Management Of The Disruptive Doctor Essay
Management Of The Disruptive Doctor Essay
Dealing with a disruptive physician is vital to keeping the work environment healthy and happy. A breakdown of that environment could come at significant risk as staff members become at odds with one another, refusing to work with each other could result in the loss of patient lives. Managing disruptive behavior by staff and colleagues isn’t just about knowing what to do but also knowing what not to do. Often, mishandling disruptive behavior can make matters worse and lead to further conflict among physicians and employees. Management Of The Disruptive Doctor Essay. Therefore, I have decided to follow the recommendations provided by the joint commission on their website to curb the behavior of this difficult physician.
The American Medical Association defines disruptive behavior as personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care. If bad behavior goes unchecked, it can jeopardize the future of a practice as tolerating the inappropriate behavior can increase the likelihood the practice will be sued or that a charge will be filed with the Equal Employment Opportunity Commission by the abused employees. Creating and implementing a code of conduct policy throughout the office would be my first intervention method and I would hold an open platform staff meeting introducing the new policy to not only get the staff on board with it but hear out their questions, comments or concerns regarding the topic.
Additionally, the meeting would serve as clarification as to what is considered disruptive behavior as well as comforting the abused and reassuring them their complaints have no gone unnoticed. Addressing the concerns in such a public matter, I believe would aide me in the confrontation process with the physician. He would not feel blindsided with the private counseling session I would give him. I often avoid confrontation as it makes me uncomfortable and I lack the ability to be affective with it. As such, I would enlist the assistance of a liaison such as another physician at the facility and empower the physician to speak on behalf of the practice. When the meeting with the disruptive doctor is scheduled, it would be clear that the liaison has the authority to speak on behalf of the practice. Conducting the meeting in a private, comfortable, professional setting reduces the tension as much as possible to encourage a positive dialogue. It is my objective to do everything possible to make this a problem-solving experience. I would also prepare an outline of points I want to cover. Sticking to a script avoids getting pulled into an argument. Additionally, I would have copies of the code of conduct and any written policies or rules that apply to the situation present for reference. It is important to get to the root cause of the behavior, often the physician may not even be aware of these outbursts have a negative impact on the work environment. Giving the disruptive doctor a chance to explain his version of events may allow him the opportunity to take responsibility for his actions and develop a level of trust between us.
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Also, asking him how he could’ve handled the situation differently provides perspective on how his actions may have been harmful to his coworkers.Management Of The Disruptive Doctor Essay. I think running team building exercises would be useful toward building meaningful and respectful work relationships between all members of staff. I also think it would be beneficial to conduct training exercises on how to deal with codes of misconducts and their resolutions, so employees would know how to handle them.
In this scenario, the physician would be put on a verbal warning complete with a counseling session. His behavior may stem from other reasons, so I would provide him with information regarding resources to curb that behavior such as anger management and stress relief seminars. Any additional complaints of this doctor would escalate into a written warning and if still the situation persisted, a mandatory anger management seminar would have to be attended followed by termination proceedings if the behavior persists.
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. Management Of The Disruptive Doctor Essay. 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.
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? Management Of The Disruptive Doctor Essay.
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]. Management Of The Disruptive Doctor Essay. 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 Table11 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. Management Of The Disruptive Doctor Essay. 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. Management Of The Disruptive Doctor Essay.
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 Table22 lists a number of different “costs” that may result from inaction.
In our last column, we published the results of an Institute for Safe Medication Practices (ISMP) survey, which clearly exposed health care’s continued tolerance of and indifference to disrespectful behavior.1 Widespread disrespectful behavior in health care persists unchecked and is found at all levels of the organization and among all disciplines of staff. The stubborn strength of this problem lies in its quiet ability to undermine critical conversations.2 In Part 2, we delve into the impact of disrespectful behavior, why it arises and persists, and how to address it. Management Of The Disruptive Doctor Essay.
Impact of Disrespectful Behavior
Disrespectful behavior chills communication and collaboration, undercuts individual contributions to care, undermines staff morale, increases staff resignations and absenteeism, creates an unhealthy or hostile work environment, causes some to abandon their profession, and ultimately harms patients. These behaviors have been linked to adverse events, medical errors, compromises in patient safety, and even patient mortality.3,4 Disrespect causes the recipient to experience fear, anger, shame, confusion, uncertainty, isolation, self-doubt, depression, and a whole host of physical ailments, such as insomnia, fatigue, nausea, and hyper tension.5 These feelings diminish a person’s ability to think clearly, make sound judgments, and speak up regarding questions or concerns. Disrespectful behavior is also at the root of difficulties encountered in developing team-based approaches to improving care.5 Patient confidence has also been undermined by disrespectful behaviors, making patients less likely to ask questions or provide important information.
Why Disrespectful Behavior Arises
Disrespectful behavior can arise in any health care setting, and both the stressful nature of the environment and human nature play roles in this destructive behavior. We are driven to function in “survival” mode when forced to cope with difficult personal frustrations and system failures. Disrespectful behavior is often “survival” behavior gone awry.2 Although personal frustrations and system failures do not excuse disrespectful behavior, they often create a tipping point by which an individual is pushed over the edge into full-blown disrespectful behavior. Management Of The Disruptive Doctor Essay. Characteristics of the individual, such as insecurity, anxiety, depression, aggressiveness, and narcissism, can also kick in and serve as a form of self-protection against feelings of inadequacy.5 Cultural, generational, and gender biases, and current events influencing mood, attitude, and actions, also contribute to disrespectful behavior.4
Differences in communication styles and power dynamics can also play a role.5,6 For example, physicians may get frustrated when nurses present information in more detail than they believe is necessary. Nurses may get frustrated when physicians do not seem interested in the information provided. These differences in communication styles can lead to disrespectful behavior. The hierarchical nature of health care and a sense of privilege and status can lead those at the top of a hierarchy to treat others lower on the hierarchy with disrespect.
Why Disrespectful Behavior Persists
Health care organizations have fed the problem of disrespectful behavior for years by ignoring it, thereby tacitly accepting such behaviors.2 The health care culture has permitted a certain degree of disrespect while considering this a normal style of communication.5 Studies have shown that disrespectful behaviors are tolerated most often in unfavorable work environments, but it is unclear whether poor working conditions create an environment where the behaviors are tolerated or if the dis respectful behaviors create the unfavorable environment.7,8
Organizations have largely failed to address disrespectful behavior for a variety of reasons. First, the behavior typically occurs daily but often goes un reported due to fear of retaliation and the stigma associated with “whistle blowing.” Disrespectful behaviors are difficult to measure, so without robust systems of environmental scanning to uncover the behavior, leaders may be ignorant of the problem.9 Leaders may also be unaware of the behavior if managers shield them from this information because they view it as a personal failure.9 If disrespectful behaviors are known, leaders may be reluctant to confront individuals if they are powerful or high-revenue producers, or they may not know how to handle the problem. It’s not a topic taught in training programs, so leaders may hesitate to take on a problem for which there is no obvious solution.9
Addressing Disrespectful Behavior
1. Set the Stage
Establish a steering committee of trustees, senior leaders, middle managers, physicians, pharmacists, nurses, and other staff. Have the committee educate itself about disrespectful behavior, define the behavior, list examples of the many forms it can take, and establish an action plan that specifies how to identify disrespectful behavior, respond to it, and measure the success of organizational efforts. Responsibility for addressing the problem belongs to the leaders, who need to raise awareness of the problem, inspire others to change, communicate respect as a core value, articulate their commitment to achieving it, and create a sense of urgency around doing so. Management Of The Disruptive Doctor Essay.
Establish a “no retribution” policy for those who report disrespectful behavior. This policy must be established at the very onset of organizational efforts to reduce disrespectful behaviors.
Open the dialogue about disrespectful behavior by surveying staff about the issue using surveys from ISMP (www.ismp.org/survey/disrespectful) or the Agency for Healthcare Research and Quality (www.ismp.org/sc?id=343). Incorporate questions about disrespectful behavior in safety rounds. Hold focus groups where frank discussions can be held with objective facilitators to keep the conversation productive. However uncomfortable, dialogue on this issue is crucial to the development of more effective and respectful ways of interacting with each other.
2. Establish a Code of Conduct
Create a code of conduct (or code of professionalism) that serves as a model of interdisciplinary collegial relationships (different but equal) and collaboration (mutual trust and respect that produces willing cooperation).10 Clearly articulate the standard of behavior desired as well as unacceptable behaviors—don’t assume staff know this, so be clear.9 Addressing disrespectful behavior must start with an absolute belief by all staff that no one deserves to be treated with disrespect. Management Of The Disruptive Doctor Essay. Furthermore, the code of conduct should not allow any exemptions. As long as those who generate the most revenue are excused from responsibility for their actions, the code of conduct will have little impact on anyone else’s behavior.11
3. Establish a Communication Strategy
Establish a standard, assertive communication process for health care staff who must convey important information. Stating the problem along with its rationale and a potential solution can improve assertive communication. Numerous communication techniques are available to help staff accomplish this, including:
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SBAR (www.ismp.org/sc?id=344): the person communicating the crucial information covers the situation, background, assessment, and recommendations
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D-E-S-C script (www.ismp.org/sc?id=345): Describe in objective terms what you observed, heard, or perceived; express concerns using “I” statements and nonjudgmental terminology; specify or inquire about an alternate course of action; discuss both positive and negative consequences
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TeamSTEPPS (http://teamstepps.ahrq.gov): Team Strategies and Tools to Enhance Performance and Patient Safety, an evidence-based teamwork system to improve communication and teamwork skills among health care professionals.
4. Manage Conflicts
An escalation policy must be established to manage conflicts about the safety of an order when the standard communication process fails to resolve an issue. Staff must know whom to call to aid in getting a satisfactory resolution. Be sure the process provides an avenue for resolution outside the typical chain of command in case the conflict involves a subordinate and his or her supervisor. Management Of The Disruptive Doctor Essay.
5. Establish Interventions
Develop an intervention policy that has full leadership support to consistently address disrespectful behaviors. An effective policy includes zero tolerance for disrespectful behaviors regardless of the offender’s standing in the organization, fairness to all parties, consistency in enforcement, a tiered response to infractions, a restorative process to help people change their behavior, and surveillance mechanisms.12 Levels of interventions might start with coaching and proceed to progressive discipline as warranted. The intervention policy should clearly articulate the behaviors or repeated behaviors that will be referred for disciplinary action, and how and when the disciplinary process will start.13 The focus of an intervention should be on building trust and holding staff accountable for making better behavioral choices. The importance of a prompt, predictable, and appropriate response to an alleged violation cannot be overemphasized.10 In all cases, those who report or cooperate in the investigation should be protected against retaliation.12
The intervention policy should also require addressing any system issues that amplify and perpetuate the disrespectful behavior. Common system problems include issues that affect workloads, staffing, budgeting, education, communication, hand-offs, physical hazards, and environmental stressors. Individual behaviors can also be altered through system improvements.2
6. Train Staff
Provide mandatory hospital-wide education for all staff about the impact of disrespectful behavior and appropriate professional behavior as defined by the code of conduct.12,14Provide skill-based training in communication methods, relationship building, business etiquette, behavioral techniques to confront and address disrespect, conflict resolution, assertiveness training, team training, and how to report disrespectful behaviors. Management Of The Disruptive Doctor Essay. Use role-playing, vignettes, or aggression scenarios to strengthen skills associated with assertive communication, conflict resolution, and interpersonal interactions. One health system provides leaders with a toolkit that includes talking points regarding the impact of disrespectful behavior, the code of conduct, definitions, surveys, communication/teamwork guides, key articles and intranet resources, “no retribution” policy, and a letter from the chief executive officer outlining full leadership support.9
7. Encourage Reporting/Surveillance
Implement a confidential reporting/surveillance program for detecting disruptive behavior and measuring compliance with the code of conduct. A formal reporting program and an informal process for unwritten reports should be offered, and anyone who experiences or witnesses disruptive behavior should be encouraged to report the event.13 The “no retribution” policy for reporting should be well known to staff and upheld. Periodic updates should be provided to those who make reports about addressing disrespectful behaviors, but individual details should remain confidential.
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No organization should assume that the absence of reports of disrespectful behavior means it is not occurring. Other means of surveillance to identify disrespectful behaviors should be employed, including feedback from patients and families, staff and patient surveys, focus groups, informal dialogue, peer and team evaluations, and making direct inquiries at routine intervals (e.g., during safety rounds). Management Of The Disruptive Doctor Essay.
8. Create a Positive Environment
Certain aspects of the workplace environment are key to combatting disrespect, including a fair and just culture, respectful management of serious adverse events, and transparency so staff members feel safe talking about disrespectful behavior without fear of reprisal.12 Another factor is visible leadership commitment to a respectful culture, which requires leading by example. Leaders should set the tone with an attitude of mutual respect for the contributions of all staff, remain open to questions and new ideas, and reward outstanding examples of collaborative teamwork, respectful communication, and positive interpersonal skills. Using key communication tools, such as email blasts, leaders can maintain an ongoing dialogue about respectful behaviors with the entire organization to help assure staff that leadership commitment to a respectful culture is not fleeting.2 Management Of The Disruptive Doctor Essay.
