Drawing the Line Effective: Management Strategies for Disruptive Behavior

November / December 2008
Drawing the Line
Effective Management Strategies for Disruptive Behavior

A trauma surgeon suspended in August 2008 by hospital administrators has filed a federal lawsuit against the county-owned hospital, alleging the action violates his constitutional rights and antitrust laws. The surgeon is alleged to have become involved in a physical confrontation with family members of a hospital patient. Three days later, the hospital asked the trauma services director to remove the surgeon from the trauma department call schedule because he might pose an “unreasonable danger to (hospital) patients, visitors, employees, and medical staff.” However, the hospital did not remove the surgeon from the general surgery on-call schedule. Since the surgeon derives 65% of his income from trauma cases, he now alleges that the suspension was driven by economic considerations, an antitrust violation.

The hospital has been advised by the district attorney’s office not to comment on the specific allegations of the lawsuit. However, hospital administrators said that the surgeon had been offered “…a simple pathway back to reinstatement to the call schedule at the trauma center through… anger management (classes). Rather than resolve the situation, Dr. (X) has again chosen to escalate matters by filing suit against (the hospital).”

Disruptive clinician behavior continues to make headlines in news media, as first reported by the lead author in 2006 (Porto & Lauve). In July of this year, The Joint Commission, recognizing that disruptive clinician behavior continues to present challenges to healthcare organizations and impacts the quality and safety of patient care, released a Sentinel Event Alert on this topic to provide guidance on how to deal with it (Joint Commission, 2008, July 9). Despite this, hospitals and healthcare organizations continue to struggle with this issue, as demonstrated by the above news account. As this news account illustrates, such behavior can place patients, visitors, and staff at risk of injury, in addition to creating an atmosphere of fear and intimidation that hampers hospitals’ safety efforts. It is clear that the time has come for hospitals and other healthcare organizations to implement a comprehensive program to deal with this serious safety issue. This article provides a “roadmap” for organizations to follow, using the experiences of one healthcare organization, Catholic Healthcare Partners, to illustrate effective strategies for dealing with disruptive clinician behavior.

The First Challenge:
Recognizing the Problem

Addressing disruptive clinician behavior is a challenge for any healthcare organization, though the reasons for this may vary. In some organizations, disruptive behavior among clinicians has been going on for so long that it has become “the norm.” In other organizations, those who engage in this behavior are viewed as powerful and thus leaders are reluctant to confront the behavioral issues. In many organizations, those charged with responsibility for addressing the behavior have had little or no experience or training in dealing with this problem and are unsure how to proceed.

Disruptive clinician behavior is known to be relatively common and to have serious negative impact on organizational culture, recruitment and retention, and patient care (Institute for Safe Medication Practices, 2003; Rosenstein & O’Daniel, 2005; Diaz & McMillin, 1991; Rosenstein, 2002; Cox, 1987; Maxfield et al., 2005). Despite this, many organizations have not investigated the frequency or severity of this problem in their own settings, and the issue of disruptive behavior becomes apparent only when it is brought to light in connection with other initiatives. This was the case at Catholic Healthcare Partners (CHP).

In 2006, as part of CHP’s perinatal safety initiative, the summary and recommendations from a thorough assessment of 18 perinatal units were presented to the CHP executive management team and physician and nursing leadership from across the system. The assessment found that disruptive physician behavior within CHP perinatal units was more widespread than generally acknowledged. Drs. Eric Knox and Kathleen Simpson, nationally recognized experts who performed the assessments, found evidence of both disruptive workplace behavior and clinical care not based on evidence and/or professional standards For example, they found use of profanity, intimidation, and name-calling in front of patients. Staff reported being hesitant to ask questions, seek clarification, or ask certain practitioners to see patients. Several physicians had threatened to take their business elsewhere in response to efforts to improve care and communication.

As leadership groups across CHP discussed this finding, it became clear that this problem and its impact were not limited to the perinatal units or to physicians. OR leaders identified disruptive clinician behavior as a major barrier to achieving compliance with such safety practices as surgical site marking and time-outs. Through further dialogue at the leadership level, CHP leaders discovered that nearly every CHP organization and region could recount stories of how this behavior affected the quality and safety of patient care. This is what spurred leadership to implement a comprehensive plan of action. The CHP experience contains valuable lessons for all healthcare organizations. No organization should assume that disruptive clinician behavior is not a problem. Instead, leaders of healthcare organizations should assume that disruptive clinician behavior is impacting the staff morale; quality and safety of patient care; and creating risk, cost, and legal issues throughout their own organizations and without their knowledge.

Research shows that intimidation and the resulting fear are powerful forces that inhibit reporting of disruptive behavior (Institute for Safe Medication Practices, 2003; Maxfield et al., 2005). Therefore, it is necessary for healthcare organizations to initiate comprehensive efforts to determine whether or not such behavior is occurring. No organization should assume that the absence of formal reports or complaints of such behavior means that it is not occurring. Instead, organizations should initiate comprehensive efforts to determine where and when such behaviors may be occurring. Such efforts should go beyond review of incident reports, since a staff member who is fearful of an intimidating or disruptive clinician is unlikely to file a formal written report. Leaders should incorporate proactive detection strategies that include:


  • Conducting focus groups with front-line clinical staff, such as perinatal units and ORs. During these focus groups, conveners should ask direct questions about whether disruptive behavior occurs in the unit and should invite attendees to give specific examples (see sidebar).
  • Incorporating questions about disruptive clinician behavior into patient safety rounding.
  • Incorporating questions about disruptive clinician behavior into culture surveys.
  • Inviting informal, unwritten reports about disruptive clinician behavior with assurance of no retaliation/no punitive consequences for volunteering the information.



Tips for Conducting Focus Groups

  • If at all possible, use a consultant or other outside facilitator to conduct the group. Intimidated staff members are more likely to discuss issues with a neutral third party than they are with organizational “insiders.”
  • Encourage staff to remove ID badges and to remain anonymous if they wish.
  • Assure staff that no comments made during the session will be attributed to any individual and that only aggregated comments will be shared with leadership — and deliver on this! Even one violation can totally destroy staff trust in the process.
  • Conduct enough focus groups in each area such that anonymity of attendees is assured and comments cannot be traced back to an individual.
  • Ask specific questions about the occurrence of disruptive behavior but do so in a non-threatening manner — i.e., “Does disruptive behavior occur on this unit?” rather than “Have you seen any instances of disruptive behavior?”
  • Invite attendees to share specific examples if they feel comfortable doing so.
  • Provide contact information for anyone who may wish to follow up privately to discuss the problem or a specific incident.
  • Share feedback and comments in an aggregated format that does not inadvertently identify the source.


Leadership Engagement and Guidance
Senior leaders often fail to address the problem of disruptive clinician behavior. Rosenstein (2005) found that only one third of hospitals that had identified disruptive clinician behavior as a problem had taken any action and only 24% of those reported any improvement. This may be discouraging to those on the “sharp end” of care, who are most directly impacted.

Leaders fail to address disruptive behavior for many reasons. One may be ignorance of the problem. Disruptive behavior often takes the form of intimidation, and in many instances, disruptive individuals can be very powerful in the organization. This may discourage individuals from reporting the problem, and, as mentioned earlier, the absence of reports is often incorrectly interpreted by leaders as absence of a problem.

Also, it is often the case that middle managers and even highly placed administrators, such as chief nursing officers and chief medical officers, shield the CEO from this information. They may view the very existence of this problem as a personal failure of leadership or management skills, or they view their primary responsibility as “maintaining the status quo,” or view the behavior as normal. For all of these reasons organizations must have robust and redundant systems of environmental scanning to determine if disruptive clinician behavior exists. Also, senior leaders must make it their business to learn if this problem exists in their organizations, and to engage in dialogue with appropriate team members about how to best address it.

Another reason leaders may fail to act is uncertainty about how to deal with the problem. Disruptive clinicians are difficult to deal with — that is the very essence of the problem. Sometimes, though not often, the individual may suffer from a personality disorder. In addition, they are often powerful — a physician who admits a lot of patients, or a long-term employee, or a highly competent clinician with a proven track record of providing excellent patient care. This makes it harder to confront them about their behavior. Also, managing conflict and interpersonal difficulties is not something usually taught in management or clinical training programs, nor is the task viewed as a pleasant one. Thus, leaders may hesitate to take on a difficult and distasteful problem for which there is no obvious solution.

Of course, none of these reasons justifies leadership inaction. However, if leadership resolve seems weak, it may be necessary for middle managers to clearly illustrate for leaders how disruptive clinician behaviors adversely affect patient care and safety, undermine morale, contribute to recruitment and retention problems, and disrupt operations. There is an abundance of studies that illustrate this (Diaz, 1991; Rosenstein, 2005; Maxfield et al., 2005; Rosenstein, 2005). Another source of leadership inspiration is the Joint Commission’s new leadership standards (2008), which clearly articulate leadership’s responsibility to assess and address this problem. Yet another possible area of motivation or inspiration may come from the organization’s own mission statement. That was the case at CHP.

In late 2006, CHP’s executive management team (EMT), which consists of divisional and regional CEOs as well as senior leaders from the home office, affirmed the need for a system-wide approach to clearly set expectations about professional behavior. Armed with information about existence of the problem, the EMT presented a compelling case to the Board of Trustees about the need to act. Disruptive clinician behavior was simply not consistent with CHP’s mission and values of compassion, excellence, human dignity, justice, sacredness of life, and service. The Board of Trustees supported the leaders’ desire to address disruptive clinician behavior through a key initiative beginning in 2007, aimed at helping everyone to pay more attention to professional behavior and commit to mutual respect and serving others with compassion and sensitivity. The initiative became known as “Setting the Standard for Professional Behavior.”


About Catholic Healthcare Partners

  • Largest health system in Ohio and one of the largest not-for-profit health systems in the United States, providing healthcare services to people in five states.
  • Composed of over 100 organizations, including 34 hospitals and 17 long-term-care facilities; nearly 37,000 employees.
  • Mission: To extend the healing ministry of Jesus by improving the health of our communities with emphasis on people who are poor and under-served.
  • Core Values: Compassion, Excellence, Human Dignity, Justice, Sacredness of Life.


Setting Behavioral Standards for the Organization
In order to eliminate undesirable or disruptive behavior, it is first necessary to articulate the standard of behavior that is desired. Many organizations have already done this, through codes of conduct, employment contracts, and policies and procedures. However, these statements and documents are often aspirational in nature, intended to inspire outstanding behavior without providing much guidance about what is unacceptable or how to deal with it. Furthermore, in many organizations, disruptive behavior has been tolerated over time, and thus these written manifestations about desirable behavior have lost meaning.

A critical first step in addressing disruptive clinician behavior on an organization-wide basis is to clearly and definitively articulate the behavioral standard that is the goal and how this relates to the organization’s mission to provide quality patient care. Equally importantly, the organization must articulate what is not acceptable. The organization should assume that there is uncertainty about this and should thus strive to provide meaningful guidance to all staff­physicians, employees, vendors­and even to patients and visitors. It may be necessary to provide data about the existence of the problem in the organization and how this impacts both patients and staff, since many “disrupters” are unaware of how their behavior impacts others and causes disruption in service. This effort should be led by a multidisciplinary team of stakeholders so as to be appropriately representative and relevant to everyone to whom the behavioral expectations will apply.

At CHP, a task force was created to operationalize the “Setting the Standard for Professional Behavior” initiative. This task force was composed of medical, nursing, and administrative leaders and was charged with:


  • developing a system-wide understanding of disruptive behavior and its impact on patient care and safety, employee morale and risk, cost and legal ramifications;
  • clarifying behavioral expectations in the context of CHP’s mission and values;
  • promoting behavioral improvement through training and clarification of existing disciplinary mechanisms; and,
  • developing appropriate monitoring and measurement processes.


One outcome of the work of this task force was the development of a definition of disruptive behavior and its incorporation into a Code of Professional Conduct (below).


CHP’s Code of Professional Conduct

  • Associates, affiliates and all members of the healthcare team will:
  • Discuss concerns about another’s action or communications with the individual, the individual’s supervisor or director in a private setting.
  • Give clear instructions when necessary for the care of patients and families.
  • Provide professional guidance as necessary to assure quality care.
  • Cooperate with and participate in quality improvement activities.
  • Adhere to medical center and medical staff policies and procedures.
  • Associates, affiliates and all members of the healthcare team will not engage in disruptive behavior which includes, but is not limited to:
  • Engaging in unwelcome or inappropriate physical contact.
  • Using verbal or written (including email) foul language, racial and ethnic slurs, sexual comments or innuendos or other abusive language.
  • Displaying anger inappropriately, including throwing instruments, charts, or other objects.
  • Humiliating, intimidating, or degrading another individual.
  • Making inappropriate entries in the medical record related to the conduct of another member of the healthcare team.
  • Acting in a manner which could adversely affect the healthcare team or impede its ability to deliver quality patient care.
  • Retaliating against anyone who has reported in good faith and/or who has participated in the investigation of an alleged violation of this Code.



Printed Name:____________________________________________


The Critical Role of Training for Leaders and Front-line Staff
Never assume that all healthcare workers share a common perception of what constitutes disruptive behavior. In fact, the opposite is likely true. Each individual, depending on his or her own values, culture, personal experiences, and personality traits, may have a different view of acceptable and unacceptable behaviors. It is also the case that most healthcare workers, whether at leadership levels or at the “sharp end” of care, have received little or no formal training on conflict resolution. Therefore, perceptions about what constitutes disruptive behavior as well as skills for dealing with it are highly variable. For these reasons, training for staff at all levels should be a prominent element of any system-wide program to address disruptive clinician behavior.

Training should include not only what is now known about the impact of disruptive behavior on patient care, but also the impact of this behavior on members of the healthcare team and on clinical operations. The training must also include the organization’s own definition of disruptive behavior and the behavior that it expects its staff to model.

The CHP task force first undertook to educate itself about disruptive clinician behavior. It did this through a review of the literature and through the engagement of thought leaders in this area as consultants. Only then did the task force create strategic plans supplemented by a formal educational program and toolkit to train other leaders, clinicians, and front-line staff.

The CHP task force understood the importance of providing comprehensive training offerings in multiple formats. These served not only to enhance staff understanding and awareness of the issue, they also helped to maintain momentum as the various phases and components of the initiative were introduced and implemented.

A key component of CHP’s training initiative was the development of a DVD entitled Setting the Standard for Professional Behavior. This DVD was scripted, taped, and produced by CHP and included scenes created in CHP facilities to illustrate both acceptable and unacceptable behaviors. The DVD “sets the standard for professional behavior” as defined by CHP leaders based on its mission and values, as well as on its goal to continually enhance clinical quality; improve patient safety; increase employee morale; and decrease risk and cost. The DVD includes interviews and commentary from experts in the field, as well as CHP physicians, staff, and leaders.

CHP also developed a toolkit that it distributed to all senior leadership team members across the system. This toolkit is based on The Joint Commission/Institute for Safe Medication Practices’ (ISMP) concepts for mapping cultural change (Smetzer & Cohen, 2005). Educational components were built around CHP’s mission, core values, and the Church’s Ethical and Religious Directives, as well as 11 action steps for cultural change recommended by the Joint Commission and ISMP. CHP’s toolkit includes:


  • Talking points to prove the impact of disruptive behavior.
  • Detailed information on how CHP has and continues to support the 11 key action steps.
  • The CHP Code of Professional Responsibility and Personal Commitment.
  • CHP’s definition of disruptive behavior.
  • Survey forms for physicians and staff.
  • The TeamSTEPPS Pocket Guide (AHRQ, n.d.1), which describes techniques and strategies to enhance teamwork and communication.
  • Key articles on disruptive clinician behavior, which are also available on CHP’s intranet.
  • CHP intranet sources of training in crucial conversations and other communication resources.
  • CHP’s position statement on its non-punitive clinical event reporting system.
  • A letter from CHP’s CEO outlining support for and commitment to a culture of professional behavior.


Measuring and Sustaining Success
Many healthcare organizations make a key mistake: Once they implement a code of conduct and train the staff, they assume the work is done. Nothing could be further from the truth. At this stage, the work is only beginning. It is likely that the dialogue about disruptive behavior and the introduction of the code of conduct will stimulate new dialogue about what is and is not acceptable, as well as new information about infractions. Also, the organization will be unable to determine whether its efforts have successfully addressed the problem without some sort of measurement strategy. Thus, the work of leaders is far from over.

A number of methods, both formal and informal, exist for determining whether disruptive behavior exists in the organization: incident reporting, rounding, focus groups, surveys, and informal staff dialogue. Of these, only surveys can really be considered a reliable measurement tool, and even then, many biases and design defects can affect the results. Still, this is probably the most expedient method available to healthcare organizations for measuring success in its disruptive behavior initiative.

A number of survey instruments are available to healthcare organizations, including the Hospital Survey on Patient Safety Culture developed by the Agency for Healthcare Research and Quality (AHRQ, n.d.1). Surveys can be useful in measuring both the pre-implementation baseline and the impact of the program after implementation. However, none of these surveys was designed specifically to measure the incidence and impact of disruptive behavior, so modification will likely be needed. This may require organizations to add very specific questions about disruptive behavior. In no instance should an organization use an existing and non-specific question, such as “How well does your unit work together as a team?” to infer that disruptive behavior does or does not exist.

CHP chose to create a survey template (included in the toolkit) by using questions from the ISMP Survey on Workplace Intimidation and questions used and recommended by Dr. Rosenstein and others to reflect specific work and issues identified by hospital leaders. CHP’s CEO established a 2008 system objective that requires all acute care facilities to complete a professional behavior survey by the end of the second quarter and to incorporate the findings into updated action plans to address disruptive behavior by the end of third quarter. The system objective is a component of compensation and performance appraisals. Sites chose how to administer their surveys and were able to modify the tool. This flexibility contributed to acceptance and success. CHP could focus on two consistent key questions: 1) whether the staff or physician had personally witnessed or experienced disruptive behavior that compromised safety or quality of care in the last year and 2) whether they believed that the organization was dealing effectively with intimidating behavior. Initial results include:


  • 1,608 staff members (36%) report personally witnessing or experiencing disruptive behavior that compromised safety/quality in the last year (4,462 responses).
  • 1,973 staff members (44%) believe that their organization deals effectively with intimidating behavior (4,462 responses).
  • 122 physicians (20%) report personally witnessing or experiencing disruptive behavior (601 responses).
  • 239 physicians (47%) indicate that the organization deals effectively with intimidating behavior (506 responses).


All CHP hospitals are in the process of incorporating survey findings and the recommendations contained in the Joint Commission’s Sentinel Event Alert on disruptive clinician behavior into their plans. These action plans began in 2007 and will continue to be a system objective in 2009. CHP will also complete its third system-wide survey using the AHRQ Hospital Patient Safety Culture Survey in 2009. Results will be compared to those from 2005 and 2007, which showed little change.

CHP will also focus on surveillance for detecting episodes of disruptive behavior and promoting interventions that immediately address the problems and decrease the chances of repeat occurrences. CHP has developed an easy-to-use reporting module in their electronic event reporting system. Staff members are encouraged to discuss professional behavior and challenges during patient safety leadership walk rounds that occur regularly in all sites across the system. In 2008, Michael Connelly, CHP’s CEO, participated in patient safety walk rounds in every region, both to make a clear and public statement about CHP’s commitment to professional behavior, as well as to continue to educate himself to provide effective leadership for CHP’s formal initiative to address disruptive behavior. Feedback has been so positive, he plans to continue this practice in 2009.

Lessons Learned: The CHP Experience
CHP is well on the way to complying with the Joint Commission’s suggested actions in the recent Sentinel Event Alert and the Leadership Standard that goes into effect January 2009. However, the system recognizes that much more work still needs to be done. CHP believes strategies for success include:


  • Enhance awareness and knowledge of the quality, safety, morale, and cost benefits of professional behavior.
  • Connect to the mission and values and the calling of healthcare professionals.
  • Address disruptive behavior not in a punitive way, but in a supportive way that helps everyone do the right thing.
  • Be prepared for a multi-year commitment; culture change takes time.
  • Never let up; this cannot be “the flavor of the month.”


Because CHP’s Setting the Standard for Professional Behavior strategies, customized regional roll-out plans, DVD, and toolkit were so widely embraced by acute care clinicians and others within the system, CHP’s senior housing and long-term care leaders requested a second DVD and toolkit focused on professional/disruptive behaviors germane to them. CHP leaders responded promptly, and a similar initiative was produced and provided for regional customization and implementation in the first quarter of 2008.

In Closing
Disruptive clinician behavior poses a serious threat to patient safety. Although this problem has been tolerated for a long time in healthcare, the time has come to eliminate dangerous behavior from healthcare settings. The Joint Commission has provided valuable guidance through its 2009 Leadership Standards and Event Alert on this topic. Healthcare organizations must implement a comprehensive and system-wide approach in order to deal effectively with this problem. As illustrated by the experience of CHP, leadership engagement is critical in this process and can make the difference between success and failure. While organizations may choose to take a different approach, they must act nonetheless. The safety of patients and staff members is at stake.

Grena Porto is the founder and principal of QRS Consulting, LLC, and is a nationally recognized expert and leader in patient safety, risk management, and quality improvement. She served previously as senior vice president at Marsh USA, senior director of clinical consulting and director of clinical risk management at VHA, and was president of American Society of Healthcare Risk Management in 1999. She also served on the Board of Directors of the National Patient Safety Foundation from 1998 to 2001. She currently serves on the Editorial Advisory Board for Patient Safety & Quality Healthcare and on the Joint Commission’s Sentinel Event Advisory Group, where she was instrumental in writing Sentinel Event Alert #40 on disruptive clinician behavior. Porto may be contacted at gporto@qrshealthcare.com.

Jana Deen is patient safety officer and vice president at Catholic Healthcare Partners in Ohio. She transitioned to her current position in 2006, after serving as a regional risk officer and associate counsel for 10 years. Her passion for patient safety is, in part, driven by her disappointment with traditional risk management and litigation approaches. She leads a team of four divisional patient safety officers who strive to create and sustain a culture of patient safety across Catholic Healthcare Partners through strategy and tools such as leadership engagement, teamwork, and patient safety walk rounds. Deen may be contacted at jbdeen@health-partners.org.


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