Joint Commission offers advice on action steps

The Joint Commission's Leadership standard (LD.03.01.01) includes two elements of performance related to intimidation and bullying:

• EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.

• EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors.

The Joint Commission suggests hospitals take actions to address the issue:

• Educate all team members — both physicians and nonphysician staff — on appropriate professional behavior defined by the organization's code of conduct. The code and education should emphasize respect. Include training in basic business etiquette (particularly phone skills) and people skills.

• Hold all team members accountable for modeling desirable behaviors, and enforce the code consistently and equitably among all staff regardless of seniority or clinical discipline in a positive fashion through reinforcement as well as punishment.

• Develop and implement policies and procedures/processes appropriate for the organization that address.

• "Zero tolerance" for intimidating and/or disruptive behaviors, especially the most egregious instances of disruptive behavior such as assault and other criminal acts. Incorporate the zero-tolerance policy into medical staff bylaws and employment agreements as well as administrative policies.

• Medical staff policies regarding intimidating and/or disruptive behaviors of physicians within a health care organization should be complementary and supportive of the policies that are present in the organization for nonphysician staff.

• Reduce fear of intimidation or retribution and protect those who report or cooperate in the investigation of intimidating, disruptive and other unprofessional behavior. Nonretaliation clauses should be included in all policy statements that address disruptive behaviors.

• Respond to patients and/or their families who are involved in or witness intimidating and/or disruptive behaviors. The response should include hearing and empathizing with their concerns, thanking them for sharing those concerns, and apologizing.

• Determine how and when to begin disciplinary actions (such as suspension, termination, loss of clinical privileges, reports to professional licensure bodies).

• Develop an organizational process for addressing intimidating and disruptive behaviors that solicits and integrates substantial input from an interprofessional team including representation of medical and nursing staff, administrators and other employees.

• Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution. Cultural assessment tools can also be used to measure whether or not attitudes change over time.

• Develop and implement a system for assessing staff perceptions of the seriousness and extent of instances of unprofessional behaviors and the risk of harm to patients.

• Develop and implement a reporting/surveillance system (possibly anonymous) for detecting unprofessional behavior. Include ombuds services and patient advocates, both of which provide important feedback from patients and families who may experience intimidating or disruptive behavior from health professionals. Monitor system effectiveness through regular surveys, focus groups, peer and team member evaluations, or other methods. Have multiple and specific strategies to learn whether intimidating or disruptive behaviors exist or recur, such as through direct inquiries at routine intervals with staff, supervisors, and peers.

• Support surveillance with tiered, nonconfrontational interventional strategies, starting with informal "cup of coffee" conversations directly addressing the problem and moving toward detailed action plans and progressive discipline, if patterns persist. These interventions should initially be nonadversarial in nature, with the focus on building trust, placing accountability on and rehabilitating the offending individual, and protecting patient safety. Make use of mediators and conflict coaches when professional dispute resolution skills are needed.

• Conduct all interventions within the context of an organizational commitment to the health and well-being of all staff, with adequate resources to support individuals whose behavior is caused or influenced by physical or mental health pathologies.

• Encourage interprofessional dialogues across a variety of forums as a proactive way of addressing ongoing conflicts, overcoming them, and moving forward through improved collaboration and communication.

• Document all attempts to address intimidating and disruptive behaviors.