Unprofessional or Disruptive Behavior
Impact on Patient Care, Medical Errors,
Working and Learning Environments
American Association of Veterinary Clinicians
March 29, 2012
Overview
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Definitions
Scope of the problem
Why has this persisted
What can be done
Disruptive Behavior
What is it? Why Does it Matter?
• Any inappropriate behavior, confrontation or conflict
ranging from verbal abuse to physical or sexual
harassment that harms or intimidates others to the
extent that quality of care or patient safety could be
compromised (American Medical Association)
• Joint Commission has replaced “disruptive behavior”
with “behavior(s) that undermine a culture of safety”
• Shown to have negative impact on work
relationships, team collaboration, communication
efficiency, and process flow.
Verbal outbursts and physical threats.
Refusing to perform assignments,
uncooperative attitudes, refusal to answer
questions, return phone calls or pages,
condescending language.
A style of interaction with other physicians,
hospital personnel, students, patients or
family members that interferes with patient
care or adversely affects the health care
team’s ability to work effectively.
3-5% persistent
Awareness of Appropriate Professional
Behavior
Not new or restricted to health professions
AAUP Statement on Professional Ethics (1966,
1987)
Professors…..
•avoid any exploitation, harassment, or
discriminatory treatment of students
• do not discriminate against or harass
colleagues.
• show due respect for the opinions of others
Why Is It Important?
• Affects patient care, teaching, teamwork,
staff morale, patient satisfaction, staff and
turnover
• It’s the law
Civil Rights Act of 1964 states that
treating anyone in the workplace in a
demeaning and disrespectful manner is a
form of discrimination under federal law
• 2002 – first studies documenting impact of
disruptive behavior on nurse satisfaction
and retention
• 2008 Joint Commission Sentinel Event Alert
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Intimidating/disruptive behavior fosters medical
errors, contributes to poor patient satisfaction
and preventable adverse outcomes, increases
cost of care, increases turnover of staff seeking
more professional environments.
• 2009 new accreditation standard
requiring hospitals to address
disruptive/inappropriate behavior
• Rosenstein & O’Daniel (2008)
• >4,500 respondents (2,846 nurses, 944
physicians, 700 other, 40 administrators
from 102 hospitals)
• 51% of physicians and 88% of nurses
reported disruptive behavior by physicians
• 73% of nurses and 48% of physicians
reported disruptive behavior by nurses
Responses to disruptive behavior
• 95% reported feeling stressed or frustrated
• 95% felt levels of communication were
reduced
• 89% felt information transfer was
compromised
• 92% felt that team collaboration was
affected
• 85% felt ability to concentrate was affected
Perceived link between disruptive behavior
and adverse patient outcomes
• 66% adverse events
• 71% medical errors
• 53% compromise in patient safety
• 72% detrimental effect on quality of care
• 75% poor staff satisfaction
• 25% patient mortality
Disruptive behavior affects patient satisfaction,
hospital reputation, and quality ratings.
Patients who witness disruptive events or
encounter unprofessional behavior more
likely to express negative response on
patient satisfaction surveys and tell others.
Strong correlation between poor
communication, patient satisfaction,
physician incident reports and the inclination
to sue.
Scope of the Problem
American College of Physician Executives
Survey (2009) (n > 2,000)
Does your health care organization ever
experience behavior problems with doctors
and nurses
Generally speaking how often do behavior
problems arise between doctors and nurses
at your health care organization
Scope of the Problem
American College of Physician Executives
Survey (2009)
Does your health care organization ever
experience behavior problems with doctors
and nurses 97.4%
Generally speaking how often do behavior
problems arise between doctors and nurses
at your health care organization
Daily 9.5%, Weekly 30.6%, Monthly 25.6%
Importance of addressing factors that affect
patient care (Milliman 2008)
• Estimated1.5 million medical errors –
average cost $13,000 ($19.5 billion)
• 1.5 million preventable drug events - $2,000
to $5,800. Institute for Safe Medication
Practices estimates 7% of drug errors due
to provider intimidation.
• 10% of surgical malpractice claims ($345K)
traced to inadequate surgical team
communication contributing to patient error.
Financial impact of disruptive behavior
• Replacement of staff – estimated $60 $100K to replace a nurse
• Adverse events
• Medication error $2,000-$6,000
• Hospital acquired infection $20K - $38.5K
• DVT $36,500
• Malpractice suit - $521,000 (mean cost
of medical error-based claim)
Predicting Risk
Importance for the practitioner and the hospital
Hickson – patient complaints can identify
doctors with interpersonal problems and
predict the likelihood of malpractice litigation
Doctors with >4 complaints in 6 year period
were 16 times more likely to have >2 risk
management files opened than those with no
complaints
Why has this persisted?
In the past this has been ignored, tolerated,
excused, reinforced, or not reported.
Common assumptions:
That’s the way it has always been
Who will listen
I don’t want to make waves or get in trouble
I can take it
Dr. X is important to the organization because
(rank/expertise/revenue) which outweighs
the impact of his behavior
Why has this Persisted?
Organizational Reluctance
• Cultural inertia
• History of tolerance
• Code of Silence
• Fear of antagonistic physician reaction
• Organizational hierarchy
• Conflicts of interest
• Lack of organizational commitment
• Ineffective structure or policies
• Inadequate intervention skills
Risk of Nonaction
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Negative staff satisfaction and morale
Staff turnover
Compromises in patient safety
Joint Commission noncompliance
Negative hospital reputation
Decreased patient satisfaction
Increased liability and malpractice exposure
Financial loss secondary to reimbursement
penalties for adverse events
• Clinical or technical competence or
excellence is necessary but not sufficient,
and cannot excuse unprofessional or
disruptive behavior
• We all work in teams (clinical, educational
and research)
• Disruptive behavior leads to stress, anger,
anxiety and frustration within the team that
leads to poor communication
• Joint Commission estimates that 70% of
sentinel events due to errors in
communication
What can be done?
Socio-cultural norms and expectations
have changed. AAMC has made it
clear that behaviors that were
previously tolerated are no longer
acceptable. Sanctions to organizations
that do not have appropriate processes
to deal with professionalism/behavioral
issues
Addressing Disruptive Behavior
• Organizational Culture
• Leadership commitment, assessment,
structure
• Recognition, awareness, education
• Diversity, sensitivity, stress management,
conflict management, assertiveness
• Collaboration/Communication tools
• Relationship building
• Policies and Procedures
• Reporting mechanisms
• Intervention (pre, concurrent, post)
Essential Elements
Cultural values that emphasize
professionalism
Institutional willingness to address issues
with a values first proposition
Institutional policies and procedures that
allow an organizational response to
disruptive behavior
Establishing the Ground Rules
Defining the expected:
Examples of Appropriate Behavior
• Criticism communicated in a reasonable
manner with the aim of improving patient
care and safety
• Expressions of dissatisfaction with policies
through appropriate grievance channels
• Use of cooperative approach to problem
resolution
Establishing the Ground Rules
Defining the unacceptable
Inappropriate behavior means conduct
that is unwarranted and is reasonably
interpreted to be demeaning or
offensive. Persistent, repeated,
inappropriate behavior can become a
form of harrassment and thereby
become disruptive, and subject to
treatment as “disruptive behavior”.
Establishing the Ground Rules
Examples of inappropriate behavior
Belittling or berating statements
Name calling
Use of profanity of disrespectful language
Inappropriate comments in the medical record
Failure to respond to patient care needs/requests
Sarcasm or cynicism
Deliberate lack of cooperation
Refusal to return phone calls, pages, messages
Condescending language, degrading comments
Establishing the Ground Rules
Disruptive behavior means any abusive
conduct including sexual or other forms
of harassment, or other forms of verbal
or non-verbal conduct that harms or
intimidates others to the extent that
quality of care or patient safety could
be compromised.
Concrete Steps
Identification of disruptive individuals
• Appropriate reporting channels and a
zero tolerance culture, establish a safe
mechanism for people to report
• Review patient complaints, 360
reviews
• Look for and address trends (repeat
offenders, units)
Concrete Steps
Develop a process to address disruptive
behavior in hospital & medical staff
bylaws
• Verification of complaints
• Include non-retaliation clause to reduce
fear of retribution
• Assess risk of harm to patients
• Notification and due process
Concrete Steps
Willingness to have the difficult/crucial
conversation
• Focus on the behavior (don’t get
distracted by discussion of the
precipitating event
• Sooner rather than later
• Careful documentation
• Proportional response
Progressive Intervention
Informal intervention/education
Identify the underlying issues
Suspension of privileges
Referral to “physicians health” committee
Disciplinary hearing
Faculty complaint process
Referral to state board
Summary
• Establish a code of conduct
• Identify the origins of disruptive
behavior and work on solutions
• Interventions should be applied
consistently and equally
• Outcomes
Improved teamwork and staff satisfaction
Improved patient care and safety