Disruptive physicians threaten patient safety more than you may realize
Get started now to comply with new Joint Commission rule
(Editor's note: This is the first of a two-part series on disruptive physicians. The next issue of Healthcare Risk Management will include more advice on how to address the problem.)
"Disruptive physicians" is the professional term, but you probably know them as the jerks nobody wants to work with. The ones who make people cry, the ones who frequently are the subjects of complaints to department managers and human resources. But have you cross-checked those reports with your adverse outcome reports to see if there is a connection?
You might find the same names occurring frequently on both reports, according to a recent alert from The Joint Commission, which is warning risk managers that disruptive physicians can threaten patient safety. That link is one reason The Joint Commission is introducing new standards requiring more than 15,000 accredited health care organizations to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior. The new standards take effect Jan. 1, 2009, for hospitals, nursing homes, home health agencies, laboratories, ambulatory care facilities, and behavioral health care facilities across the United States. (Editor's note: The topic is addressed in a recent Sentinel Event Alert.For the full Sentinel Event Alert,go to http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm.)
Health care leaders and caregivers have known for years that intimidating and disruptive behaviors are a serious problem. Verbal outbursts, condescending attitudes, refusal to take part in assigned duties, and physical threats all create breakdowns in the teamwork, communication, and collaboration necessary to deliver patient care. The Institute for Safe Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator. The abuse no longer should be tolerated, says Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission.
"Most health care workers do their jobs with care, compassion and professionalism," he says in a news release. "But sometimes professionalism breaks down and caregivers engage in behaviors that threaten patient safety. It is important for organizations to take a stand by clearly identifying such behaviors and refusing to tolerate them."
A national study of more than 1,700 health care professionals conducted by the American Association of Critical Care Nurses in Aliso Viejo, CA, found that 77% of nurses work with someone who is condescending, insulting, or rude, and 33% work with someone who is verbally abusive. One in five physicians report that they have seen harm come to patients as a result of hostile behavior. Less than one in 10 people who have been victims of hostile behavior speak up and address their concerns with their co-worker, according to the study. Many of the people who have been victims of hostile behavior did not address their concerns with their co-worker because they thought their co-worker would retaliate against them.
To help put an end to intimidating and disruptive behaviors among physicians, nurses, pharmacists, therapists, support staff, and administrators, the Sentinel Event Alert recommends that health care organizations take 11 specific steps. (Editor's note: For more detail on the 11 steps, go to www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm.)
Probably worse than you think
Risk managers must not underestimate the potential impact of disruptive physicians, says Alan H. Rosenstein, MD, MBA, vice president and medical director of VHA West Coast in Pleasanton, CA, who has conducted extensive research on the topic and spearheaded his health care system's response. Disruptive behavior affects patient safety because people lose focus and concentration when they are stressed by interactions with other team members and distracted by the inappropriate behavior. They may be reluctant to communicate with the abusive person, which can mean that important information is not exchanged.
The downstream effect can be the most dangerous, he says. The doctor may apologize after an abusive incident and dismiss it as just a bad day; but for weeks or months later, the staff may be reluctant to communicate or challenge the doctor on important issues.
"Most risk managers are not aware of how serious this can be. The problem has been going on for a long time, but people are reluctant to address it," Rosenstein says. "If the physician brings in a lot of patients and revenue to the hospital, people didn't want to talk to them about their behavior. Also, most places don't have a real system in place for addressing behavioral competency."
Even well-meaning risk managers may be unaware of how much disruptive physicians are undermining patient care and causing other problems, he notes. You may receive some reports of abusive behavior, but Rosenstein says there is probably much more going on than what you hear about. Disruptive behavior is much more common in high-stress areas and specialties, such as surgery, the emergency department, and obstetrics, Rosenstein says. The specialists most often cited for disruptive behavior are general surgeons, cardiovascular surgeons and cardiologists, neurosurgeons and neurologists, and orthopedists.
"In my experience, very few organizations are really doing what they need to do to address this problem," he says.
Rosenstein suggests that the first step is to understand what is really going on in your organization. An anonymous survey is the best way to find out, he says. Once you know where you stand, you can develop a plan. The overall goal should be to stop these incidents from occurring and protect patient safety, not simply to punish the abusive physicians, he says.
Risk managers should make a business case for addressing disruptive behavior, he says. Show your organization's leadership how this behavior affects the bottom line.
"The business case is that, whether you know it or not, bad things are happening to patients because of this behavior," he says. "There is a downstream effect when a physician is disruptive or abusive. The research shows that patient outcomes can be affected."
Health care physicians and staff should be educated about how bad behavior can affect patient safety, along with diversity training and cultural sensitivity. Even basic reminders about phone etiquette can be helpful, he says.
A culture change could be necessary in your organization, which will require a commitment from top leadership, Rosenstein says. Employees must feel that they can speak up when a physician is being abusive and that they will not suffer retaliation. Rosenstein also notes that, while The Joint Commission is focusing on physicians, other health care professionals can be disruptive also. For instance, some nurses can be so difficult to work with that they provoke what is then labeled disruptive behavior by the physician, he says.
Litigation is possible
In addition to the threats to patient safety and the risk of bad publicity if the abusive behavior becomes known, Rosenstein says litigation tied to disruptive behavior is on the rise. Helenemarie Blake, JD, a senior partner at the law firm of Fowler White in Miami, agrees. She points out that disruptive behavior isn't just about physicians interacting with staff and other doctors. Patients can be the target, also.
"A bad bedside manner, which can amount to disruptive behavior, tends to result in a greater amount of patient complaints and consequently a greater amount of litigation," Blake says. "Even if the behavior did not directly cause patient harm, a patient who walks away angry from the interaction finds it much easier to sue."
The growing evidence showing a connection between disruptive behavior and patient safety could be used by plaintiffs' attorneys to provide the physician's liability, Blake says. And if there is any indication that the hospital knew about the behavior like a risk manager's file cabinet full of complaints then the hospital could be held liable as well, she says.
Blake advises risk managers to develop a formal system for preventing and responding to disruptive behavior, using The Joint Commission's guidelines as a starting point. The system should focus on education and rehabilitation rather than punishment, she says. There must be an adequate system of documentation, also.
Though there should be a system of escalating intervention for repeat offenders, Blake cautions that you must be careful not to go overboard and demonize every doctor who is reported as disruptive.
"You do want to get people out of a disruptive pattern, but there is a danger in being too aggressive and coming down too hard on people because of one or two complaints. That could lead to the physician taking action against you and charging that you're compromising his or her career," Blake says. "The best plan would be a progressive course of action with warnings and increasing punishment that gives them a chance to modify their behavior."
Sources
For more information on disruptive physicians, contact:
- Helenemarie Blake, JD, Senior Partner, Fowler White Burnett, Miami. Telephone: (305) 789-9200. E-mail: [email protected].
- Alan H. Rosenstein, MD, MBA, Vice President and Medical Director, VHA West Coast, Pleasanton, CA. Telephone: (925) 730-3003. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content