Physician disruptive behaviors: Five year progress report

Abstract

Disruptive behaviors in health care can have a significant adverse effect on staff interactions that can negatively impact staff satisfaction, staff performance, and patient outcomes of care. As referenced in a previously published article, the Obstetrics and Gynecology specialty is one of the service areas where these behaviors occur more frequently. Despite growing evidence of the ill effects of these types of behaviors many organizations are still having a difficult time in addressing these issues in an effective manner. Gaining a better understanding of the nature, causes, and impact of these behaviors is crucial to finding the right remedies for solution. Nobody intentionally starts the day planning to be disruptive, it’s just that things get in the way. A combination of deep seated factors related to age and gender preferences, culture and ethnicity, life experiences, and other events that help shape values, attitudes and personalities, and more external factors related to training, environmental pressures, stress and burnout, and other personal issues all contribute to the mix. Given the complexities of today’s health care environment, each person needs to recognize the importance of being held accountable for appropriate actions and behaviors that affect work relationships and care coordination that impact patient care. Early recognition, early intervention, and taking a pro-active supportive approach to improve individual behaviors will result in better relationships, less disruption, more satisfaction, and better outcomes of care.

Key Words: Disruptive behaviors; Patient safety; Patient outcomes; Staff relationships; Communication; Teamwork

Core tip: Disruptive behaviors in health care can have a significant adverse effect on staff interactions that can negatively impact staff satisfaction, staff performance, and patient outcomes of care. Disruptive incidents are more likely to occur in high risk settings such as the Obstetrical arena. Despite growing evidence of the ill effects of these types of behaviors many organizations are still having a difficult time in addressing these issues in an effective manner. Gaining a better understanding of the nature, causes, and impact of these behaviors and providing appropriate early and supportive interventions is crucial to finding the right remedies for solution.

INTRODUCTION

It’s been several years since I published a paper on the impact of disruptive behaviors in the Obstetrical setting highlighting its negative impact on staff relationships, care coordination, and patient outcomes of care[1]. Follow up reactions to the article have been very positive, but due to the nature of problem, and issues around reporting, internal organizational dynamics, and confidentiality, it’s difficult to assess valid statistics as to how this has impacted the frequency of occurrence or consequences of these episodes. There have been a number of recent reports suggesting that the problem continues despite recurring evidence linking disruptive behaviors to patient harm[2-4]. Further evidence of its continued recurrence comes from research we conducted for an upcoming article in a law journal where we found a large number of cases reaching the appeal courts for incidents related to physician disruptive behaviors. The question is, why does this continue to be an ongoing problem?

HISTORY

We first reported on the impact of physician disruptive behaviors in 2002 highlighting the types of disruptive behaviors, the frequency, the specialties most involved, and its impact on nurse satisfaction and retention[5,6]. Phase two of our research extended the scope of analysis to include the incidence of disruptive behaviors in nursing and other disciplines and its impact on behaviors affecting communication and task performance leading to medical errors and other adverse events negatively impacting patient care. Our article in The Joint Commission Journal of Quality and Patient Safety was timed with the release of the Joint Commission Sentinel Event Alert #40 and the initiation of the new Joint Commission accreditation standard requiring hospitals to have a disruptive policy in place and to provide resources for its support as one of the leadership standards for accreditation[7,8]. During our research we noted that disruptive behaviors had the greatest likelihood of occurrence in high risk settings such as Obstetrics, Surgery, and the Emergency Department, and we reported on special studies conducted specifically in these areas[1,9,10]. In actuality, disruptive behaviors can occur anytime and anywhere across the full spectrum of care with similar detrimental effects on organizational culture, patient and staff satisfaction, morale, work relationships, task accountability, care efficiency, patient safety, and quality of patient care.

PROGRESS?

We have definitely made some progress in this area. Many organizations have initiated a culture of zero tolerance for disruptive behaviors supported by setting appropriate behavioral standards described in either a code of conduct or disruptive behavior policy holding individuals accountable for their actions with set ramifications for non-compliance. Some organizations have taken a more pro-active approach in trying to reduce the incidence of disruptive behaviors by providing specific training programs in diversity management, cultural competency, emotional intelligence, conflict management and/or additional training to improve communication and team collaboration skills[11]. Programs focusing on skills taught in the airline industry (crew resource management), NASCAR (pit crew mechanics), and the nuclear power industry have shown significant benefit for team based care in Obstetrics, Surgery and Critical Care[12]. But problems still persist.

BARRIERS

Table 1 lists a number of different barriers that influence organizational effectiveness in addressing disruptive behaviors.

Table 1 Barriers.

Organizational responsiveness (code of silence)

Reluctance to act (financial/hierarchy)

Structure and process (policy/reporting)

Process review (bias/conflicts of interest)

Intervention (skill sets)

Recommended action

Physician liabilities (personality)

One of the first barriers is the issue of organizational responsiveness. This starts with organizational awareness. Many events go unnoticed or are not reported due to a hidden code of silence, an inconsistent reporting system, or fears of repercussion or retaliation for making a report. Ways to enhance organizational awareness include distributing a confidential internal survey assessment and making it safe for individuals to speak up. The second part is responsiveness. The underlying organizational culture and leadership need to develop and support a zero tolerance policy for disruptive behaviors and be willing to take the necessary steps to intervene when they occur.

A second more disturbing barrier is that of tolerance and acceptance. Many of these behaviors occur in physicians who are high revenue producers and the organization may be reluctant to confront the physician in fear of an antagonistic response and threats to bring his or her patients elsewhere. There may also be issues related to hierarchy, boundaries, or “sacred saints” leading to an unwillingness to intervene.

A third issue is that of structure and process. Do you have the right policies and procedures in place? Do you have a consistent reporting process? Do you have a standardized intervention plan where evaluation, assessment, and recommendations can be made in professional non- biased manner?

One of the key liabilities of any disruptive behavior policy is the process for event review, assessment, and follows up intervention. Some organizations may turn the issues over to the Chief Medical Officer, a Department Chair, or another delegated individual or task force, but do they have the right skills necessary to adequately assess the full situation, avoid preconceived biases or conflicts of interest, diffuse anger, resolve conflict, maintain focus on the key issues, offer support, and provide appropriate recommendations for next steps? In many cases the success of the intervention is more dependent on the effectiveness of the individual doing the intervention than the scope of the disruptive behavior described.

Probably the biggest challenge has to do in dealing with the underlying personality traits of the physician involved. Physicians are by nature very competitive, task driven, perfectionists, with very strong egocentric personalities. Medical training further accentuates the problem with its focus on gaining scientific knowledge (at the expense of developing interpersonal skills) which breeds a sense of autonomy, dominance, and need to control (at the expense of emotional sensitivity). All these factors can lead to a challenging personality who may at time be difficult to deal with.

As far as the question as to whether or not disruptive behavior will go away, recent changes in the health care environment may actually make the situation worse. Issues around Health Care Reform, changing models, metrics, and financial incentives for care, and greater accountability for performance outcomes have dramatically increased physician frustration, dissatisfaction, and levels of stress and burnout which can lead to both physical and emotional states that adversely affect attitudes and behaviors[13,14]. Recognizing these underlying issues are critically important when it comes to making appropriate recommendations for improvement.

RISKS OF NON-ACTION

Sometimes we have to deliver a wake-up call for the organization to take appropriate action. Budget issues, resource issues, and the naïve sense of “no harm done” may override thoughts and willingness for organizational time and investment. Actually, it’s quite the opposite[15]. Table 2 lists a number of different “costs” that may result from inaction.

Table 2 Risks of non-action.

Organizational morale

Recruitment and retention

Staff/patient satisfaction (HCAHPS)

Community reputation

Patient complaints/malpractice

Care efficiency (process flow/delays/utilization/productivity)

Poor compliance (documentation/metric based performance)

Communication gaps/medical errors/adverse events

HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems.

One of the most obvious impacts is on employee morale. Perceptions of working in a “toxic” non- caring work environment leads to problems with staff retention and turnover and problems in recruiting new staff. The average cost to recruit a new nurse is over $60000 and at least twice as much to recruit a new physician. Anger and frustration lead to not only staff dissatisfaction, but also filters through to patient dissatisfaction which for Medicare is a key metric affecting hospital reimbursement[16]. With the growing public focus on the effects of workplace bullying, a further consequence is a tarnished community reputation which may impact market share and contract negotiations. More extreme situations may lead to patient complaints and a higher risk of costly malpractice suits[17].

Care efficiency can also suffer. Failure to follow best practice guidelines, failure to comply with hospital policies and procedures, failure to return calls, failure to collaborate, and failure to document can lead to wasted dollars related to inappropriate utilization, waste, duplication, process delays, mistakes, and reduced reimbursement.

The most serious effects occur when these behaviors disrupt care leading to costly medical errors and adverse events[15].

RECOMMENDATIONS

The discussion above highlights opportunities for improvement which are summarized in Table 3.

Table 3 Recommendations.

Awareness and responsiveness

Address organizational culture

Solicit project champions

Develop policies and procedures

Implement a consistent reporting and review process

Follow established process

Document all interactions

Intervention with trained personnel

Prevention

Provide physician/staff education (recognition/accountability)

Provide physician training (diversity/conflict management/communication skills)

Offer physician assistance and support (coaching/counseling/behavioral intervention)

Enhance physician engagement (input/motivation/alignment/satisfaction)

Recognize efforts

The first and most obvious need is organizational awareness of what is happening and the willingness to respond. The case for inaction is inexcusable.

At the core of reaction is organizational willingness to endorse and support a culture that values staff contributions and work ethic and reinforce the importance of a positive work environment which will not tolerate inappropriate behaviors. There are many articles emphasizing the importance of organizational culture and its relationship to staff satisfaction and patient outcomes of care[18]. Soliciting the help of project champions (both clinical and non- clinical) provide an excellent opportunity to further advance organizational initiatives.

Policies and procedures need to be developed to define appropriate standards of behavior and establish a consistent process for review. The organization then needs to follow due process in how it moves forward with the intervention. Not following due process and/or lack of documentation are two key issues to be considered if subsequent legal action is initiated.

The actual intervention process is probably the most critical part of the entire process and should be conducted by individuals trained in facilitation and conflict resolution techniques. The degree of intervention will depend upon the circumstances. Many disruptive behaviors occur unknowingly by the physician. In these cases just raising awareness and discussing alternative reactions will often help them self-correct. These types of informal interventions are often described as “coffee time” discussions. For more serious and repetitive disruptive behaviors the organization needs to take a more formal approach concluding with specific recommendations of what the physician needs to do to avoid these types of behaviors in the future. Depending on the circumstances additional training in diversity management, anger management, stress management, or conflict management may be appropriate. More severe cases may require individualized coaching or counseling services. These interventions can either be conducted internally or through a variety of outside programs offered by organizations that specialize in dealing with disruptive individuals. In some cases more intense behavioral modification therapy is needed which may includes assessment of possible substance abuse. In cases where the physician is resistant to change, sanctions, suspension, or termination of privileges may be the only alternative.

The best overall strategy is prevention. Most physicians don’t plan to be disruptive, it’s just that things may get in the way. Training in emotional intelligence, communication, and team collaboration skills will help provide essential tools to improve staff relationships and lower the incidence of disruptive events. If stress and burnout is an issue providing support services through either human resources, Physician Wellness Committees, a Physician EAP (Employee Assistance Program), or through the use of outside agencies to help the physician better adjust to the pressures of today’s health care environment will ease some of their emotional liabilities.

Even better, take a proactive stance in trying to increase overall physician engagement. Take time to educate them about Health Care Reform and other current issues impacting their medical practice. Provide opportunities for discussion, listen to them, and respond to some of their needs and concerns. This can be done through discussion forums or town hall meetings, agenda items at Department meetings, or though one on one discussions[19]. Allowing physician input and participation around health care matters will increase physician alignment, engagement, satisfaction, and compliance, all of which will reduce the likelihood of a disruptive event. Be responsive to their needs and when possible offer appropriate administrative, operational, or clinical support to help ease the burden of running a demanding clinical practice.

In the end, physicians, and all staff, should be regarded as a precious resource. Show them respect, recognize and thank them for what they do, and work with them to re-invigorate their passion for providing medical care.

CONCLUSION

Disruptive behaviors can have a significant impact on patient care. Most physicians are just trying to do their job and in many cases don’t even recognize the downstream effects of inappropriate behaviors. Many of these problems occur with strong personality traits further perpetuated by medical training that results in dominant, authoritative, egocentric, demanding behaviors with little emotional intelligence about the world around them. The current changes in today’s medical environment are putting even more pressures on physicians which are increasing levels of stress and burnout that can change attitudes, perspectives, and behaviors that impact patient care. Physicians often don’t recognize that they’re under stress or what it does, and even if they do, feel like they can handle it themselves. Egos and concerns about competency and confidentiality with further limit their willingness to seek outside help. All of these issues can lead to disruptive behaviors. Yes organizations need to have policies and procedures in place to address the issue and definitely need to intervene when staff relationships and patient care may be compromised. Unfortunately, that’s the punitive approach. Better yet would be for the organizations to take a different direction by taking a more pro-active approach to gaining insight into physician concerns, providing education, training, guidance, and behavioral support, and providing additional resources to help ease the burden of medical care. We can’t leave it up to physicians to take care of themselves. Compassion and early intervention will do the job.