Bioethics Discussion Blog: Hospital Doctors and Staff Must Now Squelch Disruptive Behavior!

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Friday, August 15, 2008

Hospital Doctors and Staff Must Now Squelch Disruptive Behavior!

The Joint Commission, an organization in the United States which officially accredits and certifies all hospitals for participation in the Medicare program, has recently issued a new requirement to ensure patient safety in hospitals: squelch disruptive behaviors by physicians and other non-physicians on the hospital staff. The “why” and “what” of this requirement is explained in detail, with references, on the Joint Commission’s website and is contained in this extract:

Intimidating and disruptive behaviors can foster medical errors contribute to poor patient satisfaction and to preventable adverse outcomes increase the cost of care and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated


The Commission requires that by January 2009, every hospital has in place a code of conduct that defines acceptable and disruptive and inappropriate behaviors and that hospital leaders create and implement a process for managing disruptive and inappropriate behavior. Some of the suggestions by the Commission includes: educate all team members regarding appropriate professional behavior, hold all team members accountable despite seniority or specialty and enforce the code of conduct by repeated reminders and punishment, zero tolerance for assault or criminal acts, protecting those who report unprofessional behavior and establish how and when to begin disciplinary actions. Go to the above link and read the entire requirement description.

Obviously, the establishment of what is disruptive and what is not may be difficult to define in some cases but hospitals are going to have to follow these requirements to pass accreditation inspections. I am sure some of my visitors have experienced actively disruptive (vocal or worse) or even passively disruptive (unwilling to answer phone calls or respond to a request) unprofessional behavior on the part of physicians or other hospital staff. There is no doubt that the efficiency and patient safety with regard to the diagnosis and treatment and care of all patients along with attention to their family’s concerns would be improved if “we could all get along.” ..Maurice.

8 Comments:

At Friday, August 15, 2008 11:20:00 AM, Anonymous Anonymous said...

For the Joint Commission to address this formally really emphasizes the prevalence of this problem. The problem I see with enforcement is getting peers, administration, patients, etc. to "blow the whistle" and report the guilty party. Physicians and higher ups in authority get away with things they shouldn't because of their position. Physicians that bring in a high level of revenue and not going to be reprimanded. Their egos are most times already bigger than their physical body and they do not take kindly to criticism or correction. Sounds good, just don't have a lot of confidence in implementation. For lower level personnel, I think it would be effective. It is still up to the recipient of the abuse to report it. Then, what happens, unless you carry a video camera and a tape machine, it is your word against theirs. And they are going to lie.

 
At Friday, August 15, 2008 12:22:00 PM, Anonymous TT said...

Sounds like common sense to me Dr B.

It's high time that some "health care professionals" started acting like it. They need to leave their egos and other petty BS issues outside the facility and focus their energies on the real objective - working together as a team to take care of their patients.

Just my $0.02.........

 
At Friday, August 15, 2008 1:18:00 PM, Anonymous James Gaulte said...

Those "voice intonations" are a major threat to patient safety.Thank goodness we now have a mechanism to stamp them out. More seriously, does anyone have a concern that this initiative could be used to silence or punish staff who question the way something is being done at a hospital or dares to challenge the administration on any issue.A accusation could well be morphed into a "guilty until proven innocent" situation. I am reminded of some of the most egregious misuses of the various review boards.Due process safeguards may not be quickly forth coming.

 
At Friday, August 15, 2008 2:59:00 PM, Blogger MER said...

I'd like your reaction, doctor, to a question or two I have. I read through the Joint Commission statment on "Behaviors that undermine a culture of safety."

As I read it, it appears clear to me that what we're talking about on this blog, ignoring patient modesty, comes under what the commission calls "passive activities...manifested by health care professionals in positions of power." This comes under what they call "...intimidating and disruptive behaviors..." that "erodes professional behavior and creates an unhealthy or even hostile work environment."

This could include:
1 "refusal to answer questions" -- Or, when asked for same gender care, changing the subject, ignoring the request or...
2. Using "condescending language or voice intonation." That is, not taking the request seriously and responding with "We're all professionals," and other similar expressions in a condescending tone.
3. Not reporting or interfering when a fellow health care worker ignores a patient's modesty.

I could go on, but I think you get the point. My interpretation of this document is that, when asked for same gender intimate care, health professionals should take the request seriously and either grant the request or demonstrate that they have made a fair, consciousness effort to grant that request.

What I'm asking you, doctor, is whether you think I'm on the right track with this interpretation. I ask this for two reasons:
1. If left on their own, most hospitals will not consider requests for same gender intimte care as coming under this issue. They will focus on the more serous examples that involve "patient safety." They will not even think about patient modesty as a "safety" issue and thus ignore it.
2. This document presents a real opportunity for patients concerned with this issue to see to it that hospital internal boards and commissions that are tasked with dealing with this issue include patient modesty and the double standard for men as part of the problem. Some will resist, others make take it more seriously. But, with this report available, they cannot ignore the problem. They must face it.

What's your take on this, doctor?

 
At Friday, August 15, 2008 10:33:00 PM, Blogger Maurice Bernstein, M.D. said...

James, I would say this strong suggestion about a hospital's Code of Conduct which should include the following should easily apply to your concern about "whistle blowers":

"Reducing fear of intimidation or retribution and protecting those who report or cooperate in the investigation of intimidating, disruptive and other unprofessional behavior. Non-retaliation clauses should be included in all policy statements that address disruptive behaviors."


MER, I would say that the suggested hospital Code of Conduct which should include the following could easily be interpreted as related to the response or non-response of the hospital or doctors to the patient modesty or the professional gender selection issue:

"Responding to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors. The response should include hearing and empathizing with their concerns, thanking them for sharing those concerns, thanking them for sharing those concerns and apologizing"


To both of my visitors: If you are not involved in hospital administrations or are a doctor or nurse in the hospital you may have no idea of the clout that Joint Commission holds and uses. They investigate policies and behaviors in an extensive and thorough manner of hospital and staff with regard to standards of hospital practice which they have ordered, without fully informing the hospital when the Commission staff will appear. And failure to comply is followed by warnings and potentially severe financial penalty with the loss of Medicare.
payments. The Joint Commission visits scare even the most sophisticated hospital administration. So this requirement by the Joint Commission is and will continue to be taken very seriously.

As a physician in my local community hospital, this Joint Commission order was clearly explained to us in a recent medical staff meeting. Yes, there was some discussion amongst the physicians about a value to abusive language directed to another staff member when that member was seen doing something critically wrong in an acute situation when a patient's life was at stake. However,some felt that one could notify that staff member effectively about the error without using abusive language.

I hope I have responded to both visitor's questions satisfactorily.

By the way, let's keep this thread to the more general issue of disruptive behaviors and examples and implications. But let's not turn this thread into an extensive discussion of one example. I would suggest that those visitors who came here from the patient modesty thread should return there to continue the discussion there regarding the implication of the Joint Commission's directive with regard to their patient modesty concerns. That will make this thread more open to a number of issues which are relevant. ..Maurice.

 
At Sunday, August 17, 2008 12:48:00 AM, Anonymous Mary said...

There was a thread on another blog discussing the "cultural divide" between surgeons and other physicians. The husband of a patient who accompanied his wife into the OR during a C-section recounts his observation of real fear from nurses towards the surgeons when a sponge went missing as the woman's abdomen was being sewn up. I found it very telling about OR behavior.

http://www.healthbeatblog.org/2008/08/surgeons-and-su.html

Also, on the Allnurses forum, there are many, many threads on disruptive surgeons in the OR. It seems the male nurses are either not recipients of the abuse, or if they are, they just let it roll off their backs, or in some cases quiet the tirade by verbally strike back. The female nurses almost always are so upset by abusive behavior when directed at them resulting in tears and thoughts of changing their careers.

 
At Monday, August 18, 2008 9:34:00 AM, Blogger Mike Pringle said...

As a fellow healthcare professional I have seen this from both sides - MD and RN. Granted much of the abuse comes from the MD side, there are still plenty of nurses out there that are beyond aggressive.

The one thing that Mary mentions is quite true. RNs that are male get treated differently compared to their female counter parts. I know this as I am an RN and a guy. I get called doctor all the time by staff that don't me, other physicians that don't know me and other nurses that don't know me. The patients call me doctor all the time. Be that as it may once these folks find out I am an RN their tone and conversation changes completely. It is very interesting to watch happen.

As far as the guys taking any abuse or not I think most of us don't I know I don't. I don't let anyone regardless of their position or title speak to me rudely. I have pulled several nurses aside and many many MDs into the store room and told them not so nicely that I am not going to tolerate their nonsense anymore. Most of the women nurses don't do that for what ever reason.

In any event the key to this policy as your previous readers have mentioned is the enforcement of this type of program. In the end I suppose people will be able to complain to the Joint Commission for those facilities that are not taking care of business. This will be a good topic to follow over the next year once it goes int effect.

I would also like to see if any facilities lose their accreditation.

 
At Monday, August 25, 2008 4:17:00 PM, Blogger Supremacy Claus said...

Every doctor has an affirmative duty to defend clinical care. If any doctor is subjected to this unlawful discipline, they should consult an attorney, to review the option of suing the hospital, the accuser, the JCAHO, the AMA Ethics Council, each officer and member as individuals, and all their employers for failure to control these out of control PC ideologues. These institutions have massive funds and power. They need strong deterrence.

Doctors, by their litigation and injunctions, must remind these oppressive enemies of freedom, where we live and what our Constitution says. To deter.

 

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