reimbursement increases pressure on physicians, and hospitals must recognize and try to ease that stress.
"It's a trap of our system," says Rinke. Pressure to see more patients and be more efficient can create the need to be in three places at once, leading to impatience and snapping at other care staff. Physicians cannot be expected to comply with hospital policy if the hospital does not attempt to support them toward that goal, she says.
Rinke also reminds hospital leaders that initiatives do not have to fall heavily on their shoulders; they can look to other hospitals and national guidelines to help steer their organization toward a better culture with less disruptive behavior, rather than relying solely on internally driven initiatives.
"It takes a village and strong leadership to change the culture," says Rinke. "You can't be too impatient. It takes time and people who are willing to take a stand."