Disruptive Practitioners: Managing the Risks
by Mark A. Kadzielski, Esq, Fulbright & Jaworski, LLP, Los Angeles, CA
Disruptive practitioners have become major deterrents to quality patient care. In a study published in the January 2005 issue of Nursing Management, “Disruptive Behavior & Clinical Outcomes: Perceptions of Nurses & Physicians” by Alan H. Rosenstein, M.D., MBA, and Michelle O’Daniel, MHA, MSG, VHA, a nationwide network of leading community-owned health care organizations and physicians, found that widespread disruptive behavior in healthcare had an impact on adverse events, medical errors, quality care, patient safety and patient mortality. From a legal perspective, such bad behavior results in major legal exposure to the institution from hospital staff, patients and visitors who are affected by it. From an administrative perspective, disruptive behavior is a major cost to the institution in terms of increased nursing turnover, lost days due to sickness, and workers compensation claims.
The VHA study was a comprehensive look at the issue of disruptive behavior and involved 1,500 participants at fifty VHA hospitals nationwide. The study confirms many widely held conclusions about the serious consequences of allowing disruptive practitioners to “run amok” in health care institutions. Hospital Trustees, Administrators and Medical Staff leaders who have been reluctant to take action against such practitioners, or even address such behavior, based on intimidation, focus on other issues, or fear of “losing” a heavy-hitter/big admitter, should take another look at the true “costs” of their tolerance in light of this study’s important findings.
Disruptive behavior is defined as any inappropriate behavior, confrontation or conflict. Among those behaviors are: verbal or physical assault or attack; impertinent or inappropriate statements, comments, illustrations; criticism aimed to intimidate, belittle, undermine confidence, imply stupidity or incompetence; sexual harassment; stealing; and any other inappropriate activities.
Implement a Disruptive Practitioner Policy
Health institutions need to adopt effective disruptive practitioner policies and enforce them to minimize exposure to liability and the costs associated with disruptive behavior. The objectives of such policies should (1) ensure optimum patient care; (2) prevent or eliminate conduct which disrupts the operations of the Hospital, and/or adversely affects the ability of others to do their jobs; (3) avoid creation of a “hostile work environment”; and (4) eliminate interference with other practitioners’ ability to practice.
Establish Procedures for Reporting Disruptive Conduct
Procedures for reporting disruptive conduct should be established and need to be strictly followed. Such procedures should include identification of who may report potentially disruptive conduct, and how such reports may thereafter be handled.
All reports should be submitted to the Chief of Staff, and then forwarded to the relevant department/section Chair and other appropriate persons, with the provision that any disruptive conduct may be referred to the Medical Executive Committee (“MEC”). The MEC may exercise its prerogative in calling for a formal investigation, conducted by the Chief of Staff and relevant department/section Chair.
Disciplinary Process Should be Clearly Identified
A carefully staged disciplinary process needs to be followed as well in investigating complaints of disruptive behavior. One approach that has been useful is:
1. Initial Approach: Collegial
A single incident warrants verbal warning by Chief of Staff, or designee, that such conduct is inappropriate and must cease. Notation of verbal warning is entered in the practitioner’s credentials file.
2. Repeated Behavior: Pattern of Conduct
If the Chief of Staff, or designee, determines that repeated, confirmed incidents reflect a pattern of conduct, further warning is warranted and needs to be given and documented.
3. Repeated Behavior: Further Warning
(a) If the behavior continues, formal corrective action will be taken. The MEC and CEO, and/or designee will be notified of further incidents and warnings.
(b) A follow-up letter to the practitioner shall state the problem and remind the practitioner to behave professionally and cooperatively within the Hospital. A copy of this letter will be kept in his/her credentials file.
4. Repeated Behavior: Final Warning
If the disruptive behavior continues, the Chief of Staff, the relevant department/section Chair, or designee, shall meet with and advise the practitioner such conduct must stop. This meeting constitutes the final warning. It shall be followed by a letter to the practitioner confirming the final warning. A copy of this letter will be kept in his/her credentials file.
5. Subsequent Incidents: Formal Corrective Action
Any new incident of disruptive behavior will result in corrective action pursuant to the Medical Staff Bylaws.
In sum, disruptive behavior is a serious financial, legal and operational problem. Left unaddressed, practitioners who exhibit such behaviors will repeat and escalate these behaviors. Only prompt and measured responses under a fair but firm Disruptive Practitioner Policy will curb this conduct.