Enhancing a Culture of Quality, Safety & Respect:
Addressing Disruptive Behavior
Preparation Notes—long version
Please review note pages before presenting materials
Enhancing a Culture of Safety:
Addressing Disruptive Behavior
Presentation to:
Add Your Unit/Department Name
Agenda
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Disruptive Behavior defined
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Impact of Disruptive Behavior on workplace quality and safety
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Causes of Disruptive Behavior
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Content of revised UMHS Policy 04-06-047— Disruptive or
Inappropriate Behaviors by UMHS Personnel
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Importance to Our Work Team
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Q &A
Objectives
After reviewing and discussing UMHS Policy 04-06-047 Disruptive or
Inappropriate Behavior by a UMHS Employee or Faculty Member at
the end of this session participants will:
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Understand the potential negative impact of disruptive or
inappropriate behavior on workplace quality and safety throughout
the organization—in clinical and non-clinical areas
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Be able to provide examples of appropriate and inappropriate
behavior
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Understand recommended guidelines for reacting in the moment to
disruptive or inappropriate behavior
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Use paper or on-line reporting tools to report inappropriate behavior
Disruptive Behavior defined
Any conduct that interferes with the effective
operation of UMHS or suggests a threat to UMHS
personnel or to patient care . That a person’s
behavior is unusual, unorthodox, or different is not
alone sufficient to classify it as “disruptive
behavior”.
Lateral Violence defined
Inappropriate behavior, confrontation or conflict
between coworkers that humiliates, degrades or
otherwise indicates a lack of respect for the dignity
and worth of an individual – often caused by
communication mishaps.
Disruptive Behavior Linked To
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Medical errors & adverse outcomes
Reduced staff performance, innovation
Increased staff turnover
Patient dissatisfaction
Lack of information sharing
Processing delays
Too Often, Often Unreported
With Negative Consequences
Studies with similar findings across several Health Care
organizations
 > 90% have witnessed disruptive behavior by MDs
 30% - knew nurses who left hospital as a result of disruptive
behavior
 > 70 % of nurses witnessed disruptive behavior among nurses
 14% aware of actual adverse consequences
“serious problem within and across disciplines”
Voluntary Hospital Association 2002, 2005 studies (Rosenstein)
“But I Don’t Work In Clinical Area.”
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Disruptive and
Inappropriate behavior
can negatively impact
your work environment
too.
The policy applies to all
UMHS personnel
UMHS Survey Measures Respect
UMHS asks questions about respect in
our workplace in our Employee
Engagement survey.
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Q29—We hold ourselves and others
appropriately accountable if we fail
to meet our commitments
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Q30—We treat each other with
mutual respect even when we have
clear differences of opinion
We are making some improvements
and have opportunity for more
What are our unit’s survey
results?
It Does Happen Here!
Quotes on Inappropriate Behavior
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“The doctors can be disrespectful to the nurses who can be
disrespectful to techs who are disrespectful to housekeepers, etc.)
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“There are no consequences for these behaviors so you become
demoralized and they just continue.”
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“Surgeons are very belittling—they call you names . . .”
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“There is a director who screams at his supervisors all the time and
no one does anything because they are afraid of him.”
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“I would like to see people written up—people don’t take things
seriously. Supervisors hate confronting people.”
From 2007 UMHS Employee Engagement Focus Groups
Causes of Disruptive Behavior
Historical factors
 tolerance and indifference
to disruptive behavior
Individual factors
 high stakes
 high emotion
 personal problems
 fatigue
 substance abuse
 lack of interpersonal, coping or
conflict-management skills
 lack of tolerance or understand
of workplace diversity
Leaders who fail to address
unprofessional conduct through formal
systems are indirectly promoting it.
Systemic factors
increased productivity demands changes in shifts
cost containment requirements rotations of interdepartmental
support staff
We See It
But We Don’t Speak Up
Because:
 That’s the way it’s always been.
 Who will listen?
 I don’t want to get in trouble.
 I can take it.
 We can overlook it because of the person’s
technical expertise, rank, etc.
UMHS Strategic Principles/Values
UMHS values include:
RESPECT, TRUST, INTEGRITY
Our Strategic Principles include:
 Integration, Collaboration & Team Work
 Taking Care of Our Own
 Cultural Competency
 Integrity and Trust
UMHS Policy 04-06-047--Disruptive or
Inappropriate Behavior by UMHS Personnel
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States UMHS commitment to addressing disruptive/
inappropriate behavior by UMHS personnel
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Expresses importance of collaboration, communication and
collegiality to patient care, education, research & effective
operation
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Acknowledges that reporting can be intimidating, therefore
provides support and process
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Outlines who to report to
Allows for anonymous reporting
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Identifies the procedure for reporting
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Specifies outcomes, including potential consequence of formal
corrective action
UMHS Policy 04-06-047--Disruptive or
Inappropriate Behavior by UMHS Personnel
The policy also provides:
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Definitions
Examples of Appropriate and Inappropriate Conduct
Policy Standards
Procedures
General Guidelines, including related policies
Exhibits
A. guidelines for reaction in the moment
B. reporting form
C. reporting process flowchart
References used in creating the policy
Conduct
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Appropriate Conduct
Demonstrates clear,
direct, honest and
respectful
communication
Accepts and provides
feedback in a
constructive and civil
manner
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Inappropriate Conduct
Threatening or abusive
language (e.g.
belittling, berating,
screaming . . .)
Derogatory comments
(as opposed to
constructive criticism)
about the quality of
care being provided by
the Health System . . .
Excerpts from examples provided in UMHS Policy 04-06-047.
See page 2 of policy
Exhibit A: Guidelines for Reacting in
the Moment to Disruptive Behavior
1.
2.
3.
4.
5.
Address the situation at the time it occurs
Redirect the focus onto the patient’s needs to
depersonalize
Move the conflict away from patient areas—if
needed closer to other staff
If you witness verbal abuse, signal to co-workers
to act as a witness
If a violent act occurs (immediate assistance
needed), contact a supervisor and dial 911
From Defusing Disruptive Behavior: A Workbook for Healthcare
Leaders. Joint Commission on Accreditation of Healthcare
Organizations Resources. 2007
Procedure
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Encourages reporting at department level
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Strongly encourages individuals subjected to or
witnessing disruptive behavior to report it
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Requires the reporter’s supervisor to act:
• Document
• Resolve
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May include involving the next administrative level
and HR in the investigation/resolution
Reporting Options
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Complete a Behavior Report Form or report verbally
to the supervisor who will document the form
•
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Call the University Compliance Hotline
•
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fax to Risk Management 734 763 5300 or on-line (in
development)
at 866 990-0111 or
submit on-line to https://www.tnwinc.com/WebReport/
If a violent act occurs or immediate assistance is
needed, contact a supervisor or dial 911
Behavior Report Form
Strongly Encouraged to Report!
1) Print Page in Policy (Exhibit B) & Fax to Risk
Management
- or 2) Online submission
Behavior Form Follow Through
1) Risk Management forwards online reports
to appropriate department
2) Per Disruptive Behavior policy, the
reporter’s supervisor follows up:
a) Resolves with his/her own department
b) Relays report to disruptive person’s supervisor
3) Per departmental policy, appropriate
action is determined at the local level
4) Data tracked through the RiskPro system.
Reports produced by:
a) Individual
b) Department
c) Unit/Division
(Faxed forms are inputted by Risk Management)
Joint Commission Standard
LD.03.01.01
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Sentinel Event Alert #40 issued July 2008
The alert cites a national survey on intimidation that says 40 %
of clinicians have kept quiet or remained passive during incidents.
“Most” have witnessed disruptive behavior.
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JC Standard LD .03.01.01
Leaders create and maintain a culture of safety
and quality throughout the [organization].
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UMHS Policy 04-06-047— Disruptive or
Inappropriate Behaviors by UMHS Personnel
Importance to Our Work Area
Can I Avoid All Conflict?
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No. Conflict can not always be avoided.
Conflict is a normal and can be a healthy part of
team interactions
Conflict handled appropriately allows team
members to:
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Share ideas
Voice concerns
Improve team relationships
RESPECT
Managing conflict in a respectful manner is key.
Key Considerations
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We (our patients and our co-workers) are worth the
investment
• Intervention leads to insight which leads to changed
behavior.
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The better the Patient Safety Culture, the better the Health
System performance
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Every health system employee has a role to play.
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Leadership engagement and oversight critical. Report your
concerns to me.
Questions??
Manager Resources
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The following slides are additional resources
for supervisor/manager for use in preparing
for the presentation.
Resources
(Place in Slide Show Mode and mouse over program name to view
resources for each area.)
In addition to exploring resources in your
own area, the following sources provide
some or all of the following:
• Consultation
• Assessment
• Intervention
• Training Programs
• Referrals
Department Services,
Books, Videos
Books & Articles
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Dutton, Jane. Energize Your Workplace: How To Create & Sustain high Quality Connections at Work.
San Francisco. Jossey-Bass. 2003.
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Farber, June. Smart Nursing: How to Create a Positive Work Environment that Empowers and Retains
Nurses . New York. Springer Series on Nursing Management and Leadership. 2005.
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Frederickson, Barbara. Positivity. Groundbreaking Research Reveals How to Embrace the Hidden
Strength of Positive Emotions, Overcome negativity and Thrive. New York. Crown. 2009.
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Tarkan, Laurie. “Arrogant, Abusive and Disruptive and a Doctor.” New York Times. December 2, 2008.
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Rosenstein, A.H., O’Daniel, M. “Managing Disruptive Physician Behavior: Impact on Staff Relationships
and Patient Care.” Neurology. 70. 2008. 1564-1570.
Videos—See Employee Resources-Audio/Visual Resource Inventory
http://www.med.umich.edu/i/umhshr/avinventory.htm#Conflict
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MANAGING CONFLICT VIDEOS
Self-Discipline and Emotional Control:How to Stay Calm and Productive
Under Pressure, Volume 1 (Brief video description)
Self-Discipline and Emotional Control:How to Stay Calm and Productive
Under Pressure, Volume 2 (Brief video description)
Dealing With Conflict (Brief video description)19 Min
Communicating Non-Defensively (Brief video description)20 Min
Managing Stress (Brief video description)26 Min
Dealing With Conflict and Confrontation, Volumes 1, 2, and 3 (Brief video description)
From U-M Health System Policies and Procedures
UMHS Policy 04-06-047, Disruptive or Inappropriate Behavior by UMHS Personnel
Section IV. Examples of Conduct
To aid in the clarity, examples of "appropriate" conduct, and "inappropriate or disruptive" conduct
include, but are not limited to:
APPROPRIATE
INAPPROPRIATE
Demonstrates clear, direct, honest and respectful
communication
•Responds to pages in a timely, civil manner
•Responds to requests in a cooperative manner
•Demonstrates respect for patients, their family members
and staff
•Clarifies points of agreement and seeks to partner to
resolve points of disagreement in patient-care or other
work-related matters
•Accepts and provides feedback in a constructive and civil
manner
•Respects need for privacy
•Handles problems or dilemmas in a cooperative, respectful
manner
•Chooses appropriate timing to bring up problems for
discussion
•Offers appreciation and affirmation to peers-coworkers
when they function well
•Accepts the inevitability of mistakes as a learning
opportunity
•Reliably demonstrates patient care in adherence to
agreed-upon standards
Threatening or abusive language – regardless of medium –
directed at patients, their guests, or UMHS personnel (e.g.,
belittling, berating, screaming and/or non-constructive criticism
that intimidates, undermines confidence, or implies
incompetence);
•Threatening or abusive behavior (e.g. throwing items,
slamming doors);
•Degrading or demeaning comments or nonverbal
communication regarding patients or their guests, UMHS
personnel, or the Health System
•Profanity or similarly offensive language while on Health
System sites and/or while speaking with UMHS patients, their
guests or personnel;
•Physical contact with another individual that is or appears
threatening or intimidating;
•Derogatory comments (as opposed to constructive criticism)
about the quality of care being provided by the Health System,
a medical staff member, or any other individual outside of
appropriate medical staff and/or administrative channels;
•Medical record entries impugning the quality of care being
provided by the Health System, medical staff members or any
other individual;
•Imposing unreasonable requirements on fellow UMHS
personnel;
•Refusal to abide by University of Michigan Policies, including
UMHHC Medical Staff Bylaws, U-M Medical School Bylaws,
Practices, Agreements and Policies (e.g. Hand Hygiene and
Smoke-Free Environment).
Frequently Asked Questions
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Can I avoid all conflict?
What if I am afraid to report because I fear
retaliation?
What resources are available to me if I want more
skills in handling difficult situations—so that my
behavior is not viewed as inappropriate?
My teammates always yell at each—that’s how we
get our work done. That’s okay, right?
What if the person I want to report is my supervisor
or another manager?
Can I report a single occurrence of inappropriate or
disruptive behavior?
Scenario Activity
Purpose: To practice effective ways of responding to offensive language and
behavior in conjunction with Exhibit A of the policy.
Exhibit A :Guidelines for Reacting in the Moment to Disruptive Behavior
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Address the situation at the time it occurs
Redirect the focus onto the patient’s needs to depersonalize
Move the conflict away from patent areas – if needed closer to other staff
If you witness verbal abuse, signal to co-workers to act as a witness
If a violent act occurs (immediate assistance needed), contact a supervisor
and dial 911
Activity:
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In small groups discuss and then formulate a response to one of the 7
scenarios provided by responding to the questions at the end of the scenario.
Be prepared to share your response with the larger group.
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Debrief
Scenarios follow
Scenarios for Group Discussion
Enhancing a Culture of Quality, Safety &
Respect: Addressing Disruptive Behavior
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Scenario I: Two Managers
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Scenario II: Outpatient Clinic Manager and Patient Assistant
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Scenario III: Faculty – Nurse – Technical Staff
Scenarios for Group Discussion
Enhancing a Culture of Quality, Safety & Respect:
Addressing Disruptive Behavior ~ cont’d
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Scenario IV: Office Administrator and Environmental
Services Staff
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Scenario V: Faculty – Nurse
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Scenario VI: Manager (Jane) & Outpatient Assistant (John)
Scenarios for Group Discussion
Enhancing a Culture of Quality, Safety & Respect:
Addressing Disruptive Behavior ~ cont’d
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Scenario VII: Physician and Nurse
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Scenario VIII: Two office workers
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Scenario IX: Allied Health Professional – Faculty
Resources
Nursing Health & Safety Committee
Educational Services for Nursing
Educational Plans for Management of
Aggressive Behavior
734-615-9721
Click to return
Resources
UMHS Human Resource Services
Human Resource Consultants
Human Resources Organizational
Effectiveness Consultants
Mediations Services – Fernando Caetano
734 647 5538
Click to return
Resources
Compliance Office
Information: 734-615-4400
Compliance Questions or Concerns
24 hour Compliance Hotline:
866-990-0111
Click to return
Resources
Michigan Healthy Community
Understanding U Website
Assistance in Managing the Ups / Downs of Life
Featuring tools, strategies, tutorials and resources
http://hr.umich.edu/mhealthy/programs/mental
_emotional/understandingu/
Click to return
Resources
UMHS Employee Assistance Program
Supervisory, Staff and Team Consultations
763-5409
Click to return
Resources
Health System Security Services
Full 24-hour coverage
Emergencies: 911
Non Emergencies: 936-7890
Click to return
Resources
Heather Wurster – Policy Lead ,
Resource for Staff, and Medical School Point
Person
Maureen Naszradi - Medical Staff Peer Review
Coordinator
232 - 1687
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