Disruptive Behavior
ACPE Series
Perspective Coming From
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Chief of staff
Med Exec Committee
Chief Medical Officer
Board of Directors of Hospital
PD/DIO/CEO medical education and
research foundation.
ACGME Competencies
• Professionalism – 5 year ACGME
push/NAS/CLER
• (Other 5 year concentrated initiative =
Patient Safety)
– Respect, compassion, integrity, altruism
– Responsiveness to others superseding
self-interest
– Respect for patient autonomy and privacy
– Accountability to patients, society, and
profession
– Cultural sensitivity
Definitions Disruptive
Behavior - AMA
Disruptive Behavior – any abusive
conduct including sexual or other forms of
harassment, or other forms of verbal or
nonverbal conduct which harms or
intimidates others to the extent that
quality of care or patient safety could be
compromised.
Definitions Inappropriate
Behavior - AMA
• Inappropriate Behavior – conduct which
is unwarranted and is reasonably
interpreted to be demeaning and
offensive. Persistent, repeated
inappropriate behavior can become a
form of harassment and thereby
disruptive, and subject to treatment as
disruptive behavior.
Disruptive Behavior
• Any behavior which impacts the ability
of the team to achieve the intended
outcome
• Passive or aggressive
• Inadequate communication in quantity,
quality, and promptness.
Professionalism and Self-Regulation
• Professionals commit to:
– Technical and cognitive competence
• Also commit to:
– Clear and effective communication
– Modeling respect
– Being available
– Self-awareness
• Professionalism promotes teamwork
• Professionalism demands self and
group regulation.
Hickson GB et al; Balancing systems and individual accountability in a safety
culture. From Front Office to Front Line; TJC Resources; 2012:1-36
Examples
• Best to incorporate/articulate the
following four slides into policies and
physician education, so all on same
page of what constitutes disruptive
behavior.
• Otherwise open to opinion, hard to set
expectations, remediation and due
process more difficult without common
understanding.
Verbal Abuse
• Outbursts, yelling
• Exaggerated tone of
voice
• Angry tone
• Derogatory statements
• Cursing, cussing, foul
language
• Racial/ethnic slurs
Nonverbal Abuse
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Raising eyebrows
Face making
Eye rolling
Turning away
Physically excluding
another
• Physical contact
• Sexual harassment (least
remediable)
Passive Behavior
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Refusing to return phone calls
Not answering pages
Condescending language
Displaying impatience with inquiries
Not communicating complete
information
• Silence
Passive-Aggressive Behavior
• Badmouthing the organization, nursing
staff or physicians to patients or others
• Discrediting leaders
• Encouraging other practitioners to
disregard P&P
• Backstabbing
• Confidentiality breaches
• Nonparticipation/tardy
ACPE 2009
ACPE/Quantia May 2011
• Most Common
– Yelling / Profanity
– Degrading comments / Insults
– Physical Assault
– Refusing to work / cooperate together
– Spreading malicious rumors
– Refusal to follow established protocols
Disruptive Behavior
Starts Early
• 10-15% of medical
students manifest
at-risk behaviors.
• ACGME March 2011
– 10% of residents
should be culled
secondary to nonprofessional
behavior
Disruptive Behavior
• Without feedback
disruptive behaviors may
become accepted as the
norm. (ACGME (in 2011)
estimates ~10% faculty
can provide good
feedback &
accountability)
• Clinical skills increase
while professional
behavior decreases as
training progresses
Progression
• Nonprofessional behavior in med
school/residency correlates with same
in practice(ACGME 2011)
– Best predictor of future behavior is past
behavior
– Personality tests do not help in med school
screening process to predict future
disruptive physicians.
– Nor interview style during NRMP process
Constraints
• Progression from med
school to residency to
independent practice
– Role modeling – the most
impact
– Known as the unwritten
curriculum
– Diminished altruism
– Release of external
constraints a.k.a. diploma
Boundary Violations
• Sexual
– Federal State Medical Boards of U.S.
• MD-Patient sex – is a breach of the healing
covenant.
– The physician is always responsible for the
boundary violation - not the patient or
hospital employee secondary to inability to
give meaningful consent secondary to the
power imbalance.
Prevalence
Prevalence
Do you have physician disruptive
behavior in your hospital?
A. Yes
B. No
C. Don’t know
0%
Do
n’
tk
no
w
0%
No
Ye
s
0%
Prevalence
Do you have nurse/ancillary
disruptive behavior in your hospital?
A. Yes
B. No
C. Don’t know
0%
Do
n’
tk
no
w
0%
No
Ye
s
0%
Prevalence
• 3-5% of physician and nursing
population
– Rosenstein AH; Comm J Qual Patient Safety; 2008
• 2-3% are persistent disrupters and
reach the level of upper leadership
– Likely underreported
– 0.5% of physicians disciplined by state
licensing boards
Prevalence
• ACPE 2009 – 2,100 responses from MD
and nurses
– 97.4% have disruptive MDs in their hosp
– 1/3 see it weekly, 1/3 monthly, 10% daily
• ACPE/QuantiaMD May 2011(840 MD
leaders survey)
– Monthly -70%
– Daily – 10%
Incidence
• 90-97% of nurses experience verbal
abuse from physicians (Manderins and Berkey 1997)
• Survey of 4,530 nurses, physicians and
health care employees (TJC Journal on Quality and
Patient Safety, Aug 2008)
– 77% witnessed disruptive physician
behavior
– 65% witnessed disruptive nurse behavior
– 67% linked disruptive behavior to adverse
events
Do Nurses Eat Their Young?
a.k.a. Lateral Violence
• 25/26 newly hired nurses in Boston
experience LV during orientation (Griffin
2004)
• 95% of 210 of nurses experienced LV
(South Carolina survey)
• 34% of student nurses reported LV (Leiper
2005)
• 55% if 1,129 nurses witnessed LV (Nursing,
2006)
Medical Student Mistreatment
• Common: 1 in 6 med students
• 1996-2008 UCLA >50% mistreated
– Verbal and power mistreatment most
common
• Most often from residents (40%) and
clinical faculty (36%)
•
Fried, JM et al. Eradicating medical student mistreatment: A longitudinal study of
one institution’s efforts. Academic Medicine. Epub. Sept 2012;87(9)
Resident Mistreatment
1998
• 93% report at least one incident of
mistreatment.
• 53% belittled/humiliated by more senior
residents
• 63% women at least one episode
sexual harassment/discrimination.
•
Daughtery SR, et al; Learning, Satisfaction, and Mistreatment During
Medical Internship; JAMA. April 15, 1998; 279(15):1194-1999
Interns
2013
• 93% Interns
– 54% experience it 1x/mos or more
– From attendings
– From nurses OR 10.4, p < 0.001
Mullen CP, et al; Interns’ Experiences of Disruptive Behavior in an
Academic Medical Center. JGME. Mar 2013:25-30
Reporting Incidents
• Nurses – only 6% actually
report
• Physicians
– only 51% willing to report
– Only 47% comfortable to
confront
Is there more disruptive behavior in
medicine than other industries?
A. More
B. Less
C. About the same
0%
Ab
ou
tt
he
sa
m
e
ss
0%
Le
M
or
e
0%
Disruptive Behavior
• OSHA 2004
– Private Sector – 2/10,000 employees
– Nursing – 25/10,000
– Bullying is the fastest growing area of
workplace disruptive behavior.
Impact on Workplace
HR and Patient Safety Issue
• Patient dissatisfaction/increased
complaints (greater than c/o on skills)
• Nursing/Staff dissatisfaction and
turnover
• Errors/Adverse events (Patient Safety
Issue)
– Only 1% of MDs think patient care is not
impacted – ACPE/QuantiaMD May 2011
Impact on the Workplace
• Physician, manager, administration
turnover.
• Poor teamwork
• Increased litigation
• Increased cost of care
Increasing Reports
• Increased hospital employment of
physicians (HR department)
• Hostile environment claims prevention
• TJC Sentinel Event Alert 2009
• Culture of Safety Movement
The Joint Commission
Impact on Patient Safety
August, 2009 – Sentinel Event Alert
– 70% of serious medical errors secondary
to communication
– Disruptive behavior leads to impaired
communication
– Leadership to prevent disruptive behavior
– Please read this reference
Other Stressors
High intensity high stress situation
Demands for increased
efficiency and patient
numbers (hamster wheel)
Increased paper work
Decreased autonomy
Resident Hamster Wheel
Training
Vulnerable Physician
Attributes
• Autocratic training to be quick decisionmakers, authoritative, independent; now
intersecting with new model of team
work.
• Poor conflict resolution training and skill
sets. Impatience on time it takes to
resolve.
ACPE/QuantiaMD May 2011
• Top etiologies
– #1 Learned behavior -role model
– #2 Workload
• Way down the list
– Compensation – 2%
– Patient compliance – 2%
Mentalization
• Recognition that each person:
– Has unique life experiences
– Thinks subjectively
– Motivated by internal states
– Sees others’ behavior from his/her own
perspective
Mentalization
• Disruptive physicians – some lack the
ability to:
– Recognize others may perceive their
behavior differently than it was intended.
– Predict the impact of and response to their
behavior.
• May need psych eval and Tx remediate
Mentalization
• Healthcare workers/physicians don’t
come to work with the intention of being
disruptive or a barrier to effective
communication
• Combination of inadequate
mentalization, acute-phase precipitants,
and inadequate coping, communication,
conflict resolution skills.
Personality Disorder
Top diagnosis for
physicians severe
enough to be
referred on to
Centers for
Excellence
#1 Personality Trait/Disorder
Narcissism
Personality Disorders/Traits
• Most common cause for recurrent
abusers (trended).
– Narcissism
• Axis II: They bother everyone but
themselves
• If they lack insight, strongly consider a
personality disorder exists.
• Won’t change based on guilt – need to
use constraints/penalties
• Poorer prognosis
Social Model
• Gaussian curve
• Guilt vs. Penalty
• Working on guilt
angle may not
correct behavior
for up to half.
• Disruptive physicians tend to be smart
and manipulative
• Need to set boundaries/penalties and
hold firm to them.
Culture
• It’s all about culture!
• Medicine has a history of tolerance and
indifference to intimidating and
disruptive behaviors.
• What we permit, we promote
Times Change
Resistance to Change
• Cultural Inertia
– Acceptance
– 40% do not question a known intimidator
after an event
Fear of Litigation – inhibitory
Hierarchal Inhibition
Fear of retaliation
Resistance to Change
Loss of hospital revenue
– Go across town and practice/leave
community
– Potential loss of specialty service
accreditation
– Loss of referrals from physicians who
engage disruptive physician.
Litigation Minefield
Indiana Experience
• Unlike substance
abuse
• Physician is angry
coupled with
financial resources
to fight
Culture Eats Strategy for
Lunch
• Strong Board,
Administration and
Med Staff Leader
Buy-In
• Well articulated
policies/systems
TJC 2009
Leadership Standards
• Hospital to have a code of conduct
which defines acceptable, disruptive
and inappropriate behaviors
• Leaders create and implement a
process for managing disruptive and
inappropriate behaviors.
Culture
• Zero Tolerance
– Regardless of clinical specialty, seniority,
or revenue contribution.
– Incorporate into Med Staff Bylaws,
administrative policies and employment
contracts (including physicians)
Policy Content
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Describe abnormal behaviors
Channel to report behavior
Process to verify report
Confidential process to notify reported
practitioner
• Process to monitor practitioner after
intervention
• Confidentiality
• People who report ensured protection
Don’t Judge Too Quickly
• First party seems right……..until you
talk to the other side.
• Policy to include speak with physician
before finality determined.
Documentation
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Letter of Deficiencies
State proposed action
List specific deficiencies
Goals and objectives of remediation
period
• List requirements/methods of
improvement
Documentation
• List what constitutes evidence that
deficiency(s) have been remediated
successfully – clearly defined
• Assistance available to meet
requirement
• Date performance will be reviewed
(Indicate MEC/HR will also follow
monthly)
Documentation
• Decision which will be made at end of
remediation period – including
consequences of failure (probation or
termination/loss of privileges)
• “cc” to those in need to know positions
• Notice signed by practitioner
acknowledging or agreeing
• Letter at end of remediation and status
of final determination.
Corrective Action
• Vanderbilt –
disruptive pyramid
approach
• Horty Springer Incremental collegial
interaction – offers
physician leadership
3 day classes.
Corrective Action
• Coffee cup conversation (+/-)
documentation
– Brings attention to the problem – 60%
respond
– Recidivism – 2-4%
Corrective Action
• Remaining 40%
– ½ retire or move on (geographic solution)
– ½ persist in disruptive behavior and require
secondary intervention (20%)
Corrective Action
• Authority leader intervention – 20%
– Assessment and retraining (Centers of
Excellence)
– ½ - don’t respond = 10% of initial
disrupters
– Medium size hospital = 1 MD QOYear D/C
from med staff
• Remember – privileges are leased not owned
Corrective Action
– Discipline of first physician sends strong
message
– Must treat all specialties the same
regardless of revenue flow to hospital =
consistent/fair/just
Vanderbilt
Efforts to eliminate learner mistreatment
will fail until we commit to reliably address
any and all professionals who model
behaviors that undermine a culture of
safety (even VIP).
Centers of Excellence
• Vanderbilt – Program for Distressed
Physicians
• Professional Renewal Center
• Acumen Assessments
• Refer to ismanet.org
• 3-6 weeks evaluation spaced over one
year – first eval. 7-10 days
– accountability back home
• Physician’s expense $30-60K
Centers of Excellence
• MEC to receive reports and act if
physician not following through with
recommendations – similar to following
impaired physician
• Diagnosis – sometimes receive
sometimes do not.
• Physician required to maintain
appropriate behavior throughout
treatment – discipline if disruptive
behavior occurs
Critical / Crucial
Conversations
• Within 24 hours of
event preferable
• Code White
– Real time
intervention
Prevention / Resolution
• Conduct policy (Professional Behavior)
well articulated and distributed
• Well developed Bylaws and HR policies
• Education
• Raising awareness
• Role modeling
Prevention/Resolution
• Team work-collaborative
practice/training
• Crew Resource Management
TeamSTEPPS
• Structured communication/SBAR
• Conflict resolution, negotiation,
assertive communication, anger and
stress management, diversity training
• Zero tolerance
Just Culture
Disruptive behavior = individual action =
willful engagement of unsafe behavior =
discipline
ISMA
• Most greater than 50 y/o
• EHR 4-5 mos of increased stress with
acting out
• If substance impairment – ISMA first call
• If disruptive – last call
• Zero Tolerance
Commitment to Change
Statement
Summary
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Raise awareness
Organizational commitment
Zero tolerance
Policies and procedures
Project Champions
Education and training all team
members
Summary
• Code of Conduct – sign upon
employment or during credentialing
process – hold all team members
accountable to uphold
• Develop a process to address
• Establishing a surveillance and safe
reporting system (no reprisals for
reporting)
• Tiered intervention strategy
Summary
• Training individuals to deliver the
message and conflict resolution
• Good documentation
• Providing Centers of Excellence with athome accountability
Resources/References
• www.ismanet.org website
– ISMA resources/physician
assistance/resources and links for
behavioral concerns and substance abuse
issues
• www.vanderbilt.edu
(http://www.mc.vanderbilt.edu/root/vumc
.php?site=vcap)
Reference
A Complementary Approach to Promoting
Professionalism: Identifying, Measuring, and
Addressing Unprofessional Behaviors
Gerald B. Hickson, MD, James W. Pichert, PhD, Lynn
E. Webb, PhD, and Steven G. Gabbe, MD
Acad Med. 2007; 82:1040–1048
Resources/References
• Joint Commission August, 2009
Sentinel Event Alert
– http://www.jointcommission.org/sentineleve
nts/sentineleventalert/sea_40.htm
AHRQ
http://www.psnet.ahrq.gov/search.aspx?se
archStr=disruptive+behavior
Resources/References
• AHRQ
– http://www.psnet.ahrq.gov/primer.aspx?pri
merID=15
• How to Identify and Manage Problem Behaviors.
Alan H. Rosenstein, MD, MBA; Michelle O'Daniel,
MSG, MHA. AHRQ WebM&M [serial online].
December 2009
• In Conversation with…Gerald B. Hickson, MD.
AHRQ WebM&M [serial online]. December 2009
References – Disruptive Physician
Behavior
• Joint Commission August, 2009 Sentinel
Event Alert
– http://www.jointcommission.org/sentineleve
nts/sentineleventalert/sea_40.htm
– AHRQ
http://www.psnet.ahrq.gov/search.aspx?se
archStr=disruptive+behavior
• AHRQ
– http://www.psnet.ahrq.gov/primer.aspx?pri
merID=15