Disruptive behavior in healthcare

"What we've got here is a failure to communicate." The memorable line from the 1969 movie, Cool Hand Luke, could be used to describe the situation in many families and organizations of all kinds, including healthcare. However, nowhere does it matter more than healthcare because the ultimate business of the industry is patient welfare and safety. 

Researchers from John Hopkins Medicine say in a 2016 article on Health News from NPR that medical errors take 250,000 lives each year in the US and should be ranked as the third leading cause of death behind heart disease and cancer that claim about 600,000 each. While it is almost certain that no single cause results in such an abysmal outcome, failure to communicate is high on the list.

In a video captured incidentally at a healthcare conference, Sorrel King tells the heart-wrenching story of how her 18-month old daughter died at John Hopkins Hospital in 2001 from medical errors and the refusal of doctors and nurses to listen to this young mother's pleas and reasoning. Eventually, Sorrel King and Johns Hopkins Hospital worked together to create the Josie King Foundation whose purpose is to help create a culture of patient safety.

The elephant in the room

In any significant medical facility, the healthcare cast is vast, including administrators, department leaders, physicians, nurses, aides, patients, families, contractors and many more. Yet failure to communicate a crucial bit of information from any of the parties to any other could affect the safety of a patient or even many patients. So what's the problem?

For a number of years in the healthcare industry, certain individuals, especially those in authority, have tended to exhibit patterns of behavior that are now recognized as intimidating and disruptive. A USA Today article, "When Doctors Are Bullies, Patients May Suffer," says, "Every workplace, like every schoolyard, has its bullies. But when the workplace is a doctor's office, hospital room or surgical suite — when doctors throw charts at nurses or nurses throw insults at trainees — it isn't just a workplace problem. It's a patient-safety issue…."

The fault does not lie solely with physicians. A common expression among nurses is that "nurses eat their young," referring to the bullying behavior of entrenched nurses toward nursing students or new nurses.  Kathleen Bartholomew, in her book Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their Young and Each Other, describes this practice as "horizontal hostility" and describes how it makes the environment toxic.

Those who resort to bullying, intimidation and refusal to listen to others may work in any department from purchasing and housekeeping to administration.  Their behavior may range from verbal outbursts and physical threats to use of a condescending tone or refusal to answer questions. Employees may recognize where in their organization such behavior occurs but tolerate it because it is entrenched in the culture. There may be no recognized recourse to safely and effectively refer concerns. As a result, counterproductive behaviors may have been overlooked or tolerated and, over time, have become "the elephant in the room."

In sight of the elephant

On July 9, 2008, the Joint Commission issued Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety. The alert officially recognized that "Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments." In addition the publication established a new leadership standard on the subject that set forth, in part "'zero tolerance' for intimidating and/or disruptive behaviors…." Then, in September 2016, the Joint Commission issued an update that stated succinctly, "Behaviors that undermine a culture of safety continue to be a problem in healthcare."

So the problem is recognized but not resolved.

Why the elephant flourishes

For more than two decades I have worked with healthcare providers to help reduce disruptive behavior in their organizations and establish a culture of candor. Often I have conducted one-on-one "executive coaching" sessions with individual physicians or nurses who have been perceived as disruptive toward staff or patients. Although I have occasionally counseled medical professionals who could not come to terms with the inevitable demands of the job, I much more often found that the system in which they work was a major cause of their failure.

For example, one of my clients hired me to conduct a series of coaching sessions with an emergency physician who had received complaints from a nurse. I was told that the physician had anger management problems. However in our sessions, my impression was that she had high standards for the quality care of her patients and she was very complimentary of the nursing staff. The more we discussed the dynamics of her workplace, the more I concluded this physician did not have anger management problems. She had frustration management problems. Her frustration was not with individuals but with a lack of efficiency in the department, including long wait times for patients and families, outdated computer systems, patients in beds in the hallway waiting to get to a room and customers leaving without being seen at all. While individuals should be held accountable for their behavior, it is also important to consider whether the system is at least partially at fault. When talented people are placed in a broken system, they cannot succeed.

Getting the elephant out

The real job then, as described by the Joint Commission, is to establish a culture of candor in which all employees are empowered, even encouraged, to constructively communicate critical information within an established system. In such a system, not only is it allowable to address operating deficiencies — that is the objective.  Continually discovering weaknesses allows for continual improvement.  The system and those in it must not have such thin skin that they refuse to hear that deficiencies exist and improvement is mandated. Such a system can only be possible when mandated and practiced by the officers and leaders of the system.

Although nowhere is a culture of candor more important than healthcare, it is also significant in other sectors of our economy: aviation, law enforcement, higher education, government and on and on. In fact, it is important everywhere. One notable success has been Pixar, whose approach may have implications for healthcare. Pixar is an American computer animation film company that has attained overwhelming acceptance by the public and astounding financial success, including 14 of the 50 highest grossing films of all times. In his book, Creativity, Inc., Pixar President Ed Catmull explains how fundamental a culture of candor is to their success. He said, "Candor could not be more critical to our creative process. Why? Because early on, all of our movies suck. … Pixar films are not good at first, and our job is to make them so — to go, as I say, from 'from suck to non-suck.'"

Admittedly, achieving a culture of candor in an organization for the first time is a monumental challenge.  But really what choice is there?

I recently came across an exceptional healthcare team that decided to transform their organization to a culture of safety and well-being. This innovative team led by Creative Health Care Management developed a "code of conduct" for their team. It was entitled "Commitment to My Co-Workers." The following is a synopsis.

As your co-worker and with our shared organizational goal of excellent service to our customers, I commit to the following:

  • I will accept responsibility for establishing and maintaining healthy interpersonal relationships with you and every member of this team.
  • I will talk to you promptly if I am having a problem with you. The only time I will discuss it with another person is when I need advice or help in deciding how to communicate with you appropriately.
  • I will not engage in the "3B's" (bickering, back-biting and blaming).
  • I will practice the "3 C's" (caring, committing and collaborating) in my relationship with you and ask you to do the same with me.
  • I will accept you as you are today, forgiving past problems and ask you to do the same with me.
  • I will be committed to finding solutions to problems rather than complaining about them or blaming someone for them, and ask you do the same.
  • I will affirm your contribution to the quality of our service.
  • I will remember that neither of us is perfect, and that human errors are opportunities, not for shame and guilt, but for forgiveness and growth.

In today's volatile, complex and competitive healthcare culture employees are often spending more time at work than home, more time with colleagues than family. Therefore it is imperative that we create workplaces where well-being, safety, trust and respect for differences all lead to patient safety and achieve high patient satisfaction.

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