1. Unprofessional or Disruptive Behavior Impact on Patient Care, Medical Errors, Working and Learning Environments American Association of Veterinary Clinicians March 29, 2012

2. Overview Definitions Scope of the problem Why has this persisted What can be done

3. 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.

4. 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

5. 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

6. 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

7. 2002 – first studies documenting impact of disruptive behavior on nurse satisfaction and retention 2008 Joint Commission Sentinel Event Alert 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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%

14. 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.

15. 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)

16. 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

17. 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

18. 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

19. Risk of Nonaction 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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”.

26. 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

27. 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.

28. 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)

29. 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

30. 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

31. 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

32. 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