Enhancing a Culture of Quality, Safety & Respect: Addressing Disruptive Behavior

Preparation Notes—long versionPlease review note pages before presenting materials

Enhancing a Culture of Safety: Addressing Disruptive Behavior

Presentation to:Add Your Unit/Department Name

Agenda Disruptive Behavior defined

Impact of Disruptive Behavior on workplace quality and safety

Causes of Disruptive Behavior

Content of revised UMHS Policy 04-06-047— Disruptive or Inappropriate Behaviors by UMHS Personnel

Importance to Our Work Team

Q &A

ObjectivesAfter reviewing and discussing UMHS Policy 04-06-047 Disruptive or Inappropriate Behavior by a UMHS Employee or Faculty Member at the end of this session participants will:

Understand the potential negative impact of disruptive or inappropriate behavior on workplace quality and safety throughout the organization—in clinical and non-clinical areas

Be able to provide examples of appropriate and inappropriate behavior

Understand recommended guidelines for reacting in the moment to disruptive or inappropriate behavior

Use paper or on-line reporting tools to report inappropriate behavior

Disruptive Behavior defined

Any conduct that interferes with the effective

operation of UMHS or suggests a threat to UMHS

personnel or to patient care . That a person’s

behavior is unusual, unorthodox, or different is not

alone sufficient to classify it as “disruptive

behavior”.

Lateral Violence defined

Inappropriate behavior, confrontation or conflict

between coworkers that humiliates, degrades or

otherwise indicates a lack of respect for the dignity

and worth of an individual – often caused by

communication mishaps.

Disruptive Behavior Linked To

Medical errors & adverse outcomes Reduced staff performance, innovation Increased staff turnover Patient dissatisfaction Lack of information sharing Processing delays

Too Often, Often Unreported With Negative Consequences

Studies with similar findings across several Health Care organizations

> 90% have witnessed disruptive behavior by MDs

30% - knew nurses who left hospital as a result of disruptive behavior

> 70 % of nurses witnessed disruptive behavior among nurses

14% aware of actual adverse consequences

“serious problem within and across disciplines”

Voluntary Hospital Association 2002, 2005 studies (Rosenstein)

“But I Don’t Work In Clinical Area.”

Disruptive and Inappropriate behavior can negatively impact your work environment too.

The policy applies to all UMHS personnel

UMHS Survey Measures Respect

UMHS asks questions about respect inour workplace in our Employee Engagement survey.

Q29—We hold ourselves and others appropriately accountable if we fail to meet our commitments

Q30—We treat each other with mutual respect even when we have clear differences of opinion

We are making some improvementsand have opportunity for more What are our unit’s survey

results?

It Does Happen Here!Quotes on Inappropriate Behavior

“The doctors can be disrespectful to the nurses who can be disrespectful to techs who are disrespectful to housekeepers, etc.)

“There are no consequences for these behaviors so you become demoralized and they just continue.”

“Surgeons are very belittling—they call you names . . .”

“There is a director who screams at his supervisors all the time and no one does anything because they are afraid of him.”

“I would like to see people written up—people don’t take things seriously. Supervisors hate confronting people.”

From 2007 UMHS Employee Engagement Focus Groups

Causes of Disruptive Behavior

Individual factors high stakes high emotion personal problems fatigue substance abuse lack of interpersonal, coping or conflict-management skills lack of tolerance or understand of workplace diversity

Historical factors tolerance and indifference to

disruptive behavior

Systemic factors increased productivity demands cost containment requirements

changes in shifts rotations of

interdepartmental support staff

Leaders who fail to address unprofessional conduct through formal systems are indirectly promoting it.

We See ItBut We Don’t Speak Up

Because: That’s the way it’s always been. Who will listen? I don’t want to get in trouble. I can take it. We can overlook it because of the person’s

technical expertise, rank, etc.

UMHS Strategic Principles/Values

UMHS values include: RESPECT, TRUST, INTEGRITY

Our Strategic Principles include: Integration, Collaboration & Team Work Taking Care of Our Own Cultural Competency Integrity and Trust

UMHS Policy 04-06-047--Disruptive or Inappropriate Behavior by UMHS Personnel

States UMHS commitment to addressing disruptive/ inappropriate behavior by UMHS personnel

Expresses importance of collaboration, communication and collegiality to patient care, education, research & effective operation

Acknowledges that reporting can be intimidating, therefore provides support and process• Outlines who to report to• Allows for anonymous reporting

Identifies the procedure for reporting

Specifies outcomes, including potential consequence of formal corrective action

UMHS Policy 04-06-047--Disruptive or Inappropriate Behavior by UMHS Personnel

The policy also provides:

Definitions Examples of Appropriate and Inappropriate Conduct Policy Standards Procedures General Guidelines, including related policies Exhibits

A. guidelines for reaction in the momentB. reporting formC. reporting process flowchart

References used in creating the policy

Conduct

Appropriate Conduct Demonstrates clear,

direct, honest and respectful communication

Accepts and provides feedback in a constructive and civil manner

Appropriate Conduct Demonstrates clear,

direct, honest and respectful communication

Accepts and provides feedback in a constructive and civil manner

Inappropriate Conduct Threatening or abusive

language (e.g. belittling, berating, screaming . . .)

Derogatory comments (as opposed to constructive criticism) about the quality of care being provided by the Health System . . .

Inappropriate Conduct Threatening or abusive

language (e.g. belittling, berating, screaming . . .)

Derogatory comments (as opposed to constructive criticism) about the quality of care being provided by the Health System . . .

Excerpts from examples provided in UMHS Policy 04-06-047. See page 2 of policy

Exhibit A: Guidelines for Reacting in the Moment to Disruptive Behavior

1. Address the situation at the time it occurs

2. Redirect the focus onto the patient’s needs to depersonalize

3. Move the conflict away from patient areas—if needed closer to other staff

4. If you witness verbal abuse, signal to co-workers to act as a witness

5. If a violent act occurs (immediate assistance needed), contact a supervisor and dial 911

From Defusing Disruptive Behavior: A Workbook for Healthcare Leaders. Joint Commission on Accreditation of Healthcare Organizations Resources. 2007

Procedure Encourages reporting at department level

Strongly encourages individuals subjected to or witnessing disruptive behavior to report it

Requires the reporter’s supervisor to act:• Document • Resolve

May include involving the next administrative level and HR in the investigation/resolution

Reporting Options

Complete a Behavior Report Form or report verbally to the supervisor who will document the form • fax to Risk Management 734 763 5300 or on-line (in

development) Call the University Compliance Hotline

• at 866 990-0111 or • submit on-line to https://www.tnwinc.com/WebReport/

If a violent act occurs or immediate assistance is needed, contact a supervisor or dial 911

Behavior Report Form

Strongly Encouraged to Report!

1) Print Page in Policy (Exhibit B) & Fax to Risk Management

- or -

2) Online submissionPer

son r

epor

ting

Employee/S

taff Behavio

r

Anonymous

option

Behavior Form Follow Through

1) Risk Management forwards online reports to appropriate department

2) Per Disruptive Behavior policy, the reporter’s supervisor follows up:

a) Resolves with his/her own department b) Relays report to disruptive person’s supervisor

3) Per departmental policy, appropriate action is determined at the local level

4) Data tracked through the RiskPro system. Reports produced by: a) Individual b) Department c) Unit/Division (Faxed forms are inputted by Risk Management)

Joint Commission Standard LD.03.01.01 Sentinel Event Alert #40 issued July 2008The alert cites a national survey on intimidation that says 40 % of clinicians have kept quiet or remained passive during incidents. “Most” have witnessed disruptive behavior.

JC Standard LD .03.01.01Leaders create and maintain a culture of safetyand quality throughout the [organization].

UMHS Policy 04-06-047— Disruptive or Inappropriate Behaviors by UMHS Personnel

Importance to Our Work Area

RESPECTRESPECT

Can I Avoid All Conflict? No. Conflict can not always be avoided. Conflict is a normal and can be a healthy part of

team interactions Conflict handled appropriately allows team

members to:• Share ideas• Voice concerns• Improve team relationships

Managing conflict in a respectful manner is key.

Key Considerations

We (our patients and our co-workers) are worth the investment• Intervention leads to insight which leads to changed

behavior.

The better the Patient Safety Culture, the better the Health System performance

Every health system employee has a role to play.

Leadership engagement and oversight critical. Report your concerns to me.

Questions??

Manager Resources The following slides are additional resources

for supervisor/manager for use in preparing for the presentation.

Resources (Place in Slide Show Mode and mouse over program name to view

resources for each area.)

HR EAP

SECURITYCOMPLIANCE

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In addition to exploring resources in your own area, the following sources provide some or all of the following: 

• Consultation•

Assessment• Intervention

• Training Programs• Referrals

Office of Clinical Affairs

Department Services, Books, VideosBooks & Articles Dutton, Jane. Energize Your Workplace: How To Create & Sustain high Quality Connections at Work.

San Francisco. Jossey-Bass. 2003. Farber, June. Smart Nursing: How to Create a Positive Work Environment that Empowers and Retains

Nurses . New York. Springer Series on Nursing Management and Leadership. 2005. Frederickson, Barbara. Positivity. Groundbreaking Research Reveals How to Embrace the Hidden

Strength of Positive Emotions, Overcome negativity and Thrive. New York. Crown. 2009. Tarkan, Laurie. “Arrogant, Abusive and Disruptive and a Doctor.” New York Times. December 2, 2008. Rosenstein, A.H., O’Daniel, M. “Managing Disruptive Physician Behavior: Impact on Staff Relationships

and Patient Care.” Neurology. 70. 2008. 1564-1570.

Videos—See Employee Resources-Audio/Visual Resource Inventory http://www.med.umich.edu/i/umhshr/avinventory.htm#Conflict

MANAGING CONFLICT VIDEOS Self-Discipline and Emotional Control:How to Stay Calm and Productive

Under Pressure, Volume 1 (Brief video description) Self-Discipline and Emotional Control:How to Stay Calm and Productive

Under Pressure, Volume 2 (Brief video description) Dealing With Conflict (Brief video description)19 Min Communicating Non-Defensively (Brief video description)20 Min Managing Stress (Brief video description)26 Min Dealing With Conflict and Confrontation, Volumes 1, 2, and 3 (Brief video description)

To aid in the clarity, examples of "appropriate" conduct, and "inappropriate or disruptive" conduct include, but are not limited to:

APPROPRIATE INAPPROPRIATE

Demonstrates clear, direct, honest and respectful communication •Responds to pages in a timely, civil manner •Responds to requests in a cooperative manner •Demonstrates respect for patients, their family members and staff •Clarifies points of agreement and seeks to partner to resolve points of disagreement in patient-care or other work-related matters •Accepts and provides feedback in a constructive and civil manner •Respects need for privacy •Handles problems or dilemmas in a cooperative, respectful manner •Chooses appropriate timing to bring up problems for discussion •Offers appreciation and affirmation to peers-coworkers when they function well •Accepts the inevitability of mistakes as a learning opportunity •Reliably demonstrates patient care in adherence to agreed-upon standards  

Threatening or abusive language – regardless of medium – directed at patients, their guests, or UMHS personnel (e.g., belittling, berating, screaming and/or non-constructive criticism that intimidates, undermines confidence, or implies incompetence); •Threatening or abusive behavior (e.g. throwing items, slamming doors); •Degrading or demeaning comments or nonverbal communication regarding patients or their guests, UMHS personnel, or the Health System •Profanity or similarly offensive language while on Health System sites and/or while speaking with  UMHS patients, their guests or personnel; •Physical contact with another individual that is or appears threatening or intimidating; •Derogatory comments (as opposed to constructive criticism) about the quality of care being provided by the Health System, a medical staff member, or any other individual outside of appropriate medical staff and/or administrative channels; •Medical record entries impugning the quality of care being provided by the Health System, medical staff members or any other individual;  •Imposing unreasonable requirements on fellow UMHS personnel; •Refusal to abide by University of Michigan Policies, including UMHHC Medical Staff Bylaws, U-M Medical School Bylaws, Practices, Agreements and Policies (e.g. Hand Hygiene and Smoke-Free Environment).

From U-M Health System Policies and Procedures UMHS Policy 04-06-047, Disruptive or Inappropriate Behavior by UMHS Personnel Section IV. Examples of Conduct

Frequently Asked Questions Can I avoid all conflict? What if I am afraid to report because I fear

retaliation? What resources are available to me if I want more

skills in handling difficult situations—so that my behavior is not viewed as inappropriate?

My teammates always yell at each—that’s how we get our work done. That’s okay, right?

What if the person I want to report is my supervisor or another manager?

Can I report a single occurrence of inappropriate or disruptive behavior?

Scenario ActivityPurpose: To practice effective ways of responding to offensive language and

behavior in conjunction with Exhibit A of the policy.

Exhibit A :Guidelines for Reacting in the Moment to Disruptive Behavior

Address the situation at the time it occurs Redirect the focus onto the patient’s needs to depersonalize Move the conflict away from patent areas – if needed closer to other staff If you witness verbal abuse, signal to co-workers to act as a witness If a violent act occurs (immediate assistance needed), contact a supervisor

and dial 911

Activity: In small groups discuss and then formulate a response to one of the 7

scenarios provided by responding to the questions at the end of the scenario. Be prepared to share your response with the larger group.

Debrief

Scenarios follow

Scenarios for Group DiscussionEnhancing a Culture of Quality, Safety & Respect: Addressing Disruptive Behavior

Scenario I: Two Managers

Scenario II: Outpatient Clinic Manager and Patient Assistant

Scenario III: Faculty – Nurse – Technical Staff

Scenarios for Group DiscussionEnhancing a Culture of Quality, Safety & Respect: Addressing Disruptive Behavior ~ cont’d

Scenario IV: Office Administrator and Environmental Services Staff

Scenario V: Faculty – Nurse

Scenario VI: Manager (Jane) & Outpatient Assistant (John)

Scenarios for Group DiscussionEnhancing a Culture of Quality, Safety & Respect: Addressing Disruptive Behavior ~ cont’d

Scenario VII: Physician and Nurse

Scenario VIII: Two office workers

Scenario IX: Allied Health Professional – Faculty

Resources

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Nursing Health & Safety Committee

Educational Services for Nursing

Educational Plans for Management of Aggressive Behavior

734-615-9721

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Resources

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UMHS Human Resource Services

Human Resource ConsultantsHuman Resources Organizational

Effectiveness ConsultantsMediations Services – Fernando Caetano

734 647 5538

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Compliance Office

Information: 734-615-4400

Compliance Questions or Concerns24 hour Compliance Hotline:

866-990-0111

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Resources

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Michigan Healthy Community Understanding U Website

Assistance in Managing the Ups / Downs of Life Featuring tools, strategies, tutorials and resources

http://hr.umich.edu/mhealthy/programs/mental_emotional/understandingu/

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Resources

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UMHS Employee Assistance Program

Supervisory, Staff and Team Consultations

763-5409

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Health System Security Services

Full 24-hour coverage

Emergencies: 911

Non Emergencies: 936-7890

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Heather Wurster – Policy Lead ,

Resource for Staff, and Medical School Point Person

Maureen Naszradi - Medical Staff Peer Review Coordinator 232 - 1687

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