Committee Opinion
Number 683, January 2017
(Replaces Committee Opinion Number 508, October 2011)


Committee on Patient Safety and Quality Improvement
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Patient Safety and Quality Improvement.

This document reflects emerging concepts on patient safety and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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Behavior That Undermines a Culture of Safety

ABSTRACT: A key element of an organizational safety culture is maintaining an environment of professionalism that encourages communication and promotes high-quality care. Behavior that undermines a culture of safety, including disruptive or intimidating behavior, has a negative effect on the quality and safety of patient care. Intimidating behavior and disruptive behavior are unprofessional and should not be tolerated. Confronting disruptive individuals is difficult. Co-workers often are reluctant to report disruptive behavior because of fear of retaliation and the stigma associated with “blowing the whistle” on a colleague. Additionally, negative behavior of revenue-generating physicians may be overlooked because of concern about the perceived consequences of confronting them. The Joint Commission requires that hospitals establish a code of conduct that “defines acceptable behavior and behavior that undermines a culture of safety.” Clear standards of behavior that acknowledge the consequences of disruptive and intimidating behavior must be established and communicated. Institutions and practices should develop a multifaceted approach to address disruptive behavior. Confidential reporting systems and assistance programs for physicians who exhibit disruptive behavior should be established. A concerted effort should be made within each organization to educate staff (ie, medical, nursing, and ancillary staff) about the potential negative effects of disruptive and inappropriate behavior. A clearly delineated hospital-wide policy and procedure relating to disruptive behavior should be developed and enforced by hospital administration. To preserve professional standing, physicians should understand how to respond to and mitigate the effect of complaints or reports.


Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations related to behavior that undermines a culture of safety:

  • Intimidating behavior and disruptive behavior are unprofessional and should not be tolerated.
  • Institutions and practices should develop a multifaceted approach to address behavior that undermines a culture of safety.
  • Health care organizations should make a concerted effort to educate staff about the potential negative effects of disruptive and unprofessional behavior on patient safety.

A key element of an organizational safety culture is maintaining an environment of professionalism that encourages communication and promotes high-quality care. Behavior that undermines a culture of safety, including disruptive or intimidating behavior, has a negative effect on the quality and safety of patient care. Disruptive behavior has been defined as “personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care” (1).

Several types of behavior can create distress or negatively affect morale in the work environment. Examples include overt actions such as verbal outbursts and physical threats, and passive actions such as refusing to perform assigned tasks or exhibiting uncooperative attitudes during routine activities. Disruptive behavior often is manifested by health care professionals in positions of power (2).

Disruptive and intimidating behavior undermines teamwork and collegiality. Intimidating behavior and disruptive behavior are unprofessional and should not be tolerated. Ultimately, disruptive behavior may have a negative effect on patient safety and quality of care by, among other things, creating tension and causing others to avoid the disruptive obstetrician–gynecologist or other health care provider. For example, staff may refrain from asking a disruptive physician for help or clarification and hesitate to make health care-related suggestions about patient care. Additionally, patients who witness disruptive behavior may lose confidence in the obstetrician–gynecologist or other health care provider as well as the institution.

Institutional Perspective

Co-workers often are reluctant to report disruptive behavior because of fear of retaliation and the stigma associated with “blowing the whistle” on a colleague. Additionally, negative behavior of revenue-generating physicians may be overlooked because of concern about the perceived consequences of confronting them (2). Institutions and practices should develop a multifaceted approach to address behavior that undermines a culture of safety. It is essential that the administration fully support and show a commitment to eliminating disruptive behavior.

Establishing a Code of Conduct

The Joint Commission requires that hospitals establish a code of conduct that “defines acceptable behavior and behaviors that undermine a culture of safety” (3). When establishing a code of conduct, institutions should stipulate behavioral standards and the consequences for noncompliance. A process for managing behavior that undermines a culture of safety should be created and implemented (3). At the initial appointment of medical staff and each reappointment, each member should acknowledge acceptance of the behavioral standards and the consequences of noncompliance, as detailed in the code of conduct, consistent with provisions contained in the medical staff bylaws. In addition to incorporating a prohibition against retaliation into the code itself, the organization must clearly spell out its commitment to protect all staff members and physicians against retaliation for reporting code violations or for participating in investigations of violations (4).

Developing a Monitoring and Reporting System

Institutions should establish reporting mechanisms for disruptive behavior. Ideally, this will include opportunities for confidential reporting. Additionally, policies for the evaluation of such complaints should include anonymity for the reporting individual and a process for response from the individual identified as disruptive. Implementing a confidential system for reporting disruptive behavior also could include routine confidential evaluations and formal analysis of complaints from patients, co-workers, or others. The importance of reporting negative behavior should be emphasized as a means to decrease these occurrences and increase patient safety. Emphasis also should be placed on ensuring privacy and reducing potential fears about retribution (5). Reports related to disruptive behavior should be submitted in a confidential manner to the appropriate administrative individual, such as the chair of the department of obstetrics and gynecology or the chief of staff. The individual exhibiting the negative behavior should be notified and given an opportunity to respond to the complaint.

Educating and Training

Health care organizations should make a concerted effort to educate staff (ie, medical, nursing, and ancillary staff) about the potential negative effects of disruptive and unprofessional behavior on patient safety. Additionally, leaders of the medical and nursing staff should undergo specific training in intervention techniques to help counsel individuals who exhibit disruptive or intimidating behavior.

Establishing a Resolution

Any complaints related to disruptive behavior should be handled in a confidential manner with interventions designed to assist in behavioral change. Complaint resolution should be consistent with medical staff, departmental, or other institutional policies and procedures. Appropriate steps should be taken to resolve the problem. Disciplinary actions should be appropriate to the type of infraction and frequency of behavior, including any mitigating factors. Each institution should establish thresholds for taking action that depend on the severity of the behavior. Some actions may merit zero tolerance. All attempts to address disruptive behavior should be clearly and thoroughly documented. The department chair or appropriate leader should be informed of individuals with persistent problem behavior and should be responsible for establishing an appropriate response. The response may include some or all of the following steps:

  • Face-to-face meeting with the physician or other health care provider who is exhibiting disruptive behavior
  • A follow-up meeting (if the problem is still unresolved) resulting in a behavioral contract setting forth any disciplinary actions that may be taken if the disruptive behavior persists
  • Formal counseling
  • Administrative hearing
  • Summary suspension for egregious behavior

Assessment and treatment programs that are tailored to the individual should be made available as necessary. Special attention should be given to the possibility of substance abuse or a psychiatric diagnosis, which can contribute to disruptive behavior. At least initially, these programs should attempt to enable the individual to continue or resume practice.

Practitioner Perspective

Professional competence has been defined as the “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.” (6) Although most physicians consistently exhibit professional behavior, there may be occasions when a comment, action, or gesture might be construed as offensive, resulting in a complaint. In fact, all health professionals are subject to lapses and may engage in what appear to represent single acts of unprofessional behavior (7). It is important that physicians be aware of the professional review process and of the serious potential consequences for unprofessional behavior.

Review Entities

Complaints or reports can arise from various sources. Complaints may be filed with a hospital, a professional society, or state medical board, among others. Some of these actions must be reported to the National Practitioner Data Bank. Consequently, it is incumbent upon physicians to conduct themselves in a professional manner to avoid actions that could result in restrictions on their practices.

Hospitals and Health Systems

Through the peer review process, hospitals and health care systems evaluate the competence of practitioners who provide care to patients within their facilities. The steps involved for peer review and any aspects of due process are outlined in the hospital’s medical staff bylaws. In most instances, single unprofessional incidents can be addressed through an informal process. However, when a pattern exists, the intervention may escalate, possibly to the level of disciplinary action (8).

Professional Medical Societies

Complaints also may be reported to professional medical societies. For example, the American Congress of Obstetricians and Gynecologists (ACOG) reviews and evaluates complaints from Fellows regarding professional conduct by another Fellow that may violate the Code of Professional Ethics. Furthermore, ACOG pursues and reviews final state medical board actions resulting from professional conduct inconsistent with ACOG’s bylaws.

State Medical Boards

A state medical board or state office of professional medical conduct provides a process for patients to file complaints about an obstetrician–gynecologist or other health care provider. The process varies by state. Generally, the investigations conducted by these state bodies are intended to protect the public from the unprofessional, improper, and incompetent practice of medicine (9).

National Practitioner Data Bank

Hospitals and health care systems are required to query the National Practitioner Data Bank when a physician applies for privileges and during the reappraisal process. Box 1 provides examples of actions that are reportable to the National Practitioner Data Bank.

Box 1. National Practitioner Data Bank Reportable Actions

Because of the implications of reports submitted to the National Practitioner Data Bank, individuals may wish to order a self-query. Individuals or health care organizations may add a statement to provide any additional information to be included with the report. Individuals should contact their professional medical liability carriers about any licensure restriction or any review or investigation that might affect licensure or practice privileges.

Strategies for Addressing Conduct Review

Although most physicians will rarely be the subject of a conduct review, it is important to minimize that possibility. Physicians can become familiar with their hospitals’ or health care systems’ policies and procedures. In addition, it is helpful to be aware of the requirements for maintenance of licensure by the state medical board and any related federal programs.

To avoid concerns about the quality of patient care, obstetrician–gynecologists should practice within the community standards and in accordance with institutional protocols. They also should maintain accurate and complete patient records that appropriately reflect the care provided and always exhibit professionalism when interacting with patients, staff, and colleagues.

Handling a Complaint

Physicians being investigated by any review entity will typically be notified to provide additional information. It is extremely important to respond to any requests for information in a timely manner. Depending on the nature of the complaint, it may be worthwhile to consult with an attorney, especially for any action that may have a potentially negative effect on one’s practice.

Managing Stress

Throughout any review process, it is important to maintain constructive relationships with professional colleagues, seek out personal support, and adopt healthy coping mechanisms. Physicians are at risk of burnout and often internalize the stress associated with a professional review process. Resources are available to assist physicians throughout the process.

Conclusion

Disruptive physician behavior creates a difficult working environment and threatens the quality of patient care and patient safety. Confronting disruptive individuals is difficult. Clear standards of behavior that acknowledge the consequences of disruptive and intimidating behavior must be established and communicated. Confidential reporting systems and assistance programs for physicians who exhibit disruptive behavior should be established. A clearly articulated hospital-wide policy and procedure relating to disruptive behavior should be developed and enforced by hospital administration. To preserve profes-sional standing, physicians should understand how to respond to and mitigate the effect of complaints or reports.

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-info/CultureofSafety.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

References

  1. American Medical Association. Physicians with disruptive behavior. In: Code of medical ethics of the American Medical Association: current opinions with annotations. 2014–15 ed. Chicago (IL): AMA; 2015. p. 351–3.
  2. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert Issue No. 40. Oakbrook Terrace (IL): Joint Commission; 2008. Available at: http://www.jointcommission.org/assets/1/18/SEA_40.PDF. Retrieved August 29, 2016.
  3. The Joint Commission. Leaders create and maintain a culture of safety and quality throughout the hospital. Standard LD.03.01.01. In: Comprehensive accreditation manual. CAMH for hospitals: the official handbook. Oakbrook Terrace (IL): Joint Commission; 2016. p. LD-15–LD-16.
  4. Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to patient safety. Patient Saf Qual Healthc July/August 2006:16–24. Available at: http://www.psqh.com/julaug06/disruptive.html. Retrieved August 29, 2016.
  5. Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf 2008;34:464–71. [PubMed]
  6. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002;287:226–35. [PubMed] [Full Text]
  7. Pichert JW, Moore IN, Karrass J, Jay JS, Westlake MW, Catron TF, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf 2013;39:435–46. [PubMed]
  8. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med 2007;82:1040–8. [PubMed] [Full Text]
  9. Carlson D, Thompson JN. The role of state medical boards. Virtual Mentor 2005;7(4). Available at: http://journalofethics.ama-assn.org/2005/04/pfor1-0504.html. Retrieved September 27, 2016.

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Behavior that undermines a culture of safety. Committee Opinion No. 683. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017:129:e1–4.

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