Bad Behavior Kills – in Hospitals?


amednews: Disruptive behavior by doctors, nurses persists a year after crackdown :: Nov. 16, 2009 … American Medical News

One of the two pillars of the Toyota approach is the principle of “Respect for People.” How good can quality be, regardless of the technical tools and methods being implemented, if you have a rotten organizational culture?

The healthcare industry, sadly, has tolerated bad and disrespectful behavior for a long time. Part of the dynamic seems to be the power position of physicians and surgeons — they have unique (and often rare) skills and they are often a major driver of patients (and, therefore, revenue) to the hospital.

If an administrator stands up to a surgeon, they often run the risk of that surgeon taking their patients to the competing hospital. It makes for juicy ethics discussions — short-term revenue versus doing the right thing in cases of really bad and degrading behavior.

I know one case where the Director of Perioperative Services was newly hired with a mandate to “clean up” previously abusive surgeon behavior in that particular hospital. It wasn't to the level of surgeons throwing things at the hospital employees (like nurses and techs), but there had been a serious track record of verbal abuse and other forms of disrespect. Sad. You'd like to expect more from such respected and highly-skilled professionals.

From the linked article:

A surgeon told his staff that monkeys could be trained to do what scrub nurses do, while another doctor told a patient that the nurse in the room didn't know what she was doing.

A nurse witnessed the onset of complications in an intensive care patient but refused to contact the on-call physician for fear of his temper — a delay at least one observer thought contributed to the patient's death.

This is serious stuff. In the push to get Electronic Health Records implemented, former Speaker Newt Gingrich says “paper kills,” as I heard him say at a conference last week. It seems it could also say that “fear caused by bad behavior kills.” Dr. Deming was right — leadership needs to eliminate fear from the workplace, fear of all forms, so quality work can be done.

Even though the Joint Commission mandated rules about taming bad behavior with “zero tolerance” rules for hospitals to adopt, bad behavior is still occurring too often:

Ninety-seven percent of respondents experienced unprofessional outbursts and overreactions, with most saying these happened several times a year and sometimes even weekly. Most survey respondents, 48%, said doctors and nurses were equally culpable for the conflicts, but 45% said doctors were mostly to blame.

The article addresses the revenue concerns of administrators:

While more than half of respondents said their organization offered training programs to try to reduce behavior problems, many felt that management was more lenient in its treatment of doctors, particularly those bringing in high patient volumes. Most respondents said nurses were terminated more frequently for bad conduct.

While bad behavior shouldn't be tolerated, “zero tolerance” policies in any setting make me pause and think. We all have heard of situations where mindless zero tolerance polices (taking judgment and responsibility away from administrators) have led to kids being banned from school for having Advil or a camping knife that they forgot to take out of their backpack. Any time common sense and managerial judgment are eliminated from a situation, bad things can happen.

One is that people might be under more pressure to force bad behavior deeper underground, with the abusers being MORE abusive (“if you tell anyone, you'll regret it….”).

The other risk is that people use these rules to “get” the so-called “troublemakers” in an organization. As the article says:

Tougher policies can go both ways, said Jay A. Gregory, MD, chair of the AMA Organized Medical Staff Section Governing Council. He said the Joint Commission standard gives health care facilities such broad discretion on disciplining certain behaviors that physicians can be unfairly targeted for speaking up about legitimate quality concerns.

“We see time and time again, physicians complain about things the hospital never addresses, and the physician decides to go public and all of a sudden gets labeled as disruptive,” said Dr. Gregory, a general surgeon in Muskogee, Okla. The Joint Commission standard applies across the board, but “you have to do a root-cause analysis of what led to the behavior, no matter who it is.”

This is a tough one. If a surgeon gets upset and starts throwing things, there's likely a process problem that led to the frustration. If ongoing process problems lead to cases starting late because lab work or paperwork hasn't been done on time, or because needed surgical instruments are missing, it's understandable that a surgeon would be frustrated.

The process problems need to be fixed.

But in what workplace, other than hospitals, is this sort of abusive behavior tolerated, regardless of the bad processes that caused it? People need to be adults and stand up to adversity without resorting to abusing others. End of story, right?

It always comes down to leadership:

Dr. Rosenstein said education and early, graded intervention are key. Punitive measures should be a last resort.

Commitment from the top down also is crucial, said the ACPE's Dr. Silbaugh. “Part of what we have to do is agree as a health care team [that there] are behaviors that are not acceptable.”

The linked article has survey data that shows the following behaviors have been seen by healthcare executives:

  • Degrading comments and insults — 85%
  • Yelling — 73%
  • Throwing objects — 19%

Hard to believe this is a problem, in any industry, in the year 2009, isn't it?

Does this sound like an environment where you can get the best quality care possible? Respect for People, anyone?

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  1. Robby says

    The real problem here is that hospitals are a discriminatory system (castes) engaged in a non-discriminatory business (lifesaving.) It's hard to imagine another industry in which different groups of people have more disdain for other groups. This spite is so well documented that it's not only well-known, it's even a plot device in every medical show on television. Before we can see the kinds of process improvements in hospitals promised by modern techniques, we need to address this caste system. This is an institution which is leftover from an age of conscious classism and sexism. It's hard *not* to think of doctors as male, elite and wealthy and nurses as female and working class. But the reality of medical care is that that different areas of expertise are appropriate at different times. No one is more or less important than anyone else. Until this becomes the true mindset of the hospital, we will continue to face such opposition as we work to improve business process in healthcare.

  2. Mark Graban says

    I agree, Robby. All of the technical lean tools and methods in the world can't defeat an incredibly dysfunctional culture in the places where that exists.

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