Navigating Two Standards of Disruptive Behavior, Then Effectively Addressing It

In unveiling its new standards to address disruptive and inappropriate behavior within health care organizations, the Joint Commission was clear regarding the negative impact such conduct can have on a culture of safety.

Rather than providing a definition for disruptive behavior, however, the Joint Commission offered examples of such conduct, including verbal outbursts, uncooperative attitudes and impatience with questions. Due in part to this broad definition, the American Medical Association (AMA) asked the Joint Commission to delay implementation of the new standards. And when the Joint Commission did not do so, the AMA adopted its own Model Medical Staff Code of Conduct.

With a third of the 16,000 Joint Commission–accredited health care organizations slated to be surveyed this year, it may be possible to determine whether the new guidelines—either or both—are having any immediate effect. And while the presence of these sometimes dueling standards could somewhat complicate the task of addressing disruptive behavior, organizations can generally draw on components of both in updating their policies.

The following article explains differences between the two sets of guidelines and covers best practices organizations can implement now with the overarching goal of improving patient safety.

An Ongoing Challenge for Health Care Leaders

In its July 9, 2008, issue of Sentinel Event Alert, the Joint Commission detailed the negative effects that intimidating and disruptive behaviors create for a health care organization's culture of safety. None of it was breaking news to most health care leaders.

That such 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" has long been recognized by health care leaders. Most believe these issues are worthy of the organization's time and attention.

Recognition of the problem has never been the issue. Numerous studies have been published over the years demonstrating that disruptive behavior, especially by physicians, is not an aberration, but, in fact, common and widespread.

Addressing the problem in a professional and effective manner—that eliminates the negative behavior while preserving the relationship between disruptive team members who are otherwise assets to the health care team and the organization—remains the challenge for health care leaders.

Standards Require Leaders to Take Direct Action

The bottom line is that the Joint Commission standards, which took effect January 1, require health care leaders to confront disruptive behavior head-on through means such as developing codes of conduct and evaluating physician core competencies.

Leadership Standard (LD) 03.01.01

The Joint Commission now requires health care organization leaders to "create and maintain a culture of safety and quality" by, in part "address[ing] disruptive behavior of individuals working at all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members." Specifically, the elements of performance for LD.03.01.01 require health care organizations to among other things: (1) develop a code of conduct that defines acceptable, disruptive, and inappropriate behaviors, and (2) create and implement a process for managing disruptive and inappropriate behaviors.

Medical Staff Standard (MS) 4.00

The Joint Commission also now requires the health care organization's organized medical staff to specifically address disruptive physician behavior through two new "core competencies" that must be evaluated during the credentialing and privileging process: (1) interpersonal and communication skills, and (2) professionalism.

Joint Commission Lists Array of Disruptive Behaviors

The biggest challenge for most health care organization—and the biggest concern voiced by the physician community—is defining "disruptive behavior." The new Joint Commission standards themselves do not contain a specific definition of disruptive behavior. In the Sentinel Event Alert, the Joint Commission stated:

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.

AMA Code More Narrowly Defines "Disruptive" and "Inappropriate"

In December 2008, the AMA asked the Joint Commission to delay implementation of the new standards, in part, because of this broad definition of disruptive behavior. Physicians raised concerns that health care organizations would use the disruptive behavior standard to suppress opinions and concerns about hospital operations that impact patient care and to remove outspoken physicians from the medical staff.

When the Joint Commission did not delay the new standards, the AMA adopted its own Model Medical Staff Code of Conduct and encouraged organized medical staffs to adopt the AMA model code as part of their medical staff bylaws.

The AMA model code includes a definition not only for "disruptive behavior," but also for "inappropriate behavior," which, unless persistent and repeated, does not warrant discipline. Disruptive behavior is defined as "any abusive conduct including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised." Inappropriate behavior involves "conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive."

Joint Commission, AMA Also Diverge on Reporting

Based on the language in the Joint Commission's Sentinel Event Alert, health care organizations are well served to define disruptive behavior in their organizational code of conduct somewhat more broadly than the AMA definition.

The Sentinel Event Alert indicates that an organization's process for identifying disruptive team members—including physicians—should involve a variety of means, which might include ombuds services and patient advocates, patient surveys, focus groups, peer and team member evaluations, and direct inquiries at routine intervals with staff, supervisors, and peers. While the Joint Commission supports anonymous reporting of disruptive behavior, the AMA model code does not permit anonymous reporting or allow for use of a "hotline"—rather, any complaint must be in writing and signed by the complainant.

Whatever the procedure a health care organization adopts for disruptive behavior reporting, it should include gathering of clear and specific information including date, time, location, parties involved (including patients and family members), description of non-verbal behaviors, quotes of verbal comments, reactions of others, patient care or safety consequences, etc.

Organizations should appoint a single point of contact within the organization to whom all disruptive behavior reports should be directed, or, alternatively, consider allowing disruptive behavior reports concerning physicians to be directed to the president of the medical staff as suggested by the AMA model code.

Disruptive Behavior Must Be Addressed When it Occurs

Once disruptive behavior is defined, it must be appropriately and effectively addressed. Joint Commission Standard LD 03.01.01 requires health care organization to "create and implement a process for managing disruptive and inappropriate behaviors." In the Sentinel Event Alert, Joint Commission suggested a "zero tolerance" policy approach to disruptive behaviors enforced "consistently and equitably among all staff regardless of seniority or clinical discipline."

Both the Joint Commission and the AMA model code support an initial non-confrontational approach to disruptive behavior, where the initial emphasis is on positive reinforcement, restoring trust, and placing accountability on and rehabilitating the offending team member. Additionally, both the Joint Commission and the AMA model code support a tiered, progressive approach when disciplinary action becomes necessary.

The AMA model code, however, contains a far more detailed and rigid procedure for addressing disruptive behavior complaints involving physicians, which is akin to due process rights granted to physicians in peer review actions, than does the process suggested in the Joint Commission Sentinel Event Alert.

Ultimate Goal Is Improved Patient Safety

In addressing disruptive behavior, organizations should develop specific policies and procedures for addressing both physician and non-physician team members who exhibit disruptive behaviors—with an eye toward salvaging valued members of the health care team.

Such procedures should include, at a minimum, the criteria and methods for imposing progressive discipline for disruptive team members with specific steps to be taken at each level, and should clearly identify whether the organization or the medical staff will be responsible for taking any necessary disciplinary action.

And most importantly, the actual implementation of the code of conduct and its associated policies and procedures should provide safeguards and incentives to ensure that the reporting of intimidating and disruptive behavior ultimately leads to improved patient safety and outcomes.