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Alignment
© 2008 Crisis Prevention Institute, Inc. All rights reserved. No part of this bookmay be reproduced in any form or by any means, electronic or mechanical,including photocopying, recording, or by any information storage and retrievalsystem, without written permission from the Crisis Prevention Institute, Inc.
08-BMW-INT-001 12/08
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The Joint Commission Leadership Standard (LD.03.01.01) addressing disruptive and inappropriate behaviors/
The Crisis Prevention Institute’s (CPI) Workplace Bullying seminar
2© 2008 Crisis Prevention Institute, Inc.
Alignment
BackgroundThe Joint Commission named its July 9, 2008 Issue 40 Sentinel Event Alert “Behaviors that undermine a culture of safety.” It is clear that, through the undermining of employee safety, disruptive individualsthreaten patient safety—the core mission of every accredited hospital or organization.
In response to this safety threat, effective January 1, 2009, the Joint Commission promulgated a newLeadership Standard (LD.03.01.01) to address intimidating, disruptive, and inappropriate behaviors. TheJoint Commission cited research demonstrating that negative interpersonal conduct by physicians andothers can lead to medical errors, preventable adverse patient outcomes, poor patient satisfaction,increased cost of care, increased malpractice risk, and turnover among professionals who have to dealwith the abusive offenders.
Alignment
The Joint Commission Leadership Standard(LD.03.01.01) addressing disruptive and
inappropriate behaviors
The Crisis Prevention Institute’s (CPI) Workplace Bullying seminar
Effective January 1, 2009 for all accreditationprograms, the Joint Commission has a newLeadership standard (LD.03.01.01) that addressesdisruptive and inappropriate behaviors in two ofits elements of performance (EP):
EP 4: The hospital/organization has a code ofconduct that defines acceptable and disruptiveand inappropriate behaviors. (Note:Documentation is required).
EP 5: Leaders create and implement a process formanaging disruptive and inappropriate behaviors.(Note: Direct impact requirements apply).
The Crisis Prevention Institute (CPI) has beentraining professionals to manage disruptivebehavior since 1980. CPI’s internationallyrecognized programs provide training in verbalde-escalation strategies and emphasize theprevention of potentially aggressive situations.
CPI’s Workplace Bullying seminar provides anobjective definition of both incivility and bullyingand explores related concepts as a continuum.
CPI’s Workplace Bullying seminar detailsstrategies to minimize the possibility of workplacebullying and to promote a respectful workplaceenvironment. These strategies address the issuefrom a holistic perspective, involving individualemployees, managers and supervisors, and theorganization as a whole.
3© 2008 Crisis Prevention Institute, Inc.
Alignment
The Joint Commission Leadership Standard(LD.03.01.01) addressing disruptive and
inappropriate behaviors
The Crisis Prevention Institute’s (CPI) Workplace Bullying seminar
In addition, standards in the Medical Staff chapter have been organized to follow six corecompetencies to be addressed in the credentialingprocess, including interpersonal skills andprofessionalism, which directly correlate to theissue of disruptive and inappropriate behaviors.
Patient Care
Medical Knowledge
Interpersonal and Communication Skills:Demonstrate skills that result in effectiveinformation exchange and teaming with patients,their families, and professional associates (e.g.fostering a therapeutic relationship that is ethicallysound, uses effective listening skills with non-verbal and verbal communication; working as botha team member and, at times, as a team leader).
Professionalism: Demonstrate a commitment to carrying out professional responsibilities,adherence to ethical principles, and sensitivity todiverse patient populations.
Systems-Based Practice
Practice-Based Learning and Improvement
CPI’s internationally recognized programs providetraining in interpersonal and verbal de-escalationstrategies that emphasize the prevention ofpotentially aggressive situations.
CPI programs are known worldwide for their holistic approach to maintaining theprofessionalism of staff—even during crisis moments.
Other Joint Commission suggested actions:
1. Educate all team members – both physiciansand non-physician staff – on appropriateprofessional behavior defined by theorganization’s code of conduct.
The code and education should emphasizerespect.
The philosophy of the Crisis Prevention Instituteis to promote respectful, service-oriented, andsafe workplace cultures. This philosophy ismodeled and implemented within the context of training.
Participants are provided with a policies andprocedures template to assist in addressingexpectations around respectful workplacebehavior for internal and external consumers at all levels.
4© 2008 Crisis Prevention Institute, Inc.
Alignment
The Joint Commission Leadership Standard(LD.03.01.01) addressing disruptive and
inappropriate behaviors
The Crisis Prevention Institute’s (CPI) Workplace Bullying seminar
Include training in basic business etiquette(particularly phone skills) and people skills.
2. Hold all team members accountable formodeling desirable behaviors, and enforce thecode consistently and equitably among all staffregardless of seniority or clinical discipline in apositive fashion through reinforcement as wellas punishment.
3. Develop and implement policies andprocedures/processes appropriate for theorganization that address:
• “Zero tolerance” for intimidating and/ordisruptive behaviors, especially the mostegregious instances of disruptive behaviorsuch as assault and other criminal acts.Incorporate the zero tolerance policy intomedical staff bylaws and employmentagreements as well as administrative policies.
CPI’s training addressees all forms of workplacebullying. These include face-to-face interactions,telephone and other types of electroniccommunication, written communication, cyber-bullying, and even acts of omission meeting CPI’sdefinition and criteria for workplace bullying.
Workplace incivility and bullying can occur at anylevel of an organization. These include managersand supervisors, individual employees, peers,subject matter experts, consultants, consumers,vendors, etc.
Bullying behavior can only thrive within aworkplace culture that tolerates it.
Organizations that prioritize respectful, service-oriented, and safe workplace practices take theissue of disruptive and inappropriate behaviorseriously. These organizations emphasize thatemployees and consumers at all levels have aninherent right to both physical and emotionalsafety at all times and in all interactions within the organization.
Seminar participants are provided with a policiesand procedures template to assist in addressingexpectations regarding respectful workplacebehavior and proper responses to inappropriateworkplace conduct.
A thorough review of current organizationalpolicies, procedures, and practices isrecommended.
The review should be comprehensive and addressthe following:
• Assess the clarity of expectations with regardto appropriate behavior and professionalconduct.
5© 2008 Crisis Prevention Institute, Inc.
Alignment
The Joint Commission Leadership Standard(LD.03.01.01) addressing disruptive and
inappropriate behaviors
The Crisis Prevention Institute’s (CPI) Workplace Bullying seminar
• Medical staff policies regarding intimidatingand/or disruptive behaviors of physicianswithin a health care organization should becomplementary and supportive of thepolicies that are present in the organizationfor non-physician staff.
• Reducing fear of intimidation or retributionand protecting those who report orcooperate in the investigation of intimidating,disruptive, and other unprofessionalbehavior. Non-retaliation clauses should be included in all policy statements thataddress disruptive behaviors.
• Responding to patients and/or their familieswho are involved in or witness intimidatingand/or disruptive behaviors. The responseshould include hearing and empathizingwith their concerns, thanking them forsharing those concerns, and apologizing.
• How and when to begin disciplinary actions(such as suspension, termination, loss ofclinical privileges, reports to professionallicensure bodies).
4. Develop an organizational process foraddressing intimidating and disruptivebehaviors (LD.3.10 EP 5) that solicits and integrates substantial input from an interprofessional team including representationof medical and nursing staff, administratorsand other employees.
• Provide clear expectations for all interactionswith internal and external consumers.
• Explain conduct codes and other behavioralexpectations contained in policies andprocedures.
• Clearly provide and promote proper channelsfor reporting disruptive, inappropriate, uncivil,and/or bullying behaviors.
• Ensure accountability by responding to anycomplaint in a timely manner.
• Establish a code of behavior for internal andexternal consumers.
• Clearly communicate codes of behavior,guidelines, and policies.
• Provide a structure for reporting possibledisruptive, inappropriate, uncivil, and/orbullying behaviors that can be invoked byinternal and external consumers.
• Consistently implement policies andprocedures for all internal and externalconsumers at all levels.
Participants are provided with a policies andprocedures template addressing expectationsaround respectful workplace behavior for internaland external consumers at all levels.
6© 2008 Crisis Prevention Institute, Inc.
Alignment
The Joint Commission Leadership Standard(LD.03.01.01) addressing disruptive and
inappropriate behaviors
The Crisis Prevention Institute’s (CPI) Workplace Bullying seminar
5. Provide skills-based training and coaching forall leaders and managers in relationship-building and collaborative practice, includingskills for giving feedback on unprofessionalbehavior and conflict resolution. Culturalassessment tools can also be used to measurewhether or not attitudes change over time.
6. Develop and implement a system for assessingstaff perceptions of the seriousness and extentof instances of unprofessional behaviors andthe risk of harm to patients.
7. Develop and implement a reporting/surveillancesystem (possibly anonymous) for detectingunprofessional behavior. Include ombudsservices and patient advocates, both of whichprovide important feedback from patients andfamilies who may experience intimidating ordisruptive behavior from health professionals.Monitor system effectiveness through regularsurveys, focus groups, peer and team memberevaluations, or other methods. Have multipleand specific strategies to learn whetherintimidating or disruptive behaviors exist orrecur, such as through direct inquiries atroutine intervals with staff, supervisors, and peers.
8. Support surveillance with tiered, nonconfrontational interventional strategies,starting with informal “cup of coffee”conversations directly addressing the problemand moving toward detailed action plans andprogressive discipline if patterns persist. These interventions should initially be nonadversarial in nature, with the focus onbuilding trust, placing accountability on andrehabilitating the offending individual, andprotecting patient safety. Make use of mediatorsand conflict coaches when professional disputeresolution skills are needed.
The seminar includes interactive lectures,individual and group experiential activities, large and small group discussion, and guidednote taking.
Additional assessments and consultation are also available through CPI.
Additional assessments and consultation areavailable from CPI in addressing staff perceptionsand customizing policies, procedures, protocols,and behavioral codes.
Participants are provided with a policies andprocedures template addressing expectationsregarding disruptive and inappropriate workplacebehaviors, outlining suggested procedures forreporting these behaviors, and guidelines fororganizational investigation and response.
Recommendations for targets of disruptive,inappropriate, and/or bullying behaviors are provided.
The seminar identifies steps to appropriatelyrespond to acts of disruptive, inappropriate,and/or bullying behaviors.
7© 2008 Crisis Prevention Institute, Inc.
Alignment
The Joint Commission Leadership Standard(LD.03.01.01) addressing disruptive and
inappropriate behaviors
The Crisis Prevention Institute’s (CPI) Workplace Bullying seminar
9. Conduct all interventions within the context ofan organizational commitment to the healthand well-being of all staff, with adequateresources to support individuals whosebehavior is caused or influenced by physical ormental health pathologies.
10. Encourage inter-professional dialogues acrossa variety of forums as a proactive way ofaddressing ongoing conflicts, overcomingthem, and moving forward through improvedcollaboration and communication.
11. Document all attempts to address intimidatingand disruptive behaviors.
The seminar asserts that respectful workplacebehavior begins at the level of organizationalculture.
CPI’s Workplace Bullying seminar detailsstrategies to minimize the possibility of workplacebullying and to promote a respectful workplaceenvironment. These strategies address the issuefrom a holistic perspective, involving individualemployees, managers and supervisors, and theorganization as a whole.
CPI emphasizes that all incidents involvingdisruptive behavior be documented.
The material contained in this alignment is provided for informational purposes only and is not intended to constitute legal advice. Legalcounsel should be consulted regarding the specific application of this information to your organization. For more information on this standard,please contact the Joint Commission. For more information on the Crisis Prevention Institute’s (CPI) Workplace Bullying seminar, please contactCPI at 1-800-558-8976.
