September 9, 2008 - A consensus has developed within the health care community that disruptive and inappropriate behavior such as verbal outbursts and physical threats, refusing to perform assigned tasks, and exhibiting uncooperative attitudes can compromise patient safety and lead to preventable adverse outcomes. Disruptive behavior can also result in litigation from employees and patients. As a result, the standards governing disruptive and inappropriate behavior in the medical care setting have evolved, and behavior that was previously accepted is no longer acceptable. The American Medical Association (AMA), recognizing that disruptive behavior is not acceptable, adopted a policy on Physicians with Disruptive Behavior (E-9.045). This policy recommends that medical staffs adopt bylaws and policies defining disruptive conduct and providing for evaluation and corrective action where appropriate.

On July 9, 2008 the Joint Commission built upon this consensus by issuing a sentinel event alert addressing disruptive and inappropriate behavior. The alert stressed the importance of the issue and provided further guidance and clarification regarding Joint Commission standards. Although Joint Commission standards are not binding on hospitals that are not accredited by the Joint Commission, all hospitals should take notice of the revisions because they define a set of best practices that may become a de facto community standard and because many laws already impose similar requirements. The full alert is available on the Joint Commission's website at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm. The Joint Commission has also revised its Leadership Standards to more directly address disruptive conduct.

The revised standards are effective January 1, 2009 and require hospitals accredited by the Joint Commission to adopt "a code of conduct that defines acceptable and disruptive and inappropriate behaviors" and require hospital leaders to "create and implement a process for managing disruptive and inappropriate behaviors." (LD 03.01.01, EP 4 & 5). The Joint Commission also suggests that hospitals develop reporting systems that protect against intimidation or retribution, policies and procedures that require appropriate responses to patients and their families who are involved in or witness disruptive behavior, intervention strategies that address disruptive practitioners, and educational programs that educate physicians and staff on professional conduct. Compliance with the code of conduct and applicable policies should be considered during the credentialing process as evidence of the practitioner's interpersonal skills and professionalism or lack thereof. (MS 4).

Several state and federal employment laws impose similar, and in many cases, more stringent requirements on employers to address disruptive behavior. For example, an employer's obligation to protect its employees from sexual harassment by co-workers, supervisors, and non-employees is well defined. Additionally, an employer has a duty to provide a safe workplace for its employees under federal and state job safety laws. Workplace bullying legislation has passed in several jurisdictions addressing abusive workplace environments and the mistreatment of employees in the workplace. Although such legislation has not yet passed in Washington State, it has been introduced every year since 2005, and will likely pass in some form eventually. Employers who do not address such legal requirements face liability for failing to do so.

Every employer should have written policies in place that prohibit harassment in the workplace, establish complaint resolution procedures, including discipline when harassment is found to have occurred, and prohibit retaliation. Policies should also address violence and threatening behavior in the work place. The employer should also implement a training program to educate its employees on prohibited behaviors and complaint procedures. These policies should be incorporated into or referenced within the policies addressing disruptive behaviors.

As a hospital with a compliance program, you should have a code of conduct that includes written standards of conduct and a conflict of interest policy. We recommend that you revise your code of conduct to also address disruptive behavior, and then review your policies and procedures and bylaws to ensure that they address disruptive behavior in a consistent manner. The hospital should have a policy that defines what behavior constitutes disruptive behavior and delineates specific steps that the hospital will take to address such behavior. The policy should apply to both medical staff, independent contractors and employees. The medical staff disruptive conduct policies should be linked to the hospital's physician health policies. If the hospital uses separate policies for medical staff and employees, then these policies should be consistent when appropriate.

While revising policies to address disruptive behavior, hospitals may want to take the opportunity to ensure compliance with other legal requirements. In addition to the employment laws mentioned above, hospitals are also required to have policies to combat waste, fraud and abuse that include descriptions of federal and state laws governing false claims and whistleblower protections. Other requirements include records management and HIPAA policies. A complete review should ensure that the hospital's code of conduct, bylaws, policies and procedures are internally consistent and address all of the regulatory requirements to which the hospital is subject.

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