Disruptive Behavior Defeated

An ICU patient just didn’t look right. His heart rate was mildly elevated. His blood pressure had dropped a few points. This was before the we had 24/7 in-house coverage by an intensivist. His nurse called the surgeon. He was not on his best behavior.

“This better be good,” he said. She explained the circumstances. He asked a few questions. “Is his urine output OK?”  She responded, “Well…”

“If you call me for no reason again, I am going to have you fired!” he exclaimed, and hung up on her.

Three months later, one of the surgeon’s patients died following a routine procedure. During the subsequent root cause analysis, the team identified poor communication as a contributing factor.

The nursing staff tried to avoid calling the surgeon unless absolutely necessary. He often denied giving orders that the staff had implemented. When they called him, they used the speaker phone so a second party could witness his outbursts. They were demoralized that his behavior was not being addressed.

Disruptive Behavior Threatens Patient Safety

Patient safety addresses harm that occurs due to a breakdown in delivery of care. The proper care is ordered:

• the proper antibiotic is selected,
• the right artificial joint is installed in the appropriate way,
• the timing of the pacemaker insertion follows accepted guidelines.

But something  goes wrong in the process of care:

• a feeding tube is attached to an epidural catheter,
• hydralazine is mistakenly given instead of hydroxyzine,
• necessary home medications are missed.

Or delays in communication occur because of a culture of intimidation.

Such episodes seem to occur less frequently since the advent of hospitalists and intensivists. However, sexual harassment, intimidation, intoxication and disregarded pages still threaten patient care. So, it is advisable to have a plan to address it.

5 Steps to Confronting Disruptive Behavior

Every medical group, hospital and health system needs a plan to address unacceptable behaviors. In a fully employed physician model, human resources policies can be utilized with minor modifications. For the independent medical staff, a formal structure and process will be necessary.

Here are the 5 steps needed to protect staff and patients from disruptive behavior.

1. Create Awareness and Support

• Explain to senior management and the board that this issue must be addressed. Review sentinel events and occurrence reports. Summarize those that relate to communication problems. Include complaints to the HR department about physician behavior.
• Interview nursing staff in the surgical and obstetrics suites about inappropriate language and sexual harassment. Summarize those issues for the Medical Executive Committee or Quality Committee and generate support for the next step.

2. Perform a Patient Safety Cultural Survey

• The Agency for Healthcare Research and Quality (AHRQ) provides a survey that can be downloaded and used by hospitals. Try to get a high percentage of responses from staff and physicians in the organization. Compare and rank the responses by professional group. There will probably be evidence of abusive behavior by physicians, nurses and other professionals that should be addressed.

3. Share the Findings of the Survey with Medical Staff

• Based on the findings, propose that a Code of Behavior be adopted by the entire organization. Enlist members of the medical staff, the HR department, the executive team and board to provide input. Get the Medical Executive Committee (MEC) and the Board's approval and adoption.
• Add the Code of Behavior to the new physician orientation materials and have physicians sign off on it at reappointment time.

4. Develop a Process to Address Breeches of the Code

• Create a medical staff committee that sets specific guidelines for categorizing breeches (minor, moderate, and severe/egregious). The committee can report to Quality or Patient Safety or directly to the MEC. It should include physician leaders, with support staff from HR and nursing departments and should meet regularly.
• The committee should have representation from all of the medical staff departments. It should review reports of alleged behavioral issues by members of the medical staff.
• It will decide which events are truly disruptive, and which are simply misunderstandings. The committee will distinguish communication errors from quality issues (for example, not responding to a page from a unit when on call). And it will refer quality allegations to the appropriate committee.

5. Address Disruptive Behavior

• Minor to moderate cases can initially be addressed by inviting disruptive physicians to meet with the committee. Share the Code of Behavior with them and remind them of reason for its inception. Explain the patient safety implications of disruptive physician behaviors.
• Repeat offenders should be brought to the MEC. Lines should be drawn. For repeat offenders, escalating punishments can be invoked, such as a letter of reprimand, a 3-day suspension, a one week suspension, and expulsion from the staff. Legal counsel should be consulted to ensure consistency with bylaws and state regulations.

The Benefits

When we instituted these steps, we saw a consistent decline in the number and severity of disruptive encounters. Patient safety events related to communication errors declined. Medical staff members felt that abusive physicians were not being coddled or rewarded for their bad behaviors. Other clinical staff no longer felt they were working in a hostile environment.

What have your experiences been with disruptive behavior? Have you used a different approach?