Where to start, where to start…

There are no easy answers, and in fact there isn’t always a clear place to start. Dr Alan Rosenstein, the physician whose research served as the impetus for JCAHO’s new requirements on disruptive behavior, says that there are no silver bullets. A multi-pronged approach that addresses education and training, culture, leadership, reporting, and structure, as well as an effective intervention strategy are critical. In the next several articles, we will discuss these topics in more depth. Today we begin with education. (In the interest of brevity please consider my use of the word hospital as encompassing long term care facilities, ambulatory surgery centers, physician practices, etc.)

In my somewhat arbitrary view, the education part of the equation is focused on articulating just what disruptive behavior is, and how disruptive behavior affects patients, the staff, and the institution. The training part of the equation is about equipping people with more effective behaviors for dealing with potentially disruptive situations. First, we need to get beyond the Alcoholic Parent Syndrome.

The Alcoholic Parent Syndrome. For too long, disruptive behavior in healthcare has been subject to the proverbial “alcoholic parent syndrome.” We hoped that if we ignored the bad behavior, it would go away on its own. Others took the duck-and-cover-until-they-cool-off approach. Still others “tried harder to be better” so the alcoholic parent wouldn’t get angry. Such responses have several serious side affects.

First, failure to appropriately address disruptive incidents in the past has served as a tacit form of consent. Fit-throwing children that are never rebuked by their parents often grow up to be fit-throwing adults. Similarly, hospitals that don’t act on the charge nurse who constantly berates and demeans their direct reports should not be surprised when they develop what one nurse described as a “Darwinian culture” where only the strong survive.

To add insult to injury, people often see a clear double or triple standard in how the institution responds to disruptive behavior from different groups. When a hospital’s tolerance for bad physician behavior can be correlated with that physician’s admission volume and patient profitability, people will see and resent it. It follows then that one of the early steps on the road to eliminating disruptive behavior is to actually call a spade a spade.

This could take place in many forms, but should have several key ingredients including a clear behavioral definition of disruptive behavior, a discussion about how that definition links to the hospital’s code of conduct, a zero tolerance policy, and an explanation of the hospitals reporting and peer review process.

JCAHO and the AMA offer definitions (see the links on the right of this page) or you can make your own. They key is to articulate in clear behavioral terms the kinds of:

*Words - cussing, yelling, etc.
*Actions - inappropriate touching, throwing things, etc.
*In-actions - failing to return calls, “forgetting” to do things, etc.

that consitute disruptive behavior.

When you tie the definition to your code of conduct and a zero-tolerance policy, it creates the fresh opportunity to both renew commitment, and draw a line in the sand between what was, and what is no longer acceptable. Once you have defined disruptive behavior and reinforced your commitment with a zero-tolerance policy, you need to lay out the process for reporting and handling disruptive behavior incidents (much more about this topic later).

What are your thoughts on why we are still having this discussion? Shouldn’t civility in the workplace be the norm?