Peer review and quality improvement professionals often are faced with difficult physicians — the ones who generate more than their fair share of complaints from both patients and staff. They also receive poor reviews and drag down the facility’s overall satisfaction scores. And similar trouble comes from a unit within the hospital that just does not seem to want to comply with a quality or safety directive that everyone else is following.
Dealing with such a physician or group is always a difficult proposition. That is especially so when, for example, a doctor is a high revenue generator, a leader in a specialty, or otherwise powerful and important to the organization. And how do you get staff to comply with directives without singling out individuals for discipline?
Accountability is key, even though there has been a movement away from holding individuals accountable in favor of redesigning systems to encourage the desired behavior, says Gerald B. Hickson, MD, senior vice president for quality, safety, and risk prevention at Vanderbilt University Medical Center in Nashville. He also holds the Joseph C. Ross Chair in Medical Education and Administration.
Rude or abusive physicians must be managed affirmatively no matter how much cachet or power they have within the hospital, Hickson says. Vanderbilt uses a program that addresses disruptive physician behavior in an escalating fashion, and he says it must be employed without regard to the doctor’s position in the hierarchy.
Accountability, Not Blame
Dealing with dysfunctional systems requires returning the right amount of professional accountability to the healthcare environment, but without returning to the unproductive approach of past decades, Hickson says. No one wants to go back to the old way of shaming and blaming individuals for every error, he says, but there must be accountability for disruptive and abusive behavior.
“If you focus only on intentionally designed systems without pairing it with professional accountability, you get a lot of discussions that don’t go anywhere,” he says. “We can all agree that washing hands is a good thing, but just saying that doesn’t make people wash their hands. At some point you have to hold people accountable.”
Hickson recalls how a unit at Vanderbilt was not compliant with handwashing expectations, and when called to task, staff said conditions on the unit were not conducive to good hand hygiene. He agreed that they could not be held responsible if the hospital did not provide adequate conditions for good hygiene, so the hospital improved the work area in the way the staff asked.
“After we made all of those improvements, to their specifications, their performance didn’t improve a bit,” he says. “We can spend a lot of time as quality and safety officers fixing things that need to be fixed, but it must be coupled with a clear, unambiguous declaration that we expect our members to do every time. Unless you have people, process, and technology aligned to help you with professional accountability, your safety program cannot move forward because of the influence of a very small number of people who decide these things don’t apply to them.”
Make Expectations Clear
That reasoning can be applied to a number of quality and safety efforts — everything from handwashing and timeout compliance to physician interactions with staff and patients, he says.
“If you don’t have a plan for dealing with the subset of people who don’t comply with expectations, it is hard for everyone else to maintain high reliability,” he says. “I don’t want us to return to the old days of shame and blame, but once leadership effectively embraces the need for improvement and fixes those things, then my expectation is that you’re going to wash your hands. Every time, not just when you feel like it.”
Whether the unacceptable behavior is poor hand hygiene or a physician who is verbally abusive to staff, hospital leadership must engage the problem head-on and make clear that such behavior is not acceptable, Hickson says. Once the organization makes the proper behavior possible by providing the necessary resources and processes, it is reasonable to expect compliance with your expectations, he says.
“Some of the best interventions come from people who are manning a desk somewhere but realize they are part of the safety team. If they see someone engaged in behavior that is not appropriate, they interact in a socially appropriate way,” Hickson says. “That means you never embarrass, never humiliate, but you do let them know that there was an opportunity missed to do the right thing.”
Choose Battles Wisely
At the same time, however, Hickson says healthcare leaders must remember that physicians and staff work in an inherently stressful environment and not come down hard on them for every momentary lack of performance.
Conversations about problem behavior should acknowledge that stress, note appreciation for how much the physician or staff members get right, and stress that the goal is to avoid a pattern of this unacceptable behavior, he suggests.
“It’s about providing input early and often. When we see lapses, don’t wait until everybody understands that this physician is problematic,” Hickson says. “Engage that person early, and leadership must do this in a consistent way so that it is clear nobody gets a pass.”
That consistent application of expectations and consequences can falter when the disruptive physician is a high revenue generator, or someone who wields a lot of power and influence for various reasons, Hickson says. That is when quality leaders must be steadfast in applying the same expectations as they would for any other physicians.
Otherwise, a small percentage of disruptive physicians can have an outsized effect on hospital operations, morale, turnover, outcomes, safety, and patient satisfaction, Hickson says. About 2.5% to 4% of all clinicians — physicians, nurses, and others — have difficulty being respectful to colleagues and patients, he says.
“Those same people also tend to have difficulty respecting rules and complying with expectations for behaviors,” Hickson says. “These same people can be very influential and when they decide they’re not going to do something like a timeout, then that gives others the idea that they don’t have to do it either. If nobody wants to confront that first person because he generates 24,000 RVUs a year because of the economic issue, how do you create a safety culture if the rules don’t apply to everybody?”
Cracker Thief Story
But when do you get involved? What abusive or disrespectful behavior rises to the level of needing leadership intervention? The line is not clear; rather, it is determined on a case-by-case basis regarding how much the behavior affects the work environment.
Hickson tells the story of a problem physician who was widely known for being disrespectful to others, but he was not held responsible for the behavior because he was such a high revenue generator and wielded so much clout in the organization. One of the complaints that made its way to leadership involved him eating a package of crackers that a nurse had left at her workstation.
“The cracker case was so important to us in retrospect, because of course it’s not about the crackers. How many times had this particular individual eaten someone’s crackers, and how many times had he done something equally disrespectful, or worse?” Hickson explains. “This was the incident that pushed this nurse enough to report it, but what she was really reporting was a physician who had no respect for others and was causing enough of a disruption that he affected how people did their jobs, and the safety of patients.”
Any individual’s tipping point will be different, Hickson notes. Some people are going to report the first time a physician says something snarky or grabs a cracker without asking, while others will wait a long time until they cannot stand it anymore. Still others will never report the disrespect or abuse.
Hospital leadership does not have to investigate every report of such behavior, Hickson notes. It is important to collect all information about potentially disruptive physicians or staff, he says, but only about 2% of such reports need a full investigation by the hospital.
Look for Patterns
That does not mean that you do not talk to the physician, though.
“We don’t sweat the single reports. Most of them are simply a story and there’s no way to find the truth,” Hickson says. “But we do go to the physician and say, ‘We got this report, and it doesn’t seem consistent with our core values. We know there are two sides to every story, so I’m just going to ask you to reflect on these events and I trust you to do the right thing.”
That conversation should take no more than three minutes, he says. It must be delivered by a peer, not a superior. Then you wait and see if more reports come in. Experience has shown that about 2.5% of all physicians account for about 50% of all complaints, he says.
For those physicians, Hickson says, the next conversation is different: “Dr. Smith, I need to ask you why you appear to have a pattern of this behavior.”
“That’s the stepwise approach. I don’t care whose crackers those were or why he took them,” Hickson says. “But when you accumulate a pattern of this behavior, then the evidence speaks. We code these reports according to certain themes, and in this case the complaints all pertained to a lack of respect for boundaries. That had to be addressed.”
- Gerald B. Hickson, MD, Senior Vice President for Quality, Safety & Risk Prevention; Joseph C. Ross Chair in Medical Education and Administration, Vanderbilt University Medical Center, Nashville, TN. Phone: (615) 343-8177.
