Our program consists of a three week intensive outpatient program and three one week follow up programs at 3, 6 and 9 months. This program includes psycho-educational groups, process groups, nutrition education, self-care training, mindfulness training, conflict resolution and negotiation, communication and grounding skills and family/genogram group.
Program participants will also be assigned a personal trainer and a three week gym membership for physical wellness coaching.
Dealing With Disruption
by Martha E. Brown
Only a small number of physicians and other health care professionals are disruptive in the workplace. However, their behavior can result in increased workplace stress and poor workplace environments, which ultimately results in reduced quality of patient care and an increased risk of liti gation.1 Studies have shown that three to five percent of physicians display disruptive behavior. However, the disruptive behavior intimidated 45 percent of the staff into silence about the disruptive physician’s questionable medical practice.2
Disruptive behavior is no longer just the stereotypical surgeon who throws an instrument. In reality, one finds disruptive behavior not only in physicians, but also in many different groups of health care professionals such as nurses, physician assistants, etc. The spectrum of disruptive behaviors that affect the workplace range from aggressive behaviors (such as profane language, throwing objects, sexual comments, or demeaning behavior), to passive-aggressive behavior (refusing to do tasks or derogatory comments about the hospital), or passive behaviors such as not responding to calls/ pages, inappropriate chart notes, or being chronically late.
Barriers to dealing with the problem vary. Many times the behaviors are not extensively documented, or there is a lack of policy regarding approaches to these situations. Often the disruptive professional is also a high producer for the hospital or practice. Thus, the potential loss of revenue if the professional leaves because of being reported adds to the hesitancy to report.
Finally, there is the fear of Reprisal or lawsuits against the reporting individual or hospital if the disruptive professional is “angered.” With the Joint Commission putting forth standards on disruptive behavior in 2009, it is important to quickly determine any incident’s severity and to have a plan to deal with it, regardless of the potential response from the professional being reported.
Interestingly, not all behaviors that initially appear inappropriate are disruptive.3 The significance of behavior that appears disruptive often depends on its nature, the context in which it arises, and the consequences that arise from the behavior.3 However, when true disruptive behavior occurs, it can vary in type and severity.Sometimes we find professionals who have done well most of their careers, but then exhibit a first-time incident of disruptive behavior that is relatively “mild” (i.e., routinely failing to complete records in a timely manner, being chronically late, or not answering pages).In these cases, it may be appropriate to confirm the facts, talk with the professional and discuss appropriateness, obtain assurances the behavior will not reoccur, complete a record of the incident and conversation with the professional for the personnel file, and closely follow up and monitor his or her behavior. In these types of cases, monitoring by the hospital, practice professional wellness committee, or executive committee on a monthly basis may be all that is needed to correct the behavior.
If there is a pattern of repeated behavior that disrupts the health care system, or if the first incident is particularly egregious (throwing objects, continual and demeaning language such as profanity or sexual comments, or inappropriate physical contact), the behavior should be addressed more formally. This would again include confirming the facts, as well as talking with the professional and closely documenting the incident and all conversations.
At this time it would be advisable to, at minimum, have a phone consultation with the Professionals Resource Network (PRN)4 . PRN Would then discuss whether a formal assessment/evaluation of the professional is warranted and/or if a referral to a six month continuing medical education (CME) program on disruptive behavior (such as the Distressed Physician Course offered at the University of Florida College of Medicine and at the Center for Professional Health at Vanderbilt University Medical Center),5.6 would be sufficient. Whichever direction is chosen, a brief contract should be written outlining expectations and requirements, along with deadlines for Completion. The professional should sign the contract and give his or her hospital or group practice written permission to communicate with PRN and/or the CME staff.
Regardless, all documentation should be placed in the personnel file, and the Professional’s behavior should be closely monitored. Monitoring may include getting monthly or periodic reports from PRN or the CME staff concerning the professional’s progress, along with confidential reports or 360 evaluations on the professional from surrounding staff or other professionals. If the less formal CME option is chosen alone at this point, it should be made clear that this is in lieu of a more formal report to PRN. However, Continued disruptive incidences without change will result in more formal actions, such as a referral to PRN or suspension of privileges.
Unfortunately, there are times when the behavior continues or reaches such a level that there is an immediate risk of harm to patients or staff. As always, the facts need to be confirmed.However, the process needs to follow clear, standard procedures That are much more formal and rapid in nature than those already discussed. Governing bodies such as the executive committee, chief of staff, human resources, and the CEO should be notified immediately. This should result in a meeting with the professional within 24 to 48 hours to discuss the behavior. The professional should be directed to contact PRN immediately.
Strong consideration should be given to suspension of privileges until PRN deems the professional safe to practice again. If PRN believes this to be possible, practice should resume only under supervision. After the professional has contacted PRN, a formal assessment will be obtained to examine factors that may be causing or contributing to the behavior and what type of treatment and/or monitoring is necessary. This usually results in A contract with PRN and close monitoring, as well as ongoing open communication with the referral source in order to ensure patient and workplace safety.
The good news is that studies have begun to demonstrate that addressing the behavior when it first appears can result in positive, dramatic changes in the workplace. Among 20 physicians labeled as disruptive who went through the Vanderbilt Distressed Physician CME course and consented to participate in a study, there were significant improvements in how others viewed the physician’s behavior. At three months, the physicians from the CME course showed a mean increase in motivating behaviors and impact, as well as a decrease in disruptive behaviors and impact. A six-month follow up revealed that 93 percent of the physicians felt they had a better understanding of how their behavior affected patient care, and that the course helped them change their behavior and attitudes.7
Certainly, the more severely disruptive professionals are initially in need of a more aggressive approach to their behavior, such as a referral to PRN with strong consideration given to suspension of privileges. However, it gives hope that if we learn to identify inappropriate behavior when it first occurs and confront the problems, we can make a difference in the workplace. Better team communication, improved patient safety, increased quality of patient care, reduced litigation and malpractice claims, increased staff morale, and a healthier work environment are only some of the benefits to be achieved from dealing with disruptive behavior in the workplace.
Martha E. Brown, M.D., is Assistant Medical Director for PRN and an Associate Professor of Psychiatry for the University of Florida College of Medicine. Dr. Brown is a national expert on controlled substance “misprescribing” and areas of professionalism.