Executive Summary
A highly publicized lawsuit and public comments by healthcare leaders have made the public and the plaintiffs’ bar more aware of the sometimes questionable behavior of OR personnel. Risk managers should prohibit unprofessional or disrespectful behavior during surgery.
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Creating the right culture is key to improving OR behavior.
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Misbehavior should be taken seriously, with appropriate repercussions.
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Don’t assume that you know of all or misbehavior.
Imagine walking through a unit and seeing doctors and staff openly insulting patients, laughing at racist and misogynist remarks, and even making inappropriate sexual contact. Any risk manager would react with fury and realize that something was seriously wrong with the hospital culture and that it was creating all sorts of liability risks.
That behavior would never happen on an open unit. But is it happening in your operating rooms? Recent cases in the news have put a spotlight on disrespectful and even abusive behavior during surgery, and those cases might lead to closer scrutiny by patients, plaintiffs’ attorneys, and regulators. That expected scrutiny means now is the time for risk managers to step in and put a halt to the antics that are common in some ORs.
A recent jury verdict brought attention to the issue. A Fairfax, VA, jury ordered an anesthesiologist and her practice to pay a patient $500,000 for
disparaging remarks made during surgery and for entering a false diagnosis on his chart. The patient had left his smartphone recording when it was placed in the bag of patient belongings under the OR table. The case received extensive publicity, and it informed members of the public about what sometimes happens when they are unconscious. (For more on that case, see Healthcare Risk Management, August 2015.)
Soon after that secret was revealed, an essay in the Annals of Internal Medicine also brought attention to disrespectful behavior while patients were anesthetized, including sexual innuendo and inappropriate touching. The essay was written by a physician, and the journal editors convinced him to remain anonymous. In an accompanying editorial, the editors called the incidents in the essay “disgusting and scandalous.” They cited misogyny, disrespect, racism, and “heavy overtones of sexual assault.” (For more on that essay, see the story in this issue.)
Though incidents of misbehavior might be rare in the context of all surgeries performed, any occurrence is “certainly too much and completely unprofessional,” says R. Stephen Trosty, JD, MHA, ARM, CPHRM, president of Risk Management Consulting in Haslett, MI, and a past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago. Trosty has dealt with serious OR misbehavior in the past when he was the risk manager at a hospital. (For more on Trosty’s experience with this issue, see the story in this issue.)
Zero tolerance
Improper behavior has been a problem in ORs for years, but Trosty says the issue typically is addressed only when a particular incident comes to light or possibly in educational sessions directed at surgeons.
The issue also has been addressed by various medical boards, ethics and quality improvement committees at hospitals, and medical ethicists, with little success.
“Training and the telling of actual instances in which there have been lawsuits and judgments involving this type of behavior do not seem to have put a complete stop to it,” Trosty says. “This type of behavior cannot and must not be tolerated by anyone. There usually are many medical professionals in an operating room, and none of them should accept this type of behavior.” Given the common climate that the physician is the head of the operating room and the leader of the team, it might be difficult for staff members to say anything without feeling concern for their jobs, he says. “The hospital or other institution must establish a climate that makes it very clear that this type of behavior is unacceptable and will not be tolerated,” Trosty says.
Environment is critical
Hospitals must create an environment in which people don’t feel their jobs are in jeopardy if they speak up about this type of behavior.
That culture can be created and maintained only with the support of top administration and medical leadership, Trosty says. It is “unrealistic and naïve” for a risk manager to tackle this issue without support from the higher levels of authority, he says.
“The risk manager has to continue to have sessions about this, not only with physicians, but with all professionals who are in the operating room. They have to stress why this is completely unacceptable behavior that cannot be accepted or tolerated,” Trosty says.
This education must be backed up by all levels of authority and responsibility within the organization, he emphasizes, or there will be a lack of compliance by those who are inclined to this type of behavior.
The training and risk manage-ment sessions by the risk managers should include examples and instances of actual occurrences and litigation, including the judgments against the participating physicians and/or other medical professionals, Trosty advises.
In addition, the risk management departments of insurance companies and medical societies might be resources for further educating physicians and staff. In addition to those groups reinforcing that this type of behavior will not be tolerated, physicians should be warned that their professional liability insurance can and usually will be cancelled if they are found guilty of this offense, Trosty notes.
“As long as this type of behavior is tolerated, if not accepted, within society, this type of behavior is likely to continue in those rare instances in which you have physicians and others who feel that they belong to the ‘good old boys club’ or that this type of behavior makes them appear to be part of the club,” Trosty says. “We’ve seen that this actually can apply to female as well as male physicians.”
The operating room has long been the one place in a hospital where administrators look the other way if personnel want to create their own atmosphere, whether that is quiet and professional or loud and irreverent, but that lack of response must change, says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, a patient safety and risk management consultant with The Kicklighter Group in Tamarac, FL, and a past president of the ASHRM. By its nature, the operating room always has been a challenge for oversight by risk managers, she notes.
Unlike other clinical areas, the risk manager cannot casually stroll through once in a while to observe behavior, she notes. Even if you go to the trouble of observing a procedure, the team members will be on their best behavior when the risk manager is present.
“A risk manager is never going to personally observe the kind of behavior that we’re talking about,” Kicklighter says. “That means the solution is in changing the culture, not trying to personally observe and intervene.”
She suggests that risk managers make a concerted effort to be visible to the operating room staff by making periodic rounds to meet surgeons and OR staff members face to face, as well as holding inservices for the surgical team. That visibility will breed familiarity so that the risk manager doesn’t stand out so much during a drop-in visit, and it also will encourage more trust when the risk manager advises members of the OR team on proper decorum.
“That also will help them so that when something improper happens in the operating room, they will feel comfortable in reporting it to the risk manager,” Kicklighter says.
Enlightened patients
Patients are far more likely to become aware of misbehavior now with the proliferation of smartphones and other technology, notes John Banja, PhD, medical ethicist at the Center for Ethics at Emory University in Atlanta.
Banja recently was involved with a malpractice case in which a family recorded a conversation with a physician, and that recording turned out to be damning evidence that prompted a settlement.
Some types of inappropriate behavior, such as laughing at or ridiculing an anesthetized patient’s body, are a matter of professionalism and respect for patients, Banja says, and that professionalism must flow from the hospital’s culture. Angry or frustrated clinicians are somewhat different, he says. They must be told that while wanting to vent about patients and work is understandable, it is not the professional thing to do, he says.
“They are going to encounter patients who hit all their buttons and make them defensive or angry, and they’re going to want to talk about it,” Banja says. “Our job is to reassure them that that reaction is perfectly normal, but complaining about it or insulting the patient while he’s lying unconscious in front of you is not an option. They will need to find other ways to deal with those frustrations.”
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John Banja, PhD, Medical Ethicist, Center for Ethics, Emory University, Atlanta. Email: [email protected].
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Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, The Kicklighter Group, Tamarac, FL. Telephone: (954) 294-8821. Email: [email protected].
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R. Stephen Trosty, JD, MHA, CPHRM, President, Risk Manage-ment Consulting, Haslett, MI. Telephone: (517) 339-4972. Email: [email protected].
