Innovations to Address Disruptive Behavior: Getting It Done Chapter 13

Introduction

I felt for the nurses as I listened to a frustrated OR nurse describe a recent interaction with a spine surgeon:

All he says is ‘Fix it.’  Then, we implement a fix and all he does is criticize it.  What are we supposed to do?

Effective January 1, 2009, The Joint Commission required accredited hospitals to have a code of conduct policy to address disruptive behavior at all organizational levels.  The Joint Commission’s focus on behavior, communication, and professionalism has helped bring the issue of disruptive behavior to the forefront and has lent credence to the concern that inappropriate and disruptive behavior is a patient safety risk.

Case Presentation

“Dr. Disruptive” is an excellent surgeon with a long history of difficult conduct. He has berated nurses when they called him for “stupid” questions, screamed obscenities for seemingly minor delays, and written derisive notes in patient charts about his colleagues and the hospital.

Medical staff and hospital leaders attempted collegial interventions with Dr. Disruptive through letters of counsel and letters of warning. After each intervention, Dr. Disruptive’s behavior improved, but the improvement was short-lived; he reverted each time to his former behavior within a few months.

Unsuccessful in its attempts, the medical executive committee called a meeting with Dr. Disruptive to address his behavior. Dr. Disruptive blamed the nurses, insisting that he wouldn’t get so mad if they were competent. He threatened to report the nurses to the state nursing board and the hospital to the department of health. He challenged the committee to “Go ahead and take away my OR privileges. I’ll take my patients across town and see you in court.”

Some nurses continued to file complaints about his behavior; newer nurses were reluctant to call Dr. Disruptive with questions about patients for fear of being “chewed out,” potentially compromising patient care and safety. Other nurses said they just gave up filing complaints because nothing had been done to fix the problem.

Intervention

The newly elected chief of staff was concerned that Dr. Disruptive’s behavior presented a risk to patient safety. She teamed up with the chief medical officer and met with Dr. Disruptive, listened to his side of the story, and made it clear that his behavior would have to change.

They referred Dr. Disruptive to a 360-degree physician survey feedback program called the PULSE (Physicians Universal Leadership Skills Education) Program to conduct an assessment of his behavior and determine the impact of his behavior on the healthcare team. They asked Dr. Disruptive to invite healthcare team members to complete the survey. The chief of staff and chief medical officer supplemented the list. The survey contained standardized questions, such as: “To what extent does this physician: (1) point out mistakes respectfully, (2) stay focused under stress, (3) adapt to changing policies and procedures, (4) talk down to team members, and (5) make arrogant demands?”

The feedback report identified both professional strengths and specific angry and arrogant behaviors Dr. Disruptive needed to change. When compared statistically to a national normative database of about 800 US physicians, he had many behaviors in outlying ranges. The report recommended that Dr. Disruptive watch a series of DVD modules at home on anger management, respectful communication, and emotional intelligence, so that he could see how his command-and-control leadership style might be necessary in life-threatening emergencies but detrimental to team cohesion at other times. The report also recommended that Dr. Disruptive be coached and receive ongoing 360-degree survey feedback until he achieved a one-year period in which he scored above the minimum acceptable levels and had no significant incident reports.

Upon reviewing his feedback report with the chief of staff, Dr. Disruptive was surprised. “I’m the best surgeon in the OR,” he said. “All I really care about is patient care. Doesn’t anyone else think that’s important?”

The chief of staff pointed out, “You need to understand the impact of your behavior. Your bullying makes nurses afraid to work with you. They do not ask important questions for fear that you will turn them in. Your conduct is one of the reasons you are experiencing unacceptable care outcomes.”

Dr. Disruptive grumbled, “So I have to waste time watching DVDs at home?”

“You can watch them anywhere you want. Doesn’t it beat having to leave town to be counseled?” the chief of staff asked him.

Dr. Disruptive nodded. He appreciated that he could view them at home on his own time. As he watched the DVDs with his wife, she reinforced the importance of using the frustration management and conflict resolution techniques.

By the time he received his first follow-up survey feedback report a few months later, Dr. Disruptive’s behavior had improved. The number of disruptive behaviors below acceptable statistical ranges had decreased from 18 to 4. He withheld condescending comments and made requests more constructively by asking, for example, “In the future, would you arrange my instruments this way?” His healthcare team commented that he was calmer and more agreeable as well as less hostile and demeaning. His quarterly ratings based on survey responses improved by almost 100 percent over the following year.

After receiving several acceptable feedback reports, Dr. Disruptive graduated from the program. He said, “It’s all common sense. It’s nothing I didn’t already know. In fact, I probably learned it all in elementary school. All I need to do is keep my mouth shut and remember that ‘if you don’t have anything nice to say, don’t say anything at all.’ I still get ticked off about the pathetic state of healthcare and managed care in this country, but when I’m frustrated, I’ve learned how to talk to the nurses in a better way, so I stay out of trouble. And it has also helped that the nurses are staying around longer these days, and they seem to like working with me again. It feels lighter now in the operating room.”

Conclusion

A common ploy in disruptive behavior is to deflect criticism by claiming that one’s actions are a response to quality problems. A disruptive physician who takes this approach is trying to shield himself from discipline by claiming to be a whistleblower. Leaders must take this shield away by investigating, addressing, and resolving any legitimate quality of care concerns that the disruptive physician might raise.

I hope that you will read this chapter to learn more about innovative approaches to address disruptive behavior in healthcare professionals.  As always, I welcome your input to improve healthcare collaboration and get it done.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure: I have not received any compensation for writing this content.

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