Call for civility aims to stop disruptive behavior in the OR

One step to safer surgeries may be potluck lunches.

Arranging social occasions where members of the surgical team can get to know one another as individuals is part of the patient safety approach that Andrew S. Klein, MD, is pursuing as chair of surgery and transplant medicine at Cedars-Sinai Medical Center in Los Angeles.

"In the operating room, we're all camouflaged in our gowns and masks and gloves," Dr. Klein said. "If I ask for one instrument and I get the wrong one, my options could be to swear and yell or throw that instrument on the floor. But if I know the person, if I know something about them, there is a well of good will, and you don't react that way."

Encouraging multidisciplinary social activities and promoting a culture of civility can deter the disruptive behavior associated with worse-patient outcomes, Dr. Klein wrote in an article published in the July Archives of Surgery.

He cites a study of 300 procedures where researchers graded the surgical teams on how well they shared information and sought input from all team members -- communication that can be impeded by disruptive and abusive behaviors. A study published in the May 2009 issue of The American Journal of Surgery found that 30-day mortality and complication rates were directly correlated with how well the surgical teams communicated.

Previous qualitative research has come to a similar conclusion. Yelling, abusive language, public berating, condescension and insults impair quality and contribute to adverse events and medical errors, according to nearly 70% of the 5,000-plus health professionals surveyed about disruptive behavior in the OR for a study in the July 2006 Journal of the American College of Surgeons.

A Joint Commission standard that took effect in January 2009 requires hospital administrators to adopt codes defining disruptive behavior and develop procedures to discipline medical staff and other health professionals who behave badly.

The American Medical Association has policy stating that the medical staff should develop its own code of conduct, define disruptive behavior, implement due process procedures and discipline physicians appropriately. The medical staff also should have a way to work with hospital administrators to determine whether the system of medical delivery in the hospital contributed to the disruptive behavior, the AMA says.

"No jerks" rule

Disruptive-behavior codes are just the start when it comes to encouraging civility in health care, Dr. Klein said. When recruiting, physician groups and hospitals should adopt a "no jerks" rule and seek health professionals who behave courteously toward their colleagues.

"In medicine, we hire on the basis of accomplishment, grants or clinical practice, even when there are major red flags that someone will be difficult to work with," he said. "There is this magical thinking that we'll make them better where we are."

Disruptive behavior continues to bedevil medicine. More than 70% of physicians said disruptive behavior happens monthly at their organizations, according to a survey of 840 doctors released in May by QuantiaMD and the American College of Physician Executives.

Dr. Klein said encouraging civility in medicine should begin with medical school and residency, where surveys have found widespread harassment and belittlement. Medical educators are beginning to make progress on this front, adding courses on communication and testing students for their psychosocial skills, said Alan H. Rosenstein, MD, a San Francisco internist and consultant on disruptive behavior.

The growing body of evidence indicating a link between incivility and poor care quality may get through to physicians and other health professionals who let the stress of their jobs get to them, Dr. Rosenstein said.

"I don't think anybody starts out the day planning to be disruptive," he said. "But the first thing the individual needs to do is recognize the repercussions of their actions. They may think that they will yell or throw things and they can just move to the next order of business. They need to see the downstream effect, that this behavior can lead to communication gaps that lead to medical errors."