Hospitals will have greater reason to crack down on unruly medical staff and employees now that the Joint Commission is forcing them to scrutinize disruptive behavior more closely.
The new standard, which accompanied a sentinel-event alert released last week by the accrediting body, will ensure hospitals have established codes of conduct and policies to manage unprofessional behaviora direction that hospital officials welcomed. The recommendations outlined in the alert and the standard to be effective in January 2009 open dialogue and foster a culture of safety, executives said.
Overt and passive-aggressive behaviors lead to breakdowns in communication, which interfere with patient safety, according to the commission. (See the Top Story in the June 9 issue of our sister publication Modern Physician, Joint Commission standard targets bad doc behavior, for more on the commissions research.) This means surgeons who throw tools, nurses who are rude to patients and even employees who refuse to stop using BlackBerry devices during meetings should not be tolerated.
The issue of behavior is extraordinarily important, and it shouldnt have taken regulatory pressure for executives to begin focusing on culture changes in their hospitals, said David Munch, physician and chief clinical and quality officer for 423-bed Exempla Lutheran Medical Center, Wheat Ridge, Colo. Evidence has shown a strong correlation between respect in the workplace and mortality, he said, adding that the commissions new stance is a good starting point for hospitals that have not taken that correlation seriously enough.
A code-of-conduct standard already appears in the leadership chapter of the commissions accreditation manual. Originally the commission had thought to fold disruptive behavior guidelines into its National Patient Safety Goals, but decided that would be too repetitive, said physician Peter Angood, vice president and chief patient safety officer for the Oakbrook Terrace, Ill.-based commission. Under the revised standard, more-specific elements of performance will give executives detailed guidelines on how conduct policies should be established.
But whether the new standard will lead to actual changes in individuals remains unclear. Just having a standard is not enough to change behavior at the personal level, according to physician William Bornstein, chief quality officer for three-hospital Emory Healthcare system in Atlanta. Hospitals will have to develop a systemwide approach to understand the contributing factors that lead to outburstssuch as fatigue and personal issues outside of workand address each of those, he said. Its not just zero tolerance.
While the commission recognizes the need for established policies, it doesnt address how hospitals can remove disruptive doctors from staff, a process that can include a costly one- to two-year legal battle, said Rick Anderson, chief medical officer of 290-bed Methodist Medical Center of Illinois, Peoria. The commission should make it less onerous for hospitals to take action when needed, he said.
Behavioral issues, while a problem in hospitals, do not occur so frequently that its happening all the time, said Michael Bryant, Methodists president and chief executive officer. But when action is needed, the commission has created a method to help hospitals manage them. It gives you more strength and more support to have that discussion, he said. I think most physicians will respond appropriately.
Just how physicians will view the commissions latest guideline remains to be seen. Medical staff are not hospital employees and therefore are governed by their own bylaws, a sometimes challenging relationship, especially when it comes to enforcing conduct policies, said Gregory Wise, vice president of medical affairs at Kettering (Ohio) Medical Center. Most physicians in a community hospital couldnt care less about the Joint Commission, he said. It is the hospital that is regulated, not individual physicians, he added.
The commissions alert creates greater uniformity across hospitals to help create an environment that lets everyone in the facility understand that disruptive behavior will not be tolerated, Wise said. Nurses who bear the brunt of verbal abuse will feel more comfortable coming forward without fear of retaliation, and doctors will better understand they work in teams, he said. Younger physicians already are more aware of the teamwork concept, he added.
But medical staff members can and do take it upon themselves to create respectful work environments, said Thinh Tran, physician and chief quality and patient-safety officer for the five-hospital Baptist Health South Florida system, based in Coral Gables. Because that relationship between hospital and medical staff can sometimes be challenging, physicians ensure their colleagues understand the medical staff leaderships expectations, he said. The policy focuses on remedial instead of punitive actions in instances of disruptive behavior.
The Joint Commission highlights policies and procedures but doesnt go far enough in defining codes of conduct, Tran said.
While there might be some concern that the commissions alert applies more to doctors, its position on bad behavior extends to all people in the healthcare setting, said physician Alexis Polles, medical director of the professional enhancement program at Pine Grove Behavioral Health & Addiction Services in Hattiesburg, Miss. Having a formal process to manage problems helps facilities find the underlying causes of behavior, she said. In addition to stress and burnout, many times there are personality and medical issues as well as untreated psychiatric conditions that are at the root of outbursts, she said. Those wont be found, and people wont get the help they need, if the focus is on disciplinary actions, she added.
Just making the statement that the commission will focus on unprofessional behavior indicates that hospitals should have this on their radar screens, said Gerald Hickson, physician and associate dean for clinical affairs and director of the Center for Patient and Professional Advocacy at 793-bed Vanderbilt University Medical Center, Nashville. Developing strategies at the institutional level shows that leadership has made a commitment to stamping out unprofessional behavior, he said.