How to end disruptive behavior that compromises patient safety

When faced with disruptive behavior, managers at hospitals and other healthcare facilities often will brush it under the rug. They're reluctant to deal with it, says Dr. Alan Rosenstein, medical director at Physician Wellness Services, which helps doctors with performance and behavioral issues. Rosenstein has written extensively on the topic of disruptive physicians.

Failing to confront the problem allows it to grow. A 2004 study by the American College of Physician Executives found that 70 percent of respondents said most problems involved repeat offenders.

The risks of not addressing bad behavior are significant. Taking the path of least resistance and doing nothing can not only compromise a person's ability to do a job and lower staff morale, it also can potentially harm the patient. A physician could end up on TV as the target of a malpractice suit.

Since the landmark Institute of Medicine report, To Err is Human, was published in 2000, much has been said about the need for the right systems and processes to improve patient safety. While human factors deserve far more attention than they tend to receive, though, it seems that no one ever wants to talk about them.

Hospitals fail to address behavioral problems, in part, because not everyone knows what disruptive behavior is. Some physicians see disruptive behavior as physical assault, while dismissing yelling and screaming as such. Others can overreact to the latter. Ultimately, there's a fine line, especially in the case of yelling. You have to distinguish when barked out orders are warranted. Perhaps a patient's care is on the verge of being compromised and someone had to take charge.

Dangerous behavior isn't always loud, nor must it involve overtly abusive language. In fact, one passive aggressive approach is to not respond at all to questions, or to withhold important information, David Danielson told me. Danielson is senior executive vice president and chief administrative officer for Sanford Clinic, which has over 340 physicians and more than 120 clinic sites in the Upper Midwest.

When poor behavior or interpersonal skills begin to interfere with another person's ability to think or do their job, it can affect patient care. Case in point, a physician doesn't return calls, or when he does, tends to be abrupt or antagonistic. People will not want to call that physician. A nurse's reluctance to make the call to a physician about a change in a patient's condition and resulting delays could lead to a compromise patient safety. (Note: Nurses too can be chronic disruptors.)

The good news is that in most interventions, it's enough to just sit down and tell the physician what happens when they behave a certain way, said Danielson. Show them how it affects other people and patients.  Most people don't know the extent of their impact on another or downstream on patient care.

"They self correct," Rosenstein said. "When you show them the downstream effect of something bad happening to the patient, that's a wake-up call."

An informal discussion with the individual is one way to probe for underlying causes. Some offenders may be dealing with stress or burnout. Chronic offenders may benefit from stress management, anger management or diversity training. Others may need more intensive counseling, especially if something like substance abuse is involved.

Seven things organizations can do to prevent disruptive behavior from putting patient safety at risk include the following:

  • Use a mediator who has no hiring or firing authority. People will open up more. And make sure any discussion of behavior does not come off as a witch hunt.
  • Ensure your organization has a disruptive behavior policy that doctors sign upon re-credentialing.
  • Find a champion for this, perhaps the chief medical officer or VP or medical affairs. A clinical head who aims to both improve staff relations and clinical outcomes could make a difference.
  • Create a reporting mechanism and formal process for reviewing incidents.
  • Provide educational programs to define disruptive behavior and its impact. This will raise the level of awareness.
  • Offer sensitivity training, conflict management, stress management and improve overall communication skills.
  • Add more behavioral expectations to your orientations.

Even if your hospital or healthcare organization doesn't have much in place right now to discourage disruptive behavior, it's never too late to get started. It's one way to make your care more patient-centered. - Sandra