Effects of Disruptive Behavior
Can we go so far as to say disruptive behavior affects clinical outcomes?
“It has to,” says Scott Flanders, MD, associate professor of medicine at the University of Michigan and director of the hospitalist program, Ann Arbor, and member of SHM’s board of directors. “People clearly understand the importance of teamwork in hospital medicine. If one member of the team is dysfunctional from an emotional intelligence/behavioral standpoint, that drags down the team in its entirety and impacts patient care.”
Providing safe and effective care should be the first priority of all healthcare professionals. Excellent outcomes have been associated with procedural efficiency and the use of evidence-based standards and tools designed to reduce the likelihood of medical error. The effects of work relationships on clinical outcomes are less well documented, but attention to the matter is increasing in parallel with the focus on patient safety.3,5
Dr. Leape, one of the founders of the National Patient Safety Foundation, devotes concerted energy to making organizations aware of the need to upgrade systems to diagnose and treat this problem.2 “Physician performance failures are not rare and pose substantial threats to patient welfare and safety,” he writes. “Few hospitals respond to such failures promptly or effectively. Failure to ensure the quality and safety of the performance of colleagues is a breach of medicine’s fiduciary responsibility to the public.”6
When it comes to the issues of behavior, besides monitoring their own performance, what do hospitalists do when they come up against colleagues whose shortcomings require correction in order for the entire institution to uphold its legal obligation to each patient?
Physician, Heal Thyself
A study published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reported that 24% of sentinel events could be attributed to problems referred to as human factors, including communication gaps, staffing issues, and lack of teamwork.2, 5 The March 2004 issue of the Institute for Safe Medication Practice’s (ISMP) Medication Safety Alert reported that 7% of medication errors could be attributed to nurses feeling intimidated by physicians.4 And, as a response to this growing problem, the Institute of Medicine’s groundbreaking report on medical errors and patient safety, To Err is Human, shifted the focus from individual blame to that of preventing errors through efforts to “design safety into systems.”7
Dr. Flanders, who is also associate chief for the Division of General Internal Medicine for Inpatient Programs at the University of Michigan Medical Center (Ann Arbor), certainly understands the need to grapple with these types of issues. He is a member of his institution’s interdisciplinary Medical Staff Quality Committee (MSQC), which works to get a better handle on individual physician-level quality and performance.
“A lot stems from JCAHO’s increased focus on institutions doing a better job of trying to figure out, in short, who’s a good doctor and who’s a bad doctor,” he says, “And having medical staff appointments, privileging, and assessment of clinical skills be something a little more robust than just asking four of your friends if they think you’re a good doctor.”
One of the charges of the MSQC is developing a better system of tracking physicians’ clinical skills down to the individual level, which Dr. Flanders says is a difficult task. But their second charge is even more elusive to track: examining “the range of daily activities, behaviors, and actions that encompass being a physician.” As part of that, the committee deals with interpersonal relations: interactions with other staff and behavioral issues.
Make the Diagnosis, Initiate Treatment
As with most academic medical centers, when someone at MSQC observes a behavioral issue, that person’s supervisor (often a department chair) is the next place for the buck to stop. There are clearly defined lines of communication and “very robust systems” to deal with these kinds of things, says Dr. Flanders.