Disruptive Behavior In The Workplace Behaviors that undermine a culture of safety and quality Martha E. Brown, MD PRN Associate Medical Director And UF Associate Professor of Psychiatry Addiction Medicine Division William Swiggart, MS, LPC/MHSP Associate in Medicine Co-Director Vanderbilt Center for Professional Health www.mc.vanderbilt.edu/cph
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Martha E. Brown, MD PRN Associate Medical Director And UF Associate Professor of Psychiatry Addiction Medicine Division William Swiggart, MS, LPC/MHSP.
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Disruptive Behavior In The Workplace
Behaviors that undermine a culture of safety and quality
Martha E. Brown, MD
PRN Associate Medical Director
And
UF Associate Professor of Psychiatry
Addiction Medicine Division
William Swiggart, MS, LPC/MHSPAssociate in Medicine
Co-DirectorVanderbilt Center for Professional Health
disruptive/distressed behaviorProvide resources and
examples of interventions.
Goals
Describe the Joint Commission requirements List examples of disruptive behavior Estimate the impact of disruptive behavior Explore the etiology of disruptive behavior Discuss the components of a comprehensive
evaluation Apply specific educational approaches Identify some appropriate resources
“Physicians are often poorly socialized and enter medical school with inadequate
social skills for practice.”
“There is a growing body of literature documenting that residency programs do
not prepare resident physicians adequately for the practice of medicine.”
Defined disruptive behavior as a Sentinel Event Recognition that disruptive behavior can:
Foster medical errors Contribute to poor patient satisfaction Contribute to preventable adverse outcomes Increase the cost of care (including malpractice) Lead to turnover/loss of qualified medical staff
Joint Commission, Issue 40July 9, 2008
Defined by The Joint Commission as:
“Any unanticipated event in a healthcare setting resulting in death or serious physical injury or psychological injury to a person or persons not related to the natural course of the patient’s illness.”
Sentinel Events
Goal of including Disruptive Behavior as a Sentinel Event:
Reform health care settings to address the problem
There is a history of tolerance and indifference Promote a culture of safety Improve the quality of patient care by improving
the communication and collaboration of health care teams
Joint Commission
Hospitals establish a formal Code of Conduct Leadership creates a process for reporting,
evaluating and managing disruptive behavior
Joint Commission Requirements
Educate all team members about
professionalism Hold all team members accountable for
modeling desirable behaviors Enforce the code consistently and equitably Non-confrontational intervention strategies Progressive discipline
Joint Commission Recommendations
Disruptive behavior includes, but is not limited to, words or actions that:
Prevent or interfere w/an individual’s or group’s work, academic performance, or ability to achieve intended outcomes (e.g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution)
Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e.g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating)
Threaten personal or group safety, such as aggressive or violent physical actions
Behavior or behaviors that undermine a culture of safety Violate Vanderbilt University and/or VUMC policies, including those
related to conflicts of interest and compliance
Definition of Disruptive Behavior
Vanderbilt University and Medical Center Policy #HR-027,
2010
An occasional “out of character” reaction of an
individual Lack of perfectionism. No one is perfect Constructive criticism in good faith with the aim of
improving patient care or education Expressions of concern about a patient’s care and
safety Expressions of dissatisfaction with policies through
appropriate grievance channels or other non-personal means
Disruptive Behavior Is Not
Vanderbilt University and Medical Center Policy #HR-027,
2010
Aggressive
Anger Outbursts
Profane/Disrespectful
Language
Throwing Objects
Demeaning Behavior Jokes
Physical Aggression
Sexual Comments or Harassment
Racial/Ethnic
PassiveAggressive
Derogatory comments about institution, hospital, group, etc.
Refusing to do tasks
Passive
Chronically late Alcohol and other drugs
Not responding to call
Inappropriate or inadequate chart notes
Spectrum of Disruptive Behaviors
Policies will not work if
disruptive behavior goes unreported and unaddressed.
14
DVD
Examples of disruptive behavior and a do over
Why bother dealing with disruptive behavior?
Perceptions of inequality when members of the
team compare their contributions to those of the disruptive member (Kulik & Ambrose, 1992)
Some team members will decrease their contributions, withdraw (Schroeder et al, 2003; Pearson & Porath, 2005)
Failure to Address Disruptive Conduct Leads
to:
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
Team members may adopt disruptive person’s
negative mood/anger (Dimberg & Ohman, 1996) Lessened trust among team members can lead
to lessened task performance (always monitoring disruptive person)... effects quality and patient safety (Lewicki & Bunker, 1995; Wageman, 2000)
Financial costs and litigation
Failure to Address Disruptive Conduct Leads
To:
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
High turnover
Pearson et al, 2000 found that 50% of people who were targets of disruptive behavior thought about leaving their jobs
Found that 12% of people actually quitThese results indicate a negative effect
on return on investment
Failure to Address Disruptive Conduct Leads
To:
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
Failure to Address Disruptive Conduct Leads
To: disharmony and poor morale1, staff turnover2, incomplete and dysfunctional
communication1, heightened financial risk and litigation3, reduced self-esteem among staff1, reduced public image of hospital1, financial cost1, unhealthy and dysfunctional work
environment1, and potentially poor quality of care1,2,3
1. Piper, 20002. Rosenstein, 20023. Hickson, 2002
Communication breakdown factored in OR errors
50% of the time2
Communication mishaps were associated with 30% of adverse events in OBGYN3
Communication failures contributed to 91% of adverse events involving residents4
Gerald B. Hickson, MD
James W. Pichert, PhD
Center for Patient & Professional Advocacy
Vanderbilt University School of Medicine
Disruptive Behavior Leads to Communication Problems…Communication
Problems Lead To Adverse Events1
1. Dayton et al, J Qual & Patient Saf 2007; 33:34-44. 3. White et al, Obstet Gynecol 2005; 105(5 Pt1):1031-1038.
2. Gewande et al, Surgery 2003; 133: 614-621. 4. Lingard et al, Qual Saf Health Care 2004; 13: 330-334
Why Might a Medical Professional Behave in Ways that are Disruptive?
(cont’d)
4. Poorly controlled anger/Snaps under heightened stress, perhaps due to:a. Poor clinical/administrative/systems supportb. Poor mgmt skills, dept out of controlc. Back biters create poor practice environments
5. Well, it seems to work pretty well and the system reinforces the behavior6. No one addressed it earlier (why? See #5)7. Family of origin issues—guilt and shame8. Training or poor social skills entering into medicine9.10.
“The Perfect Storm”
PhysicianHospital/Clinic
The external system
The internal system
Two Systems Interact
Good skills
Poor skills
Functional & nurturing
Dysfunctional
Systems
"Every system is perfectly designed to get the results it
gets.”
BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010
Individual Factors
Predisposing Psychological Factors (1) Alcohol and Drug Family History Trauma History Religious Fundamentalism Familial High Achievement, lack of skills regarding conflict
and negotiation and other family of origin patterns Personality Traits (2)
Narcissism Obsessive/Compulsive
Physician Burnout (3) Clinical Skills Satisfactory or Above Average (4)
Scapegoats System Reinforces Behavior Individual Pathology may over-shadow
institutional pathology
Etiologies
Williams and Williams, 2004
The role of a comprehensive evaluation The importance of consequences Educational programs Feedback from colleagues, patients, staff, etc. Monitoring and accountability External resources
Methods to Address Behavioral Problems
Clinical Approaches To The Disruptive
Professional
Confirm facts Immediately talk with the professional and discuss
that what happened was not appropriate Obtain assurances the behavior will not reoccur Complete a record of the incident and conversation
for the personnel file Closely follow up and monitor their behavior Do not be intimidated by threats of legal action
What to do? (Protocol for all cases)
First time incident of disruptive behavior that is
relatively “mild” and not egregious (i.e., routinely failing to complete records in a timely manner affecting patient care, being chronically late, or not answering pages) might be handled by executive committee
CME course should be mandated in most cases (MD should allow committee to talk with CME staff)
Mentoring of professional Behavior closely watched by executive committee
Step-wise Protocol for Handling Disruption
Originally developed at the Vanderbilt Center for
Professional Health (now offered at Vanderbilt, University of Florida, and Professional Renewal Center)
Designed to address the specific needs of professionals whose workplace conduct has become problematic, but
not risen to the point of a formal referral 3 days with 1 day follow-ups at 1, 3, and 6 months
CME Program for Distressed Physicians
Repeated behavior that disrupts healthcare system or
if 1st incident particularly egregious (throwing objects, continual/demeaning language such as profanity/sexual comments) must be addressed more formally
Call your PHP to discuss whether formal assessment is warranted or if referral to CME might be sufficient in lieu of a more formal report to the PHP at this time
Brief contract outlining expectations/requirements should be signed by professional (include written permission to talk with CME staff or PHP)
Step-wise Protocol for Handling Disruption
If behavior reaches a level that there is an
immediate risk of harm to patients or staff, then a more formal procedure needs to happen
The professional should be directed to contact their PHP immediately
Strong consideration should be given to suspension of privileges until the PHP deems the professional safe to practice again
This type of behavior usually results in a comprehensive residential evaluation and treatment
Step-wise Protocol for Handling Disruption
Professional will be sent to a program that specializes in
evaluating disruptive professionals Multidisciplinary evaluation lasting 1-5 days
Medical workup Psychiatric/substance abuse evaluation Psychosocial information including genogram Neuropsychological testing Collateral information
Comprehensive report results with recommendations by evaluation team which may include Outpatient treatment Residential treatment Long-term psychotherapy 360 evaluations
Comprehensive Evaluation
CME Program for Distressed Physicians
Components:Phone interviewThree-day CME course (47.5 AMA PRA
Category 1 Credits ™)Teach Specific tools/skills - e.g., grounding
skills, Alter, communication strategiesThree follow-up sessions with the core group
over the next six months; importance of group process
Teach specific skills related to preventing disruptive
behavior Promote peer accountability and support Identify risk factors and prevention strategies Understand their own behavior and how it affects
others Discuss healthy boundaries and appropriate
expression of emotions Understand socialization of professionals learned in
training that contributes to maladaptive patterns This is NOT treatment, but rather education
CME Course Goals
Let’s practice
Flooding*“ This means you feel so stressed that you become emotionally and physically overwhelmed…”
“Pounding heart, sweaty hands, and shallow breathing.”
“When you’re in this state of mind…you are not capable of hearing new information or accepting influence.”
*John M. Gottman, Ph.D. The Relationship Cure, Crown Publishers, New York, 2001, 74-78.
SELF-TEST: FLOODING 1. At times, when I get angry I feel confused. Yes No 2. My discussions get far too heated. Yes No 3. I have a hard time calming down when I discuss disagreements. Yes No 4. I’m worried that I will say something I will regret. Yes No 5. I get far more upset than is necessary. Yes No 6. After a conflict I want to keep away or isolate for a while. Yes No 7. There’s no need to raise my voice the way I do in a discussion. Yes No
8. It really is overwhelming when a conflict gets going. Yes No 9. I can’t think straight when I get so negative. Yes No 10. I think, “Why can’t we talk things out logically?” Yes No
John M. Gottman, All Rights Reserved (revised 11/17/03)
11. My negative moods come out of nowhere. Yes No 12. When my temper gets going there is no stopping it. Yes No 13. I feel cold and empty after a conflict. Yes No 14. When there is so much negativity I have difficulty focusing my thoughts. Yes No 15. Small issues suddenly become big ones for no apparent reason. Yes No 16. I can never seem to soothe myself after a conflict. Yes No 17. Sometimes I think that my moods are just crazy. Yes No 18. Things get out of hand quickly in discussions. Yes No 19. My feelings are very easily hurt Yes No
20. When I get negative, stopping it is like trying to stop an oncoming truck. Yes No 21. My negativity drags me down. Yes No 22. I feel disorganized by all this negative emotion. Yes No 23. I can never tell when a blowup is going to happen. Yes No 24. When I have a conflict it takes a very long time before I feel at ease again. Yes No
Scoring: If you answered “yes” to more than eight statements, this is a strong sign that you are prone to feeling flooded during conflict. Because this state can be harmful to you, it’s important to let others know how you are feeling. The antidote to flooding is to practice soothing yourself. There are four secrets of soothing yourself: breathing, relaxation, heaviness, and warmth. The first secret is to get control of your breathing. When you are getting flooded, you will find yourself either holding your breath a lot or breathing shallowly. Change your breathing so it is even and you take deep regular breaths. Take your time inhaling and exhaling. The second secret is to find areas of tension in your body and first tense and then relax these muscle groups. First, examine your face, particularly your forehead and jaw, then your neck, shoulders, arms, and back. Let the tension flow out and start feeling heavy. The secret is to meditate, focusing your attention on one calming vision or idea. It can be a very specific place you go to that was once a very comforting place, like a forest or a beach. Imagine this place as vividly as you can as you calm yourself down. The fourth part is to imagine the body part becoming warm.
Flooding - Scoring
John M. Gottman, All Rights Reserved (revised 11/17/03)
GROUNDING
Categories exercise Judge versus describe Mindfulness with all senses Breathe
SKILLS TO USE WHEN FLOODING
Describe an incident you are concerned about.
Who was there?Pick someone to play you.A powerful cathartic exercise viewing their
behavior from multiple points of view.Example.
Role Play Exercise
When asking for something, use the
acronym DRAN
DescribeReinforce
AssertNegotiate
ASSERTIVE COMMUNICATION GUIDELINES
Describe the other person’s behavior objectively Use concrete terms Describe a specified time, place & frequency of
action Describe the action, not the “motive”
Describe
Recognize the other person’s past efforts
Reinforce
Express your feelings Express them calmly State feelings in a positive manner Direct yourself to the offending behavior, not
the entire person’s character Ask explicitly for change in the other person’s
behavior
Assert Directly & Specifically
Request a small change at first Take into account whether the person can meet
you needs or goals Specify behaviors you are willing to change Make consequences explicit Reward positive changes
Negotiate: Work Towards A Compromise That is
Reasonable
The 8:1 Ratio
Communication
*John M. Gottman, Ph.D. The Relationship Cure, Crown Publishers, New York, 2001, 74-78.
It is not enough to have good motives;
others respond to our behavior.
Physicians are often not given essential feedback about their behavior.
The Team Behavior Survey (B-29) is designed to provide feedback from those we work with.
If the physician is returned to the institution to practice, it is necessary to ensure that the behavior does not recur. There is a significant level of recidivism As high as 20% among “severe offenders”
(Grant and Alfred 2007) Prior behavioral issues are a significant risk
factor for later disruption (Papadakis, Arnold, et. al. 2008)
BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010
Disruptive behavior Social Systems
A monitoring system that measures these issues using a 360◦ survey.
Early data show the survey to be valid.
The survey was developed to facilitate integration with institutional systems.
BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010
Communication Concern for patients and families Accessibility and timeliness Work environment Ethical behavior Interpersonal behavior & respect for others System-based practice Ability to work with other members of the
medical team
The Survey is Based on the Core Competencies of the
State BME Professional Societies QI Officers EAP Others State Physician Health
Program
There is a need to develop standard, model policies for
hospitals and medical practices Medical student and resident training cultivates many of
the disruptive behaviors, as trainees learn from their mentor’s behavior
Many physicians and other professionals come to training “predisposed” to having problems
Information needs to be widely distributed to hospitals and medical practices that this is treatable, saves money, prevents malpractice suits, and that early intervention is best
Disruptive behavior is a patient safety issue and needs to be quickly addressed