Addressing the Medical Staff - Disruptive Behavior

In previous posts, I have presented an interview with one of our administrative clinicians outlining how he deals with disruptive behavior and the Principles of Partnership we have with Ministry Health Care clinicians. We also must deal with this issue at our hospitals, most of which have independent physicians.  Regardless of the setting, we have to establish the baseline for acceptable behavior. One of our hospital medical staffs formed a Respect Committee that then interviewed a number of individuals.  The interviews uncovered numerous examples of respectful behavior and a few examples showing disrespect.  The Committee then produced a PowerPoint presentation that has served as a cornerstone establishing respectful behavior.  The basic contents of the PowerPoint is listed below. Examples of respectful and disrespectful behavior has proven to be helpful on many occassions.

 

Ministry Health Care:  Values Behavior

• Treating Others with such a sincere regard that each person  feels important and worthwhile
• Recognizes others for their achievements and capabilities
• Provides honest, non-judgmental feedback to others
• Creates an environment where frustrations and concerns can be expressed without fear of repercussion    

 

Ministry Medical Group Professional Practice Standards

• We believe each patient, customer and staff member is important.  …. we strive to treat each person in a respectful nature that honors his or her importance and worth.

 

Cultural Assessment Questionnaire:

• Ministry-wide and local norms 
  • Physicians in this organization treat other staff members with respect
  • Employees Treat Each Other with Respect

 

What Additional Data Did We Want to Gather?

• Are there recognizable characteristics of “Best Practices”?
• Are there characteristics of the opposite?
• What makes staff feel that they are respected?
• What makes staff feel that they are disrespected?
• Can we show improvement in staff perception of respect over time?
• Can we change behaviors to achieve this end?

 

Respect Committee Intentions

• This is NOT a disciplinary committee
• Emphasize the POSITIVE, the IMPROVEMENT
• To be EDUCATIONAL, not punitive
• To provide TOOLS for the Medical Staff  and MMG Clinic Divisional Chairs to  improve RESPECT
• To EDUCATE all employees regarding respect issues and holding ALL WHO WORK here to the same standards
• Try to learn something about SUCCESSFUL physician/nurse and physician/employee relationships that can benefit all.

 

WHY

• IT HAS DIRECT CONSEQUENCES AFFECTING PATIENT CARE

Intimidating and verbally abusing nurses and pharmacists may lead to patient harm:  Institute for Safe Medication Practices (ISMP) Survey of Nurses and Pharmacists

• 7% involved in medication error where intimidation played a role
• 49% said history of intimidation altered the way they asked for clarification of medication orders
• 40% said at least once in past year a concern was overlooked in order to avoid confrontation

Types of Behavior :

•     Condescending language 21%
•     Impatience 19%
•     Verbal Abuse 48%
•     Threatening body language 43%

 

AMA News: Sept 2004

• Staff Less Tolerant of Rude Doctors            
• Survey of Physician Executives :
  •      One physician can taint the culture of the unit
  •      83%  problems with physician behavior involve disrespect
  •      50%  problems only reported when doctor completely out of line and serious violation occurs
  •      95%  met with disruptive physician in last two years
  •      40% said physicians who generate high amount of revenue are treated more leniently than doctors who bring in less revenue    OUCH !

 

What We Did

• Focus groups were interviewed  with representatives from Clinic and Hospital  departments with high and low respect scores. Included  nursing and  clinical staff,  administrative, and non-clinical employees.
  • Confidential
  • Qualitative
  • Individual Responses                                   
  • Highlight the most pressing and prevalent problems

 

Questions Asked

• What are some examples of times you felt very respected by physicians?  What specific behaviors caused you to feel this way?
• In general, is this behavior on the part of most or all physicians? Or is it more specific to a minority of them-but a minority who have a significant impact on others?
• What are some examples of times you felt you were not respected by a physician? What specific behaviors caused you to feel this way?
• In general, is this behavior on the part of most or all physicians? Or is it more specific to a minority of them-but a minority who have significant impact on others?
• What physician/employee situations have you heard of?
• How many times have you heard about situations versus times you actually experienced them?
• How frequently does this behavior occur?

 

Sample of Comments Regarding Positive Respect  

• MAJORITY of physicians
• Has IMPROVED over couple years
• HOSPITALIST program has decreased call issue complaints and a change for the better, hospitalists working together
• LISTENING and taking  suggestions.                                      
• INCLUDING nurses as part of a team by discussing plan of care and asking for input
• ACKNOWLEDGE skill level, opinion and judgment
• RECOGNITION for good patient care
• THANKING YOU  for asking questions, bringing patient concerns to the attention of the physician
• APOLOGIZING  when a mistake has been made
• Basic MANNERS…thank you, acknowledgement in hallways even if just say “hi”, using pleasant voice, eye contact
• ASKING rather than telling
• Creating a learning environment
• There are no “dumb” questions, no belittlement
• Performance is improved by physicians who teach
• Errors are handled non-judgmentally
• Physicians act upon being called
• Compliments in front of others and patients
• Positive outweighs the negative

Sample of Comments Regarding Disrespect

• Minority, some departments
• Dismisses what you (staff) are doing
• Expecting problem to be immediately fixed
• Complaints about other departments/doctors
• Belittling in front of patients or peers
• Inappropriate comments about other physicians to patients
• Not dealing directly with the issue
• Yelling, hanging up phone
• Taking out frustration on wrong people
• Using sarcasm or intimidation
• Requests to move patients to other areas without discussing reason
• Unavailable, not answering page
• Personal things taking precedence of work related duties
• Being told not to call for certain reasons by on-call physicians and reprimand for calling
• Unapproachable, avoid connecting
• Being asked to lie/give excuses when physician is scheduled to be in two places at once
• Taking out anger on staff for being awoke or called while on call
• Criticizing staff for not being as prepared or skilled as another unit
• Poor communication of treatment plan
• Physician behavior differs between hospital and clinic
• Heard about disrespect more than experienced it

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Prinicples of Partnership

This post contains the Principles of Partnership referred to in last week’s interview with Dr. Sockochoff.  The document establishes the standards of behavior for the organization.

Ministry Medical Group

Introduction

The Medical Staff and Employees of Ministry Medical Group recognize their considerable interdependence in the rapidly-changing health care environment.  They acknowledge that providing high-quality, cost-effective health care depends in large part upon their ability to develop trust, communicate well, collaborate effectively, be mutually supportive, and work as an effective team.

Medical Staff and Employees further acknowledge that there are many participants in the process of effective health care, including patients, their families, Allied Health Professionals, and others, and that working harmoniously with them is a necessary aspect of modern health care.  Both parties affirm that everyone, both recipients and providers of care, must be treated in a dignified, respectful manner at all times in order for their mutual goal of high-quality health care to be accomplished.

Medical Staff and Employees further affirm that it is their mutual responsibility to work together in an ongoing, positive, dynamic process that requires frequent, continual communication and feedback.  Both agree to devote the necessary time and resources toward achieving these goals.

Principles

In order to accomplish these goals, Medical Staff and Employees agree to the following principles and guidelines.  Both parties agree to work collaboratively to promote them in the organization and in the community.

 1.      Respectful Treatment

All members of the health care provider team (physicians, hospital employees, Allied Health Professionals, vendors, contract personnel, etc.) and all direct and indirect recipients of health care (patients, their families, visitors, etc.) shall be treated in a respectful, dignified manner at all times.  Language, nonverbal behavior and gestures, and attitudes shall reflect this respect and dignity of the individual at all times.  Medical Staff and Employees also agree to exercise commonly-accepted principles of social interaction and courtesy in their dealings with others. 

 2.      Language

Medical Staff and Employees agree to use respectful language and demeanor, and not to use language that is disrespectful, profane, vulgar, intimidating, degrading, sexually suggestive or explicit, or prejudicial (racially, ethnically, religiously, etc).

 3.      Behavior

Medical Staff and Employees agree to behave respectfully toward others at all times, and to refrain from any behavior that is disrespectful, profane, vulgar, intimidating, demeaning, harassing, humiliating, or sexually inappropriate.  This includes but is not limited to:  obscene gestures, violation of reasonable personal space, yelling, throwing of objects, menacing gestures, unwanted or sexual touching, degrading or sexually-oriented jokes or comments, or requests for personal or sexual favors.  It also includes making inappropriate comments regarding physicians, hospital employees, other providers, or patients.

 4.      Confidentiality and Privacy

Medical Staff and Employees agree to maintain complete confidentiality of patient care information at all times, in a manner consistent with generally-accepted principles of medical confidentiality and HIPAA.  The parties also recognize that practitioners and hospital staff have the right to have personal or performance problems and concerns about competence discussed in a confidential manner in a private setting.  Medical Staff and Employees agree to maintain this confidentiality and to seek proper, professional, objective arenas in which to deal with these issues.  It is particularly important that patients, families, and other hospital visitors not overhear such discussions.

 5.      Respectful Communication and Feedback

Verbal and written communication, including chart notes and other documents, should be respectful and professional in language and tone.  Communication about a physician or employee should be made directly to that person, in a constructive manner, in objective, behavioral terms, without impugning motives.  It is not appropriate to make critical comments about others to a third party or to relay gossip.

Medical Staff and Employees recognize the need for an organizational chain of command, in order for the Medical Center to run smoothly and efficiently.  Both parties recognize the need for each others’ input regarding quality and performance.  Employees recognize the importance of Medical Staff in the education of employees.  However, significant concerns about performance need to be made through appropriate channels, i.e. to supervisors, and not directly to employees.  Medical Staff agree to take these concerns about employee performance or hospital issues through the appropriate chain of command.  Both parties agree to engage other parties in constructive and timely dialogue and to work collaboratively to address these issues.

 6.      Supporting Rules and Regulations

Medical Staff and Employees recognize the need for certain rules and regulations for all to follow, in order to assure the smooth, harmonious, and safe functioning of the Medical Center, both clinically and otherwise.  Both parties agree to abide by these regulations, including such things as relate to safety, scheduling, confidentiality, documentation, parking, traffic, HIPAA, and the like.

 7.      No Retribution

Medical Staff and Employees agree not to engage in any behavior that could reasonably be considered retribution, such as:  making implied or direct threats, physically-intimidating behavior, withholding information, refusing to speak to coworkers, attempting to find out who might have registered a complaint, etc.

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Interview with Dr. Bob Sockochoff - Dealing with Clinicians Displaying Dysfunctional Behavior

This interview is part of a series of posts about  Disruptive Behavior.  Dr. Sockochoff has developed expertise in dealing with this difficult issue through focused training and real life experience. I am delighted he has chosen to share his experiences with us.

Please  introduce yourself.  I’m Bob Sockochoff, I’m currently the Regional Vice President for Ministry Medical Group, Northern Region. I’m a family practice physician who has been in family practice for 27 years and over the last 5 years I’ve taken on a greater administrative role.

Bob, in your role as Administrative Physician you’ve increasingly been dealing with physicians displaying dysfunctional behavior.  Could you tell us a little bit about the journey that you’ve followed and how you learned the skills necessary to deal with these issues?  Dysfunctional behavior amongst physicians is one of those issues that frequently gets ignored,  and in fact, under certain circumstances, has been accepted as “normal” behavior. Dr. Mo Nunez, our previous CEO, developed an initiative to provide us with some more education and tools around this issue.  You could say we had a backlog of dysfunctional physician behavior within our medical group.  He enlisted the help of Dr. Kent Neff, who is an expert in dealing with these issues.  Kent is a Psychiatrist and author with many years of experience in the field.  He provided educational sessions for medical and administrative leadership.  He helped us develop standards and processes to help us address these problems more effectively. We termed the road map the Principles of Partnership.  (I will place the Principles of Partnership into a separate post early next week)

What are the steps you now follow when you become aware of dysfunctional behavior that needs to be addressed?  The first thing we do is try to judge the severity of the behavior and determine from that initial assessment how quickly we need to react. If you are faced with some obviously outrageous behavior then we react immediately to intervene and stop it.  Often though, what we found was that an individual episode wasn’t particularly outrageous but the cumulative over time was toxic.  Often there was a pattern of disrespectful behavior that may have repeated itself over many, many years.  Occasionally the behavior has propagated itself throughout multiple members of a department.  The Neff approach is simple and respectful:  1)Good person 2)Unacceptable Behavior 3)Consequences and Future Expectations. The general approach would be to set up a meeting with the physician that has been exhibiting the behavior.  The meeting generally should be on administrative or neutral turf out of the office space the provider.  We always arrange for two or more people (a mix of medical directors and administrative partners) to meet with the provider.  We arrange a pre-meeting to discuss individual roles in the conversation - sometime even going so far as to role play.  When you first get into the room with the physician,  you ask them to agree to certain ground rules. The way I phrase it would be like this, “Dr. X, Thank-you for coming.  I have some important issues that I would like to discuss with you today. I would ask that you give me time to present all the information that I have and I would ask that you not to interrupt me. After I’m finished presenting my information we’ll have plenty of time to discuss and get your side of the story.  Can we agree to that?”  It is important to get the physician’s agreement before proceeding.  If they do start to interrupt, you can say, “Please Dr. X, you agreed you would let me finish.  Please let me continue and we’ll have plenty of time for your comments after I’m done”.  We would start out the conversation with a statement as to the value of the physician, “Dr. X, you are a good person and an excellent physician.  We appreciate your contributions to your patients and our organization.  But there has been some aspects of your behavior recently that are unacceptable”. The word unacceptable is a word that Dr. Neff suggests using.  We then go on to detail the specific behaviors that are unacceptable.  An example might be, “On May 10th there was an incident while you were talking to your medical assistant. You raised your voice, made threatening gestures, invaded her personal space.  You then slammed your fist on the desk.  Later that afternoon, your MA was seen to be in tears by her coworkers”.  After cataloging the specific behaviors then you move on to options regarding consequences and plans.

As far as the consequences, it depends on the severity, chronicity and repetitive nature of the behavior.  Sometimes, in physicians that have good insight, all it takes is just some consciousness raising and a gentle warning that the behavior should not be repeated.  If the behaviors are more severe an assessment may be necessary.  Assessments can be voluntary or mandatory.  A request for a voluntary assessment takes place in a situation where you have an individual that has a fair amount of self awareness.  This option is framed in a helping, rather than disciplinary, way.  “Dr. X, you’re a good person and a good physician but you really appear to be struggling lately.  Sometimes we all face difficult situations like this. We would like to offer you an opportunity to go for an assessment, so you can figure out how to best address your situation. The organization would be happy to sponsor the assessment.  We can facilitate you getting time off from your practice for the assessment.  We would ensure confidentiality surrounding your decision.”

If the behavior is clearly unacceptable it may be necessary to insist upon a mandatory assessment.  Again, you want to concentrate on the behavior and separate the behavior from the person.  The behavior then becomes a problem that you can work on together, as opposed to some sort of personal failure.  “Dr. X your behavior is so disruptive we feel it’s a threat to you and the organization.  Under these circumstances we must insist that you go for an assessment.”  Such conversations should be accompanied by an official letter that contains the same information as the conversation.  The letter should be presented to the physician after the conversation is completed.  On rare occasions, legal counsel may be involved in the drafting of the letter, especially when disability or ADA issues are involved.

Bob, it sounds like that these can be extraordinarily difficult and emotional situations to deal with. Since you’re often times dealing with clinicians who have exhibited dysfunctional behavior over the course of time many, administrators go into these type of sessions expecting a low success rate.  Do you have a sense of how often your intervention is successful and the dysfunctional behavior is improved? Well, it depends on the physician, the behavior and the nature of the underlying problem. Dr. Neff identified certain types of dysfunctional behavior that had higher degrees of success - a better prognosis.  It turns out that around 20 to 30% of the time physicians with dysfunctional behavior will be have a psychiatric diagnosis.  The most common problem is depression and depression tends to be fairly treatable.  Alcoholism and addictive behavior amongst physicians is double that of the general population and is highly treatable. Dr. Neff commented that he was always happy to see alcoholism at the root of the dysfunction because you had a greater degree of success.  Some other types of psychiatric problems such as bi-polar disorder and personality disorders are more difficult to treat, yet some of those are recoverable as well.  In our own experience, in situations where clinicians have had assessments and received treatment, we’ve been successful around half the time regarding a successful return to work as functional members of their departments.  You might say 50% doesn’t seem all that great, but in the past we really only had two options; one option was to continue to tolerate the behavior and the other option was fire the physician and have them leave the organization.  Our approach has given us a third option with a reasonable degree of success.

There are plenty of good reasons to try, including economic reasons, recruiting reasons, cultural reasons, and the sense that it’s the right thing to do.  Everyone deserves a chance.  If you are successful, you end up with a dedicated and grateful employee that helps with employee commitment and culture.  Physicians generally have a difficult life, they have demanding jobs and it is easy to become frustrated and act in ways that are disrespectful.  If they see one of their partners struggling and see their organization responding it promotes good will and trust within with the organization.

Our policy is to cover the cost of the assessment but make any treatment the responsibility of the physician.  We will work with them in terms of arranging practice coverage, FMLA, sick leave, short term disability etc.  On occasion we’ve made some special arrangements for short term loans to help the physician with their financial needs surrounding treatment.

Bob, thank you very much for your time.  I think many individuals will find this information extremely helpful to them as they begin to develop their own plans as to how to deal with dysfunctional clinicians.

You’re very welcome Pete.

In upcoming posts I will be presenting the contents of a PowerPoint that was presented to a medical staff establishing expectations of respectful behavior and the Principles of Partnership used by Ministry Medical Group.

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JCAHO and Disruptive Behavior

My recent post, No Assholes Allowed, generated comments from a number of readers and reminded me The Joint Commission on the Accreditation of Healthcare Organizations is now addressing disruptive behavior. Standard LD.3.10 (Culture of Safety and Quality) states each organization should have “a code of conduct that defines acceptable and disruptive and inappropriate behaviors.” The Standard further adds that leaders will “create and implement a process for managing disruptive and inappropriate behaviors.”

Good work JCAHO.

http://md-leader.com

Disruptive Behavior

No Assholes Allowed

I recently had the opportunity to listen to a CD, The No Asshole Rule, based on book written by Robert Sutton.

We have all had known one, and we have all been one at times - the asshole.  Even though we have all been assholes from time to time only a few of us would qualify as what Sutton calls a certified asshole: displaying episodes of asshole behavior over time directed towards multiple individuals. 

Certified Assholes Are Not Limited to Certain Professions

Certified assholes are in every type of business, Sutton provides numerous examples.  My sixteen year old daughter saw The No Asshole Rule CD cover in my car one day when we were driving to an out of town engagement.  She asked a few questions and quickly identified several teachers who are certified assholes.  She is smarter than most of us, she quickly ejected all the assholes out of her life.  Medicine, I am sorry to say, has a large number of assholes.  We refer to physician assholes using a more tolerable term – physicians displaying disruptive behavior. 

I first became aware of clinicians showing what we now call disruptive behavior (they were also being certified assholes) in medical school. The culture in medical school accepted asshole behavior especially among prestigious faculty.  Faculty were assholes to residents, residents were assholes to medical students, and medical students in turn were assholes to nursing students.  I personally do not believe the culture produced any new assholes, but it did allow the latent assholes to fester and develop into full blown certified assholes. 

Certified Assholes Clinicians Are Often Involved in Sentinel Events

My first dealings with clinician assholes after finishing my medical training occurred when I became a facilitator of root cause analysis of sentinel events in a hospital setting.  A sentinel event is an unexpected occurrence that places the patient at risk for death or serious physical injury.  During a root cause analysis, we ask a series of questions to get beyond the apparent obvious cause of the event to the root causes.  I was amazed at how often a lack of communication was a contributor to the sentinel event. Clinicians who would qualify as certified assholes were at times involved with the event. 

Sutton makes a good case for a large negative economic impact assholes make on an organization.  Had he concentrated on a medical organization, he would have also detailed a large negative patient safety impact.  We began to appreciate clinicians and staff often hesitated to call a certified asshole for questionable issues or point out little errors or inconsistencies.  This lack of communication at times grew to a sentinel event. In reviewing reports from other organizations, clinicians involved in sentinel events have pointed to the episode as a prime example of staff incompetence rather than recognizing it was a direct consequence of his or her certified asshole behavior. 

Clinicians Who Are Certified Assholes Are a Danger to Patients

At about the time the hospital organization was recognizing the impact of clinician behavior on patient safety, I assumed a leadership role in the medical group providing the majority of the hospital’s medical staff.  Our certified assholes tended to be very productive; in fact, management had previously tolerated their behavior partly because of productivity.  As we struggled to effectively alter their behavior, we became aware of a program at Abbot Northwestern Hospital in Minneapolis, started by Dr. Kent Neff for troubled doctors.  Dr Neff found clinicians were not recognized as a danger to patients until they had done considerable damage.  Their behavior had been recurrent, ongoing and had affected multiple individuals. Neff’s description of a troubled (now termed disruptive) clinician is nearly identical to Sutton’s definition of a certified asshole.   Neff authored a book, Managing Physicians with Disruptive Behavior, recommending a series of steps useful for confronting and managing clinicians who exhibit disruptive behavior.  His recommended approach is similar to the approach detailed by Sutton. 

Past Behavior is a Predictor of Future Behavior

Unfortunately, the negative patient safety impact disruptive clinicians impart on patient care is wide spread because the medical profession has enabled the behavior.  We can go through the pain of addressing the issue within our organization but we can also take action by not allowing asshole clinicians to join our medical staffs or enter our medical groups.  For too long clinician behavior has not been considered a significant factor of clinician competence, but it is.  Both Sutton and Neff point out certified asshole behavior is recurrent.  We can use past behavior as a predictor of future behavior.  We now use a process called “Selecting Winners” to deliver a behavior based interview process when hiring new clinician and staff employees. If a clinician shows prior or current evidence of disruptive behavior, they are not hired. 

The cost of certified asshole clinicians in a medical organization are considerable and on going.  In addition to patient safety issues, they are surrounded by staff positions with a higher than average staff turnover and they consume a disproportionate amount of management time.  Afflicted clinicians will have much thicker quality assurance folders and credential folders than normal clinicians.  A recent medical journal article (Papadakis MA, Teherani A, Banach MA, et al. Disciplinary Action by Medical Boards and Prior Behavior in Medical School. N Engl J Med. 2005;353:2673-2682, e22.) suggests the behavior extends to back to at least medical school.  Dealing with disruptive clinicians can be intimidating and is a skill not common among medical leadership.  Intervention is difficult as many of the involved clinicians tend to be very productive and are other wise very competent.

Sutton’s book has significant impact for medical organizations. It is one more body of work detailing the evils of certified assholes while providing a mechanism for an organization to confront the issue.   The No Asshole Rule: Building a Civilized Workplace and Surviving One That Isn’t can be used by management as a call to change medical group culture and should be required reading for medical professionals.

http://md-leader.com

Disruptive Behavior