A physician who threatened to use an AK-47, a sexually harassing doctor who looked at porn on work computers and a specialist who used to cause nurses to draw straws with the loser having to interact with her. These were some of the horror stories about disruptive provider behavior that Dean White, a Texas-based consultant and former chief of the medical staff at Texas Health Harris Methodist HEB Hospital in Dallas, had shared at this week's American College of Healthcare Executives' (ACHE) annual congress in Chicago.
The Joint Commission requires that accredited institutions have a code of conduct that defines acceptable, disruptive and inappropriate behaviors. In addition, leaders must create and implement a process for managing that. Although The Joint Commission changed the elements of performance standards language from "disruptive behavior" to "behavior or behaviors that undermine the culture of safety," it's essentially the same thing by a different name, White noted. "If it quacks like a duck ..." White said Wednesday regarding the disruptive terminology.
"You have to tell them what disruptive behavior is," White said about training providers about behavior. For instance, White recalled an incident in which a physician didn't think the f-word constituted profanity, and the medical staff had to explain that such language was unacceptable in the workplace. Thus, White encouraged explicitly clarifying what is and isn't acceptable.
In another instance, a surgeon who unrelentingly asked another coworker out crossed the line when, upon her declining his advances, touched her and flipped her ponytail. "The ponytail flipping is sexual harassment," said Sarah Fontenot, adjunct professor in the department of healthcare administration at Trinity University in San Antonio. Fontenot further explained that the definitions of sexual harassment today are not what we may be used to, and the repercussions can be "horrifyingly expensive" for sexual harassment and hostile work environment cases.
"These people are on your staff," White explained. Just like the general public, the medical staff isn't immune to mental health cases, sex addicts or jerks, as evidenced by the three stories he mentioned.
White and Fontenot recommended the following:
Set expectations for professional conduct.
Introduce to your medical staff leadership first what the code of conduct will be and include it in the medical staff orientation, credentialing, general medical staff meetings, and even the newsletter so that all providers know up front what is expected. The code of conduct should include clarified expectations on:
- Intimidating, abusive or demeaning language
- Profanity, inappropriate or loud language
- Unnecessary sarcasm or cynicism
- Threats of retribution, violence or litigation
- Uncooperative, defiant approach to problems
- Degrading comments about patients, families or hospital personnel
- Refusing to abide by the medical staff bylaws, regulations and policies, including cooperation with the medical staff committees
"Publishing it and hanging it on a staff wall isn't going to do it," White said about the code of conduct. "You have to explain, explain, explain."
Create a behavior event review committee.
The behavior event review committee (BERC) consists of three medical staff officers, vice president of quality management, medical staff advisor and the director of medical staff services who meet monthly to review incident reports, unless urgent behavior incidents require immediate intervention. The BERC hears all sides of the story, has face-to-face meetings with the parties involved with written documentation, and uses a behavioral contract with the provider if disruptive conduct continues.
Consider implementing a physician health committee.
The physician health committee (PHC) includes past chiefs of staff, a medical staff advisor who serves as a liaison between BERC and PHC, and the credentials committee or another staff member or has experience handing addiction or patient safety. The PHC emphasizes discussion as a committee, evaluation and treatment to professionals, and the use of voluntary medical leave of absence.
Furthermore, White and Fontenot suggested all providers are held to the same standards, meaning no excuses for physicians who have good outcomes but are still unbearable to work with. Don't treat anyone special, they said.
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