Are conflicts and disruptive behavior putting patients at risk at your hospital?

Intimidation, rudeness can be dangerous

Rude remarks, intimidated staff, unresolved conflicts between leaders, and abusive behavior — your organization will need to have effective processes in place to address all of these scenarios.

After a field review by The Joint Commission of the entire leadership chapter in May 2006, two proposed standards were developed with new requirements for conflict management and disruptive behavior. The standards have completed field review, and, if approved, will be implemented in January 2008.

The proposed conflict management standard was developed in response to concerns about potential conflicts between leadership groups in hospitals, according to a spokesperson for The Joint Commission. The proposed standard is an expansion of an existing requirement in hospitals and would require organizations to develop an ongoing process to manage conflict among leadership groups, including meeting with involved parties to identify and resolve the conflict.

Disruptive behavior and its effect on patient safety have been the focus of several studies by groups including the VHA, the American College of Physician Executives, and the Institute for Safe Medicine Practices, which identified intimidation as a significant factor impacting the quality of care patients receive.1 The Joint Commission's proposed standard would require leaders to develop a code of conduct defining desirable and disruptive behavior, and develop processes to manage disruptive behavior.

"The Joint Commission is becoming more involved in setting standards for human behavior," says Geri Amori, PhD, a Shelburne, VT-based health care consultant specializing in patient safety issues. "What they are requiring of health care organizations is a more sophisticated level of psychological awareness than ever before."

The proposed standards address important issues for health care organizations, says Adele Sullivan, PhD, president of Palm Beach Gardens, FL-based Interventus Inc., a health care consulting firm specializing in conflict management. "Constructive conflict resolution in health care organizations is essential to provide quality patient care," she says.

More training is needed

"Unfortunately, these standards are necessary as people don't know how to be kind and professional to others these days," says Diane Horvath, Joint Commission coordinator and director of the medical staff office at Sacred Heart Hospital in Allentown, PA. "Enforcement of this type of standard may create more conflict in the beginning, but eventually most health care professionals will conform."

Disruptive behavior has been considered "normal" in many settings for years, notes Horvath. "Most hospitals today have a code of conduct but the disruptive behavior piece will have to be strengthened," she says. "More education and training on how to effectively control this type of behavior would be necessary."

Traditional methods of resolving conflict often do more harm than good, leading to adversarial working conditions and less interdepartmental teamwork, notes Sullivan. "As managers and executives, we expect leaders know how to manage conflict. However, they usually use the strategies that are most comfortable to them without knowing whether it is the best strategy," she says.

In fact, most conflicts reoccur because they aren't resolved at the root level, says Sullivan. "This allows it to resurface, perhaps with a different face or name, but nonetheless the same conflict," she says.

As a quality professional, you play an important role in seeing that the necessary structure for constructive conflict resolution is established, including the education and training to support it. "The silent costs of conflict are many, including the quality of patient care, employee and patient satisfaction, turnover, inferior decision making, and the bottom line," says Sullivan.

At Louisiana State University Health Sciences Center in Shreveport, a team was put together to address conflict resolution and disruptive behavior, composed of administration, human resources staff, and a privacy officer. "It is a difficult standard. However, if institutions review the intent, most will find they have policies already in place that address the standard," says Leisa Oglesby, assistant hospital administrator of quality.

The hospital's current policies address most of the proposed requirements, says Oglesby. The biggest change that will have to be made is the education and documented approval of the governing body for the staff conflict management process and code of ethical behavior, she says.

For example, most organizations have a code of conduct that is reviewed with all new employees, with policies in place to address disruptive behavior should it occur. In addition, there is usually an organization-wide policy that addresses conflict resolution. "Both are usually reviewed with new employees during their hospital orientation," says Oglesby. "The policies have probably been in place for a long time; however, they usually have not been presented and approved by the governing body."

The hospital's medical staff have approved a due process to manage disruptive behavior exhibited by individuals granted with clinical privileges, which was also approved by the governing body.

If organizations are truly seeking to improve the quality and safety of care, they are already measuring staff perceptions, which may enhance the quality and safety of care delivered, says Oglesby, with variance or incident reporting processes in place to track and trend safety issues on an ongoing basis.

"We are in favor of these changes," says Herman Williams, MD, MBA, chief medical officer at Baptist Health System in San Antonio. "Currently, we not only have a process for conflict management, we have a disruptive policy and sexual harassment policy that clearly states the expectations of behavior."

At Durham (NC) Regional Hospital, the medical staff bylaws, code of conduct, and conflict resolution policy already in place cover the new elements that The Joint Commission is proposing, says Edward N. LaMay, MD, chief medical officer. "These proposed changes don't come as a surprise," he adds.

At Baptist Hospital of Miami, issues related to conflict management are addressed at a sub-committee of the board, where administration, board members, and medical staff leaders meet monthly. "We also have staff at our system level that are trained in conflict management. Issues, if they arise, would be identified through these activities," says Faith D. Solkoff, RN, BSN, MPA, assistant vice president. Risk management and medical staff leaders track the outcomes related to disruptive behaviors.

"I believe we have many pieces to this puzzle already, but the process related to conflict management will need to be more formalized so that the process meets the intent of the standards," Solkoff says. "I think the conflict management standards will create a lot of busy work, but at the end of the day, will not prove meaningful to most organizations."

As for disruptive behavior, a human resource process is used for staff and a disruptive physician policy is used for medical staff members. "Both have measurable outcomes," says Solkoff. "Again, the process owners track compliance — human resources for staff and risk management for physicians."

The measurable outcomes are related to whether the individual counseled changes his or her behaviors, as well as the responses by both staff and physicians on annual satisfaction surveys related to culture and patient safety. "Our outcomes have trended well, compared to national comparative rates," says Solkoff.

If disruptive physician behavior occurs, bring in the hospital attorney early on in the process, advises Kathleen Catalano, RN, JD, a consultant with Plano, TX-based Perotsystems. "The medical staff policy and procedure on disruptive behavior should be followed to the letter for each and every such occurrence," she says.

To address the upcoming standards from The Joint Commission, consider the following items:

Be specific with definitions.

"The Joint Commission is walking into an area where definition of what is meant by the words used are extremely important," says Amori. For example, the rationale in the disruptive behavior standard refers to use of "rude language" and "threatening manners"— both broad terms that can be interpreted in many different ways.

What one person considers rude or threatening, another may not. "So one of the things that organizations are going to have to do is to take this out of the realm of the subjective, and make it very specific," says Amori. "Otherwise I see potential for abuse for these standards. You can get into, 'That was rude. No, it wasn't.' It could get out of hand unless this is clearly defined."

Address underlying issues.

Just as your process for incident reporting should address system failures instead of placing blame on specific individuals, the same should be done with disruptive incidents, says Amori. "We need to look at what in the system precipitates stress, which leads to disruptive behavior," she says. "It would be too easy to jump to a blame position, without looking at the involvement of system failure."

Encourage staff to report problems.

Even if your hospital has an "open door" policy, staff might not feel comfortable walking through that door. Consider the various ways that staff handle conflict currently other than filing a grievance, such as spreading rumors, complaining, and talking with union representatives. "These are usually unproductive and not in the organization's best interest," says Sullivan.

Develop an alternative dispute resolution process and present this to the governing body, leadership, management, and key individuals. "You need a system that is stakeholder-derived, accepts conflict as a normal part of interaction, and that is realistic and collaborative," Sullivan says. She advises the following:

  • Create multiple points of entry so an individual can bring up a dispute through many people or positions.
  • Build prevention mechanisms into the foundation of the conflict management system.
  • Design procedures to get disputants back to negotiation and communicating with each other.
  • Set up a database to compare similar conflicts, to determine what worked and what is recurring.

Measure success.

To assess the impact of your conflict resolution system, Sullivan recommends measuring the expense of legal disputes, employee turnover, the number of grievances, hours and expenses related to managing disputes, employee and patient satisfaction, and the number of days used for sick leave.

You also should be seeing fewer incidents over time. "Measure the willingness of staff to use the tools available to them, and how they are utilizing the skills they learned in training," says Amori. "Do this not right after a training, but by spot checking."

Have a specified group of individuals skilled in conflict management.

At Baptist Health, annual education is given in conflict and negotiation management skills for medical staff leaders. "We also have chiefs at each of our facilities, as well as selected clinical specialty chairs who have delineated roles for addressing complaints, behavior, and peer review," says Williams.

Have effective follow-up in place.

The rationale for the proposed conflict management standard states that some of the organization's leaders should be skilled in managing conflict through experience, education, and training. Although most organizations have taken steps to prepare leaders for conflict management, many don't have adequate follow-up after these programs are completed, says Catalano. "Quality professionals will need to be kept current on instances where conflict management skills have been called into play, and the effectiveness of these efforts," she adds.

In addition, when conflict management skills have been initiated, the outcomes will need to be tracked. "Has the behavior or conflict arisen subsequent to intervention? All of this will be important to further shape the conflict management program," says Catalano.

Reference

  1. Institute for Safe Medication Practices. (2004, March 11). Intimidation: Practitioners speak up about this unresolved problem (Part I). ISMP Medication Safety Alert!

[For more information, contact:

Geri Amori, PhD, 105 Covington Lane, Shelburne, VT. Phone: (802) 985-5458. Fax: (517) 327-4650. E-mail: gamori@rmpsi.com.

Kathleen Catalano, RN, JD, Perotsystems, Healthcare Transformation, 2300 W. Plano Parkway, Plano, TX 75075. Phone: (214) 709-7940. E-mail: kathleen.catalano@ps.net

Diane Horvath, Joint Commission Coordinator, Sacred Heart Hospital, 421 Chew Street, Allentown, PA 18102. E-mail: Dhorvath@SHH.ORG.

Faith D. Solkoff, RN, BSN, MPA, Assistant Vice President, Baptist Hospital of Miami, 8900 North Kendall Drive, Miami, FL 33176. Phone: (786) 596-2685. Fax: (786) 596-5983. E-mail: faiths@baptisthealth.net

Adele Sullivan, PhD, FACHE, President, Interventus, 6231 PGA Blvd., Suite 104-116, Palm Beach Gardens, FL 33418. Phone: (561) 301-9415. E-mail: sullivan@interventusinc.com. Web: www.interventusinc.com.]