Friday, December 12, 2008

More about Joint Commission’s disruptive behavior policy

Chris Rangel wrote a provocative post about Joint Commission’s new disruptive behavior policy set to go into effect in 2009. He’s concerned that the definition of disruptive behavior (for which the JC recommends a zero tolerance policy) is a little vague, particularly this language (italics mine):

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.

He points out:

Wait a minute! What this second part means is that basically, if you are having a bad day, then you’re a disruptive physician. If you have a bad bedside manner or you are not chummy with the hospital staff then you are disruptive. If you are distracted by a personal or professional crisis, then you are being disruptive. As one AMA delegate put it, if you are perceived as being disruptive to any particular staff member then you ARE disruptive.

By this definition a hospital administration could invoke the disruptive behavior policy to sanction anyone they don’t happen to like.

He goes on to point out an important unintended consequence of such a policy, which is to suppress strong opinions and concerns about hospital operations which may impact patient care. As I first noted here, such whistle blowing on the part of physicians, even legitimate expressions of concern, may be construed as disruptive.

He concludes:

The JC shouldn’t be trying to codify specific behaviors. Each case is unique and should be decided without specific description of behaviors leading to unfair bias while loosing sight of the endpoint of this whole endeavor. Neither should we expect every person in a high stress job where people’s lives are on the line to walk around like a smiling jackass in some hall monitor’s idea of the perfect Stepford Wives-like medical nightmare where everyone is pleasant and totally incompetent. Given the choice, I’d rather be treated by the brilliant asshole* then Dr. Smiley Mannequin. So far the AMA has asked the JC to reconsider their proposal. Let’s hope that the JC grows some CS.

While I agree with Rangel for the most part he failed to mention that the new JC policy is no respecter of persons---it applies equally to nurses, pharmacists, doctors and administrators. There’s no double standard. Everyone in the health care environment is expected to be civil. It’s not just about doctors anymore. As I pointed out in a recent post Alan H. Rosenstein, MD, MBA, an expert who has written a great deal on this subject, said that many doctors are the recipients rather than the perpetrators of disruptive behavior.

The Joint Commission, much to its credit, recognizes that fact. The Sentinel Event Alert regarding the new standard is careful to avoid the term “disruptive physician” and says:

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.

The report recommends several actions including (italics mine):

Educate all team members – both physicians and non-physician staff – on appropriate professional behavior defined by the organization’s code of conduct.

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…

If you’ve worked in a hospital for any length of time you know that this disruptive behavior thing works both ways. That’s why I’m more than a little disappointed in the New York Times distortion of the issue in their recent article Arrogant, Abusive and Disruptive — and a Doctor. It’s a one sided portrayal of the stereotypical instrument throwing physician who intimidates everyone else on the health care team:

Still, every nurse has a story about obnoxious doctors. A few say they have ducked scalpels thrown across the operating room by angry surgeons. More frequently, though, they are belittled, insulted or yelled at — often in front of patients and other staff members — and made to feel like the bottom of the food chain. A third of the nurses in Dr. Rosenstein’s study were aware of a nurse who had left a hospital because of a disruptive physician.

With JC’s broad definition of disruptive behavior applied across the whole spectrum of health care providers the possibilities are endless. If a nurse grudgingly carries out a doctor’s orders, if an attending leans a little too heavily on a medical student or if administration is unreceptive to expressed concerns about patient care, one can invoke the disruptive behavior policy.

1 comment:

PookieMD said...

At my hospital we would like to see a "disruptive patient" manifesto from JACHO. Alas, not likely to happen! Personally, there is a hospital where I refuse to work because the NURSES are so nasty. It has a reputation amongst the local hospitalists of being horrific to work at because the nurses make the physicians lives miserable by being uncooperative, surly, inflammatory and confrontational. Hmmm, sounds like what JACHO was talking about.