Steve Evans' presentation from ACSCC12

1. Defining Disruptive Behavior
STEPHEN EVANS, MD
PROFESSOR OF SURGERY
VICE PRESIDENT FOR MEDICAL AFFAIRS
SENIOR ASSOCIATE DEAN
GEORGETOWN UNIVERSITY MEDICAL
CENTER

2. No Financial Disclosures

3. Disruptive Behavior
Why Surgeons?
 234 million surgical procedures are performed
worldwide
 Complexity and volume create a stressful
environment
 A perceived notion that surgeons should
display focused and authoritative behavior

4. The Potential for Disruptive Behavior is High

5. Surgeons and Disruptive Behavior
 6 year study queried over 4500 medical
professionals (physicians, nurses, technicians,
etc.)*
 Over 100 hospitals in the assessment
(community, rural, academic, etc)
 Among physicians, disruptive behavior was
observed greater than 75% of the time among
surgical specialties
*Rosenstein and O’Daniel. Neurology 70:
1564, 2008.

6. Surgeons and Disruptive Behavior
 Highest ranking incidence of disruptive
behavior by medical specialty:*
 General Surgery
 Neurosurgery
 Cardiovascular Surgery
 Orthopedic Surgery
*Rosenstein and O’Daniel. Jt. Comm J Qual. Patient
Safety, 2008.

7. Surgeons and Disruptive Behavior
 When 110 surgeons at one hospital system
were surveyed regarding nine behaviors that
had been previously been identified as
disruptive by various national organizations,
only four of the behaviors were classified as
disruptive by most of the surgeons.*
*Dull and Fox. Am J Med Qual., 2010.

8. Mind vs. Body
We judge ourselves based upon our
intentions.
Others judge us based upon our
behaviors.

9. Disruptive Behavior
“We propose that disrespectful
behavior is the “root cause” of
the dysfunctional culture that
permeates health care and
stymies progress in safety and
that it is also a product of that
culture.”
Leape et al. Acad. Med. July 2012.

10. Joint Commission Sentinel Event Alert
July 9, 2008
 Behaviors that undermine a culture of safety
 Intimidation and disruption
 Foster errors
 Discourage teamwork
 Verbal outbursts
 Linked to stress, personality, issues of authority
and autonomy, emotional pressures
 Common and historically tolerated

11. AMA and Disruptive Behavior
“Personal conduct . . . that may effect patient
care negatively constitutes disruptive behavior.
However, criticism that is offered in good faith
with the aim of improving patient care should
not be construed as disruptive behavior.”*
*AMA Report on the Council of Ethical
and judicial Affairs, 2008.

12. ACS and Disruptive Behavior
Alert Aims to Stop Bad Behavior Among Health
Care Professionals*
“Health care is a high -stakes pressure packed
environment that can test the limits of civility in
the workplace.”
*Bulletin of the American College of Surgeons, Oct. 2008

13. ACS Cont’d.
 A new Sentinel Event Alert issued by the Joint
Commission warns that rude language and
hostile behavior among health care
professionals goes beyond . . . unpleasant and
poses a serious threat to patient safety and the
overall quality of care.
 40% of clinicians have kept quiet or remained
passive during disruptive events . . . rather
than question a known intimidator.”
*Bulletin of the American College of Surgeons, Oct. 2008

14. Joint Commission Standards*
The term “disruptive behavior” is changed in the standards
The term “disruptive behavior” in two elements of performance
(LD.03.01.01, EPs 4 and 5) has been revised to “behavior or
behaviors that undermine a culture of safety.” It has
been brought to the attention of staff at The Joint Commission that
the term “disruptive behavior” is not viewed favorably by some in
health care, and it can be ambiguous for some audiences. For
example, some physicians object that strong
advocacy for improvements in patient care can be
characterized as disruptive behavior. Also, the phrase
“disruptive behavior” may be used in the context of a care
environment that has become temporarily unsettled by the behavior
of a patient.
*Joint Commission Online, Nov. 2011

15. A Fine Line . . . .
Authoritative vs. Demeaning
Instructive vs. Belittling
Critical vs. Overbearing
Tone, inflection,
emotional engagement,
degree of professional
intimacy, etc.

16. Recommendations
 The Physician Leaders in conjunction with
Hospital Administration (not Administration
alone) should develop a code of conduct that
defines acceptable behavior and behaviors that
undermine a culture of safety.
 This code of conduct should be widely vetted
among all physicians with full buy-in.
 A reporting structure for such events should be
established and well communicated

17. Recommendations Cont’d.
 A Physician Health Committee (PHC) should be
established to render a fair evaluation (using
such tools as RCA, etc.) of such events and
make a recommendation to the VPMA
 The PHC should include legal counsel, HR,
nursing representation, and a diversity of
physician reps (including the DIO/ GME rep)
 Management of disruptive behavior should be
clearly defined and extremely well
communicated to all physicians

18. Recommendations Cont’d.
 Mandatory team training for all physicians will
lead to far fewer disruptive behavioral issues
and clearer communication channels

19. The Stakes are High
 The severity (leading to patient disability or
death) or the frequency of disruptive events can
lead to loss of privileging and possible
additional reporting
 Leal vs. Sec. of HHS, 11th Circ., 9/22/10.
 The U.S. Court of Appeals for the Eleventh Circuit
 The hospital reported the practitioner, a Urologist to the
NPDB after having been suspended from the hospital for
60 days

20. Disruptive Behavior
We have an obligation to protect
the public . . . . and also our
surgeons!

21. Conclusions
 Disruptive behavior appears to be seen most
commonly among surgeons
 Definitions must be put in place to define such
behavior
 A clear process should be established to
determine whether disruptive behavior in fact
did occur
 Professional staff need complete buy-in on the
definitions, processes and consequences of
disruptive behavior