Breaking ground on Leadership standard LD.03.01.01
In 2009, The Joint Commission added Leadership standard LD.03.01.01, "Leaders create and maintain a culture of safety and quality throughout the hospital," to recognize that behavior that intimidates others and affects staff morale and turnover can also be damaging to patient care, and to require a formal process to manage unacceptable behavior in accredited hospitals. Elements of performance (EP) 4 and 5 of this standard contain language about "acceptable, disruptive, and inappropriate behavior" of individuals working in healthcare organizations.
Effective July 1, the term "disruptive behavior" in the glossary and in the two EPs in the Leadership standard was revised to say "behaviors that undermine a culture of safety." The revision is applicable to ambulatory care, behavioral healthcare, critical access hospitals, home care, hospitals, laboratories, long-term care, and office-based surgery accredited facilities, and will reflect a broader range of unacceptable behavior that healthcare facilities currently face.
Behaviors that undermine a culture of safety
"Behaviors that undermine a culture of safety" is a bit more all-encompassing than "disruptive behavior." In fact, Bud Pate, REHS, practice director for The Greeley Company, a division of HCPro, Inc., in Danvers, Mass., says that disruptive behavior is just one behavior among a number of others that could undermine a culture of safety.
"Disruptive behavior is only one of the kinds of behaviors that leaders need to address. There are many other examples, such as giving not necessarily disruptive, but negative feedback when a safety issue arises, and not cooperating with patient safety initiatives," Pate explains.
The Joint Commission says in its January issue of Perspectives that, according to some physicians, strong advocacy for improvements in patient care can be characterized as disruptive behavior, and that the phrase could be used in the context of a care environment that has become temporarily unsettled by the behavior of a patient, resident, or other individual.
While the primary reason behind this change in language is for clarity, Pate says that the change is not really anything new, but rather an extension of what is already being defined as a culture of safety in healthcare today. Over the past four or five years, he says, expectations have already been placed on hospitals to establish a baseline measure of their culture of safety and take steps to improve it on an individual and collective level, using resources like the Agency for Healthcare Research and Quality's (AHRQ) patient safety tool and definitions in Sentinel Event Alerts released by The Joint Commission. Pate says that among those steps are expectations for behaviors for both leaders and physicians in particular.
So what exactly are these expectations and behaviors that undermine a culture of safety that leaders should be looking out for? "Behaviors that undermine a culture of safety can be verbal, nonverbal, may include the use of rude language, possessing a threatening manner, or even physical abuse," says Sue Dill Calloway, RN, MSN, JD, CPHRM, chief learning officer of the Emergency Medicine Patient Safety Foundation in Dublin, Ohio.
In addition to the obvious behaviors such as violence, yelling or shouting, profanity, insults, bullying, or harassment, Calloway says some examples of behaviors that undermine a culture of safety could also include less obvious things like:
- Inappropriate comments written in the medical record
- Blatant failure to respond to patient care needs or staff requests
- Personal sarcasm or cynicism
- Deliberate lack of cooperation without good cause
- Deliberate refusal to return phone calls, pages, or other messages that may concern patient care or safety
- Insensitive words or actions directed toward another person
- Rude responses to patient needs or staff requests
- Disruption of meetings
- Uncooperative or defiant approach to problems
- Refusal to complete a task or carry out duties
- Repeated violations of policies or rules
- Nonconstructive criticism that is addressed to its recipient in such a way as to intimidate, undermine confidence, belittle, or to impute stupidity or incompetence
- Threatening to get someone fired
- Refusing to answer someone's questions
- Criticizing other caregivers in front of patients
- Behavior that disparages or undermines confidence in the hospital or its leaders
- Public derogatory comments about quality of care being provided by others
This isn't exactly a 'tomato, tomahto' situation
Generally speaking, the term "leader" throughout the years has been used to define everyone from the board of directors all the way down to department or unit heads, and although this change in language might not seem to affect the processes that hospitals have put in place to deal with behaviors that undermine safety in care settings, it in fact further emphasizes the dire need for such processes to change.
Pate says that the wrong thing to do would be to just take the Joint Commission language and develop an isolated policy that defines "behaviors that undermine a culture of safety." In fact, he says, making a policy that broad would be impossible to implement.
"It's difficult enough to define what disruptive behavior is, much less the much broader definition," Pate says. "And that's not the intent. The intent is to align those leadership standards with the other expectations around safety, and to keep on keeping on. If they haven't really truly started embracing a culture of safety, they need to do that, and that's not a new expectation, that's been an expectation for some time. This [standard] dovetails into that expectation; it doesn't really layer anything on top of it."
Breaking the barriers, step one: You'll need a bigger pan
Even though culture change is an entirely separate fish to fry, and a huge one at that, it's a fish that everyone seems to be coming back to. Healthcare professionals have a lot on their plate already, and when it comes to completely overhauling an entire culture, where do you start? How do you fry a fish that big?
Pate says that one of the biggest barriers to truly achieving a culture of safety is the sheer size of the issue.
"A lot of the folks will do the AHRQ culture of safety survey, and then they'll do the survey again, and then they'll do the survey again, and the survey is so broad that, unless the hospital is very sophisticated, they sort of take a broad approach to it and don't really get down to the cultural issues," Pate says. "I mean, you'll know when you have a culture of safety when all surgeons react to a scrub technician who shuts down a procedure because they're concerned about something: the sterility of the equipment, the readiness of the survey, the identity of the patient.
"And if that scrub tech has not only the ability to stop the procedure, but to stop the procedure and then say, 'No, everything's okay, we're going to go forward,' and the surgeon says 'thank you,' " he continues.
"That's not the behavior that we have. When a nurse calls a physician about a problem with a patient or a question about clarfiying an order and the doctor says, 'Yes, I wanted that, but thank you for calling and double checking,' When the folks who have the power start doing that, you'll know we've begun to have a culture of safety," says Pate. "But that is huge change."
Breaking the barriers, step two: Reverse the food chain
There's a saying that goes, "Culture eats process for lunch." When the culture of an organization is deeply engrained, change becomes very difficult. Pate says that this is another barrier to creating a culture of safety, and that too much time and attention is being devoted to putting out fires and monitoring skipped measures.
Safety programs, such as the management of incidents and medication errors, are often robbed of attention and resources because there are millions of dollars in the value-based purchasing program that is taking those resources and putting them into outcome measurement, Pate says. "A medium-sized hospital is at risk for many millions of dollars in the next three or four years if they don't make significant improvements in patient satisfaction and performance in certain predefined indicators," he says.
Patient safety indicators are part of value-based purchasing, but it doesn't really take a culture of safety to implement them. However, value-based purchasing is something that the C-suite, particularly the chief financial officer, is very focused on, and although value-based purchasing is a leadership issue, it's also an area where the responsibilities of accreditation professionals and survey coordinators can have an impact on creating a culture of safety.
Patient safety professionals can take concrete action
Patient safety Professionals can start looking at the behavior of physicians and other leaders and defining what is and is not acceptable-i.e., identifying what supports safety and what detracts from it-and start dealing with such behavior at their quality council, says Pate. "The patient safety professional, although a leader, is not in the operational chain," he says. "They don't lead the medical staff, they don't lead the nursing or the other support departments, and they don't make the financial decisions. But if they could queue up unacceptable behavior along with the results of the culture of safety survey and somehow find a way to put that in the framework of value-based purchasing, that's one thing that they can do that's really concrete."
Something possibly even more concrete that Pate suggests is for healthcare professionals to adamantly point out the numerous vulnerabilities and adverse events that occur on a regular basis and bring them to the attention of leadership.
Facilities across the country are being hit with adverse event findings left and right by state agencies; the findings include nursing service issues, patient rights issues, and quality assessment or performance improvement. Pate says these citations-which frequently arise from individual patient events that are brought to the attention of the CMS-could threaten a facility's financial well-being and compromise its certification.
"It's not because they come by if they don't have anything better to do that day, it's because an adverse event happens, and CMS comes out and looks at it," he says. "So it compels the healthcare professional to bring this to the attention of leadership and say, 'Hey, we are vulnerable. As long as we have adverse events that are happening and we haven't drilled down and addressed the underlying issues that are causing these events, we are vulnerable to being distracted from our core mission.' "
One hundred percent of the time, Pate says, the root of those issues involves the need to improve the culture of safety and the behaviors that the leadership standard is more clearly addressing.