Overview

Unprofessional or Disruptive Behavior

Impact on Patient Care, Medical Errors, Working and Learning Environments

American Association of Veterinary CliniciansMarch 29, 2012

Overview

• Definitions

• Scope of the problem

• Why has this persisted

• What can be done

Disruptive Behavior What is it? Why Does it Matter?

• Any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment that harms or intimidates others to the extent that quality of care or patient safety could be compromised (American Medical Association)

• Joint Commission has replaced “disruptive behavior” with “behavior(s) that undermine a culture of safety”

• Shown to have negative impact on work relationships, team collaboration, communication efficiency, and process flow.

Verbal outbursts and physical threats. Refusing to perform assignments, uncooperative attitudes, refusal to answer questions, return phone calls or pages, condescending language.

A style of interaction with other physicians, hospital personnel, students, patients or family members that interferes with patient care or adversely affects the health care team’s ability to work effectively.

3-5% persistent

Awareness of Appropriate Professional Behavior

Not new or restricted to health professions

AAUP Statement on Professional Ethics (1966, 1987)

Professors…..• avoid any exploitation, harassment, or

discriminatory treatment of students• do not discriminate against or harass

colleagues. • show due respect for the opinions of others

Why Is It Important?

• Affects patient care, teaching, teamwork, staff morale, patient satisfaction, staff and turnover

• It’s the law

Civil Rights Act of 1964 states that treating anyone in the workplace in a demeaning and disrespectful manner is a form of discrimination under federal law

• 2002 – first studies documenting impact of disruptive behavior on nurse satisfaction and retention

• 2008 Joint Commission Sentinel Event Alert• Intimidating/disruptive behavior fosters medical

errors, contributes to poor patient satisfaction and preventable adverse outcomes, increases cost of care, increases turnover of staff seeking more professional environments.

• 2009 new accreditation standard requiring hospitals to address disruptive/inappropriate behavior

• Rosenstein & O’Daniel (2008)• >4,500 respondents (2,846 nurses, 944

physicians, 700 other, 40 administrators from 102 hospitals)

• 51% of physicians and 88% of nurses reported disruptive behavior by physicians

• 73% of nurses and 48% of physicians reported disruptive behavior by nurses

Responses to disruptive behavior• 95% reported feeling stressed or frustrated• 95% felt levels of communication were

reduced• 89% felt information transfer was

compromised• 92% felt that team collaboration was affected• 85% felt ability to concentrate was affected

Perceived link between disruptive behavior and adverse patient outcomes

• 66% adverse events• 71% medical errors• 53% compromise in patient safety• 72% detrimental effect on quality of care• 75% poor staff satisfaction• 25% patient mortality

Disruptive behavior affects patient satisfaction, hospital reputation, and quality ratings.

Patients who witness disruptive events or encounter unprofessional behavior more likely to express negative response on patient satisfaction surveys and tell others.

Strong correlation between poor communication, patient satisfaction, physician incident reports and the inclination to sue.

Scope of the Problem

American College of Physician Executives Survey (2009) (n > 2,000)

Does your health care organization ever experience behavior problems with doctors and nurses

Generally speaking how often do behavior problems arise between doctors and nurses at your health care organization

Scope of the Problem

American College of Physician Executives Survey (2009)

Does your health care organization ever experience behavior problems with doctors and nurses 97.4%

Generally speaking how often do behavior problems arise between doctors and nurses at your health care organization

Daily 9.5%, Weekly 30.6%, Monthly 25.6%

Importance of addressing factors that affect patient care (Milliman 2008)

• Estimated1.5 million medical errors – average cost $13,000 ($19.5 billion)

• 1.5 million preventable drug events - $2,000 to $5,800. Institute for Safe Medication Practices estimates 7% of drug errors due to provider intimidation.

• 10% of surgical malpractice claims ($345K) traced to inadequate surgical team communication contributing to patient error.

Financial impact of disruptive behavior

• Replacement of staff – estimated $60 - $100K to replace a nurse

• Adverse events• Medication error $2,000-$6,000• Hospital acquired infection $20K - $38.5K• DVT $36,500

• Malpractice suit - $521,000 (mean cost of medical error-based claim)

Predicting Risk

Importance for the practitioner and the hospital

Hickson – patient complaints can identify doctors with interpersonal problems and predict the likelihood of malpractice litigation

Doctors with >4 complaints in 6 year period were 16 times more likely to have >2 risk management files opened than those with no complaints

Why has this persisted?

In the past this has been ignored, tolerated, excused, reinforced, or not reported.

Common assumptions:That’s the way it has always beenWho will listenI don’t want to make waves or get in troubleI can take itDr. X is important to the organization because

(rank/expertise/revenue) which outweighs the impact of his behavior

Why has this Persisted?

Organizational Reluctance• Cultural inertia• History of tolerance• Code of Silence• Fear of antagonistic physician reaction• Organizational hierarchy• Conflicts of interest• Lack of organizational commitment• Ineffective structure or policies• Inadequate intervention skills

Risk of Nonaction

• Negative staff satisfaction and morale• Staff turnover• Compromises in patient safety• Joint Commission noncompliance• Negative hospital reputation• Decreased patient satisfaction• Increased liability and malpractice exposure• Financial loss secondary to reimbursement

penalties for adverse events

• Clinical or technical competence or excellence is necessary but not sufficient, and cannot excuse unprofessional or disruptive behavior

• We all work in teams (clinical, educational and research)

• Disruptive behavior leads to stress, anger, anxiety and frustration within the team that leads to poor communication

• Joint Commission estimates that 70% of sentinel events due to errors in communication

What can be done?

Socio-cultural norms and expectations have changed. AAMC has made it clear that behaviors that were previously tolerated are no longer acceptable. Sanctions to organizations that do not have appropriate processes to deal with professionalism/behavioral issues

Addressing Disruptive Behavior

• Organizational Culture• Leadership commitment, assessment,

structure• Recognition, awareness, education

• Diversity, sensitivity, stress management, conflict management, assertiveness

• Collaboration/Communication tools• Relationship building• Policies and Procedures• Reporting mechanisms• Intervention (pre, concurrent, post)

Essential Elements

Cultural values that emphasize professionalism

Institutional willingness to address issues with a values first proposition

Institutional policies and procedures that allow an organizational response to disruptive behavior

Establishing the Ground Rules

Defining the expected:

Examples of Appropriate Behavior• Criticism communicated in a reasonable

manner with the aim of improving patient care and safety

• Expressions of dissatisfaction with policies through appropriate grievance channels

• Use of cooperative approach to problem resolution

Establishing the Ground Rules

Defining the unacceptable

Inappropriate behavior means conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated, inappropriate behavior can become a form of harrassment and thereby become disruptive, and subject to treatment as “disruptive behavior”.

Establishing the Ground Rules

Examples of inappropriate behaviorBelittling or berating statements

Name calling

Use of profanity of disrespectful language

Inappropriate comments in the medical record

Failure to respond to patient care needs/requests

Sarcasm or cynicism

Deliberate lack of cooperation

Refusal to return phone calls, pages, messages

Condescending language, degrading comments

Establishing the Ground Rules

Disruptive behavior means any abusive conduct including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.

Concrete Steps

Identification of disruptive individuals

• Appropriate reporting channels and a zero tolerance culture, establish a safe mechanism for people to report

• Review patient complaints, 360 reviews

• Look for and address trends (repeat offenders, units)

Concrete Steps

Develop a process to address disruptive behavior in hospital & medical staff bylaws• Verification of complaints• Include non-retaliation clause to reduce

fear of retribution• Assess risk of harm to patients• Notification and due process

Concrete Steps

Willingness to have the difficult/crucial conversation• Focus on the behavior (don’t get

distracted by discussion of the precipitating event

• Sooner rather than later• Careful documentation• Proportional response

Progressive Intervention

Informal intervention/education

Identify the underlying issues

Suspension of privileges

Referral to “physicians health” committee

Disciplinary hearing

Faculty complaint process

Referral to state board

Summary

• Establish a code of conduct

• Identify the origins of disruptive behavior and work on solutions

• Interventions should be applied consistently and equally• Outcomes

Improved teamwork and staff satisfaction

Improved patient care and safety