Joint Commission defines Disruptive Behavior as “conduct by a health care professional that intimidates others working in the organization to the extent that quality and safety are compromised”. Research has found that disruptive behavior not only impacts the morale and staffing of an organization but can lead to medical errors and breakdowns in the quality of care, treatment, and services delivered.

1. Presented at the Middle East Patient Safety & Quality Congress
Abu Dhabi 11th – 13th May 2015
Presented By
Krishnan Sankaranayanan MS, MBA, CPHQ, FASHRM, LHRM
Senior Safety Officer / Tawam Hospital
Disruptive Behavior- “its impact on Staff & Patient Safety”

2. Disclosure
The presenter has nothing to disclose, nor has any commercial interest
with any of those information's displayed in this presentation.
2015/5/14 2

3. About Tawam Hospital
• Tawam is a 466-bed tertiary care facility located in the garden city Al Ain in the middle of the desert, and one
among the largest healthcare facilities in the United Arab Emirates.
• In 2006 the General Authority of Heath Services now called as the Abu Dhabi Health Services Company PJSC
(SEHA) entered in to a ten year affiliation contract with Johns Hopkins Medicine.
• Tawam Hospital has current status with
• Joint Commission International Accreditation (2006; 2009; 2012),
• College of American Pathology (CAP; 2011) and
• American College of Graduate Medical Education- International (ACGME; Program Accreditation)
2015/5/14 3

4. Learning Objectives
Attendees will be able to demonstrate knowledge on:-
• The definition and the types of disruptive behavior.
• Ways to identify and mitigate them.
• Creating support mechanism to help staff affected by disruptive
behavior.

5. Disruptive Behavior -Definition
• Conduct by a health care professional that intimidates others working
in the organization to the extent that quality and safety are
compromised. (Joint Commission)
• One of the requirements under Standard GLD.(Governance Leadership and
Direction)

6. Examples of these behaviors
• Abusive language
• Humiliating someone in front of others
• Rolling eyes in disgust
• Refusing to help others
• Throwing items
• Physically assaulting

8. Some facts
• Incivility can lead to social isolation or exclusion, the devaluation of
someone else’s work, verbal threats, and even physical
confrontations. The costs associated with incivility in the OR can be
substantial. (Physicians Weekly Incivility in Surgery March 27, 2012)
• Disruptive and disrespectful behavior by physicians has also been tied
to nursing dissatisfaction and likelihood of leaving the nursing
profession, and has been linked to adverse events in the operating
room.
• In a survey of 1,565 nurses, intimidation by physicians was found to
have a negative impact on patient care (Institute for Safe Medication
Practices, 2009)

9. Source: Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and
communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008:34;464-
471.

10. Reported
Not reported

11. Key strategies for improving the behavioral
culture in ORs:
• 1. Recognize the power of civility. Developing clear, consistent code
for all staff—regardless of stature within the organization.
• 2. Eliminate anonymity. staff needs to know each other. When
recruiting assess social skills and personality traits that will nurture a
culture of civility.
• 3. Get leadership “buy-in.” Administrative leaders should help model
the behavioral culture for the team working in the OR.

12. Ten commandments to deal with disruptive
behavior
1. Recognition and awareness- assess the frequency and significance
of disruptive behaviors.
2. Cultural commitment/leadership/champions- Commitment and
endorsement from the board, administration, and clinical
leadership.
3. Policies and procedures- establish a zero-tolerance policy, code of
conduct agreement as part of their employee contracts.
4. Incident reporting- adopt a uniform approach to event reporting
5. Structure and process- uniform methodology for addressing the
issues. Trained multidisciplinary team approach.

13. Ten commandments to deal with disruptive
behavior
6. Initiating factors- to understand the background as to why these
events might occur.
7. Education and training- raising awareness, role play.
8. Communication tools- Body language and voice inclination have a
greater impact. Providing scripted messages.
9. Discussion forums- encouraging staff interaction during patient
rounds or joint conferences.
10. Intervention strategies- implement a “code-white” or debriefing to
discuss constructive suggestions.

14. 2.2 Tawam Hospital has a zero-tolerance stand and approach to vertical and
horizontal bullying, violence, and demeaning behaviors. This approach applies
to employees, visitors, patients and family members.

15. Our data- PSN’s on Disruptive Behavior
5
3 3
2
1
0
1
0
1
2
3
4
5
6
7
8
2013 2014 2015
NoofPSN's
Year
PSNs on Disruptive Behavior
Doctor Vs Nurse Nurse Vs Porter Nurse Vs Nurse

16. “Plans for 2015 to achieve- Team brain storming”- Sticky Notes

17. Raise awareness
• Created video case study with scenarios
• Presented it at the OR staff meeting.

18. Staff major concern
• Staff appreciated the video
• Wanted assurance of strict & timely enforcement of “Zero Tolerance”

19. Approach
• Pilot Create task force (Multidisciplinary- Surgeon,
Anesthetist, Nursing)
• SWORD Team - Supporting Workers in the Operating Room
Affected by Disruptive Behavior.
• The main functions
• Respond
• Support
• Mediate
• Deescalate
• Facilitate
• Monitor

20. Approach –Contd…..
• Create frame work/guidelines for the functioning of the
SWORD Team.
• Aim:-
• To reinforce “ Zero Tolerance” to disruptive behavior
• To address the concerns logically and objectively
• Staff involved in disruptive behavior situations can call
SWORD Team.
• SWORD Team to meet within 24 hours with the staff
involved.
• At the end SWORD Team to de-brief and monitor.

21. Most Important variable!!
• Leadership support

22. Conclusion
• Leadership must enforce “Zero tolerance” to such behaviors.
• “if senior management fail to challenge unsafe behaviors they
unwittingly reinforce the notion that this behavior is acceptable to
the organization.”
safety matters a guide to health & safety at work leadership and organizational safety culture

24. References
• Rosenstein AH, Naylor B. Incidence and impact of physician and nurse
disruptive behaviors in the emergency department. J Emerg Med.
2012;43(1):139–148.
• Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors
and communication defects on patient safety. Jt Comm J Qual Patient Saf.
2008;34(8):464–471.
• Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes:
perceptions of nurses and physicians. Am J Nurs. 2005;105(1):54–64.
• Rosenstein AH, O’Daniel M. Impact and implications of disruptive behavior
in the perioperative arena. J Am Coll Surg. 2006;203(1):96–105.
• McLaren K, Lord J, Murray S. Perspective: delivering effective and engaging
continuing medical education on physicians’ disruptive behavior. Acad
Med. 2011;86(5):612–617.

25. Thank you
Contacts:
ksankara@tawamhospital.ae
+971 50 9211649