Disruptive Behavior Affects
Hospital Financial Health

 

It has long been known that disruptive behavior by healthcare professionals undermines a culture of safety, team collaboration, and communication flow. A new study shows that it also has a direct effect on a hospital's financial health.

It may be impossible to specifically quantify the economic consequences of physicians and others who "act out," intimidate and bully colleagues, or just are not good team players. The study, by Alan H. Rosenstein, MD, medical director of Physician Wellness Services of Minneapolis, Minnesota, in the Journal of Healthcare Risk Management, estimates the financial risk of disruptive behavior in terms of staff recruitment and retention, malpractice lawsuits, and "no pay for adverse events" reimbursement policies of many insurers.

It also proposes a 10-point process to reduce those effects and curtail negative conduct that can damage patient satisfaction and a hospital's reputation.

"The joint commission states that nearly 70% of sentinel events can be traced back to an error in communication," Dr. Rosenstein told Medscape Medical News. "There is a strong correlation between bad behavior and bad things happening. People who are intimidated are reluctant to speak up when they see something about to go wrong. The essential information flow is broken when nurses are afraid to call a physician who routinely verbally abuses them.

"Addressing disruptive behaviors as one of the human factor issues affecting healthcare delivery should be a key component of all risk management programs," he said. "These behaviors are more widespread than many thought, often because the health professional acting out under stressful conditions doesn't understand the downstream effect his actions have on others."

Dr. Rosenstein defines disruptive behavior as "any any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse (yelling, intimidation, condescending, berating, disrespectful, abusive behaviors) to physical or sexual harassment, that can negatively affect work relationships, communication efficiency, information transfer, and the process and outcomes of care." Although the data have shown that usually only 3% to 5% of the medical staff is truly disruptive, these individuals can have a profound effect on the entire organization.

Nurse Retention

The survey showed that more than 80% of respondents had witnessed disruptive behavior by physicians, and more than one third knew of a nurse who had left the hospital because of it.

"The direct costs of recruiting a new nurse can range between $60,000 and $100,000," in addition to the indirect costs of orientation, training, and the time needed to get a newly hired nurse up to speed.

"More than 90% of respondents stated that as a result of a disruptive incident, they were stressed or intimidated, or lost their ability to focus and concentrate, which led to significant gaps in communication, collaboration, and information transfer," the author notes.

In addition: "More than 70% of the respondents saw a direct linkage between disruptive behaviors and compromises in patient quality and the occurrence of medical errors, more than 50% felt there were compromises in patient safety, and 25% felt there was a linkage to patient mortality. Fifteen percent of the respondents stated that they were aware of a specific adverse event that could be attributed to a disruptive episode."

Adverse Events

Many insurers are refusing additional payments to cover the expense of preventable adverse events, including those following disruptive behaviors. The author and colleagues conducted a multihospital study, looking at the frequency of selected adverse events and their effect on hospital lengths of stay, cost, and patient mortality.

"While not all adverse events are directly caused by bad behavior, there's strong anecdotal evidence that many are due to the communication breakdown, and the costs are quite high," Dr. Rosenstein said.

For example, the cost of an adverse drug event ranges from $2000 to $5800 per hospitalization, and an increase in length of hospital stay of 2.2 to 4.6 days. An estimated 1.5 million preventable drug events occur each year, and 1 of every 10 patients suffers as a result.

Likewise, the costs of a hospital-acquired infection averages between $20,000 and $38,000 in additional costs of care. An estimated 1.7 million infections and 99,000 deaths occur each year related to hospital infections.

Malpractice Liability, State Fines, and Accreditation

Negligence claims are often precipitated by exposures related to poor communication, dissatisfaction, and adverse events. "Several studies have shown a strong correlation among provider communication, patient dissatisfaction, physician incident reports and the likelihood of being sued," Dr. Rosenstein writes. The average cost of a medical error–based claim was $521,560, according to a 2006 study in the New England Journal of Medicine.

In addition, states are imposing fines for organizational mistakes. In 2009, California fined 7 hospitals for harm caused to patients from avoidable mistakes. The fines range from $25,000 to $100,000 per hospital. Since 2007, the state has issued 134 fines to 90 hospitals, totaling $4.225 million.

Regarding accreditation, the joint commission issued a standard in January 2008 requiring hospitals to confront "disruptive" medical staff members. Hospitals must implement a code-of-conduct policy and provide education to address disruptive behavior, or they could face accreditation problems.

Ways to Address Disruptive Behaviors

Dr. Rosenstein calls on hospitals to be more proactive in addressing negative behaviors by first trying a remedial approach instead of a confrontational or punitive legal one.

"Many doctors don't recognize that they are acting in a disruptive manner and may not be aware of the negative impact it has on staff relationships and outcomes of care," Dr. Rosenstein said. "We're suggesting that early intervention by friends, family, or colleagues can help physicians recognize the extent of the problem before it causes an adverse event."

Virginia Hood, MD, a nephrologist in Burlington, Vermont, and president-elect of the American College of Physicians, agrees that hospital staff and administration need better ways to deal with disruptive behavior before it becomes a legal case.

"An outburst can be triggered by exhaustion and undue stress. The people who yell and scream need assistance," she says. "If it's an isolated case, a senior person should take them aside in a nonconfrontational way and help resolve what's going on, and educate the doctor that his behavior can't be repeated regardless of the stress."

Dr. Hood emphasized that any hospital committee must make sure "the complaint isn't mischievous, some political game that goes on in hospitals. You need a good organizational structure to be set up to investigate the complaint, counsel the disruptor, and protect patient safety."

Dr. Rosenstein's study calls for a greater organizational commitment by enacting policies that specifically identify impermissible actions and providing resources, including sensitivity training, to address the problem.

Incident reporting must be consistent. "All complaints should be channeled to one committee and reviewed by a multidisciplinary group to avoid personal bias or potential conflicts of interest regarding the individuals involved. The committee should be responsible for directing the complaint to the appropriate party and ensuring that follow-up action is taken."

Dr. Rosenstein recommends a range of programs, including assertiveness training, team collaboration training, cockpit management, and pit crew management, that "can help individuals gain the confidence to speak up immediately without fear of intimidation or retaliation."

Only those with experience in conflict management and dispute resolution should intervene in situations of disruptive behavior, Dr. Rosenstein concludes. "For some individuals, particularly first-time offenders, the act of bringing the event to their attention will help them recognize the consequences of their behaviors, and the behaviors do not recur. Other individuals require a more comprehensive approach and in-depth training in stress or anger management or, in some cases, individualized therapy."

The author has disclosed no relevant financial relationships.

J Healthcare Risk Manage. 2010;30:20-26.

Authors and Disclosures

Journalist Mark Crane, BA, Freelance medical writer, Brick, New Jersey

-From “Disruptive Behavior Affects Hospital Financial Health” by Mark Crane, Medscape Medical News, December 11, 2010.

 

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