Health Choice Network

1. Health Choice Network Jackie Gaines, Executive Coach The Challenging Physician

2. So Who are We Talking About? • Physician who comes in late often, but happens to see the most patients and generate the most revenue • Physician who is always behind in their tasks (labs and notes unsigned as per policy etc.) • Physician who is rude to patients and staff • Physician with illegible handwriting and not improving • ??? What are the behaviors of your disruptive physicians??

3. So…what do you want to know by the end of this session?

4. What cements our Mission and Values to our Actions? What guides how we live and serve patients, colleagues, our organization and our community?

5. All Life’s Variables Impact Our Behavior in the Workplace Organizational Expectations Family/Personal Misaligned values Medical Training/Previous work experiences Genetic Hardwiring External pressures/politics

6. Successful Physician Collaboration Starts Prior to Hire Clarity is the Essential Ingredient!

7. What was conveyed to you prior to hire? Did it match reality?

8. Standards of Behavior • Define behavioral expectation consistent with mission, vision, training, measurement, orientation and organizational culture • Foster positive and reduce negative/disruptive behavior by clarifying expectations upfront

9. Can you name one standard? How is it currently enforced?

10. Physician “Code of Conduct” • Creates physician commitment to more specific behaviors within the “standards” positioning physicians and their organizations for success • Puts in place a process to address and correct deviation from standards.

11. Reality Check: In 2009, the Joint Commission introduced new standards requiring more than 15,000 accredited health care organizations to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior~Joint Commissions, 2009

12. Physician Behavioral Standards/Code • Barriers …… • Physician culture has traditionally been one of independence and autonomy – results • Code of conduct / standards may be • Ignored • Rejected • Attacked

13. Physicians are more receptive when… • Physicians create the Standards/Code • Standards/Code reinforce the strategy and vision of the organization • There is a compelling and understood need for consistency throughout the organization • Physician leaders make it a priority • There is consensus on the content of Behavioral Standards

14. Behavior Standards Impact • High • Used for orientation/signed • Used for “Selection” • Consistent with “Vision” • Physicians trained in Behavioral Standards • Supported and projected by Leadership • Consequence for violation • Low • No upfront signing/orientation • No training of physicians • Low leader visibility • No consequences for violations of Behavioral Standards

15. Six Competency AreasAdopted by Joint Commission Patient Care - that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Medical Knowledge - about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement - that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

16. Professionalism - as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Systems-Based Practice - as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value Interpersonal and Communication Skills - that result in effective information exchange and teaming with patients, their families, and other health professionals

17. Physicians’ Major Priorities 1. Responsivenessof Administration to the ideas and needs of medical staff members 2. Ease of Practice: Facility makes caring for patients easier. 3. Agility: Administration has positioned health center to deal with changes in the health care environment 4. Trust: Confidence in the Administration to carry out its duties and responsibilities 5. Communication between Administration and physicians.

18. Prevalence of Physician Performance Problems • Disruptive Behavior • 4% - 5% of physicians • Distress • Impairment …at least one third of all physicians will experience...a period during which they have a condition that impairs their ability to practice medicine safely Leape LL & Fromson JA. Annal Intern Med.2006;14(2);107-115 www.TheResilientPhysician.com

19. What Does Disruption Look Like? Passive Aggressive Passive Aggressive Outbursts (90%) Intimidation (20%) Harassment (10%) Chronically late or not responsive to calls (15%) Inappropriate or inadequate documentations (15%) Derogatory comments (5%) Refusals to do tasks (20%) Samenow CP et al. Phys Exec. 2008.34(1):32-40

20. Most Frequent Source of Abuse? Most Common Disruption… “Lateral Violence” Nurses, Pharmacists Radiology, Lab Inst for Safe Medication Prac. 2003 www.ismp.org Rosenstein & O’Daniel. Amer J Nur.2005;1:54-64 Rowe MM & Sherlock H. J of NursManag. 2005;13(3):242.

21. What is Considered Disruptive?  Apprehension and Anxiety  Loss of Focus  Team Effectiveness  Communication What is Considered Disruption? www.TheResilientPhysician.com Federation of State Medical Boards, 1998

22. The Obvious Profane or disrespectful language Demeaning or intimidating behavior Sexual comments or innuendo Inappropriate touching, sexual or otherwise Comments that undermine patients trust in physician or health center Racial or ethnic jokes Outbursts of rage or violent behavior Throwing Inappropriate criticizing colleagues in front of pts. or staff Boundary violations w staff, pts, surrogates or key third parties Federation of State Medical Boards, 1998

23. The Somewhat More Subtle Inappropriate chart notes Unethical or dishonest behavior Difficulty working collaboratively with others Repeated failure to respond to calls Inappropriate arguments with patients, family, staff, or other physicians Resistance to recommended corrective action Poor hygiene Federation of State Medical Boards, 1998

24. Adverse medical events... 60% attributed to “out-of-control physicians” (Atlantic Information Services, Report on Medicare Compliance. 2005 14(17):1-8.) “Between 53% and 75%.. Say they saw a strong link between disruptive behavior and negative clinical outcomes Rosenstein AH & O’Daniel M. Neurology. 2008.70:1564-70. The Consequences www.TheResilientPhysician.com

25. Turnover  Risk 4 or more complaints over 6 yrs ~16x likelihood of 2 or more risk management complaints Hickson GB et al. JAMA. 2002;287:2951-7 The Consequences www.TheResilientPhysician.com

26. What Is Disruptive Workplace Behavior? Focus on Communication Behaviors Physical Intimidation Subjective? “Offensive” “Frightening” In Eyes of Beholder? Def. In Terms of Effects on Work Environment Interferes with Patient Care Interferes with Efficient Operations www.TheResilientPhysician.com Fooks, C & Maslove L. Coll of Phys and Surg of Ontario, Oct, 2003.

27. Drivers of Physician Change • Visionary Leadership • Trust and Confidence in the Leadership team • Knowledge of Performance • Clarity of Expectations • Logic for Efforts • Behavioral training • Colleagues doing the same • Recognition for doing well • Incentives to achieve Goals

28. When Expectations are not Communicated… Difficult behaviors are addressed reactively instead of prevented proactively Consistency of care is difficult to achieve and “behavioral variance” becomes the norm An Organization IS what it DOES all of the time

29. Expected Behaviors: Treatment of Patients • Physicians will introduce themselves to patients and family and clarify their role in the care of the patient • Physicians use curtains and doors, and conduct conversations in private areas to protect patient privacy • Each patient is an individual and will be treated honestly and with kindness • Each patient should understand treatment needs, treatment options and potential treatment outcomes • Medications will be explained including the purpose, therapeutic intent, duration of use and possible side effects

30. Expected Behaviors: Treatment of Staff • Speak positively about your staff to patients and families when an opportunity arises • When difficulties with staff arise, take ownership, speak-up and educate in private to improve performance • Communicate your whereabouts if your staff may need you for patient care issues • Thank your staff for the hard work they do

31. Effective Standards/Code are Specific and Observable Always ask, “What does it look like?” • “Courteous” is not specific or observable. What does “courteous” look like? • “Makes eye contact with patients and peers” • “Introduces self in interactions with patients and families” • “Uses patient’s name during clinical encounter”

32. Physician Orientation Standards/Code of Conduct

33. “Code of Conduct” Must Haves • Are defined and process documented • Impact Behavior • Violation have consequences that are in place and understood

34. When Breakdowns Occur Have a process in place • Fair • Consistent • Matching values & standards • Peer driven • Legal • Evidence based – best practice

35. Start Collegially Separate the Person from the Problem Behavior Clarify Underlying Issues Focus On the problem behavior How to Confront Inappropriate Behavior The Resilient Physician (Sotile & Sotile, 2002) • Do not debate: Each topic deserves it’s own conversation • Convey hope beyond tension

36. Process • Incident reported - any source • Investigated – Informal first • Reviewed by Chair/CMO • Meeting called with Chair/CMO - “cup of coffee” • Escalated to leadership if repeated behavior or clearly egregious. • Moved to a corrective action plan.

37. Language Matters • Some things you might say... • “We are here to discuss your behavior, and your behavior is not consistent with...” • “Recall that we have a Professional Behavior policy, and behavior was not...” • “We expect that our team acts...” • “We have __ episodes documented when you did [or failed to do]__” Discouraging Disruptive Behavior. Vanderbilt School of Medicine. Nov, 2008.

38. Confronting Disruptive BehaviorAnticipated Reactions • Flight • Subject-Changer • Apologizer • Denier Virginia Beeson. The Advisory Board, 2009

39. Confronting Disruptive BehaviorAnticipated Reactions • Fight • Rationalizer • Blame-Shifter • Score-Keeper • Negotiator Virginia Beeson. The Advisory Board, 2009

40. Confronting Disruptive BehaviorLanguage Matters • Use “Nevertheless, the fact remains....” • Separate process issues from the point of this intervention “In the meantime...”

41. Intervention Guidelines • Don’t Ignore the Obvious • Anticipate responses ranging from acceptance to denial to anger to hurt • Remember: The higher the hierarchy, the higher the shame and guilt

42. Language Matters • Explain that You Will Follow-Up • “If things don’t improve, or if you don’t comply with the plan, the consequences will be...” Document Document Document Document! Discouraging Disruptive Behavior. Vanderbilt School of Medicine. Nov, 2008.

43. How to Confront Inappropriate Behavior The Resilient Physician (Sotile & Sotile, 2002) • Follow-up • Manage Post-Disruptions Turmoil • Provide staff protection against retaliation • Decreased productivity • Workarounds • Turnover • “Lost” Administrative Time

44. In the Final Analysis:a preemptive plan most effective • Appointment of Excellent Physicians • Orient heavily on Vision and Culture • Build trust between Physicians & Leaders • Set and communicate expectations • Coach and train physician behaviors • Measure performance vs. expectations • Provide feedback on performance • Coach to improve poor performance

45. Transformation Requires An appeal to the “Heart”, not just the “Head”~Comments from The Heart of Change by John Kotter“Changing behavior is less a matter of giving people analysis to influence their thoughts, than helping them to see a truth to influence their feelings. Both thinking and feeling are essential, and both are found in successful organizations, but the heart of change is in the emotions. The flow of see-feel-changeis more powerful than that of analysis-think-change.”

46. Promoting Resilience 1. Protect Happiness 2. Focus on Uplifts 3. Believe in Something Bigger 4. Accept the Call to Character 5. Manage Your Coping Style 6. Rethink “The Balanced Life” 7. Embrace Good Work 8. Lead with Passion! 9. Deepen Your Relationships 10. Be a Hero Source: Sotile, WM & Sotile MO. Letting Go of What’s Holding You Back. 2007

47. Hero A hero is someone who creates safe spaces for other people —The Resilient Physician. Wayne & Mary Sotile (2002)

48. Striking a Balance in Physician Selection ! Primary Care Referrals Unique talent New physicians Specialty gap Word of mouth Growth Everyone else is Need Interest

49. Leaders must own the process!

50. Effective Physician Selection • Organizational Needs • Organizational Values • Process of recruitment – we or they formally or informally - Pre application • Meets criteria - send application • Process of evaluation – gather information • Process of selection – Peer interview – committee deliberation - is there a fit?