DISRUPTIVE BEHAVIOR

Stephen Hale M.D., Verda Hale, RN, MSN

Oregon Rural Healthcare Quality Network September 16-17, 2013

Bend, Oregon

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Learning Objectives

Gain a better understanding of disruptive behaviors Discuss the negative impact of disruptive behaviors on staff

relationships, patient safety and quality of care Learn how to effectively address disruptive behaviors

Describe effective policies and procedures, education, and Team STEPPS intervention strategies to enhance communication and collaboration

Stress the importance of early proactive intervention programs

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Outline

Definition Review research findings Impact and implications Call to action Cause and effect Repercussions Solution strategies Interventions

Acute Retrospective Preventive Positive

Implementation

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Definition:

“Disruptive behavior” is defined as any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment that can potentially negatively impact patient care.

0 20 40 60 80 100

Other

Physical abuse

Berating in private

Berating in front of patients

Abusive anger

Insults

Condescension

Berating in front of peers

Abusive language

Disrespecful interaction

Yelling/ Raising voice

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Physician/ Nurse Disruptive Behavior

NURSE (Horizontal hostility Passive aggressive Behind the scenes Cliques/ generation gaps Middle management

PHYSICIAN • Overt • Course of action • Short term • Mal-intent? • Noncompliance

• Protocols • Charting • Availability • Communication

Have You Ever Witnessed Disruptive Behavior?

Joint Commission Journal on Quality & Patient Safety August 2008

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Linkage Between Disruptive Behavior and Undesirable Behavioral Factors Occurring Sometimes, Frequent and Constant

95 95 85

92 89 95

0

20

40

60

80

100S

tress

Frus

tratio

n

Loss

of

Con

cent

ratio

n

Red

uced

RN

/MD

Col

labo

ratio

n

Red

uced

Info

rmat

ion

Tran

sfer

Red

uced

Com

mun

icat

ion

Perc

ent

…

92% 90% 83%

77% 82% 88%

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Linkage of Disruptive Behavior to Undesirable Clinical Outcomes Occurring

Sometimes, Frequent, and Constant

…

68% 74% 67%

57%

78%

Are You Aware of Any Specific Adverse Event That Occurred as a Result of Disruptive Behavior

18%

…

Could These Specific Adverse Events Have Been Prevented?

75%

…

Comments:

Cardiologist upset by phone calls and refused to come in. RN told it was not her job to think, just to follow orders. Rx delayed. MI extended.

MD was told twice that sponge count was off. She said “they will find it later”. Patient had to be re-opened.

Yes, many incidents are preventable if both parties are willing to listen to each other, but many doctors are unwilling to accept a nurse’s opinion just as some nurses are unwilling to listen to the opinions of LVNs, techs or CNAs, and it may have to do with the entrenched pecking order that exists at most hospitals.

The disruptive behavior from nurses is much more upsetting because I expect that behavior from the surgeons NOT the nurses b/c I rely on them as my peers (RN)

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Call to Action

ORGANIZATIONAL RELUCTANCE

RISK OF NON-ACTION

Awareness/ Tolerance Financial Hierarchy/ boundaries MD autonomy Code of silence Conflict of interest Structure? Skill set? Organizational support?

Staff/ patient satisfaction Staff retention/recruitment Quality and patient safety Fines/ Liability Joint Commission standard Reputation (media/ blogs)

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Risk Management: Action vs. Avoidance Recruitment/Retention RN: $60,000-100,000/additional opportunity costs

MD: $60,000-1,000,000 Adverse Events “NO Pay” for adverse events initiatives:

Medication error: $2,000-$5,800 per case/additional increase

LOS 2.2-4.6 days Hospital Acquired Infection: $20,000-$38,500 Deep Vein Thrombosis: $36,000/additional increase LOS 4.2

days Pressure Ulcers: 22,000/additional increase LOS 4.1 days Ventilator Associated Pneumonia: 49,000/additional increase

LOS 5.3 days Malpractice $521,560 /Lawsuits Patient Satisfaction/Reputation Market share implications ($) Compliance Issues Impact on documentation and coding ($)

Impact on utilization efficiency (LOS/resource efficiency/discharge planning) Impact on quality Impact on productivity and efficiency (downtime/waste/delays)

Communication Inefficiencies $4 million (500 bed hospital)

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American Journal of Medical Quality September/October 2011

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What Influences Physician Behaviors?

Age and generational Gender Culture and ethnicity Life experiences Personality:

Dictatorial Narcissism, perfectionism De-sensitization Low Emotional Intelligence

Training Healthcare environment Work environment Personal issues Behavioral health, e.g.:

Stress/ fatigue/ burnout Depression Substance abuse Suicidal ideation

INTERNAL EXTERNAL

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Physician Training

• Competitive nature

• Low self- esteem

• Focus on knowledge/ technical expertise

• Autonomy

• Desensitization

• Command control

• Communication/ Team collaboration skills

• Hierarchy

• Change is on the way • College major • MCATs • Curriculum

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Health care environment:

Reform

Complexity

Intrusion

Accountability

Patient expectations

MD expectations

Revenue

Changing models of care

Career implications

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Physician Stress: Consequences

Individual

• Dissatisfaction/ Frustration/ Anger

• Fatigue/ burnout/ depression/ substance abuse/ suicidal ideation

• Career changes

Organizational

• Impaired relationships

• Impaired communication and collaboration

• Disruptive behaviors

• Reduced productivity and efficiency

• Impaired judgment/ mistakes

• Adverse patient outcomes

• Litigation

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Nurse Stress: Burnout and Compassion Fatigue

Definition:

Physical, emotional, and mental exhaustion caused by long term involvement in emotionally demanding situations that negatively impacts the desire, ability and energy to care for others

Causes:

Role as “rescuers”

Progressive wearing down by exposure to patient

suffering/ empathy (person vs. situation)

Workplace demands (staffing, scheduling, non- clinical

tasks, competing priorities, stress and burnout

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Consequences

Self: Loss of self worth and purpose Physical, mental, emotional well being

Organization: Culture Morale Turnover/ recruitment and retention Relationships/ team performance/ flexibility/ productivity Resistance/ disruptive behaviors/ task accountability Quality Mistakes Patient satisfaction Philanthropathy

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What Have We Learned?

Multi-factorial cause and effect relationship Inciting event vs. deep seated values and attitudes Profound effect on organization morale and patient care Beyond disruptive behavior Communication Solutions:

Awareness Education Prevention Support Dissolution Resolution

Intervention spectrum

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Recommendations: Ten Point Plan POINT RECOMMENDATION

1 Organizational Culture Leadership commitment/structure and process

2 Clinical Champion

3 Recognition and Awareness Education: Responsibility and Accountability

4 Structured Education/Training Diversity/Sensitivity/Conflict Management/Assertiveness

5 Collaboration/Communication Tools Intent/Barriers/Exchange/Outcomes

6 Policies and Procedures

7 Reporting Mechanisms

8 Intervention Real-Time/Post-Event/Chronic

9 Reinforcement of Patient Safety Initiatives

10 Prevention

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Organizational Culture

Assessment Commitment Leadership

Structure Task force Champion

Commitment Leadership Championship

Survey

Champion

Task Force

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Education: Recognition and Awareness

General education (all staff)

Structured education o Phone etiquette/ charm school o Sensitivity training/ diversity training o Assertiveness training/ language support o Conflict management/ anger management o Time management/ stress management/ wellness o Communication competency: - Technical competency - Knowledge competency - Cultural competency (Unconscious bias) - Language competency - Assertiveness/ Critical thinking

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Team Collaboration Skills (TeamStepps)

Anticipate/ Assist

Build trust, respect and commitment

Understand your role and roles of others

Reinforce accountability and task responsibilities

Leadership/ Assertiveness

Check lists

Avoid/ manage conflict or confusion

Discussion/ briefing … debriefing

Enhanced communication

Job well done

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Reporting Disruptive Behaviors

Zero tolerance policy Non-punitive environment Confidentiality

No repercussions Reporting vehicle

Consistency Non- biased evaluation Action oriented Provide feedback

Incident Patient complaints

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Intervention Strategies

Prevention

- Raise awareness

- Education/ Training

- Accountability

Early event intervention

- Empathy and assistance/ Support services

- Coaching and Counseling (HR/ Wellness Committees/ EAP)

Real time intervention

- Assertiveness/ Assistance/ “Code white”

- Discussion

Trend based intervention

- Skill sets

Support Termination

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TOOLS Advocacy, Assertion, and Conflict

Resolution

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Disruptive Behavior: Evaluation Process

Code of behavior policy

Designated task force or committee

Formal process of review/ defined standards

Dedicated/ trained review/ intervention team*

Skill set:

Interview

Set tone/ expectations/ accountability

Coach

Mediator

Conflict management

Action plan

Coffee time/ Awareness/ Authority/ Discipline (Vanderbilt)

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What to Do…..

Complicated situation

Commitment

Structure, process, resources, personnel

Education

Communication

Accountability

Intervention o Internal o External

Resolution

Prevention

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End Game

Physicians/ Nurses/ staff a precious resource Just trying to do their job Resistant to interference and intrusion Reluctant to seek outside help Address confidentiality and convenience Focus on physician/nurse/ staff/ patient satisfaction Listen to what they have to say Provide structural and individual support Provide necessary coaching and intervention: skilled personnel Recognize and reward

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Our Journey

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How We Got Started

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Why did your hospital want to do this?

We acknowledged an organizational problem. Committed to take an active approach to disruptive behavior knowing the growing concerns about workforce shortages, staff satisfaction and retention, hospital reputation, liability and patient safety.

How did you engage staff and get ownership?

Spreading the word through staff, manager and medical staff meetings

Expert education/training- Dr. Alan Rosenstein

Developed a reporting tool with a closed-loop feedback mechanism

Zero-tolerance and persistence

Top management commitment

To what extent was your hospital’s administration involved?

Senior management/CEO highly committed

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Timeline of Events

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Dates Event Description

Spring 2009 First Team STEPPS Master Trainers

Fall 2010 5 more trainers and a physician leader is born

Fall 2010 Employee training begins

Spring & Summer 2011 Master Team STEPPS instructors spend time “walking the talk” on unit rounds, team debriefings, case reviews, RCAs.

Winter 2012 First multidisciplinary RCA using Team STEPPS as the framework.

October 2012 Disruptive Behavior survey distributed to all employees through survey monkey. Formal disruptive behavior training is embedded in Team STEPPS training.

December 2012 Disruptive Behavior Task Form is born and a reporting system implemented.

Present Spread and sustain Team STEPPS and Disruptive Behavior initiatives.

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Intervention Process

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Organizational Culture Assessment Recruitment behavior & personality/leadership commitment/structure and

process Types of physicians; environment

Clinical Champions Peer mentoring; trust; collaboration

Recognition and Awareness Early identification by incident reporting, following rules Education: responsibility and accountability

Structured Education/Training Diversity, sensitivity, conflict management, assertiveness

Collaboration/Communication Tools Intent, barriers, exchange, outcomes

Policies and Procedures Reporting Mechanism Intervention

Prevention, real-time, post-event, long-term Reinforcement of Patient Safety Initiatives Prevention

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Intervention Strategies

Prevention

Raise awareness

Education/training/accountability

Pre-event early intervention

Empathy and assistance/support services

Coaching and counseling (HR/Wellness Committees)

Real-time intervention

Assertiveness/assistance/support

Discussion “cup of coffee”

Cause/effect analysis; probe for other issues

Organization based intervention

Gather data with follow-up.

Options (bad day)

Pattern Vanderbilt (algorithm)

Develop action plan (1,3 and 6 mos-HR, EAP)

Other resources (dyad model)

Disruptive Behavior witnessed

Attempt Resolution and/orTeam STEPPS Tools

Utilized

Resolution Successful?

Yes No

Inform Supervisor and Manager

DISRUPTIVE BEHAVIOR REPORTING ALGORITHMLast revised: August 20, 2012

DBTF will report Performance Improvement measures quarterly to the

Administrative Team

If further attention is necessary, information will be passed to appropriate department

administrator for follow-up

The Disruptive Behavior Task Force (DBTF) will evaluate reported incidences to

determine if the incident should be referred on (either in addition to or instead of) as an

Incident Security Report or an Unusual occurrence Report.

A response letter ( opportunities for improvement) and the attached copy of

the reporting form will be sent to the reporting individual/manager for review if

appropriate.

Complete Disruptive Behavior Report Form

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Barriers and Solutions

Barriers Solutions

• Culture • Lack of institutional integrity • Lack of definition • Fear of reporting • No process for reporting • Poor adherence to practice

guidelines • Resistance to physician

ownership/”witch hunt”

• Civility • Zero Tolerance • Educate • Breakdown hierarchy • Reporting tool • Low Emotional Intelligence • Patient

safety/reputation/external/ part of design

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Advice for Others & Lessons Learned

Awareness (covert vs overt) Committed senior management (CEO, CNO, Physician

champion) Consistent reporting (timely feedback)

Zero-tolerance (Rationalization/Justification) How to: Effective intervention (engagement vs enforcement),

Action plan-carrot/stick

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Plan for Spread/Sustainment

Conflict management training EAP Periodic Employee Wellness Assessment (MBI,

ProQual) Staff Retreats

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Next Steps

Post survey Annual competency Employee wellness- a missing quality indicator Patient/staff satisfaction Recognize and reward

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Questions ???

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