Kendall L. Stewart, MD, MBA, DFAPA January 11, 2010

1. Disruptive BehaviorA Process for Preventing and Containing Unacceptable Behavior1,2,3A Presentation for Pomerene Hospital Leaders Kendall L. Stewart, MD, MBA, DFAPA January 11, 2010 1Refer to the SOMC Code of Conduct. 2I intend to offer practical suggestions that you can use at work tomorrow. 3Please let me know whether I have succeeded on your evaluation form.

2. Why is this important? • Unfortunately, disruptive behavior happens.1,2,3 • When it does, it negatively impacts our organizational performance around • Safety, • Quality, • Service, • Relationships, and • Performance. • This presentation focuses on the SOMC process as an example for preventing and managing disruptive behavior. • After mastering the information in this presentation, you will be able to • Define disruptive behavior, • Describe three disruptive behaviors, • Summarize a process for preventing disruptive behavior, • Identify three steps in a model process for managing disruptive behavior when it occurs. • The Joint Commission now requires that hospitals “address disruptive behavior of individuals working at all levels.”2 1And physicians are not the only offenders. 2This creates an opportunity to enhance and document our current processes around these issues. 3Drunks often behaved disruptively in my father’s church.

3. What disruptive behaviors have we observed at SOMC?1 • Berating colleagues publicly • Using profanity • Yelling • Refusing to answer pages • Making suggestive sexual comments • Throwing things in frustration • Disagreeing in front of patients • Arguing with colleagues in public • Refusing to accept responsibility for one’s patient • Putting colleagues in the middle • Belittling others behinds their backs2 • Physically moving colleagues out of one’s way • Using harsh, aggressive language and behavior • Refusing to follow SOMC processes • Lying • Engaging in a repetitive pattern of tardiness • Having temper tantrums • Conducting inappropriate conversations in the presence of patients and families • Bullying colleagues 1This list is not comprehensive. 2My patient once quoted the criticisms of a hospital administrator and a colleague; the administrator came to see me.

4. What is disruptive behavior?1,2,3 1See Porto and Lauve (2006) and Neff (2000) in the reference section of this presentation. 2SOMC Code of Conduct 3These behaviors are not always disruptive. Take eye rolling for example.

5. Not that it matters, but why do disruptive people behave that way? • It makes them feel special. • They think they can get away with it. • They have observed others behave that way and get away with it. • They are spoiled and emotionally immature. • They think their outbursts are justified because of their position or rank in the organization.1,2,3 • They believe that their colleagues exist primarily to meet their needs– to keep them happy and content. • Disruptive people are ordinarily not psychiatrically impaired; they are just garden-variety bullies. 1Bullying does not end on the playground. 2People in any position of power are always tempted to abuse that power. 3A nurse manager refused to permit her employee to come to see me.

6. What should you do if you are a victim? • Calm yourself.1,2 • Don’t blame yourself. • Remove yourself. • Express yourself. • Document what happened quickly and dispassionately. • Ask other witnesses to document what they observed. • Ask your manager to investigate. • Participate fully in the investigation. • Develop realistic expectations. 1Captain ChesleySullenberger, III, reported that he first had to calm himself. 2Controlled breathing, note taking and mental distractions are the best approaches.

7. What is the SOMC process for preventing disruptive behavior? • We will clarify our behavioral expectations as a part of every job offer. • We will specifically inquire about a past pattern of disruptive behavior in our referencing process. • If a significant past history of disruptive behavior in the workplace is confirmed, we will not hire that applicant. • We will provide each applicant with a copy of SOMC’s Code of Conduct. • We will require our applicants to confirm in writing that they understand they understand and will comply with the SOMC Code of Conduct. • We will make it clear in our orientation programs that a pattern of disruptive behavior will result in administrative action up to and including dismissal.

8. What is the SOMC process for dealing with disruptive behavior? • An incident of perceived disruptive behavior occurs. • The people who directly observe that behavior will document it promptly and completely. • The documentation will focus on observable behaviors, not suspected motives. • The incident documentation will be submitted promptly to the appropriate manager. • The documentation will be revised if necessary.1 • The manager will contact all parties directly involved in the allegation and complete an investigation promptly. • If the issue is resolved satisfactorily and this incident is not a pattern of disruptive behavior, the process will end at this point. • If there is a pattern or if the issue cannot be promptly and satisfactorily resolved, the manager will refer the issue and all documentation to the appropriate executive. • The executive will take the appropriate administrative action. 1Emotional and judgmental language will be excluded; additional clarifying behavioral detail may be needed.

9. What is the SOMC process for dealing with disruptive behavior? Alleged disruptive behavior occurs Appropriate leader investigates promptly Investigator reaches a conclusion Involves Physician(s) Involves Employee(s) HR CMO Review Violation occurred? Complaint dismissed No Yes Appropriate action taken and documented in Quantros ™ 1Our process is to follow our process. 2If there is no process, our process is to design and deploy a process.

10. What administrative outcomes may occur? • The complaint may be found to be without merit.1 • An informal counseling may occur.2 • The organizational corrective action process may be initiated or continued. • A referral for anger management may be made. • A behavioral contract may be required. • Dismissal or loss of privileges may occur. 1Inappropriate complaints have infrequently been lodged in the past. 2I spoke to a physician and he followed my advice to take roses to the offended nurse.

11. Where can you learn more?1 • APAOnline, “Is Your Hospital Safe? Disruptive Behavior and Workplace Bullying,” Psychology in the News, September 12, 2008 • The Joint Commission, “Behaviors That Undermine a Culture of Safety,” Sentinel Event Alert, Issue 40, July 9, 2008 • Porto, Grena and Lauve, Richard, “Disruptive Clinician Behavior: A Persistent Threat to Patient Safety,” Patient Safety & Quality Healthcare, July/August 2006 • Neff, KE, “Understanding and Managing Physicians with Disruptive Behavior,” In Ransom, et. al., Enhancing Physician Performance: Advanced Principles of Medical Management, American College of Healthcare Executives, 2000: 45-72 1Please visit www.KendallLStewartMD.comto download related white papers and presentations.

12. Are there other questions? www.somc.org SafetyQualityServiceRelationshipsPerformance 