Field Report:  An Effective Approach to Disruptive Behavior

By Michael Handler, MD, MMM, FAAPL
January 2, 2018

The author outlines a process similar to peer review in which cases are reviewed, adjudicated, tracked and trended to effectively eradicate the problem.

ABSTRACT: This article describes an innovative approach in management of the disruptive practitioner. The author outlines the problem and a process similar to peer review in which cases are reviewed, adjudicated, and tracked and trended to effect improvement from the practitioner and effectively eradicate the problem of disruptive behavior in the facility.

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Disruptive practitioner behavior is defined as any behavior that shows disrespect for others, or any interpersonal interaction that impedes the delivery of patient care, and it interferes with a culture of safety.

In a 2013 Institute for Safe Medication Practices study, a survey of physicians, nurses, pharmacists and other staff members showed 70 percent of all practitioners had experienced some type of disrespectful behavior while at work. The most common included negative comments about colleagues or leaders, reluctance or refusal to answer questions or phone calls, condescending language or demeaning comments, impatience with questions, hanging up the phone, or reluctance to follow safe practices or work collaboratively.

Further, half of the respondents reported that this behavior adversely affected the way that they practiced, and this was most commonly manifested by avoidance of the disruptive individual. In effect, it could lead to a practitioner being afraid to call — or not call at all — a specific colleague to ask even a clarifying question, and the result could be a significant safety error. Obviously, that’s not consistent with promoting a culture of safety in an organization.

The meeting began with a reading of the most recent cases and some of the more egregious incidents that were reported. The group was in shock. Responses included such comments as, “What hospital did these incidents come from?” and “These could never happen here.”

In the summer of 2012, there was a significant increase in the number of complaints related to disruptive behavior at a 122-bed suburban hospital in Missouri with a medical staff of approximately 500 physicians.

The complaints were coming from physicians, nurses and other staff members throughout the hospital, and they varied in severity from rude remarks and recurrent condescending comments to what nearly became a hallway fistfight between two physicians over a time slot in an operating suite.

A few years earlier, such incidents were few and far between. But the frequency was increasing to at least one situation a week, and it was obvious something had to be done.

Leaders convened a special meeting of the physician members of the medical executive committee to outline the problem and brainstorm ideas to control it. The meeting began with a reading of the most recent cases and some of the more egregious incidents that were reported.

The group was in shock. Responses included such comments as, “What hospital did these incidents come from?” and “These could never happen here.” When the group was told that these, indeed, were recent events at their modest suburban hospital, the group overwhelmingly decided a different approach to maintaining discipline was necessary. The Hospital Provider Citizenship Committee was born.

A Solution Proposed

Over the next several months, much time was spent on the composition of the committee, and creating the policies and procedures that would form its guiding principles. The group chose to function like a peer-review committee but would focus on behavioral issues. The composition was entirely physician peers, with three medical executive members and three nonmedical executive members.

Although consideration was given to including nonphysician members on the committee, its founders said that because it was meant to address only physician issues, it should be composed solely of physicians.

The president of the medical staff serves as chair, and the hospital’s vice president of medical affairs is an ex-officio member with no vote. As a peer-review committee, its operations are under the authority of and report directly to the medical executive committee.

As is the case with peer review, referrals to this committee come from various sources. They include reports from hospital staff and other physicians, occurrence reports, patient complaints and the risk management team. Typically, they are channeled through the hospital’s vice president of medical affairs in coordination with the hospital quality department and can come via reports, secure emails or other types of communication. While anonymity of sources is the goal, it is understood that this may not always be the case because of the nature of the complaints.

A physician, upon hearing of the complaint, often remembers the scenario vividly. Therefore, a strict no-retaliation policy is in place, and retaliation is cause for further action.

How It Works

The committee meets monthly, as needed, and cases referred to the committee are reviewed. Each case is discussed for its merit, and any case without merit is closed. In cases with possible merit, a letter is sent to the physician involved asking for his or her recollection of the situation. After the letter is received back (not more than two months), the case is brought back to the full committee for discussion and scoring.

The scoring system is numeric, on a scale of 0-3, with numbers assigned based on the severity of the incident. That number is used to track and trend behaviors. Scores and their meaning:

0: Incident lacks merit or credibility.

1: Incident posed slight risk to hospital operations and/or patient care. This includes derogatory comments and various unprofessional behaviors.

2: Incident posed greater risk to hospital operations and/or patient care. This includes such things as shouting or profanity in front of a patient or a visitor.

3: Incident posed significant risk to hospital operations and/or patient care. This includes such severe events as physical contact.

Grossly egregious behavior bypasses this committee completely and goes immediately to the medical executive committee for action.

Points are tracked in the physician’s file in the medical staff office. Accumulation of six or more points in a rolling two-year period is cause for the creation of a performance improvement plan implemented by the medical staff. Such a plan also is merited for any single case in which a physician scores three points. A physician’s score becomes a part of his or her ongoing professional performance evaluation and is part of the package that is reviewed for each practitioner at the time of reappointment to the medical staff.

FIGURE 1: BY THE NUMBERS

Number of events each year based on citizenship scores, 2013-16.

handler figure

Data and Outcomes

In the 3½ years since its January 2013 inception, the committee reviewed 137 cases. Of those, 84 (61 percent) were deemed meritless. Twenty-nine cases (21 percent) scored a 1. Nine cases (7 percent) scored a 2. Twelve cases resulted in physicians receiving an educational letter, meaning that their cases did not quite merit a score but did raise some level of concern. It represented an opportunity to educate physicians on the feelings of others involved in their situations (see Figure 1).

Many other outcomes resulted from creation of this committee. One physician had many cases come up, most of which were significant, and the group’s proceedings ultimately led to the physician’s expulsion from the medical staff. The committee’s point system made a solid case.

Another physician experienced a similar pattern, but he successfully completed a prescribed performance improvement plan that included several sessions with a professional coach. This physician has shown extreme improvement in his professional decorum and has become a good example for other physicians on the staff. He might be considered one of the program’s greatest successes. Several other physicians have completed similar plans and have shown improvement as well.

A few physicians did resign from the medical staff because of this committee. Some said they did not like “the changing culture” of the medical staff.

Two physicians were given only one-year reappointments instead of the usual two years. One of them asked a medical staff leader what that indicated, and he was told that the physician leaders were concerned about his continued aberrant behavior, and that he should consider it a warning to improve behavior over the ensuing year to get full reappointment. It was a humbling moment for this physician as he realized the gravity of the situation. He, too, showed significant improvement in his professionalism in the hospital afterward.

Many unintended consequences have arisen from creation of this committee, and almost all of them have been positive. Most notable: significant increase in productive dialogue between physicians and nurses. It also has created an incentive for physicians to resolve differences on the spot so occurrences never reach the committee. One physician said he wanted to resolve the issue so he wouldn’t have to explain anything to “that committee.” In one case, the committee received a letter of apology from a physician with the comment that he had no idea how strong the impact of his comment was on the nursing staff.

In addition, many positive comments have come from the nursing staff. As the committee began, there were many concerns from the nursing staff about how it would function as well as any actions taken. Of course, this could not be shared. However, with continuous and early reassurance from the committee, the nursing staff frequently advises that they have noticed significant improvement in the behavior of specific physicians and that some have been “a pleasure to work with.”

Conclusions

Although it is difficult to ascertain a definite cause-and-effect relationship between the committee and objective data points, there are several pieces of data that can be inferred to be an indirect result of the work of this committee.

TABLE 1: ESTABLISHING A PROVIDER CITIZENSHIP COMMITTEE

BENEFITS

  • Increased dialogue between physicians and nurses.
  • Enhanced accountability of physicians for their actions.
  • High acceptance rate from physicians of case review.
CHALLENGES
  • Initial difficulty to gain the confidence of nursing staff.
  • Mindset of physician leaders to address difficult issues.

The overall perception of safety by the staff in the AHRQ Culture of Safety survey for the hospital increased from the 55th percentile in 2014 to the 70th percentile in 2016. Physician engagement scores with the hospital improved steadily each year since 2013; at last measure for this report, they were near the 90th percentile. Nurse employee engagement has also been in the 90th percentile, and the hospital’s serious safety event rate decreased by 50 percent. Since the committee’s formation, the number of reported events has decreased.

In retrospect, there was no significant downside from its formation. One early hurdle was gaining acceptance of the physicians on the medical staff. Some thought it was established to be a “witch hunt” for the physicians by a small group of nurses. But after its first several months, the committee was accepted by all but a few physicians. In fact, physicians who had cases reviewed by the committee generally felt that they were treated fairly and that it helped improve the culture of the hospital as it was supposed to do.

The Provider Citizenship Committee (see Table 1) has been a significant stepping stone in hardwiring a culture of safety in the facility. It has proved to be an innovative and effective tool to curb and even eliminate disruptive behavior, which can be a barrier to professional communication. The hospital has taken one large step closer to elevating the culture of safety.

Michael Handler, MD, MMM, FAAPL, is chief medical officer for Amita Health Alexian Brothers Medical Center in Elk Grove Village, Illinois, and Amita Health St. Alexius Medical Center in Hoffman Estates, Illinois.

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