Tolerating Disruptive Behavior

In a recent survey of nurses, physicians, and administrators 96% of respondents say they had witnessed or experienced disruptive behavior from a physician.

In my first post, I wrote about becoming a "Topgun" or being the best of the best. In that post I mentioned the major difference between healthcare and aviation I have seen is the willingness of healthcare organizations (as compared to aviation organizations) to tolerate "selective compliance."

I can think of few examples of selective compliance that are more egregious than disruptive behavior. No organization will truly be SAFE or provide the highest level of care when it tolerates disruptive behavior. Intimidation, violence, abusive language, and angry or dismissive responses to patient needs or staff requests torpedo safe patient care. Patient safety just cannot flourish in that environment. That sort of behavior also leads to exceptionally strong staff dissatisfaction and high turnover. And when your patients see it, it will affect your HCAHPS surveys.

The problem of disruptive behavior and its effect on quality care is becoming so important the Joint Commission is weighing in on the subject. They have released draft standards on behavioral expectations. The standards will require hospitals to develop and enforce a code of conduct.

Based on my experiences with over 75 healthcare organizations, the Joint Commission effort can't come too soon. Rarely do I work with an organization where the nurses and staff don't say something like this, "What about Dr. Jones? (or What about Nurse Smith?) Until I see the administration crack down on his behavior, I won't believe they are serious about changing the culture around here. We've been complaining for years and still the behavior persists."

I am often asked about the keys to creating and sustaining a "Just Culture" or a "Culture of Safety." One of those critical, but often overlooked, keys to success is having the courage to confront and change disruptive behavior. Culture change is often as much "caught" as it is "taught." Meaning that leadership has to demonstrate the strength and willingness to do the right things and model the right behaviors.

If, in the interest of patient safety, leadership expects nurses and staff to use assertive, cross checking communications and be willing to speak up at the right time with the right words, then leadership must display the willingness to do the same. Nowhere is this more important than dealing with disruptive behavior. The patient's welfare demands nothing less.

All Possible Objections

Samuel Johnson wrote in 1759, “Nothing will ever be attempted, if all possible objections must be first overcome.”

I work with a lot of hospitals to help them adopt some of the best practices (things like teamwork training and checklists) from aviation to improve their patient safety and quality of care.

Hospitals, and the people who work there are largely consensus driven. Meaning that many decisions about which improvement initiatives to pursue are made based on the consensus of the staff. "Does every one agree this is a good thing? Can we get total buy in from the staff?"

Which means I rarely work with an organization which isn't overly concerned about objections, objectors, and naysayers. "Dr. Smith will never buy this." Or, "Nurse Jones doesn't think this will succeed." Or, Tom just won't do something like this."

The secret to success in getting the hospital to go ahead and press forward is to help the senior leaders realize they don't need total consensus, and that the focus on the naysayers is often misplaced.

I have seen very large hospitals be wildly successful in changing their culture and adopting best practices from aviation when starting with the support of less than 10 key leaders. Of course, those 10 must be carefully selected, and be in critical positions, but it takes far fewer supporters than most can ever imagine to start down the road to success.

Many other hospitals are no farther than they were last year because they are paralyzed by responding to the all of the "possible objections." Therefore, nothing is attempted.

I just received an email from a nurse manager in a Labor/Delivery unit at a hospital that is five months into their new patient safety initiative. When I read her comments I had to smile.

Here's what she said.

"We are doing very well here on the LifeWings project. Your LifeWings instructor, Steve Chafe, really helped us get rolling during our Hardwired Safety Tools workshop. Over the 3 day workshop we created a total of 8 tools, ( e.g. Infant Warmer Checklist, Labor SBAR, Pre Shift Huddle Briefing Guide, Post Shift Debrief Guide, Circumcision Preparation Checklist, Time Out Tool, etc.) I just had evaluations for all of the staff and during that time I asked them what they thought about the tools we created and implemented. Overall, the staff are using the tools and I have had plenty of positive feedback on them. I really am surprised at how well this initiative is going so far, and also am surprised at how some of the nurses who I thought would not embrace the concept have accepted it wholeheartedly."

She's a great example of someone who has learned the lesson of stepping off with the support you have and not being paralyzed by all the possible objections. Line up your key leaders, work with the willing few, use good change management leadership and go for it. You'll be surprised at your success.