Case & Commentary (3/5) - AHRQ WebM&M

Difficult Encounters: A CMO and CNO Respond
Case Objectives

Appreciate the risk of disruptive behavior and understand institutional response to such behavior.
Describe characteristics of a culture that encourages open communication, respect, and opportunities for interprofessional learning and teamwork.

The Case
An 89-year-old man was admitted to the orthopedic service after sustaining a hip fracture. The patient's family physician requested a cardiology evaluation. Surgery was delayed while the consultant evaluated the patient. The cardiologist identified severe aortic stenosis (echocardiogram showed an aortic valve area of 0.9 cm2) and recommended that the patient not go to surgery. On the late afternoon following the cardiologist's report, the orthopedic resident called the operating room to schedule the patient for surgery later that evening. The nurse on the floor paged the orthopedic resident and read the cardiologist's conclusions and recommendations over the phone. The resident came to the floor, told the nurse that she was "stupid" and confidently explained that the case would be done under spinal anesthesia, so the cardiologist's concerns were nothing to worry about.

Spinal anesthesia can cause unexpected and sudden hypotension resulting in hypoperfusion of the coronary arteries and sudden death. At 7:00 PM, the nurse called the hospital's Chief Medical Officer (CMO), who was getting ready to leave for the day. The CMO promptly paged the orthopedic resident, who was meeting with the attending orthopedic surgeon to review x-rays of the case. The CMO went to the x-ray department and talked with two residents and the attending. The CMO patiently explained the risk of perioperative death associated with hypotension in the presence of severe aortic stenosis. The attending then called the operating room to cancel the case. The following day, the CMO reviewed the nurse's intervention with the Chief Nursing Officer (CNO).

Two days later, the patient suddenly arrested on the floor. Resuscitation efforts were unsuccessful.


The Commentary: Part 1
Commentary by Ernest J. Ring, MD, former Chief Medical Officer, UCSF Medical Center

This incident highlights the problem of unprofessional physician behavior and the increasing recognition that caregiver incivility can directly jeopardize patient safety. In this case, a resident was rude and disrespectful to a nurse for pointing out a consulting cardiologist's concern about a patient's high risk for surgery. The resident responded by demeaning the nurse. Furthermore, he ignored her warning, moving ahead to schedule the surgery. This prompted the nurse to take immediate action by contacting the CMO and asking him to intervene and stop the surgery.

The CMO's most important responsibility is protecting patient safety. Had I been the CMO in this case, I would have quickly evaluated the clinical facts and confirmed that immediate cancellation of the hip surgery was warranted. It's highly unusual for a CMO to be asked to second-guess a surgeon's clinical judgment in matters directly related to the surgeon's specialty expertise. If the nature of the operation had been the issue, I would have sought the opinion of the Chief of Orthopedic Surgery. However, in this case the concern was about the risk of spinal anesthesia, so I would have met with the attending anesthesiologist to review the cardiologist's findings. If the anesthesiologist agreed that the patient's condition was so poor that he would not tolerate the anesthesia, we would have gone together to confer with the orthopedic surgeon and cancel the operation.

Once the immediate safety issue was resolved, I would have handled the complaint about the resident's behavior toward the nurse in the same manner I investigated all unprofessional behavior incident reports involving physicians—interview any witnesses and try to understand both sides of the story, including that of the physician. Typically, when a complaint involves a resident's behavior at a "name-calling" level, I would refer the matter to the resident's training program director. As with most training hospitals, residents are not credentialed by the medical center and their behavior is not tracked by our Medical Staff Office. Instead, the residency program director and department chair have direct authority over the residents and maintain records of their performance in each of the hospitals in which they rotate. They would therefore be in the best position to know whether this incident was an isolated event or part of a more worrisome pattern of unprofessional behavior.

Both our medical center and University have written codes of conduct concerning intimidating or disruptive behavior. Clearly, acts involving physical contact, throwing equipment, or the use of very threatening language are never tolerated and have to be dealt with at the highest leadership level. If this resident's behavior had been that serious, I would have met with him along with his program director and department chair and likely the Associate Dean for Graduate Medical Education. Depending on the history of previous complaints about this resident, the actions taken could range from referral to an anger management program to immediate dismissal from the residency. If this was a first complaint, I would ask the department leadership to take the lead and counsel him about the importance of good communication and a collaborative work environment for safe and high-quality patient care. I would also expect them to warn him that insulting behavior toward nurses or any other hospital staff is never acceptable and that any further complaints about his behavior could jeopardize his status in the residency program. Finally, I would require that he apologize to the nurse.

Our medical center expects no less civility in the behavior of attending physicians than from our residents. Surely, the more authoritative position of an attending physician, especially a senior faculty member, creates a much more threatening power perception, and the impact of any improper attending behavior on the health care team would be substantially greater. As CMO, I responded to every complaint I received about unprofessional attending physician behavior. My first step was to send an email to the person who reported the incident, thanking them for taking the time to submit the report and assuring them that I would follow up. I would then arrange for the physician-subject of the complaint to come to my office to discuss his or her perception of the events surrounding the incident. Interestingly, when I met with physicians to discuss an incident, they virtually always wanted to focus first on whatever underlying issue triggered their behavior. I would always patiently hear them out but explain that things cannot always go perfectly in a complex medical center environment. No matter what prompted it, I'd add, their reaction was inappropriate and they must find a better way to deal with their frustrations in the future. I would also inform them that a letter describing their behavior was going to be placed in their credentials file with a copy to the chairman of their department.

The great difference between enforcing rules on faculty behavior compared with incidents involving residents is the limited authority that CMOs and hospitals have over attending physicians. As mentioned previously, resident behavior can be addressed at the department level in multiple ways, up to and including discharge from the program. Governance over attending physician behavior is much more complicated. Attending physicians are credentialed members of the Medical Staff and are governed by the Medical Staff bylaws, which provide them numerous rights and extensive due process guarantees. The medical center leadership, including the CMO, can summarily restrict or suspend privileges "to protect the life of any patient or to reduce the likelihood of imminent danger to the health or safety of any individual," but physician behavior is only rarely threatening enough to warrant this action. Summary suspensions are also time limited and must be rapidly ratified by a senior governance body, in our case the Executive Medical Board.

More commonly, the problem is an ongoing pattern of unprofessional behavior that continues despite counseling by the department chair or CMO. When this occurs, implementing corrective action is very difficult and time consuming and must follow a highly proscribed legal process. I'll describe the process at UCSF Medical Center—although the process may vary in a few of its details from hospital to hospital or state to state, in my experience, the overall flavor is similar. First, a written request must be submitted to the President of the Medical Staff. The President then appoints an ad hoc committee of the Medical Staff to investigate the allegations. They meet several times to interview individuals who have direct knowledge of the physician's behavior and talk to the physician-subject of the investigation. When they have completed their investigation, the committee chair makes a presentation to the Executive Medical Board with the committee's findings and any recommendations on appropriate actions. The subject of the investigation is invited to provide a written response and may attend the Executive Medical Board meeting when the ad hoc report is presented.

The Executive Medical Board then deliberates to decide whether the physician's actions warrant a reduction, modification, or suspension of clinical privileges. If so, the physician is still allowed to maintain full privileges until a "fair hearing" is held. The fair hearing panel is appointed by the President of the Medical Staff and can only include individuals not involved with the Executive Medical Board or the ad hoc committee. The physician is allowed to have legal representation. If the fair hearing panel agrees with the Executive Medical Board decision, a corrective action can finally be taken.

During my tenure as CMO, we went through this process on several occasions with several different physicians. Each time, the ad hoc committee meetings were difficult to schedule because of committee members' busy schedules, so the process took many months—nearly 2 years in one case. The committees and the Executive Medical Board tended toward conflict avoidance and often recommended the physician be given another chance and not have privileges limited unless he or she "did it" one more time. In the few cases in which the Executive Medical Board recommended termination or limitation of privileges, the physician resigned from the medical staff before a fair hearing could be completed.

It seems very clear to me that in order for a medical center to oversee disruptive physician behavior, there must be a series of punishments available that actually fit the crimes. Currently, the only punishments we have at hand are too severe and cumbersome to be applied, except in the most extreme situations. This leaves the medical center legally responsible for protecting its employees from a hostile work environment (and its patients from problem physicians) without adequate control over the physician staff. Fortunately, almost all the physicians on our medical staff are dedicated clinicians and scientists and are never the subject of behavior complaints. That allows the CMO and the Executive Medical Board the time to keep after the few who seem to cause all the trouble.


The Commentary: Part 2
Commentary by Jane E. Hirsch, RN, MS, former Chief Nursing Officer, UCSF Medical Center

Although efforts to improve relationships among health care professionals have been underway for many years, the patient safety movement has given them greater urgency. It is clear that teamwork, communication, and collaboration enhance patient safety and quality. Yet patterns of disrespectful, disruptive, or hostile behavior remain significant issues in health care, leading to increased medical errors and sentinel events. On July 9, 2008, The Joint Commission issued a Sentinel Event Alert stating that "intimidating and disruptive behaviors can foster medical errors, contribute to poor and preventable adverse outcomes, [and] increase the cost of care...."(1)

Because of these concerns, The Joint Commission developed a leadership standard (LD.03.01.01) that now requires hospitals to address disruptive and inappropriate behaviors and to develop a comprehensive approach for managing unacceptable behavior.

This case highlights the type of adverse event that can occur as a result of unprofessional communication and poor teamwork. From the beginning, it would have helped had the cardiologist communicated his or her conclusions directly to either the orthopedic resident or attending, rather than leaving written recommendations that the nurse had to read over the phone to the resident. Questions regarding this patient's risk of perioperative death could have been discussed at this time. When the resident called the nurse "stupid," an immediate breakdown in respect, communication, and trust occurred. It is well documented that intimidating, hostile behavior can lead to conflict avoidance, silence, or poor morale that can have a devastating effect on patient safety—particularly if a caregiver, in this case a nurse, decides not to challenge the behavior.(2)

In this scenario, the nurse decided, appropriately, to speak up, and contacted the CMO after the conversation with the orthopedic resident. Although it appears that the nurse "jumped" several levels in the chain of command and communication, she is to be commended for ensuring that the cardiologist's recommendations were reviewed further and that the patient be prevented from having surgery that evening. Impressively, the CMO acted promptly, by calling the resident and physically going to the radiology department to meet with the resident and attending. (It was also fortunate that the CMO was knowledgeable about the risks of spinal anesthesia in patients with severe aortic stenosis, since apparently the orthopedic attending was unaware of this.) However, it is not clear whether the CMO also addressed the resident's inappropriate comment to the nurse at that time; it would be important for the orthopedic attending to be made aware of the resident's behavior. Since the CMO and CNO reviewed the nurse's intervention the following day, it would be appropriate if both chain of command communication and the resident's disrespectful comment were discussed and handled.

Development of a culture that encourages open communication, trust, and respectful behavior, even when it involves challenging or questioning a colleague, is critical. There is evidence that interpersonal dynamics within teams are key contributors to good outcomes and decreased patient care errors.(3) Promoting behaviors that facilitate effective interpersonal interactions among health professionals can help improve safety at a foundational level. Organizations that aspire to create cultures of safety must address the pervasive behavioral patterns that undermine effective communication and team performance.(2) The CNO and CMO are important purveyors of this message, and by role-modeling professional collaborative behavior, problem-solving, and strong teamwork, the two can create a productive collegial relationship and culture that set the tone for the other health care professionals within the organization.

Development of a culture such as this, however, requires more than role-modeling. There must be an organizational commitment to skills training in conflict resolution, opportunities for interprofessional learning and teamwork, and an emphasis on conflict engagement, which is learning to deal with conflict constructively and accepting the challenges of addressing conflict with an understanding that resolution may not be possible (4), so that safe patient care is supported and enhanced. The CNO must ensure that nursing staff are adequately prepared, encouraged, and commended when patient care questions are brought forward. Nurses who are intimidated or feel that they lack the skills to intervene or question a situation are unlikely to handle conflict in the most optimal way. This makes it important to emphasize that appropriate conflict engagement, communication, and teamwork have a major impact on patient safety and that these are expected competencies. Educational interventions, preferably via interprofessional training, may be needed to enhance these skills. Examples of these educational offerings might include Conflict Management/Engagement, Engaging in Collaborative Practice, Difficult Conversations, and Teamwork and Decision-Making.

Early in my career, as a staff nurse, I was comfortable questioning physicians, nurses, or administrators about decisions that I thought might compromise quality of care or patient safety. When I became CNO and had a broader view of care across an entire institution—even in a place with as many excellent people as UCSF—I was surprised by the degree and depth of unprofessional, disrespectful, and intimidating behavior among professional colleagues. Just as the staff nurse needs to learn to speak up to defend patient safety, so too does the effective nurse administrator, and this tone is set by the CNO. I came to rapidly appreciate the importance of early intervention, appropriate conflict engagement, and teamwork in addressing these critical issues. I also learned that this work depended on having strong collaboration with physician leaders and so I was most fortunate to have an excellent relationship with a wonderful CMO!


The Commentary: Part 3
Dr. Ring responds:

It seems to me that our medical center's culture has evolved considerably over the past few years. Today, it is much less likely that a patient would be harmed by the kind of events described in this scenario. Safety and quality innovations that were incorporated into our daily hospital operations (eg, rapid response teams, time outs, and intra-service handoff protocols, to name a few) have not only improved caregiver communication but also led to increased appreciation of the value of interdisciplinary teamwork. Teamwork training programs—which brought together physicians, nurses, pharmacists, and other staff from high-risk environments such as the operating rooms and medicine wards—gave providers a clear message that anyone suspecting that a patient is in jeopardy for any reason has an obligation to bring their concern to the attention of the nursing leadership, an attending physician, a department chair, or, as in this case, even to the CMO.

I fully realize that the kind of rude behavior displayed by the resident in this case still occurs sometimes—even in our medical center—but it is clearly happening much less often. Our clinical departments are now required by The Joint Commission and the ACGME to regularly evaluate both their attending physicians and residents for competencies including professionalism and interpersonal and communication skills. In my experience, department chairs take incident reports and complaints about their faculty and residents very seriously and generally act on them. Moreover, the word is out that physicians are being held accountable for inappropriate behavior and that even senior faculty have lost clinical privileges. Unfortunately, our governance mechanisms for dealing with problem physicians remain very cumbersome. They leave us with too few alternatives for remediation, which means that legal counsel still has to oversee every step for anything more serious than a reprimand.

Dr. Hirsch responds:

Dr. Ring's remarks describe his commitment, as CMO, to handling issues of unprofessional conduct with physicians. I respect his view that patient safety is a CMO's first responsibility, and his description of how he would have handled this particular situation is thoughtful and comprehensive. He has also identified that there is increasing recognition that incivility, especially interprofessional disrespect, can directly jeopardize patient safety. I am particularly pleased that he would contact the individual reporting a complaint against a physician, assuring them that there would be follow up. Often, individuals feel that their complaints fall into a black hole, are not taken seriously, or will not be addressed because of the "power perception" that he mentions.

Notwithstanding Dr. Ring's leadership, there is clearly a perception in our institution that there is a double standard in this area: employees (particularly nurses) can be disciplined and terminated for problematic behavior, but the perception is that such behavior by physicians is often tolerated.

Dr. Ring's commentary highlights the difficulty in addressing unprofessional conduct issues with medical staff, including house staff. Medical centers often have limited authority over house staff and attending physicians and must utilize lengthy and cumbersome Medical Staff processes to effectively address these issues. While Medical Staff bylaws are designed to protect medical staff, their "numerous rights and extensive due process guarantees" mean that implementing corrective action is extraordinarily time-consuming and cumbersome and often results in no action being taken, even in cases of problematic patterns of behavior. Not only is the lack of action a problem for other caregivers and patients who interact with the physician in question, but in a teaching setting, attending physicians' unchecked unprofessional behavior can serve as a negative role-model for junior physicians and house staff—the perception spreads that disruptive, disrespectful behavior is acceptable.

I wholeheartedly agree with Dr. Ring's comment that the Executive Medical Board at our facility has tended toward conflict avoidance, often recommending that problem physicians be given yet one more chance; I suspect this is true in most institutions. I appreciate that the leadership of individuals like Dr. Ring is increasing the chances of prompt and direct action in cases of unprofessional conduct, but in my view, this is happening far too slowly. As Dr. Ring says, fortunately most physicians are dedicated clinicians, as are most health care professionals, but the potential impact on patient safety and staff satisfaction caused by problematic individuals is significant. It seems time for CNOs and CMOs to work together to ensure that their health care institutions develop timely and thorough processes to adequately address disrespectful, disruptive behavior by physicians as well as by other providers.

Ernest J. Ring, MD
Professor Emeritus, Department of Radiology
University of California, San Francisco

Jane E. Hirsch, RN, MS
Clinical Professor
Director, Nursing & Health Systems Leadership (Administration) Masters Specialty Area
UCSF School of Nursing

Faculty Disclosure: Dr. Ring and Dr. Hirsch have declared that neither they, nor any immediate member of their families, have a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, his commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References
1. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. July 9, 2008. [Available at]

2. Gerardi D, Forse A. Conflict Engagement—An Essential Competency for Addressing Behaviors that Undermine Safe Patient Care and Contribute to Unhealthy Work Environments, unpublished manuscript.

3. Keeping Patients Safe: Transforming the Work Environment of Nurses, Institute of Medicine. Washington, DC: National Academies Press; 2004. ISBN: 9780309090674. [Available at]

4. Mayer B. Beyond Neutrality: Confronting the Crisis in Conflict Resolution. San Francisco, CA: Jossey-Bass; 2004. ISBN: 9780787968069.

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