For some medical staffs, one bad apple can ruin the whole batch. Since 2008, the Joint Commission intensified its focus on curbing disruptive physician behavior because of the potential negative impact on providers and their patients.

The Advisory Board spoke with Ralph Topinka of von Briesen & Roper, s.c. to discuss how providers can address disruptive physician behavior and preserve a culture of safety.

What are some challenges that providers face in dealing with disruptive physician behavior compared to other staff members?

The issue of disruptive physicians is receiving added focus from providers for a variety of reasons—providers should now be more focused on ensuring appropriate physician behavior because of the potential impact on an organization's accreditation status. In 2008, the Joint Commission incorporated conduct standards into their hospital accreditation process to curb disruptive and intimidating behavior from physicians—behaviors that ultimately undermine an organization's culture of safety.

As a result, providers have become less tolerant of disruptive and intimidating behavior from "bad apple" physicians who can jeopardize an organization's Joint Commission accreditation status as well as the safety of its employees and patients.

Overall, accreditation bodies as well as both employed and non-employed medical staffs have become increasingly intolerant of disruptive behavior and take their roles in safeguarding quality of care seriously.

Are there different challenges in dealing with employed versus non-employed physicians?

Yes, providers face a separate set of challenges depending on the employment status of the disruptive physician.

For employed physicians, issues often arise through human resources channels and Administrators must often decide whether to deal with them as employment matters, medical staff matters, or jointly in some situations. If a provider employs all physicians, then the medical staff is still involved in the disciplinary process as described by state laws, Medicare's conditions of participation, and accreditation standards.

If the disruptive physician is not employed, providers may choose to simply honor the disciplinary actions of the organized medical staff since every medical staff typically follows their own set of by-laws that describe corrective actions, disruptive behavior policies and procedures, and fair hearing processes. Providers may also choose to impose additional sanctions at their discretion.

Most providers give physicians and other physicians a hearing before an internal hearing body that is often comprised of medical staff medical members and/or laypeople. The hearing committee will then submit a recommendation to the organization's Executive Physician Committee who then reports to the Board. Providers' ultimate objective must be to ensure fairness and transparency with a disruptive physician's due process regardless of his or her employment status.

What should providers do from a risk management perspective once an adverse event involving a disruptive physician arises?

From a risk management perspective, providers should establish disruptive behavior policies describing what "disruptive" physician behavior means, as well as procedures to mitigate any adverse event that occurs. Providers typically fill out an occurrence/incident report to describe the adverse event, which should trigger a thorough investigation into the incident.

If an investigation reveals that there were underlying health issues causing the disruptive behavior, then providers can deal with the incident as a behavioral health or mental health issue and implement mandatory counseling or a leave of absence. If an investigation reveals that no underlying health issues caused the disruptive behavior, then providers can implement disciplinary measures such as reprimands, loss of privileges, or something more severe, such as termination.

Providers must maintain a pulse check on their medical staffs to ensure appropriate, professional behavior is followed. According to the Joint Commission, it is the provider's responsibility to conduct focused and ongoing professional practice evaluations to ensure that medical staffs are actively reviewing what's going on in the hospital regarding physicians new to the organization and/or to a specific procedure. These ongoing evaluations are critical to providers in addressing physician behavioral problems before they escalate.

Should providers report adverse events related to disruptive behavior to any state or national agencies?

The answer to that question depends on the nature of the disruptive behavior. Some states have requirements for physicians to report when their peers engage in professional misconduct, which can ultimately end up being heard by state licensing boards. If an adverse action is severe enough or indicative of a pattern of gross misconduct, then there may be an obligation to report the action to the National Physician Data Bank.

What are some negative consequences that could occur from failing to properly mitigate or prevent disruptive behavior?

Disruptive medical staff members can cause a myriad of problems for providers. In severe cases where there is a significant pattern of egregious physician behavior, providers could lose accreditation statuses or even participation in the Medicare program.

Disruptions in the health care environment can also negatively affect quality of care, which is the most significant consequence. If physicians are reluctant to call on peer out of fear or resentment, for instance, that can negatively impact patient care. There is a strong correlation between medical staff satisfaction and the quality of care delivered to patients.

Overall, disruptive physicians can negatively impact providers financially, operationally, and from a quality of care perspective. Providers should address disruptive physician behavior as soon as it arises in order to protect their organization and their patients.