Executive Summary
A highly publicized lawsuit and public comments by healthcare leaders have made the public and the plaintiffs’ bar more aware of the sometimes questionable behavior of OR personnel. Managers should prohibit unprofessional or disrespectful behavior during surgery.
- Creating the right culture is key to improving OR behavior.
- Misbehavior should be taken seriously, with appropriate repercussions.
- Don’t assume that you know of all OR misbehavior.
(In this first part of a two-part series, we tell you about behavior issues in the OR. In next month’s issue, we’ll provide more details about a report in the Annals of Internal Medicine, and we’ll tell you about a specific incident involving an anesthetized patient who was ridiculed.)
Imagine walking through a healthcare facility and seeing doctors and staff openly insulting patients, laughing at racist and misogynist remarks, and even making inappropriate sexual contact.
Any healthcare manager would react with fury and realize that something was seriously wrong with the facility culture and that it was creating all sorts of liability risks. That behavior would never happen openly. But is it happening in your operating rooms?
Recent cases in the news have put a spotlight on disrespectful and even abusive behavior during surgery, and those cases might lead to closer scrutiny by patients, plaintiffs’ attorneys, and regulators. That expected scrutiny means now is the time for managers to step in and put a halt to the antics that are common in some ORs.
A recent jury verdict brought attention to the issue. A Fairfax, VA, jury ordered an anesthesiologist and her practice to pay a patient $500,000 for disparaging remarks made during surgery and for entering a false diagnosis on his chart. The patient had left his smartphone recording when it was placed in the bag of patient belongings under the OR table. The case received extensive publicity, and it informed members of the public about what sometimes happens when they are unconscious. Soon after that secret was revealed, an essay in the Annals of Internal Medicine also brought attention to disrespectful behavior while patients were anesthetized, including sexual innuendo and inappropriate touching. The essay was written by a physician, and the journal editors convinced him to remain anonymous. In an accompanying editorial, the editors called the incidents in the essay “disgusting and scandalous.” They cited misogyny, disrespect, racism, and “heavy overtones of sexual assault.” (Access to the essay is available online at http://tinyurl.com/oovn85m. The cost is $32.)
Though incidents of misbehavior might be rare in the context of all surgeries performed, any occurrence is “certainly too much and completely unprofessional,” says R. Stephen Trosty, JD, MHA, ARM, CPHRM, president of Risk Management Consulting in Haslett, MI, and a past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago. Trosty has dealt with serious OR misbehavior in the past when he was the risk manager at a hospital.
Improper behavior has been a problem in ORs for years, but Trosty says the issue typically is addressed only when a particular incident comes to light or possibly in educational sessions directed at surgeons. The issue also has been addressed by various medical boards, ethics and quality improvement committees at healthcare facilities, and medical ethicists, with little success.
“Training and the telling of actual instances in which there have been lawsuits and judgments involving this type of behavior do not seem to have put a complete stop to it,” Trosty says. “This type of behavior cannot and must not be tolerated by anyone. There usually are many medical professionals in an operating room, and none of them should accept this type of behavior.”
Given the common climate in which many see the physician as the head of the operating room and the leader of the team, it might be difficult for staff members to say anything without feeling concern for their jobs, he says. “The hospital or other institution must establish a climate that makes it very clear that this type of behavior is unacceptable and will not be tolerated,” Trosty says.
Healthcare facilities must create an environment in which people don’t feel their jobs are in jeopardy if they speak up about this type of behavior. That culture can be created and maintained only with the support of top administration and medical leadership, Trosty says.
It is “unrealistic and naïve” for a manager to tackle this issue without support from the higher levels of authority, he says. The managers have “to continue to have sessions about this, not only with physicians, but with all professionals who are in the operating room. They have to stress why this is completely unacceptable behavior that cannot be accepted or tolerated,” Trosty says.
This education must be backed up by all levels of authority and responsibility within the organization, he emphasizes, or there will be a lack of compliance by those who are inclined to this type of behavior. The training and risk management sessions should include examples and instances of actual occurrences and litigation, including the judgments against the participating physicians and/or other medical professionals, Trosty advises. The risk management departments of insurance companies and medical societies might be resources for further educating physicians and staff. In addition to those groups reinforcing that this type of behavior will not be tolerated, physicians should be warned that their professional liability insurance can and usually will be cancelled if they are found guilty of this offense, Trosty notes.
“As long as this type of behavior is tolerated, if not accepted, within society, this type of behavior is likely to continue in those rare instances in which you have physicians and others who feel that they belong to the ‘good old boys club’ or that this type of behavior makes them appear to be part of the club,” Trosty says. “We’ve seen that this actually can apply to female as well as male physicians.”
The operating room has long been the one place in a facility where administrators look the other way if personnel want to create their own atmosphere, whether that is quiet and professional or loud and irreverent, but that lack of response must change, says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, a patient safety and risk management consultant with The Kicklighter Group in Tamarac, FL, and a past president of the ASHRM. By its nature, the operating room always has been a challenge for oversight, she notes.
Even if you go to the trouble of observing a procedure, the team members will be on their best behavior when the manager is present.
A manager responsible for risk management will rarely “personally observe the kind of behavior that we’re talking about,” Kicklighter says. “That means the solution is in changing the culture, not trying to personally observe and intervene.”
She suggests that managers make a concerted effort to be visible to the operating room staff by making periodic rounds to meet surgeons and OR staff members face to face, as well as holding inservices for the surgical team. That visibility will breed familiarity so that the manager doesn’t stand out so much during a drop-in visit, and it also will encourage more trust when the manager advises members of the OR team on proper decorum.
Also, when something improper happens in the operating room, the staff members will feel comfortable in reporting it to the manager, Kicklighter says.
Consider these additional steps from Mark Mayo, CASC, executive director of Golf Surgical Center in Des Plaines, IL:
- Create a culture of profession-alism during training and orientation.
- Allow any staff to comment.
- Take immediate action to address any potential inappropriate behavior so that small events don’t lead to a major violation.
Some types of inappropriate behavior, such as laughing at or ridiculing an anesthetized patient’s body, are a matter of professionalism and respect for patients, and that professionalism must flow from the facility’s culture, notes John Banja, PhD, medical ethicist at the Center for Ethics at Emory University in Atlanta.
Angry or frustrated clinicians are somewhat different, he says. They must be told that while wanting to vent about patients and work is understandable, it is not the professional thing to do, he says.
“They are going to encounter patients who hit all their buttons and make them defensive or angry, and they’re going to want to talk about it,” Banja says. “Our job is to reassure them that that reaction is perfectly normal, but complaining about it or insulting the patient while he’s lying unconscious in front of you is not an option. They will need to find other ways to deal with those frustrations.”
Recent cases show lots of bad behavior and it's not a pretty picture.
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