Addressing Disruptive Behavior in Anesthesia Group Practices

Gregory R. Zinser
Vice President, Anesthesia Business Consultants, Jackson, MI

Stress is a part of life for all of us, and anesthesiologists have more than their share in a practice environment where rules seem to shift from day-to-day as the burden of paperwork and performance measurement increases and financial rewards are diminishing or put at risk. Add this to the already daunting pressures associated with long hours in the surgical suites and on-call responsibilities, and it is no wonder that patience wears thin from time-to-time.

I have been impressed throughout my career with the manner in which the vast majority of anesthesiologists handle this pressure, but have also seen a few situations where the pressures resulted in behavior that was detrimental to patient satisfaction and/or the reputation of the group. All of us have had times where stress in our personal or professional life has caused us to act or react in a way that we later find regrettable, but for those on the front lines of the medical profession, a continuous pattern of negative reaction that is disrespectful, unprofessional and toxic to the workplace (often called “disruptive”) can have an impact on the group’s business relationships, and in some cases directly affect patient care.

Although this may occur infrequently, every practice should have policies in place to identify and deal with situations involving disruptive physicians. In addition to having direct responsibility for patient safety and satisfaction, the group is a business entity with business relationships and a reputation to protect. Any behavior that has the potential to negatively affect the group’s reputation and relationships with hospital administration and staff also has the potential to undermine practice stability and value. The ability of the group to retain hospital contracts and attract new business is directly related not only to their ability to deliver clinical quality, but also the ability of all group members to work harmoniously with the entire care team to achieve the highest level of patient care and satisfaction.

A 2011 study conducted by QuantiaMD surveyed 523 physician leaders and 321 staff physicians in a variety of healthcare settings regarding disruptive behaviors. Seventy-one percent of responding physicians reported that they had witnessed disruptive behavior within the previous month, and 26 percent of those surveyed reportedly had been disruptive at one time in their career. Disruptive incidents were of higher frequency in surgery, anesthesia and obstetrics and gynecology. To the point of contract retention and business relationships, in this same study, 60 percent of physicians said their organizations have received written complaints from patients or their families relating to disruptive behavior, and 50 percent have seen patients change physicians or leave a practice due to such behavior.

Professional Association Guidance

The American Society of Anesthesiologists (ASA) Guidelines for the Ethical Practice of Anesthesiology declare that “Anesthesiologists should promote a cooperative and respectful relationship with their colleagues…[as well as] other care providers including physicians, medical students, nurses, technicians and assistants.”

Joint Commission standards require the establishment of a code of conduct that defines abusive and disruptive behaviors as well as the creation and implementation of a process for their management.

According to the American Medical Association (AMA) Council on Ethical and Judicial Affairs, disruptive behavior “generally refers to a style of interaction by physicians with others, including hospital personnel, patients and family members, that interferes with patient care or adversely affects the healthcare team’s ability to work effectively. It encompasses behavior that adversely affects morale, focus and concentration, collaboration, and communication and information transfer, all of which can lead to substandard patient care.” The AMA’s Code of Medical Ethics specifically recognizes the importance of civility and respect as a non-negotiable professional mandate.

Establishing Policies and Procedures

A group’s policy relating to disruptive physicians should start with a written Code of Conduct that establishes the general framework for all group members relating to professional conduct and procedural compliance. This Code will typically have one section that covers matters relating directly to patient care, and another covering physician professionalism.

Patient care responsibilities may require group members to:

1. Be familiar with and follow protocols relating to patient care established by the group and all contracted facilities.
2. Provide services to patients in accordance with the patient’s medical needs and physical condition, not on the basis of ethnic or racial background, gender or age.
3. Maintain the confidentiality of all patients’ healthcare information in accordance with federal and state laws, and group’s policies and procedures;
4. To respond promptly and courteously to patient inquiries or requests; and,
5. To disclose adverse events according to the appropriate process.

The physician professionalism section may include requirements to:

1. Respect all group contractual obligations;
2. Not pay for referrals or offer or accept kickbacks and avoid conflicts of interest in accordance with group policies and procedures;
3. Maintain all professional licenses, certifications or other accreditations required by law, the group bylaws, the group physician’s respective employment agreement and group contracted facilities;
4. Fulfill their obligations to carry out duties in compliance with state and federal laws and regulations, group’s policies and procedures and any facility rules and regulations;
5. Participate in mandatory compliance and other educational training provided by group;
6. Contribute to a workplace environment that is free from violence, harassment, intimidation, and is conducive to maintaining the highest professional and ethical standards;
7. Consult with or seek advice from a group board member or a management/billing company representative, when the proper course of action is unknown;
8. Commit to be alert and ready to perform job responsibilities while on duty, including not being under the influence of alcohol or any illegal or controlled substance;
9. Not engage in criminal conduct including, but not limited to, the inappropriate use, sale, possession, transfer, manufacture, distribution, dispensation or purchase of non-medically prescribed controlled substances;
10. Refrain from any behavior that is deemed to be intimidating or harassing, including but not limited to, unwanted touching, sexually-oriented or degrading jokes or comments, obscene gestures, or making inappropriate comments about other physicians, allied health professionals, facility staff or patients;
11. Treat patients, family members, visitors, members of the healthcare team and facility employees in a respectful and dignified manner at all times.
12. Work with other members of the healthcare team to resolve conflicts or address lapses of decorum when they arise;
13. Avoid the use of language that is profane, vulgar, sexually suggestive or explicit, intimidating, degrading or racially/ethnically/religiously slurring in any professional setting; and
14. Report concerns about another group physician’s conduct to those authorized to receive such information and address the issue.

The Disruptive Physician Policy should clearly state the objectives and expectations with direct reference to the group’s Code of Conduct, and in terms that ensure high standards of patient care and promote a professional practice environment. The recitals section should also define and describe the behavior or types of behavior that will prompt intervention.

The policy should then cover the process to be followed if disruptive behavior is encountered. This process should:

• Provide a channel through which disruptive behavior can be reported and appropriately recorded.
• Establish a process to review or verify reports of disruptive behavior.
• Establish a process to notify a physician whose behavior is disruptive that a report has been made, and providing the physician with an opportunity to respond to the report.
• Describe remedial action to be taken, being specific regarding responsibilities, timing and progressive disciplinary action.
• Include means of monitoring whether a physician’s disruptive conduct improves after intervention.
• Provide for evaluative and corrective actions that are commensurate with the behavior, such as self-correction and structured rehabilitation.
• Identify which individuals will be involved in the various stages of the process, from reviewing reports to notifying physicians and monitoring conduct after intervention.
• Describe the appeal process and provide clear guidelines for confidentiality.

Situations perceived as a threat to patient safety should be specifically and separately addressed in the policy.

Recognizing that not all physicians will have the skills necessary to address these situations effectively on behalf of the group, some groups have appointed an administrative liaison that acts as in-house counselor with respect to physician members’ ethics and behavioral practices. This position reports directly to the board, serving as a consultant to the board and committee chairs on matters requiring historical perspective. Qualifications include exceptional interpersonal communication skills and knowledge of group history, philosophy and policies. This position is typically held by a senior member of the group and former board member. He or she is available to physician members to discuss issues and problems related to their practice within the group including, but not limited to career advice, clinical practice issues not directly affecting patient care, conflict resolution, interpersonal relationships and patient complaints.

Many practices take the time and effort to develop behavior standards, but do not take the extra step to make the policies an integral part of the recruiting process, new physician orientation programs and employment agreements.

The recruiting process is the first line of defense, as it is obvious that recruiting to the established Code of Conduct and policies will go a long way towards avoiding future problems. Many groups handle this function through a recruiting or “manpower” committee where the interview process standards can be discussed to ensure they are designed to highlight the potential for disruptive behavior and are applied consistently. Multiple group members should be involved in the interview process, and references should be checked using a set of questions designed by group leadership.

Group employment agreements should include a section where the employee acknowledges review of all group policies and the Code of Conduct, and agrees to abide by them. To the extent permitted by state laws relating to employment and shareholder status, this section should also give the board the power to enforce the policies if a physician is acting contrary to them in a way that is detrimental to the group’s best interest (in the sole discretion of the board). The following is a sample of such a provision that could be included in an employment agreement:

Professionalism in the performance of his/her duties under this agreement, employee will conduct himself/herself at all times in a professional and collegial manner, and in a manner that reflects favorably upon the professionalism and reputation of employer. Without limiting the foregoing, employee will use all reasonable efforts to maintain harmonious and professional working relationships with other employees or representatives of employer, patients, physicians, nursing staff and representatives of facilities at which employer provides services. Employee also agrees to act consistently with federal, state and local laws governing discrimination in employment and to refrain from any action that could reasonably be construed to violate those laws. Employee hereby confirms that he/she has reviewed the group’s Code of Conduct (attached as Exhibit ___) and understands that full compliance is essential to protect the business interests of the group. Employee also hereby acknowledges the authority of the group’s Board of Directors (or Executive Committee as applicable) to enforce this Code, and all other group policies, and obligation to enforce them by all means necessary to protect the group’s reputation, business interests and patient safety.

As with all other significant components of employment agreements, this paragraph should be reviewed by legal counsel for consistency with state and federal employment and contract law.

Responding to Reported Incidents

So now that you have policies in place, what exactly should be done when a complaint is received? Your first step should be to assure the individual filing the complaint that you take it seriously, that you will investigate the concerns and, if appropriate, will see that remedial measures are taken to prevent recurrence of the conduct. All complaints should be requested in writing, and initial discussions with the party making the complaint (taking place either by phone or in person) should be well documented with comprehensive factual notes regarding the complaints. Offer to keep the complaint as confidential as possible, provide assurance that there will be no retaliation for reporting the incidents, and request that the employee advise you immediately if he or she believes there have been retaliatory actions by the physician involved or anyone else.

Your second step is to determine the most effective way to confront the physician about his or her behavior. If the board has appointed a physician liaison as described above, he or she will become involved immediately and will arrange to meet with both the individual filing the complaint and with the physician who is the subject of the complaint, separately. If you have established policies, all of the next steps are outlined in that policy as describe above. If you do not have a liaison or established policies, you will need to partner with at least one other influential physician in the group who shares your concerns and is willing to support your efforts to confront the issue and act as a liaison between the accused physician and the group. In order to maintain objectivity, both in appearance and in fact, the individual chosen to take the lead in the investigation should not be a personal friend of the physician involved, and should also not be an individual perceived by as an adversary by the physician being investigated.

Especially disruptive behavior involves threats, violence or sexual harassment, the practice must act promptly to remedy the problem. In all other types of situations, where a process will be carried out starting with a meeting with the physician under investigation, following are suggestions for conducting those meetings:

• Empower your board liaison or other designated individual to speak on behalf of the practice. When the meeting is scheduled, it should be clear that the liaison has the authority to speak on behalf of the practice.
• Prepare an outline of points you want to cover. Stick to a script so you avoid getting pulled into an argument. To the extent they exist, have copies of your code of conduct and any written policies and rules that apply to the situation.
• Conduct the meeting in a private, comfortable, professional setting. Reduce the tension as much as possible to encourage a positive dialogue. Do everything possible to make this a constructive problem-solving experience.
• Explain the problem behavior in factual terms. Describe the sequence of events and discuss the effect the physicians’ behavior had on staff, and the potential adverse effects his actions had on his professional reputation and the reputation of the group.
• Refrain from using emotional terms such as bad behavior, tirade or childish tantrum to describe the conduct. These terms might describe the conduct but can polarize the situation and create defensiveness.
• Give the accused physician the opportunity to explain the situation in his own words. Chances are he will not take responsibility for his behavior or might blame staff incompetence for an outburst. He may attempt to change the subject and begin listing the ways the group is at fault for mistreating him. Don’t take the bait. Insist those grievances be taken up at a different time and remind the physician that the purpose of the meeting is to address his conduct on specific dates.
• Ask for the physicians input on how past situations could have been handled differently to avoid the incidents that gave rise to complaints. Make it clear that there is never a valid reason for treating staff members disrespectfully.
• When discussing conduct, consider whether the outbursts may be a result of a drug or alcohol problem or whether his conduct could be the result of mental illness, such as depression. If there is some indication that the conduct is a result of one of these issues, it might be appropriate to refrain from taking any action until you consult with the executive committee and act in accordance with your substance abuse policy.
• Advise the physician that you will be drafting a performance improvement plan that will require him to make immediate, permanent changes in his behavior. Make it clear that failure to comply with the terms may result in discipline, up to and including termination. The plan should include objective, measurable and achievable goals designed to prevent disruptive behavior in the future.
• Make it very clear to the physician that no retaliation of any kind will be tolerated. If you have a written retaliation policy, be prepared to provide a copy at the end of the meeting.
• Carefully document what occurred and what was discussed during the meeting.
• Follow through. If you put the physician on an improvement plan, monitor his behavior and respond quickly and appropriately if requirements are not met.

Summary

Medical group and healthcare facility leadership share responsibility for creating a work environment that contributes to achieving the highest level of patient care and satisfaction by minimizing stress and maximizing professional fulfillment in that environment for the entire healthcare delivery team.

In the workplace, recurring behavioral issues interfere with the normal process of collegiality, cooperation and communication within a healthcare service team, and, in extreme cases, can undermine the institutional culture of safety and quality of care. Healthcare facility governing bodies and leadership should ensure that policies and systems are in place that foster collegiality, mentoring, respectful dialogue, promoting the belief that all physicians within the institution are important.

At the group level, addressing this issue is a matter of protecting reputation and other business interests, as well as ensuring a healthy and fulfilling work environment for all group members. A priority of group leadership must therefore be to recognize the detrimental effects on culture, reputation and stability that can result from recurring behavior problems, and have policies in place to address behavioral situations before they occur.

Gregory R. Zinser, Vice President at Anesthesia Business Consultants, has a broad range of experience in healthcare finance and administration. Mr. Zinser’s recent experience includes four years as CEO of one of the nation’s largest anesthesia billing and practice management companies, and CEO of the management company for one of the nation’s largest anesthesia groups. With experience in all facets of anesthesia practice management, Zinser adds additional strength and depth to an ABC management team that has become the industry standard in terms of both responsiveness and quality of resources. He is a licensed CPA with an undergraduate degree in accounting with honors from the Ohio State University. Mr. Zinser can be reached at Greg.Zinser@AnesthesiaLLC.com.