New Joint Commission standard tells hospitals to squelch disruptive behaviors

One physician had the social skills of a 2-year-old, said a nurse in an anonymous survey on disruptive behavior published last year. A cardiologist was upset by phone calls and told a nurse it was not her job to think, just follow orders -- a squabble that delayed treatment for a patient with a heart attack. On the other hand, a doctor complained about an increasing lack of respect from nurses who frequently challenged or flatly disobeyed clinician orders.

The Joint Commission is calling on hospitals to crack down on "disruptive" health care professionals, over concerns that such behavior impacts patient care. A new commission standard taking effect in January 2009 will require hospital administrators to adopt codes defining disruptive behavior and develop procedures to discipline medical staff and other health professionals who behave badly.

Ahead of the standard, the commission in July issued a sentinel event alert highlighting the problem and making recommendations on how hospitals should handle it. The accreditation organization defines a sentinel event as "any process variation for which a recurrence would carry a significant chance of a serious adverse outcome."

The moves are drawing fire from doctors. They say disruptive behavior policies, which can cover everything from criminal assaults to condescension, are often too vague and used against physicians who may step on toes when advocating for patients or who own competing specialty hospitals and ambulatory surgical centers.

Some worry that the commission's actions could make it easier for hospitals to target outspoken medical staff members.

Disruptive behavior policies have "already been used to remove from the medical staff physicians who have a different opinion from administration," said Jay A. Gregory, MD, chair of the American Medical Association's Organized Medical Staff Section Governing Council. "We'll see more of that as time goes on.

"If somebody's not a 'team player,' individuals will try to remove them from the team, and the disruptive physician policy is one mechanism by which that can be done," said Dr. Gregory, a general surgeon and trustee at the Muskogee Regional Medical Center in Oklahoma.

Policies on bad behavior

It is not clear how many hospitals have conduct codes, but experts said many have policies that explicitly address disruptive behavior.

The commission's alert says "intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. ... Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions."

These behaviors "undermine team effectiveness and can compromise the safety of patients" and "should not be tolerated," the alert states.

The commission said hospitals should have zero tolerance for egregiously bad behavior such as assaults. Facilities should educate team members about acceptable behavior, hold everyone accountable regardless of position, and lay out how and when to begin disciplinary actions. Hospitals also should protect staff who report bad behavior from retribution, and intervene early and in a nonconfrontational way with doctors or others accused of troublesome behavior.

In addition, medical staff policies on disruptive behavior should be "complementary and supportive" of a hospital's policy for nonphysician staff, the commission noted.

Dr. Gregory said it is critical that organized medical staffs incorporate policies on bad behavior into their bylaws to ensure legally protected peer review processes that are fair to physicians accused of being disruptive. An guide on medical staff bylaws, published by the American Medical Association, includes a sample policy.

The AMA says policies should distinguish between good-faith criticisms and verbal or physical conduct that negatively affects patient care. Also, hospitals should have processes in place to verify allegations and discipline physicians in a fair way, with suspension of clinical privileges being a last resort.

Lawrence R. Huntoon, MD, PhD, chair of the Assn. of American Physicians and Surgeons' Committee to Combat Sham Peer Review, said he gets calls from concerned physicians weekly. Many of them say hospitals are retaliating against them for complaining about substandard hospital care.

"I think the new disruptive-behavior standard puts a lot of physicians, particularly ethical physicians, at great peril," said Dr. Huntoon, a Lake View, N.Y., neurologist.

But some experts welcome the Joint Commission's actions.

"It's about time," said Alan H. Rosenstein, MD, whose studies on the impact of disruptive behavior in hospitals were cited in the sentinel event alert. "It's an issue that needs to be addressed. Hospitals have been reluctant to confront some disruptive physicians because they are often heavy admitters."

Dr. Rosenstein, vice president and medical director of the West Coast chapter of nonprofit hospital alliance VHA Inc., added that nurses, pharmacists and other health professionals also are guilty of behaving badly.

"People need to understand what the ramifications are and be held accountable," he said. "There's really no sacred ground when it comes to patient safety."