Archive for July, 2008

Behaviors that undermine a culture of safety
from JCAHO Sentinel Event Alert

Intimidating and disruptive behaviors can foster medical errors,(1,2,3) contribute to poor patient satisfaction and to preventable adverse outcomes,(1,4,5) increase the cost of care,(4,5) and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. (1,6) 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.(2) Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.(7, 8, 11) All intimidating and disruptive behaviors are unprofessional and should not be tolerated.

Intimidating and disruptive behaviors in health care organizations are not rare.(1,2,7,8,9) A survey on intimidation conducted by the Institute for Safe Medication Practices found that 40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator.(2,10) While most formal research centers on intimidating and disruptive behaviors among physicians and nurses, there is evidence that these behaviors occur among other health care professionals, such as pharmacists, therapists, and support staff, as well as among administrators. (1,2) Several surveys have found that most care providers have experienced or witnessed intimidating or disruptive behaviors.(1,2,8,12,13) These behaviors are not limited to one gender and occur during interactions within and across disciplines.(1,2,7) Nor are such behaviors confined to the small number of individuals who habitually exhibit them.(2) It is likely that these individuals are not involved in the large majority of episodes of intimidating or disruptive behaviors. It is important that organizations recognize that it is the behaviors that threaten patient safety, irrespective of who engages in them.

The majority of health care professionals enter their chosen discipline for altruistic reasons and have a strong interest in caring for and helping other human beings. The preponderance of these individuals carry out their duties in a manner consistent with this idealism and maintain high levels of professionalism. The presence of intimidating and disruptive behaviors in an organization, however, erodes professional behavior and creates an unhealthy or even hostile work environment – one that is readily recognized by patients and their families. Health care organizations that ignore these behaviors also expose themselves to litigation from both employees and patients. Studies link patient complaints about unprofessional, disruptive behaviors and malpractice risk.(13,14,15) “Any behavior which impairs the health care team’s ability to function well creates risk,” says Gerald Hickson, M.D., associate dean for Clinical Affairs and director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center. “If health care organizations encourage patients and families to speak up, their observations and complaints, if recorded and fed back to organizational leadership, can serve as part of a surveillance system to identify behaviors by members of the health care team that create unnecessary risk.”

Root causes and contributing factors

There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.(10) Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it. (9,11) Intimidating and disruptive behavior stems from both individual and systemic factors.(4) The inherent stresses of dealing with high stakes, high emotion situations can contribute to occasional intimidating or disruptive behavior, particularly in the presence of factors such as fatigue. Individual care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior.(8,11) They can lack interpersonal, coping or conflict management skills.

Systemic factors stem from the unique health care cultural environment, which is marked by pressures that include increased productivity demands, cost containment requirements, embedded hierarchies, and fear of or stress from litigation. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the health care team, (5,7,16) as well as by the continual flux of daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for inter-professional communication and for the development of trust among team members.

Disruptive behaviors often go unreported, and therefore unaddressed, for a number of reasons. Fear of retaliation and the stigma associated with “blowing the whistle” on a colleague, as well as a general reluctance to confront an intimidator all contribute to underreporting of intimidating and/or disruptive behavior.(2,9,12,16) Additionally, staff within institutions often perceive that powerful, revenue-generating physicians are “let off the hook” for inappropriate behavior due to the perceived consequences of confronting them.(8,10,12,17) The American College of Physician Executives (ACPE) conducted a physician behavior survey and found that 38.9 percent of the respondents agreed that “physicians in my organization who generate high amounts of revenue are treated more leniently when it comes to behavior problems than those who bring in less revenue.”(17)

Existing Joint Commission requirements

Effective January 1, 2009 for all accreditation programs, The Joint Commission has a new Leadership standard (LD.03.01.01)* that addresses disruptive and inappropriate behaviors in two of its elements of performance:

EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.

EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors.

In addition, standards in the Medical Staff chapter have been organized to follow six core competencies (see the introduction to MS.4) to be addressed in the credentialing process, including interpersonal skills and professionalism.
Other Joint Commission suggested actions

1. Educate all team members – both physicians and non-physician staff – on appropriate professional behavior defined by the organization’s code of conduct. The code and education should emphasize respect. Include training in basic business etiquette (particularly phone skills) and people skills.(10, 18,19)
2. Hold all team members accountable for modeling desirable behaviors, and enforce the code consistently and equitably among all staff regardless of seniority or clinical discipline in a positive fashion through reinforcement as well as punishment.(2,4,9,10,11)
3. Develop and implement policies and procedures/processes appropriate for the organization that address:
* “Zero tolerance” for intimidating and/or disruptive behaviors, especially the most egregious instances of disruptive behavior such as assault and other criminal acts. Incorporate the zero tolerance policy into medical staff bylaws and employment agreements as well as administrative policies.
* Medical staff policies regarding intimidating and/or disruptive behaviors of physicians within a health care organization should be complementary and supportive of the policies that are present in the organization for non-physician staff.
* 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.
* 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, and apologizing.(11)
* How and when to begin disciplinary actions (such as suspension, termination, loss of clinical privileges, reports to professional licensure bodies).
4. Develop an organizational process for addressing intimidating and disruptive behaviors (LD.3.10 EP 5) that solicits and integrates substantial input from an inter-professional team including representation of medical and nursing staff, administrators and other employees.(4,10)
5. Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution.(4,7,10,11,17,20) Cultural assessment tools can also be used to measure whether or not attitudes change over time.
6. Develop and implement a system for assessing staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients.(10,17)
7. Develop and implement a reporting/surveillance system (possibly anonymous) for detecting unprofessional behavior. Include ombuds services(20) and patient advocates,(2,11) both of which provide important feedback from patients and families who may experience intimidating or disruptive behavior from health professionals. Monitor system effectiveness through regular surveys, focus groups, peer and team member evaluations, or other methods.(10) Have multiple and specific strategies to learn whether intimidating or disruptive behaviors exist or recur, such as through direct inquiries at routine intervals with staff, supervisors, and peers.
8. Support surveillance with tiered, non-confrontational interventional strategies, starting with informal “cup of coffee” conversations directly addressing the problem and moving toward detailed action plans and progressive discipline, if patterns persist. (4,5,10,11) These interventions should initially be non-adversarial in nature, with the focus on building trust, placing accountability on and rehabilitating the offending individual, and protecting patient safety.(4,5) Make use of mediators and conflict coaches when professional dispute resolution skills are needed.(4,7,14)
9. Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff, (11) with adequate resources to support individuals whose behavior is caused or influenced by physical or mental health pathologies.
10. Encourage inter-professional dialogues across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.(1,2,4,10)
11. Document all attempts to address intimidating and disruptive behaviors.

JCAHO Sentinel Event Alert
Better Hospital Manners by Mandate from WSJ

Excerpt from
Harvard Medical School 2005 commencement address
by Dr. Atul Gawande
I must point out, however, that my rules for medical practice should be distinguished from the laws of medical practice. Rules are personal instructions you might follow in your life as a doctor. Laws are the immutable realities you come up against in that life. For example, one law is: The labs are always normal, the lumps are never cancer, and the sixteen year-olds are never pregnant, unless you don’t check them. Or: If your new patient is on five or more drugs, you will not have heard of at least one of them.
Many other laws exist. There are, for example, thirty-five laws governing the behavior of pagers alone. But these are not what we want to talk about today. What we want to talk about is how one survives among the hundreds of thousands who make their life in this strange and teeming world—and, moreover, having survived, how one might make a worthy difference.
My Rule #1 for you comes from a favorite essay by the writer Paul Auster: Ask an unscripted question. Ours is a job of talking to strangers. Why not learn something about them?
On the surface, this seems easy enough. Then your new patient arrives. You still have three others to see, two pages to return, and the hour is getting late. In the instant, all you will want is to get things over with. Where’s the pain, the lump, whatever it is? How long has it been there? Does anything make it better or worse? What are your past medical problems? You all know the drill by now.
But I want you, at an appropriate point, to take a small moment with your patient. Make yourself ask an unscripted question: “Where did you grow up?” Or “What made you move to Boston?” Or “Did you watch last night’s Red Sox game?” I’m not looking for a deep or important question, just one that lets you make a human connection.
Some people will not be interested in making that connection. They just want you to look at the lump. That’s okay. Look at the lump in that case. Do your job.
You will find that many respond, however—because they’re polite, or friendly, or perhaps in need of that human contact. When this happens, see if you can keep the conversation going for more than two sentences. Listen. Make note of what you learn. This is not a 46 year old male with a right inguinal hernia. This is a 46 year old former mortician, who hated the funeral business, with a right inguinal hernia.
You can do this for more than just patients, too. Ask a random question of the ICU nurse you see on rounds, the medical assistant who checks their vitals. It’s not that doing
this necessarily helps anyone. But you will start to remember the people you see, instead of having them all blur together. Sometimes you will discover the unexpected.
I learned, for instance, that an elderly Pakistani phlebotomist I saw every day in residency had been a general surgeon in Karachi for twenty years, but emigrated for the sake of his children’s education. I learned that a quiet, carefully buttoned-down nurse I work with had once traveled with Jimi Hendrix on tour.
The machine will gradually feel less like a machine.
My Rule #2 is: Don’t whine. To be sure, doctors have plenty to complain about: computer system crashes, 2 a.m. pages, insurance companies, work getting dumped on you at 6 o’clock on a Friday night. We all know what it is to be tired and beaten down. Yet nothing in medicine is more dispiriting than hearing doctors whine.
Anyone who has played high school sports knows the dynamic I’m talking about. Morale is an elusive and fragile entity. My southern Ohio hometown high school tennis team traveled up to 75 miles through Appalachia for matches against other teams. We were undefeated. But when the weather got hot, a few bad calls went against us, the matches grew close, and that long un-air-conditioned van-ride home began to loom, the griping would begin to well up. It was all Coach Roach could do (that really was his name) to keep us from giving into defeat. He’d yell and stomp—“What are you cry-babies belly-aching about?”, and since he was also the school psychologist, we’d finally remember what we were there for.
The practice of medicine can go the same way. It is a team sport with two differences: the stakes are people’s lives and we have no coach. This latter is the most relevant difference. Doctors are supposed to coach themselves. We have no one but ourselves to buck us up. But we’re not good at it. Wherever you find doctors—sitting with fellow residents in the hospital cafeteria, waiting in a conference hall for grand rounds to start—you will find the natural pull of conversational gravity is toward the litany of woes all around us.
Resist it. It’s boring, and it will get you down. I’m not saying you have to be all Julie-Andrews-Mary-Poppins about everything. Just be prepared with something else to talk about: An interesting patient you saw, an idea you read about, even the weather if that’s all you’ve got.
Then see if you can keep the conversation going.

Rule #3 is: Count something. No matter what you ultimately do in medicine—whether you go into purely clinical practice or work in research or business and never touch a patient again—a doctor should be a scientist in his or her world. In the simplest terms, this means that we should count something. The laboratory researcher may count the number of tumor cell lines with a particular gene defect. Likewise, the clinician might count the number of patients who develop a particular complication—or even just how many are seen on time and how many were made to wait. It doesn’t really matter what you count. You don’t need a research grant. The only requirement is that what you count should be interesting to you.
When I was a resident I began counting how often one of our patients had something forgotten inside them after surgery—either a sponge or an instrument. It wasn’t very frequently: about one in 15,000 operations. But they could be badly injured. One patient had a 13 inch retractor left in him and it tore into his bowel and bladder. Another had a small sponge left in his brain, which caused an abscess and a permanent seizure disorder.
Then I counted how often such cases happened because the nurses hadn’t counted all the sponges like they were supposed to, or because the doctors ignored nurses’ warnings that something was missing. It turned out to be hardly ever.
I got a little more sophisticated and compared patients who had stuff left inside them with ones who didn’t. It turned out that the mishaps predominantly occurred in patients with emergency operations or operations in which something unexpected was encountered—like a cancer when one expected appendicitis. Things began to make sense. If nurses have to track fifty sponges and a couple hundred instruments during an operation, already a tricky thing to do, it is understandably much harder under emergency circumstances, or when unexpected changes require bringing in lots more equipment. Punishing people more therefore wasn’t going to eliminate the problem. Only a technological solution would—perhaps a way of scanning for sponges and instruments in everyone.
If you count something interesting to you, I tell you: you will find something interesting.
My Rule #4 is: Write something. It makes no difference whether you write a paper for a medical journal, five paragraphs for a website, or a collection of poetry. Try to put your name in print at least once a year. What you write does not need to achieve perfection. It only needs to add some small observation about our world.
One should not underestimate the effect of one’s contributions. The physician and poet Lewis Thomas once pointed out, “The invention of a mechanism for the systematic publication of fragments of scientific work may well have been the key event in the history of modern science.” For by soliciting modest contributions from the many, it has produced a store of collective know-how with far greater power than any one individual could have achieved. I think this is as true outside science as inside.
One should also not underestimate the power of the act of writing itself. I did not write until I became a doctor. But once I became a doctor, I found I needed to write. Medicine is retail. We provide our services to one person at a time, one after another. It is a grind. For all its complexity, it is more physically than intellectually taxing. But writing let me step back, engage as something more than a retailer, and think through a problem. Even the angriest rant forces the writer to achieve a degree of thoughtfulness.
Furthermore, by putting your writing out to an audience, even a small one, you connect yourself to something larger than yourself. The first thing I ever published was a diary in an online magazine of five days as a surgical resident. I remember that feeling of having it come out in print. One is proud but also nervous. Will people notice it? What will they think? Did I say something dumb? An audience is a community. The published word is a declaration of membership in that community, and also of concern to contribute something meaningful to it.
So choose your audience. Then write something.
Rule #5, my final rule for a good life in medicine, is: Change.
In medicine, as in any human endeavor, people respond to new ideas in one of three ways. A few become early adopters, as the business-types call them. Most become late adopters. And some remain persistent skeptics, who never stop resisting. A doctor has good reasons to adopt any of these stances. When Joseph Murray and Francis Moore performed the world’s first successful kidney transplant in the hospital behind us fifty years ago, but also had 30 deaths; when a French gynecologist first pointed his laparoscope in a new direction and used it to take out a gallbladder; when cholesterol-lowering drugs first came out; when the first electronic medical record was invented—who was to say whether these were truly good ideas or not? We have seen plenty of bad ones. Frontal lobotomies were once done for control of chronic pain. Vioxx turns out to cause heart attacks. Viagra, it was recently discovered, may cause partial vision loss.
Nonetheless, make yourself an early adopter. Look for the opportunity to change. I am not saying you should take on every new thing that comes along. But be willing to recognize the inadequacies in what we do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure. This is what makes it human, at times painful, and also so worthwhile.
You become a doctor today, and the choices you will make with your patients will be imperfect but nonetheless alter their lives. There will come a time when, because of that reality, it seems safest to do what everyone else is doing—to be just another white-coated cog in the machine.
Don’t let yourself be. Find something new to try, something to change. Count how often it succeeds and how often it doesn’t. Write about it. Ask a patient or a colleague what they think about it. See if you can keep the conversation going.

To read the full text, go to:
Harvard Med School 2005 Commencement Address

“Better” by Atul Gawande