They are in every hospital—physicians and other professionals who throw tantrums, throw instruments, refuse to answer pagers, roll their eyes at colleagues, and otherwise disrupt the care of patients.
Now the Joint Commission is cracking down on these problem individuals. Under new Joint Commission standards that will go into effect in January 2009, hospitals and other health care organizations will be required to establish a code of conduct that defines unacceptable behavior and spells out the consequences for misconduct.
The issue is so important to the Joint Commission that officials there decided to highlight it through the release of a Sentinel Event Alert this summer. The alert warns that disruptive behaviors ranging from verbal outbursts and physical threats to refusing to perform assigned tasks can cause medical errors, contribute to patient dissatisfaction, and increase the cost of care.
“This is the medical version of 'road rage' and sometimes it's just little passive-aggressive things and other times it's very, very flagrant,” said Dr. Peter B. Angood, vice president and chief patient safety officer for the Joint Commission.
These events are not uncommon, according to the Joint Commission. About 40% of clinicians have declined to question medication orders in the past year because they wanted to avoid interacting with an intimidating prescriber, according to a 2003 survey of more than 2,000 health care professionals conducted by the Institute for Safe Medication Practices. And even when clinicians spoke up, 49% said they felt pressured into dispensing or administering the medication despite their concerns, the survey found.
Other surveys have found similar trends. A 2004 survey of more than 1,600 physician executives, conducted by the American College of Physician Executives, found that 14% of respondents observed problems with physician behavior in their own organizations on a weekly basis.
In addition to establishing a code of conduct, the Joint Commission is recommending that hospitals and other health care organizations:
▸ Educate their physician and nonphysician workforce on appropriate professional behavior and provide training and coaching to managers on conflict resolution.
▸ Enforce the code of conduct consistently among staff members regardless of seniority or clinical specialty.
▸ Adhere to a “zero tolerance” policy for the most egregious incidents such as assault and put in place a progressive system of discipline for addressing lesser violations.
▸ Protect those who report incidents and include nonretaliation clauses into policy statements.
▸ Develop a system to assess the prevalence of unprofessional behaviors in the organization and implement a reporting surveillance system to detect unprofessional behavior.
Those organizations that have already successfully addressed disruptive behaviors have found it helpful to establish anonymous reporting systems, Dr. Angood said. Another essential component of a successful system is ensuring that every report will be investigated, regardless of the stature of the person involved.
“There's nothing more frustrating than for someone to be intimidated and feel that they can't report it or if they do report it, that nothing is going to happen,” Dr. Angood said.
The Joint Commission alert is “important” because it raises the issue, said Dr. Gerald B. Hickson, associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.
Since 1996, Vanderbilt has been using the Patient Advocates Reporting System, which collects and analyzes patient complaints, to identify problem physicians. Over the last decade, the system has also been adopted by a number of large academic medical centers and community medical centers. The information is then used to try to alter physician behavior by first alerting them to the complaints. Later, if problems persist, physicians may be required to participate in wellness programs, or take classes on risk management or on improving communication skills. If problems continue after that, corrective action may be taken.
Overall, the Vanderbilt data suggest that about 4%-6% of the physician population engages in some form of disruptive behavior, Dr. Hickson said. Some clinicians who behave in hostile or disruptive ways may have family life problems or even personality disorders, Dr. Hickson said. It's important for organizations to offer support and counseling services but in many cases clinicians won't utilize these services until their problems have boiled over into a disruptive event, he said.
“We really don't play well in the sand box together,” said Hedy Cohen, R.N., vice president of nursing at the Institute for Safe Medication Practices.
Any organization that is interested in safety needs to pay attention to this issue, Ms. Cohen said, because it creates a huge obstacle to communication among members of the health care team. Even passive behaviors—such as rolling eyes at a colleague or hanging up the phone on someone—make it difficult for clinicians to question orders or advocate for patients.