CHICAGO (FRONTLINE MEDICAL NEWS) – Dealing with disruptive behavior by staff and colleagues isn’t just about knowing what to do – it’s also about knowing what not to do.

Often, mishandling disruptive behavior can make matters worse and lead to further conflict among physicians and employees, health law experts warn. At a conference held by the American Bar Association, attorneys offered guidance on the dos and don’ts of disruptive behavior management.

Don’t discipline for the wrong reasons

Know what disruptive behavior is not, advised Margo S. Struthers , a Minneapolis-based health law attorney. Criticism offered in good faith with the aim of improving patient care should not be considered disruptive, she said.

“This is a problem that comes up a lot because, often, there is some element of criticism that is offered by the supposed disruptive physician, which may or may not be justified, may or may have been done in good faith, and may or may not have been in a respectful manner.”

An isolated incident of behavior that is not reflective of a pattern of inappropriate, deep-seated, and habitual behavior should not be construed as disruptive, Ms. Struthers added. In addition, disruptive behavior is not respectful disagreement with leadership, presentation of controversial ideas, or the respectful complaining about processes that endanger patient care.

Do address behavior that is truly disruptive

According to the American Medical Association , disruptive behavior is defined as personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care, including conduct that interferes the ability to work with members of the health care team. Such behavior can be passive, such as ignoring calls or frequently missing meetings; passive-aggressive, such as excessive sarcasm or veiled threats; or aggressive, such as yelling or bullying.

Don’t focus solely on the behavior

Most disruptive behavior has a root cause, and efforts should be made to get to the bottom of the conduct, according to Sidney Welch , an Atlanta-based health law attorney.

“Often, there’s an underlying frustration in terms of clinical care or what they’re being told to do or the systems and processes [in play],” she said “Where is the sources of the tension that is creating the behavior?”

Do identify contributing factors

Personality characteristics that could lead to hostile behavior include self-centeredness, immaturity, resentfulness, or a need for power and control. Systemic factors could include increased productivity demands, cost-containment requirements, embedded hierarchies, fear of litigation, ineffective or absent conflict-resolution processes, competition between hospitals and medical staff, new care settings, and marketplace demands. Shortages of staff and high work burdens also could fuel disruptive behavior, Ms. Welch said.

“There are situations where there [is] a psychiatric disorder or a personality disorder that’s the root cause of the disruption,” she said. But “sometimes it’s just a stressful situation. A lot of these cases [in which] the physician is the disruption, we’re seeing them in high stakes emergency departments or situations where decisions have to be made very quickly, or fatigue and external stresses may be the source.”

Don’t apply corrective actions inconsistently

Make expectations clear by having a code of conduct supported by policies that apply to every employee, Ms. Welch noted. A lack of fairness among employees can create greater tension and generate increased conflict during a disruptive situation. Ensure that physicians are not be treated differently than nurses or administrators when addressing complaints, she said.

Do implement a graduated set of responses

A tiered response system (informal, formal, disciplinary, regulatory) helps manage disruptive situations based on the extent of conduct, Ms. Welch said.

“The process and disciplinary process [should] to be multileveled so that people know the rules of the road, and the parameters and the bumpers so to speak, are defined.”

Don’t necessarily involve HR

Be cautious of allowing human resource (HR) departments to direct potential disruptive physician issues, Ms. Struthers said.

“I have some concerns about HR getting involved for a couple of reasons,” she said. “If you get nonphysicians involved, it seems to exacerbate the level of tension.”

In addition, if a hospital has a significant number of both employed and independent physicians, HR can sometimes apply different standards and varied courses of action depending on employment status, she said. Of course, if the alleged disrupter is a nonphysician, HR is generally the only route for remedy within a hospital setting, Ms. Welch noted.

Do address the issue through internal processes

Every medical staff should develop and adopt bylaw provisions or policies for intervening in situations in which a physician’s behavior is identified as disruptive, according to AMA policy. Medical staff bylaw provisions or policies should contain procedural safeguards that protect due process.

For doctors in groups or small practices, employment policies and procedures should address protocols when disruption matters arise, Ms. Struthers said.

“The dynamics in a small clinic is that some doctors may more have power than others, so it may be harder in some contexts to treat everyone the same,” she said in an interview. “But that’s a really important thing to do. Any well-advised clinics would have a code of conduct or conduct policy, really to protect the clinic from employee lawsuits.”

Don’t let policies collect dust

“As we all know, you can write the policies, you can put them on the shelf, but if people aren’t reading them and understanding them and aren’t educated on them, then it really does no good,” Ms. Welch said.

Do ensure everyone knows how disruptive behavior is handled

Make certain that all staff review disruptive behavior policies and are adequately trained in how the process works, Ms. Welch added. Employees should know where to seek help if experiencing a disruption matter. Consider having staff members sign or acknowledge a code of conduct upon credentialing or hiring.

“Obviously, disruptive behavior can impact patient care, and it can come from a lot of differ directions; It’s not just physicians,” Ms. Struthers said. “Hospitals [and practices] like other places of business, need to have comprehensive polices and procedures, and they need to follow them.”

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