The recent focus on “intimidating and disruptive behaviors” by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as well as structural changes in hospital environments has created significant risks to the functioning of healthcare institutions. These risks include the loss of valuable personnel, decreased morale among professional teams, increased litigation by accused practitioners, and the potential for misuse of the process for inappropriate reasons._
PROBLEM
1) The rise in concern about disruptive professionals puts pressure on medical institutions to act quickly and forcefully when an accusation is made. When circumstance are in dispute, then administrators are at risk for errors and, equally problematic, for the perception of bias.
The 2008 Sentinel Alert by JCAOH impelled medical facilities to “address the problem of behaviors that threaten the performance of the health care team.” In 2013, JCAHO revisited the issue claiming, "Now there is compelling evidence that some behaviors contribute directly to medical errors." However, what constitutes a disruptive professional, and guidelines concerning identification and remediation, are vague, while a zero tolerance policy is encouraged. As a result, when a physician or other professional is accused of disruptive behavior, whether fairly or not, administrators may take – or at least be perceived as taking – the path of least resistance, acting punitively or disproportionately in order to keep the peace and/or avoid scrutiny. The process can also be subject to abuse for personal or political reasons. An incorrect decision can ruin a career unjustly and deprive the hospital of a valuable employee. If an argument can be made for unfairness, even if the complaint is warranted, then the accused professional may be empowered to take legal action against the institution. Conversely, when an institution does not act aggressively when a complaint is issued, even if it is unmerited, it may appear that the administration is unconcerned or taking one side against the other. This can adversely affect the work environment and may trigger cumbersome and unnecessary scrutiny.
2) Changes in the structure of health care institutions have altered traditional roles and created new anxieties and risks for medical professionals.
The structure of healthcare institutions has been changing relatively quickly from a hierarchical model to one in which decision-making is more distributed. Although the benefits to patient care may be considerable, a consequence is also an increase in uncertainty and anxiety. Practitioners who are traditionally farther down in the hierarchy now feel more at risk of being blamed for mistakes such as following incorrect orders that, in the past, would have been the responsibility of prescribers. Greater vulnerability leads to greater anxiety, more likelihood of reactivity, and an increase in conflict. Moreover, institutional cultures, rivalry between specialties, breakdowns in communication, and other factors may exacerbate strife and finger-pointing. Additionally, more and more physicians have become employees of hospitals rather than practice-owners. As they become more dependent on their ability to work in a hospital setting they are also at greater risk of completely losing their livelihoods if they are labeled as problematic. This increases the motivation to take legal action against the institution if they perceive the sanctions or termination as unfair.
USUAL SOLUTION
Typically, complaints about problem interactions are ascribed to anger or issues of personality. The first line of approach, apart from termination, is to insist on anger management training or some analog. If the diagnosis is correct, this may be the right solution. Often, however, the problem is more complex. A wide variety of factors can contribute, including individual personality, stress-inducing situations, the complainant, the system itself, or interactions between more than one of these factors. When this is the case, and other underlying problems – interpersonal or structural – remain unaddressed, focusing on only one aspect is unlikely to work and the problem is likely to recur.
PROBLEM
1) The rise in concern about disruptive professionals puts pressure on medical institutions to act quickly and forcefully when an accusation is made. When circumstance are in dispute, then administrators are at risk for errors and, equally problematic, for the perception of bias.
The 2008 Sentinel Alert by JCAOH impelled medical facilities to “address the problem of behaviors that threaten the performance of the health care team.” In 2013, JCAHO revisited the issue claiming, "Now there is compelling evidence that some behaviors contribute directly to medical errors." However, what constitutes a disruptive professional, and guidelines concerning identification and remediation, are vague, while a zero tolerance policy is encouraged. As a result, when a physician or other professional is accused of disruptive behavior, whether fairly or not, administrators may take – or at least be perceived as taking – the path of least resistance, acting punitively or disproportionately in order to keep the peace and/or avoid scrutiny. The process can also be subject to abuse for personal or political reasons. An incorrect decision can ruin a career unjustly and deprive the hospital of a valuable employee. If an argument can be made for unfairness, even if the complaint is warranted, then the accused professional may be empowered to take legal action against the institution. Conversely, when an institution does not act aggressively when a complaint is issued, even if it is unmerited, it may appear that the administration is unconcerned or taking one side against the other. This can adversely affect the work environment and may trigger cumbersome and unnecessary scrutiny.
2) Changes in the structure of health care institutions have altered traditional roles and created new anxieties and risks for medical professionals.
The structure of healthcare institutions has been changing relatively quickly from a hierarchical model to one in which decision-making is more distributed. Although the benefits to patient care may be considerable, a consequence is also an increase in uncertainty and anxiety. Practitioners who are traditionally farther down in the hierarchy now feel more at risk of being blamed for mistakes such as following incorrect orders that, in the past, would have been the responsibility of prescribers. Greater vulnerability leads to greater anxiety, more likelihood of reactivity, and an increase in conflict. Moreover, institutional cultures, rivalry between specialties, breakdowns in communication, and other factors may exacerbate strife and finger-pointing. Additionally, more and more physicians have become employees of hospitals rather than practice-owners. As they become more dependent on their ability to work in a hospital setting they are also at greater risk of completely losing their livelihoods if they are labeled as problematic. This increases the motivation to take legal action against the institution if they perceive the sanctions or termination as unfair.
USUAL SOLUTION
Typically, complaints about problem interactions are ascribed to anger or issues of personality. The first line of approach, apart from termination, is to insist on anger management training or some analog. If the diagnosis is correct, this may be the right solution. Often, however, the problem is more complex. A wide variety of factors can contribute, including individual personality, stress-inducing situations, the complainant, the system itself, or interactions between more than one of these factors. When this is the case, and other underlying problems – interpersonal or structural – remain unaddressed, focusing on only one aspect is unlikely to work and the problem is likely to recur.