HomeLearnBehavior that Undermines a Culture of Safety

Submitted Courtesy of Mary-Lynn Ryan
Risk Management
NORCAL Mutual Insurance Company and the NORCAL Group

Disruptive behavior by professionals in healthcare settings is well documented as a threat to quality care and patient safety. Managing disruptive behavior requires a coordinated effort based on a written policy and established procedures that cover reporting, confrontation, documentation, response, outside consultation, reprimand, follow-up, and monitoring, as well as support for subject physicians.

Although there is no universally accepted definition of disruptive behavior, the American Medical Association (AMA) defines it as “personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively.” It also includes “conduct that interferes with one’s ability to work with other members of the health care team.”1 Everyone who behaves inappropriately should be treated in the same manner, including excellent practitioners.2  This expectation should be clear in the policy.

All members of the healthcare team should be aware of the policy and the definitions of disruptive behavior it contains. Leaders who are expected to enforce the policy should be trained in the process for addressing disruptive behavior, as well as the legal ramifications of limiting a practitioner’s practice and the legal protections available to both parties in such an action.1

One goal of a disruptive-behavior policy is to create a safe and supportive environment where everyone knows what is reportable and feels empowered to make a report. Research indicates that many instances of disruptive behaviors are not reported because the would-be reporter is afraid of reprisal.3 To address this issue, the Joint Commission recommends making the process confidential and including non-retaliation clauses in the policy. Interviewing reporters in confidence assures them that their reports are being taken seriously.4

A history of delayed or hesitant responses to disruptive behavior can discourage staff from reporting such behavior in the future. Therefore, it is important to investigate and intervene as quickly as possible. Prompt response reassures witnesses and reporters that the problem is being addressed pursuant to the policy.

When the decision has been made to perform an “intervention,” the designated team should plan every step (even rehearsing, if necessary), taking into consideration the effects and consequences of planned actions. The planning, goals and outcomes of an intervention should be carefully documented. If necessary, the resulting report can serve as evidence that the reported practitioner received due process.

An initial intervention without follow-up will generally not put an end to disruptive behavior, which tends to be triggered by ongoing circumstances in the healthcare environment (e.g., lack of equipment, understaffing, fatigue or practitioner health issues). A reported provider should understand that he or she is being monitored for compliance.3

Treat the reported behavior as a problem with the physician’s behavior, not with the physician. In other words, the physician should not be labeled a “disruptive physician.”4  When it is too difficult to conduct an objective assessment in-house, an outside evaluation can assure the involved parties of the process’s fairness and objectivity. In some cases, the most prudent course will be to involve legal counsel for guidance.4

Disruptive behavior compromises patient care and increases professional liability risk. Although disciplining a healthcare provider for disruptive behavior can be difficult for a variety of reasons, it must be done in a timely, organized and fair manner. Individual practitioners who struggle with anger/frustration management must also take responsibility for their disruptive behavior and seek help. To create a culture of safety for patients and a supportive and productive environment for all members of the healthcare team, practitioners, Medical Executive Committee (MEC) members and administrators are encouraged to consider the risk management recommendations offered in this article.

It should be noted that in many states (including California) disciplinary actions based on physician conduct are reserved exclusively to the medical staff, not hospital administration.5

Endnotes

1. AMA. Model Medical Staff Code of Conduct. Available  on the AMA Web site at www.amaassn.

org/ama1/pub/upload/mm/21/medicalstaffcodeof conduct.pdf (accessed 1/21/2010).

2. ECRI. Healthcare Risk Control. Executive Summary. Medical Staff 8. Supplement A. March 2009 Disruptive Practitioner Behavior.

3. Weber, DO. Poll results: Doctors’ disruptive behavior  disturbs physician leaders. The Physician Executive 2004: 30 (4) 6-14. (2004). Available on the ACPE Web site athttp://net.acpe.org/resources/publications/OnTarget DisruptivePhysician.pdf (accessed 1/18/2010).

4. Joint Commission. Sentinel Event Alert. Issue 40, July 9, 2008. Behaviors that undermine a culture of safety. Available on the Joint Commission Web site at http://www.jointcommission.org/SentinelEvents/

Sentineleventalert/sea_40.htm (accessed1/21/2010).

5. California Medical Association (CMA). Disruptive Behavior Involving Members of the Medical Staff. CMA On-Call Document #1241. January 2009. Available on the CMA website at www.cmanet.org (accessed 1/21/2010).

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