Patient Safety Tip
of the Week
October 2, 2018
Speaking Up About
Disruptive Behavior
One of the biggest barriers to patient safety is a culture
that discourages healthcare workers at all levels from speaking up. We’ve
discussed disruptive behavior in multiple columns and noted how it has a
negative impact on both staff morale and patient care. In our January 2011 What's New in the Patient Safety
World column “No
Improvement in Patient Safety: Why Not?”, we echoed the theme of John Nance’s
book “Why Hospitals Should Fly” that we have failed to create a true culture of
safety in healthcare.
Then in our March
29, 2011 Patient Safety Tip of the Week “The
Silent Treatment: A Dose of Reality” we highlighted a study “The Silent Treatment. Why Safety
Tools and Checklists Aren’t Enough to Save Lives” by AORN (Association of perioperative Registered Nurses) and the
AACN (American Association of Critical-Care Nurses). They honed
in on three “undiscussable”
issues: dangerous shortcuts, incompetence, and disrespect. They found that 4 out of 5 nurses participating in the
study admitted having concerns that one or more of these three “undiscussables”
were potentially causing patient harm and that very often they did not discuss
the issues with the party doing the undiscussable (who could be another nurse
or a physician or other healthcare worker). In some cases
they were more likely to bring the undiscussable to the attention of a
supervisor. But even the nursing supervisors participating in the study
admitted that they often did not confront the offending party or take
appropriate action.
In that column we also highlighted a 2007 American College
of Physician Executives (ACPE) Quality of Care Survey (Steiger
2007) that revealed numerous issues considered by physician
executives to be obstacles to quality of care or patient safety. But in many of
the cases the perceived obstacles were failure of the system as
a whole to deal with incompetent, impaired or disruptive physicians.
Below are some of the quotes from respondents to that survey:
- “An interventional
cardiologist with questionable skills (is) being allowed to continue with
endovascular procedures because he’s part of the dominant cardiology
group.”
- “One of our highest
volume cardiac catheterization physicians routinely exercises questionable
judgement. All in administration acknowledge this but do not ‘rock the
boat.’”
- “Orthopedic surgeons are
tolerated in their unprofessional behavior and erratic delivery of care,
as long as they keep booking their spines and total joints.”
- “An orthopedist who is
terribly out of date and refuses ED call, but is intimidating and
generates big bucks for the hospital.”
Then in our July 2012 What's New in the Patient Safety World
column “A
Culture of Disrespect” we discussed Lucien Leape’s
provocative concept that disrespectful behavior goes well beyond the classic “disruptive”
behavior (the physician yelling and screaming, perhaps throwing things) and
that some of the more passive forms of disrespect may have consequences that
are even more detrimental.
And in our September
22, 2015 Patient Safety Tip of the Week “The
Cost of Being Rude” we discussed several studies showing how physicians or
nurses being rude to each other can impact patient care and patient safety.
The basic tenet of
all these columns is that a culture which discourages people from speaking up
allows perpetuation of undesirable behaviors that ultimately may lead to
adverse patient events and to problems with staff morale, retention, and
turnover.
Johns Hopkins Medicine addressed this issue head on. Following
discovery of serious misconduct by a physician, the Hopkins medical system
commissioned a study to assess why healthcare workers fail to speak up and then
to implement a program to encourage “voice” (Dixon-Woods
2018). In the “diagnostic” phase, confidential interviews with both senior
leaders and frontline staff were conducted by a group of independent
researchers.
Two
main themes emerged as reasons for reluctance to speak up:
- generalized fearfulness at almost
every level
- concern that nothing would result from
speaking up
The former was the result of a hierarchical culture “where
territories and autonomies were often fiercely defended by powerful individuals
and their allies”. They described the “untouchables”: individuals,
usually senior physicians, who were able to engage in transgressive or
disruptive conduct with impunity, often because of their positions of power or
ability to generate revenue. (Hey! Didn’t we hear that in the quotes in that 2007
ACPE Quality of Care Survey we noted above?). The behavior of the “untouchables”
created conflict-laden working environments that led to poor teamwork and
difficulties in
staff retention. Gaps between policy and practice were
created and there was “normalization of deviance”. We’ve discussed “normalization of deviance” in several
of our columns. This is where
the culture of the system has led to acceptance of a certain deviation from
proper practice as being “normal” and allowed that deviation to be performed by
many individuals. The deviation has been used so frequently without serious adverse
consequences occurring that staff no longer consider it abnormal.
But just as important was the perception,
by both frontline staff and senior leaders, that their concerns were not always
taken seriously or that nothing happened when they spoke up.
The results of that “diagnostic” phase probably don’t surprise
any of you. Such problems occur at the majority of
healthcare organizations in this country, even at respected organizations like
Johns Hopkins.
So what do you do about them?
Hopkins took a 4-step approach:
- Publicly share the study
findings
- Coordinate and formalize
mechanisms to identify, assess, and remedy disruptive behavior
- Training in leadership behaviors
to encourage voice
- Build capacity to have
difficult conversations
The results of the interviews were
shared in multiple venues, not only in departmental or unit meetings but also
in “town hall” type meetings that were well attended. Simply discussing the
issues led to a perception that openness was now encouraged and staff began to come forward and speak
up just as a result of those meetings. They then built upon an existing program,
“Safe at Hopkins”, which focused on disruptive, bullying, or violent behavior
and sought to intervene early. With strong support from upper levels at both
the hospitals and medical school and university in the form of a Physician
Executive Oversight Committee, interventions included graduated steps that
would escalate if the unwanted behaviors continued.
In addition, leaders (for example, department directors) were
provided with training and tools regarding voice opportunities, including how
to deal with reported concerns and identifying and investigating disruptive
behaviors. This included a 30-minute e-learning module followed by a two-hour
interactive simulation workshop which leaders practiced having difficult
conversations. Department directors often appreciated that the details collected
in the “Safe at Hopkins” program provided “cover” and helped them in dealing
with those difficult conversations with physicians with whom they were intervening.
Kudos to Johns Hopkins Medicine and the outside
researchers/consultants who recognized this problem, delved into the causes,
and implemented the program to address those causes. Being able to “speak up” without
fear of retribution and knowing that your concerns will be addressed and lead
to positive change are critical to having a culture of safety.
Some of our prior
columns on the impact of “bad behavior” of healthcare workers:
January 2011 “No
Improvement in Patient Safety: Why Not?”
March 29, 2011 “The
Silent Treatment: A Dose of Reality”
July 2012 “A
Culture of Disrespect”
July 2013 “"Bad
Apples" Back In?”
July 7, 2015 “Medical
Staff Risk Issues”
September 22, 2015 “The
Cost of Being Rude”
April 2017 “Relation
of Complaints about Physicians to Outcomes”
Some of our prior
columns related to the “culture of safety”:
April 2009 “New
Patient Safety Culture Assessments”
June 2, 2009 “Why
Hospitals Should Fly...John Nance Nails It!”
January 2011 “No
Improvement in Patient Safety: Why Not?”
March 2011 “Michigan
ICU Collaborative Wins Big”).
March 29, 2011 “The
Silent Treatment: A Dose of Reality”
May 24, 2011 “Hand
Hygiene Resources”
March 2012 “Human
Factors and Operating Room Safety”
July 2012 “A
Culture of Disrespect”
July 2013 “"Bad
Apples" Back In?”
July 22, 2014 “More
on Operating Room Briefings and Debriefings”
October 7, 2014 “Our
Take on Patient Safety Walk Rounds”
July 7, 2015 “Medical
Staff Risk Issues”
September 22, 2015 “The
Cost of Being Rude”
May 2016 “ECRI
Institute’s Top Ten Patient Safety Concerns for 2016”
June 28, 2016 “Culture
of Safety and Catheter-Associated Infections”
April 2017 “Relation
of Complaints about Physicians to Outcomes”
April 2017 “Joint
Commission Sentinel Event Alert on Safety Culture”
References:
AACN/AORN/VitalSmarts. The Silent
Treatment. Why Safety Tools and Checklists Aren’t Enough to Save Lives. 2011
http://www.silenttreatmentstudy.com/
Steiger B. Doctors Say Many
Obstacles Block Paths to Patient Safety. The Physician Executive 2007; 6-14 May
• June 2007
http://net.acpe.org/MembersOnly/pejournal/2007/May_June/Steiger.pdf
Dixon-Woods M, Campbell A, Martin G, et al. Improving
Employee Voice About Transgressive or Disruptive Behavior: A Case Study. Academic
Medicine 2018; Published Ahead of Print September 11, 2018
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