In 2009, the Joint Commission Leadership Standard issued a mandate stating that leaders need to create and maintain a culture of safety and quality throughout hospitals. In 2013, this mandate was updated, requiring that leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety. The Joint Commission also required that leaders create and implement processes for managing behaviors that undermine a culture of safety. These new mandates spurred hospitals and healthcare systems across the United States to develop policies and programs to address these issues in medicine.
Unprofessional behavior intimidates others and affects morale as well as staff turnover, according to Lee A. Fleisher, MD. “It undermines a culture of safety, making it potentially harmful to patient care,” he says. However, disciplining disruptive physicians has not been well defined and varies widely. While a growing body of evidence has suggested that there is a link between disruptive or unprofessional behavior and a culture of safety, few reports have described effective and successful approaches to defining and managing unprofessional behavior.
A New Model
For a study published in the Joint Commission Journal on Quality and Patient Safety, Dr. Fleisher and colleagues at the University of Pennsylvania Health System (UPHS) reported on their experience using a Professionalism Committee (PC)-based approach to define and manage unprofessional behavior among physicians. In this model, a PC was established at each of the UPHS teaching hospitals and reports to a Medical Executive Committee. The PC chair—Jody J. Foster, MD, MBA—is a psychiatrist and acts as the first point of contact for department chairs when behavioral issues arise.
The role of the PC chair is to gather information from the offending faculty member’s department chair. If necessary, the PC chair conducts one-on-one meetings with faculty members to discuss incidents (Figure). The chair then recommends next steps, which can range from no intervention to recommendations for treatment or executive coaching. The chair can also recommend further evaluation or referral to the Medical Executive Committee for a formal investigation. The PC chair makes a recommendation to the department chair about the next steps, and the department chair must then assure that the faculty member follows through with the outlined program.
In complicated incidences or in cases in which many parties are involved, the full Medical Executive Committee may be convened for fact-finding purposes. For certain very serious cases, the Medical Executive Committee will engage the Credentials Committee for a formal investigation and action.
“The program developed at UPHS meets our needs in terms of structure and function,” says Dr. Fleisher, who also serves as chair of the UPHS Credentialing Committee. “In many cases, physicians are unaware of how their behavior might impact patient satisfaction, quality, or patient safety. By bringing it to their attention, most physicians are able to self-correct. Our approach gives authority to the PC chair to sort out issues and conflicts promptly and unimpeded by the bureaucracy that often exists within healthcare systems. Having a psychiatrist lead the program allows us to identify and address the role of behavioral health early. Timely triaging by the PC chair eliminates delays of additional meetings and evaluations, providing physicians with timely help. We’re essentially lowering the bar in order to get help for physicians who need it.”
Making an Impact
In an analysis of the PC-based model, Dr. Fleisher and colleagues reported on data collected from the UPHS. The PC chair received contacts concerning physician behavior on only two clinicians in 2009, but this increased substantially after implementing the model in 2011 and 2012. After implementation, contacts often involved referrals, management consults, interview screening, and the need for general advice (Table). Of 79 resolved cases, 30 involved interpersonal issues and two were associated with poor clinical outcomes. The PCs effectively integrated information from patient and staff complaints and general behavioral concerns in a forum that allowed for individual interventions rather than going directly to disciplinary action from the Medical Executive Committee.
“The PC-based model we’re using at UPHS is one that can be replicated by other institutions, but this require patience and buy-in from all stakeholders in order to work effectively,” Dr. Fleisher says. “In our institution, it has provided faculty with the tools to address unprofessional behaviors before they have a detrimental effect on patient care. With hospitals and academic medical centers increasingly recognizing the importance of culture in optimizing health outcomes, taking a proactive approach to professionalism is an issue that merits attention. Programs like the PC model are a great example of how clinical and administrative leadership can show their commitment to improving outcomes and reducing harm.”
Speck RM, Foster JF, Mulhern VA, Burke SV, Fleisher LA. Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center. Jt Comm J Qual Patient Saf. 2014;40:161-167. Available at: http://psnet.ahrq.gov/resource.aspx?resourceID=27816.
Rosenstein AH, Naylor B. Incidence and impact of physician and nurse disruptive behaviors in the emergency department. J Emerg Med. 2011;43:139-148.
Wasserstein AG, Brennan PJ, Rubenstein AH. Institutional leadership and faculty response: fostering professionalism at the University of Pennsylvania School of Medicine. Acad Med. 2007;82:1049-1056.
Veltman LL. Disruptive behavior in obstetrics: A hidden threat to patient safety. Am J Obstet Gynecol. 2007;196:587.e1-e4.