Second, independent groups must communicate closely with the hospital when a behavior issue arises. “If you have a hospitalist who is not directly employed by the hospital, there is a dual responsibility for managing their disruptive behavior,” Dr. Holman says. “The hospital has medical staff standards, which are reflected in the medical staff bylaws and rules and regulations. These documents need to include policy and procedures around the incidence of disruptive physician behavior.”
But just because procedures are in place doesn’t mean the hospital will address a problem hospitalist. “This is where in practice, things can get a little fuzzy,” Dr. Holman admits. “The hospital may defer the responsibility for managing the physician to the employer. This is the scenario that has come up in hospital medicine.” He adds, “In my personal opinion, there is a dual responsibility. The hospital needs to apply its standard to all medical staff, regardless of specialty, tenure or employment status.” At the same time, the hospital medicine group/employer should have—and should implement—an approach to managing disruptive behavior.
“Different employers will have different capabilities,” Dr. Holman says. “For example, large, multi-specialty medical groups may have an infrastructure, including human resources professionals, risk managers and depth of medical and operational management, in place for dealing with disruptive behavior. … Small practices won’t have this. They may rely more heavily on the hospital’s infrastructure.”
—Russell L. Holman, MD, COO, Cogent Healthcare, Nashville, Tenn.
Regardless of the hospital medicine group’s size and capabilities, it should promote two-way communication with the hospital regarding problems with individual hospitalists. “If an incident occurs in the hospital, the employer needs to know the details so they can follow up,” Dr. Holman says. “They have to be careful about sharing appropriate information, and protect all privacies. And they have to balance this communication with the fact that it doesn’t absolve one or the other from acting. There must be follow through from both parties, including disciplinary or corrective action as necessary.”
Defining “Disruptive”
One concern healthcare leaders—and the people they lead—may have is deciding the standard used in crafting a policy that specifies what types of behavior are unprofessional. “The challenge is defining disruptive behavior,” Dr. Holman says. “Of course, it can be very clear sometimes. But a surgeon throwing instruments in the operating room is different than someone who is a little bit outspoken.” Consider a hospitalist or other physician who’s in the habit of questioning authority; could this requirement lead to efforts to shut them down?
“Naturally, there is a degree of concern amongst physicians that this is a physician-directed standard, and that there may be a tough time distinguishing between the good faith criticisms of outspoken physicians and those who demonstrate physically threatening behavior,” Dr. Holman says.
The best way for hospitals, hospital medicine groups and other healthcare organizations to avoid this is to find established policies on this subject that are fair, carefully phrased and comprehensive, then customize one or more to their own specifications and distribute to all affected employees.
“I think these policies are nice to include in new physician orientations or training programs, so that physicians are aware of them,” Dr. Holman suggests.
For more information on the code of conduct standard, visit www.jointcommis-sion.org/SentinelEvents/SentinelEventAlert/sea_40.htm. TH
Jane Jerrard is a medical writer based in Chicago.