Many of us are entertained by the antics of the irreverent misanthrope, Gregory House, on the television show, "House MD." While Dr. House's behavior makes for good television, in the real world Dr. House would likely be in violation of disruptive behavior policies in place at his hospital. Examples of disruptive behavior in a healthcare setting are:

Historically, disruptive behavior has been routinely tolerated in healthcare settings for a number of reasons, including the lack of comfort with confronting physicians with behavior problems, fear of retribution, protection of high revenue producers, and poor management skills.

 

Rather than addressing disruptive behavior problems directly, administrators may make excuses such as: "But he's such a good doctor; his patients love him!;" "She just has a surgeon's personality;" or "He just holds others to his own high standards."²

 

More recently, though, the healthcare profession has come to the realization that a physician's disruptive behaviors can undermine safety in the healthcare setting. On January 1, 2009, new requirements of the Joint Commission on the Accreditation of Healthcare Organization (JCAHO) mandated that accredited institutions implement policies addressing disruptive behaviors. JCAHO explained the necessity for these new requirements:

 

Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, healthcare organizations must address the problem of behaviors that threaten the performance of the healthcare team.⁴

 

Specifically, JCAHO requires that all accredited programs address disruptive and inappropriate behaviors in a healthcare setting by 1) having a code of conduct that defines acceptable and disruptive and inappropriate behaviors, and 2) creating and implementing a process for managing disruptive and inappropriate behaviors.⁵

 

While the need to address disruptive behavior in a healthcare setting has been recognized by the industry, implementing fair and effective policies remains a problem. As noted by Gina Porto, RN and Richard Lauve, MD in their article "Disruptive Clinician Behavior: A Persistent Threat to Patient Safety":

 

A major reason [hospital responses to disruptive behaviors] fail is that many organizations have not implemented a comprehensive and consistent plan that addresses all the pertinent issues and provides sufficient options for intervention. Instead, most hospitals have policies in place to address only the most egregious behaviors and often ignore patterns of disruptive behavior until they reach dangerous levels. In effect, organizations often provide only two alternatives for dealing with disruptive colleagues: the "fly swatter" approach [(i.e. physician to physician counseling)], … or the "sledgehammer" approach [(i.e. suspension or termination of privileges)].⁶

 

Porto and Lauve also noted the tendency for organizations to rely on impaired physician programs (for physicians with alcohol or substance abuse problems) to deal with physicians exhibiting disruptive behavior problems. Because most disruptive physicians are not impaired physicians, however, such programs often do not address the problem appropriately. Furthermore, the uneven application of behavior policies within the organization due to politics, revenues and/or power of the parties involved impedes the effectiveness of these policies as a whole.

 

While JCAHO's requirement that accredited institutions have a disruptive behavior policy is a significant step in the right direction, simply having a disruptive behavior policy will not be sufficient. Effective implementation of the policy is essential. JCAHO's "suggested actions" that follow the policy requirements provide good guidance on how an organization should implement this policy. ⁷ Additionally, the following are recommendations for implementing an effective approach to address disruptive behavior in the healthcare setting: ⁸

1) Universal Code of Conduct – An organization should draft a code of conduct that clearly defines unacceptable behaviors for physicians, hospital staff, patients, guests and vendors at the hospital. The code should include policies and procedures addressing how the organization will deal with such behavior.

2) Planned Implementation of Universal Code of Conduct – An organization must implement the code of conduct in a way that emphasizes the importance of the policy to the organization. Implementation should include training at all levels and the requirement that all participants execute a statement confirming their agreement to abide by the code of conduct.

3) Compliance Monitoring – Because people are reluctant to voluntarily report inappropriate behavior, the organization should conduct regular surveys to solicit such reports. Also hospital management should receive training on how to be vigilant about identifying code of conduct violations.

4) Non-retaliation Provisions – The organization should implement and publicize a clear policy of non-retaliation that includes severe penalties for retaliatory behavior.

5) Code Enforcement – Each instance of disruptive behavior must be investigated and documented, including interviews with both witnesses and the individual accused of the inappropriate behavior. The investigator should consider the severity of the behavior, mitigating factors, and risk of harm to patients. Hospital policies and medical staff by-laws must provide the procedures for responding to each report of disruptive behavior and the investigation of that behavior. It is imperative that code enforcement begin at the outset of a potential problem and that the code of conduct is applied in the same way to all people, regardless of their seniority, age or position within the organization.

6) Flexibility – The organization must provide the resources to properly address the situation from relatively benign measures such as mentoring and counseling to more severe actions such as suspension of privileges, depending upon the evaluation of the disruptive behavior. Flexibility in the process will not be possible unless the organization operates the policy so that everyone is treated consistently, fairly and in a timely manner.

7) Oversight Committee – A multi-disciplinary oversight committee should monitor both code implementation and individual violations of the code. Committee oversight can provide both a secondary review for fairness and also an organization-wide review to identify factors that appear to be exacerbating disruptive behaviors.⁹

 

JCAHO stated in its Sentinel Event Alert that "[o]rganizations that fail to address unprofessional behavior through formal systems are indirectly promoting it." Hospitals may no longer tolerate inappropriate behavior in a health care setting. Hospitals must now have a code of conduct and a process to implement the code of conduct. Adoption of a code of conduct will have little effect, however, unless the health care organization accepts the code at all levels, regularly monitors adherence to the code, promptly investigates potential violations of the code, and requires adherence to the code by every person who is part of the organization.

 
 

¹The Joint Commission Sentinel Event Alert, "Behaviors that undermine a culture of safety", July 9, 2008; available on-line www.jointcommission.org.SentinalEvents/SentinalEventAlert/sea_40.htm; Porto, G. and Lauve, R.: Disruptive Clinical Behavior: A persistent threat to patient safety. Patient Safety and Quality Healthcare, July/August 2006; available on-line http://www.psqh.com/julaug06/disruptive.html; Leape, Ll and Fromson, JA: Problem Doctors? Is there a system-level solution? Annals of Internal Medicine, 2006, 144:107-155.

 

² Weber, DO: Poll results: Doctors' disruptive behavior disturbs physician leaders. Physician Executive, September/October 2004, 30(5):6-14.

 

³ The Joint Commission Sentinel Event Alert, "Behaviors that undermine a culture of safety," July 9, 2008; available on-line www.jointcommission.org.SentinalEvents/SentinalEventAlert/sea_40.htm

 

⁴Id.(internal citations omitted.)

 

⁵Id.

 

⁶Porto, G. and Lauve, R.: Disruptive Clinical Behavior: A persistent threat to patient safety. Patient Safety and Quality Healthcare, July/August 2006; available on-line http://www.psqh.com/julaug06/disruptive.html.

 

⁷The Joint Commission Sentinel Event Alert, "Behaviors that undermine a culture of safety," July 9, 2008; available on-line www.jointcommission.org.SentinalEvents/SentinalEventAlert/sea_40.htm.

 

⁸Porto, G. and Lauve, R.: Disruptive Clinical Behavior: A persistent threat to patient safety. Patient Safety and Quality Healthcare, July/August 2006; available on-line http://www.psqh.com/julaug06/disruptive.html.