Prevention is key when dealing with disruptive physicians

Confronting and controlling disruptive behavior is one of the most challenging problems for
administrators. In the May issue of MGMA Connection magazine, we addressed three steps administrators can take to protect their practices from disruptive physicians causing irreparable damage. In this issue, we tackle prevention. 

A comprehensive code of conduct

Bad behavior can have a profound effect on the reputation of a group as well as on the economic success of a practice.

“The failure of a group to deal with a disruptive physician can bring liability to the entire practice,” explains Stephen Dickens, JD, FACMPE, past MGMA Board chair, senior consultant, Organizational Dynamics, SVMIC, Nashville, Tenn. “Consider the distressed physician with poor communication skills who is ultimately sued by a patient. The entire group is going to be named in the lawsuit. A truly distressed physician may even have employees willing to testify against him/her. At the very least, this physician will likely have higher employee turnover. Not only will this cost the entire practice in terms of dollars, but a constant influx of new employees creates patient experience issues and presents more risk opportunities as these new employees become accustomed to new policies and procedures.”

Set clear expectations

Because the conduct of every physician is a reflection of the entire group, your practice should have a document that describes standards of conduct expected of the physicians in your practice. Developing a code of conduct is an important first step to establish expectations and hold physicians accountable to their patients, the practice and each other. The code should address topics such as professionalism; leadership; teamwork; confidentiality; conflicts of interest; accountability to other practice members; obligations to the hospital; and respect for colleagues, staff and patients. It should also define unacceptable, disruptive and inappropriate behavior and give examples.

Involve all of the physicians in the implementation process to get the widest range of viewpoints. You might find that the perspective expressed by tenured physicians will be different from the values and ideas expressed by associates, who have recently completed a residency program. Similarly, physicians who have practiced with other groups can give practical guidance as to what works, what doesn’t and why. 

Buy-in

Input leads to buy-in from physicians, which is important when you are trying to change behavior and improve practice culture. In our experience, if all physicians in the group have the opportunity to weigh in on the content of the code of conduct, they are more likely to follow it themselves and encourage others to comply.

Consider appointing a committee to draft the code to present to the group for consideration or ask the practice’s attorney to prepare a first draft for review. Once a draft is circulated, give the group time to review, analyze and offer suggested changes. Scheduling one or more dinner discussions or a Saturday retreat can help you focus the group on adopting an effective document. Meeting outside the clinic or office helps everyone concentrate on the topic without interruptions and distractions. 

When discussing the content of the draft code, work toward a consensus and vote on contested issues. Brainstorm what types of behavior and conduct affect patient care, interpersonal relationships and practice reputation, and incorporate that information into your draft code. 

Next, ask an attorney to review the draft. The outcome of this entire process should be the adoption of a finalized code that provides a comprehensive set of guiding principles that all members of the practice will respect. 

Compliance

If your practice has a code of conduct and you are still having problems with disruptive behavior, analyze why the code is being ignored and consider these questions:

• When was the last time you discussed your code of conduct document? 
• When was the last time its terms were applied to a difficult behavioral situation? 
• Do you discuss the importance of your code and review its terms with new physicians? 

It might be time to review and analyze your practice’s code by applying the following steps:

• Distribute a copy.
• Schedule time to discuss it.
• Evaluate its effectiveness.
• Make necessary revisions.

Every member of the group should be familiar with its contents and understand the importance of consistent compliance.

Involving all of your physicians in the review and revision process will reinforce the importance of the code of conduct. It will also highlight the damage caused by allowing bad behavior to go unchecked. Intimidating and disruptive behaviors can foster medical errors; contribute to poor patient satisfaction and preventable adverse outcomes; increase the cost of care; and cause qualified clinicians, administrators and managers to seek new positions in different environments. You might elect to have your practice attorney provide information to raise awareness about how a colleague’s disruptive behavior can adversely affect every member of the group. 

No excuses

The document should make it clear that one physician’s conduct affects the entire group and that no physician should ignore, excuse or condone disruptive behavior. Once you raise awareness, peer pressure can be a subtle but effective tool to modify behavior. When physicians are aware of the importance of adhering to the terms of the code of conduct, they are more likely to confront their disruptive colleagues and remind them that disruptive behavior is a violation of the code and that the conduct is unacceptable.  

Sometimes peer pressure is not enough to manage a difficult physician who engages in disruptive behavior and shows no willingness to modify behavior to comport with the code. If the practice has allowed disruptive behavior to go unchecked, you might need to take additional steps to rein in those who are not willing to comply with the standards of behavior outlined in the code: 

The practice should implement disciplinary policies and procedures, describing the consequences for failing to adhere to the code.  

• There should be clear guidelines for imposing discipline. The group should apply the disciplinary policy consistently and without favored treatment for some physicians over others.
• As part of that disciplinary policy, the practice should consider adopting a “zero tolerance” policy for conduct involving violence, harassment or dishonesty.

The practice should also consider adding a provision to future employment agreements, making it clear that violations of the code of conduct may be considered a breach of a physician’s employment contract and could result in termination.  

Involve the practice’s employment counsel in making changes to employment contracts and in drafting the disciplinary policies and procedures.

Confrontation

While preventive measures are best, the question of how you deal with problems caused by disruptive physicians is ever-present. Administrators must maintain good working relationships with everyone, including disruptive physicians, which is why they need to remain above the fray. The other part of the issue is that some behavior and conflict situations are sensitive and don’t lend themselves to intervention by an administrator or a disciplinary committee. For example:

• A physician in your group simply does not have the necessary social skills to handle many situations appropriately. He or she needs coaching on the basics of getting along with colleagues and communicating effectively with staff and patients.
• Two or more physicians in the practice are chronically at war with each other, and the lack of trust and respect has affected the staff and physicians’ ability to work together effectively.
• A physician has a chip on her shoulder and feels personally wronged by every action taken by the administrator and governing board. Any comments made about her performance or behavior intensify her belief that the group is unfairly targeting her.
• Two physicians in the group have been accused of engaging in conduct that could be construed as unlawful discrimination, harassment or retaliation against staff members and other physicians. This behavior, if allowed to continue, will result in complaints filed with the hospital or Equal Employment Opportunity Commission. Neither the administrator nor members of the board have the expertise to effectively address the legal issues surrounding the offensive behavior.
• A top-producing senior physician continues to engage in abusive, disruptive behavior and intimidates those who attempt to address the problem.  

In these cases, consider a neutral third party who can address the problem appropriately and confidentially without directly involving other physicians in the group. Someone with conflict-resolution experience and an understanding of applicable legal issues can help resolve difficult interpersonal issues while allowing an administrator to remain neutral. Some of the many effective techniques that can be used to tackle the problem include:

• Group meetings about a sensitive topic or implementing new policies and procedures.
• One-on-one counseling with a disruptive physician, conducted confidentially, respectfully and with potential legal issues in mind.
• Conflict resolution workshops to address specific problems a group is having and help implement changes by building consensus. 
• Small group meetings with individuals to resolve ongoing disputes and personality conflicts that have led to problem behavior.
• Educational seminars on issues such as prevention of workplace harassment, discrimination, retaliation and violence. Training should also be provided to the management staff and governing board on how to handle conflict, conduct internal investigations and enforce policies that reduce chronic behavior problems.

Ridding a practice of disruptive behavior is a daunting task but well worth the effort. Respectful treatment of colleagues and employees leads to harmonious working relationships that foster teamwork, result in better financial outcomes and reduce the risk of employment-related suits and claims.