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Behavior and Patient Safety-Perfect Together?

Medical Staff Affairs Monthly, August 13, 2008

On July 9, The Joint Commission (TJC) issued a sentinel event alert, Issue 40, describing behaviors that undermine a culture of safety. By raising this to a sentinel event alert level, make no mistake that the spotlight will shine brightly on this issue during your next visit from TJC. The sentinel event alert highlights the new leadership standard, LD.03.01.01, effective January 1, 2009, that requires two elements of performance:

• EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors
• EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors

Reactions have been swift and often visceral. They range from “long overdue” to “another Joint Commission standard to nail physicians.” This is clearly another get-over-it moment. Once the emotion passes, it is necessary for hospitals and medical staffs to understand what LD.03.01.01 requires, but more importantly to understand the reasoning behind it and how best-practice organizations have already dealt with this issue.

Lest anyone still requires the rationale of the effect of behavior on patient safety, consider the following:

1. A nurse is reluctant to call a bariatric surgeon physician known to be a “hothead” for a routine intervention that could prevent a serious, if not mortal, outcome if not implemented. As a result, the patient dies of a postop anastomotic leak that could have been corrected with timely intervention in the operating room.
2. Staff members are reluctant to point out some solutions easy to implement for patient flow and care safety to the CEO, who has an anger management problem. As a result, patients continue to be treated in hallways and other areas with less-than-optimal staff and monitoring support.
3. A passive-aggressive pharmacist fails to fill a physician order in a timely fashion because the physician’s order is judged to be incomplete. As a result, the initial dose of antibiotic is delayed by 24 hours.
4. A patient’s family overhears an outburst from an RN who is railing about what an awful place the hospital is to work in. Their confidence level plummets.

Truly effective hospitals and medical staffs have already adopted thorough and comprehensive code-of-conduct policies. More importantly, they follow their policies and processes in a consistent fashion and provide the leadership required to move to a genuine culture of patient safety.

So what needs to be done for those hospitals and medical staffs that are at an earlier point in this journey? Every medical staff and hospital needs to conduct an inventory now to ensure that everything is in place, working, and effective by January 1, 2009. If not, there is much to do and little time to do it. The following is necessary:

1. Does the hospital have a code of conduct policy that defines acceptable, disruptive, and inappropriate behaviors? Have leaders created and implemented a process for investigating and managing disruptive and inappropriate behaviors?
2. Is it clear that the hospital policy applies to everyone, including board, executives, management, and line staff?
3. Does the voluntary medical staff have a similar code-of-conduct policy that is complimentary and supportive of the hospital policy and includes the following?
   1. A definition of acceptable, disruptive, and inappropriate behaviors
   2. A process to investigate and manage disruptive and inappropriate behaviors
   3. A credentialing process that addresses the six core competencies (MS4.15), including interpersonal skills and professionalism
4. Have all physician and non-physician staff members been educated on the organization’s and medical staff’s code-of-conduct policy?
5. Are all team members held equally accountable through positive reinforcement for professional behaviors and management of noncompliance with expectations?
6. Has the medical staff incorporated into their peer review process clear expectations of performance on multiple dimensions, including professionalism, and that these expectations are measured and feedback is provided to individuals as part of the ongoing professional performance evaluation of physicians?
7. Has zero tolerance for egregious and criminal acts been defined and imbedded in medical staff bylaws, employment agreements, and hospital administrative policies?

The Greeley Company, through its accreditation and medical staff services, has worked with hospitals and medical staffs across the country about these issues of professional conduct for years. Let us know if we can help.

Until next time, be the best that you can be.

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