Evidence shows that the vast majority of clinicians perform professionally most of the time. However the small number of outliers can cost your organisation significantly. Cognitive Institute’s Associate Medical Director Dr Stephen Walker explains.
Unprofessional behaviour in healthcare institutions leads to preventable adverse events, errors, safety and quality compromises and increased patient mortality (1). These behaviours, therefore, have a significant impact on the organisations in which they occur, from both the perspective of delivering safe patient care, and also financially. While we know that the overwhelming majority of those working in healthcare are driven both individually and collectively towards excellence in technical skill, theoretical knowledge and behaviours, we also know that approximately 3% of doctors are responsible for almost half of patient complaints. Indeed, 1% of doctors are responsible for a quarter of these complaints. (2)
Of course, it is easy to assume that when we are referring to disruptive behaviour we are referring purely to doctors, however, Rosenstein (1) found that nurses were reported to have almost the same frequency of disruptive behaviour as physicians.
Clinicians who have been subject to previous complaints are also known to be at significant risk of future complaint or claim, with Bismark et al identifying a very clear correlation between the numbers of previously received complaints and the likelihood of another complaint being received within the next twelve months. (2) Numerous studies show us the impact this small number of clinicians can have on our safety and quality, as well as financial efficiency.
A recent study by Catron et al examined 66 surgeons and over 10,000 surgical procedures. It found that for patients classified as high risk pre-operatively there are a significantly higher number of post-operative complications and events in the patients of surgeons who receive a high number of complaints when directly compared to their colleagues who receive fewer complaints. The suggestion is that other clinicians’ individual and team performance is reduced when caring for these higher risk patients due to the association with the disruptive clinician. (3) This finding is consistent with other literature showing how individual and team performance is adversely affected in the presence of ‘bad apples’. (4)
Consistently, studies show that a minority of clinicians’ behaviour accounts for a disproportionately high number of patient complaints (2) (5), and with these complaints come significant organisational impacts. Research from many marketing studies shows us that if someone is pleased with a service they may tell a few, but if they are unhappy or disappointed the experience will be shared with between 10 – 20 other people. The risk to reputation can be significant.
Hickson et al (1994) showed a very direct link between patient complaints and legal suit over 20 years ago, and this finding has been consistent in later studies. Aside from the costs of legal processes, we are all aware of the administrative time and effort associated with reviewing and responding to patient complaints and impact it has in systems that are already very busy. (6)
In addition to the complaints and evidence of worse clinician outcomes for patients following from the behaviour of some clinicians, patients can actually withdraw from care and clinical follow up after bad experiences. The impact of this on the patients themselves and the costs transferred to other healthcare services that then need to take on their care — with all the inefficiencies incurred by the broken continuity of care — is near impossible to estimate.
Studies have shown a strong link between exposure to disruptive behaviour in the healthcare setting and reduced job satisfaction (7) and staff actually leaving a position. Rosenstein found that a third of nursing staff leave an organisation as a result of disruptive behaviour experienced. The same survey found that other staff took actions such as changing rosters or departments to avoid particular individuals. (1)
If we couple this information with the estimates of the costs to replace staff, we can uncover what is likely a hidden cost of disruptive behaviour. Province estimated that the cost of replacing a nurse is approximately double their salary, estimating that for a large academic institution such as Massachusetts General Hospital, this can account for approximately US$11 million per year. (8) Replacement costs for a nurse in Australia range widely but are estimated to be over AU$40,000 on average. (9)
Province’s 2010 study attempted to quantify the costs of disruptive physician behaviour to American hospitals, concluding that ‘the cost of retaining disruptive physicians is high’ and that ‘it is the team around the physician that the hospital cannot afford to lose’. (8)
Aside from the costs directly associated with replacing staff, if staff are repeatedly exposed to unprofessional behaviour that is not addressed, they can choose less formal ways to express their frustration and concern, including subtle but real criticism of the disruptive clinician. Consistently we have found that a very real driver for patient and families to pursue legal solutions following adverse events is, in fact, other staff who have made a negative comment or overtly expressed a negative opinion. (10) Staff dissatisfaction can be very costly.
Total cost considerations
Province estimated the cost per annum of allowing disruptive physician behaviour to continue in a typical academic medical centre in the United States to be approximately US$38,000 per physician per year. (8) This figure includes costs associated with nurse turnover, adverse outcomes, and costs associated with administration and management time. But we know the disruptive behaviour is not spread evenly across clinicians, so a few are costing us a lot.
Rawson et al found that for a typical 400 bed hospital, the total cost of managing disruptive behaviour over a campus per annum can be in excess of US$1million. (11) They argue that cost savings associated with dealing effectively with these behaviours can be invested in supporting academic activities leading to improved patient safety, reduced medical errors, and improved education frameworks.
With more and more evidence of the impact the behaviours of a few clinicians have on our patient care and indeed financial efficiency, the challenge is in how to deal with this behaviour. We should use the evidence that is accumulating to redefine the behaviours away from terms like ‘disruptive’ and ‘difficult’ to describing them as behaviour we know to undermine the culture of patient safety. Any behaviour we feel does not align with a culture of safety should be tackled. This includes overtly aggressive behaviour that we know impacts on other individual staff and team performance and directly impacts patient outcomes. It should also include passive behaviours such as non-adherence to standards of practice we know to improve patient safety (eg, checklists, bundles of care, huddles, handover, clinical record keeping etc,) and non-engagement with our safety and quality procedures.
The Promoting Professional Accountability model, developed by Vanderbilt University Medical Center in Nashville, Tennessee, and now available to Asia Pacific healthcare organisations through Cognitive Institute, provides healthcare organisations with a sustainable framework to develop a safe and reliable culture. It provides organisations with a tiered intervention model that complements existing HR practices to escalate individuals expressing ‘outlier’ behaviour up an intervention model to address unprofessional behaviours. The Vanderbilt University Medical Center researchers have published extensively on the success of their model and the central theme that the majority of professionals, whose behaviour is a risk to safety, will modify their behaviour if held accountable. The interventions need to be tiered, delivered by clinicians who are specifically trained in an organisation that is open in measuring and monitoring staff performance and has leadership steadfast commitment to ‘not blink’ when it comes to patient safety.
1. Rosenstein A, Nurse-physician relationships: impact on nurse satisfaction and retention, AJN 106(6); 26-34 (2002)
2. Bismark et al, Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia, BMJ Qual Saf 22:532-40 (2013)
3. Catron, Guillamondegui et al (2014, submitted for publication)
4. Felps W, Mitchell T, Byington E, How, when and why bad apples spoil the barrel: Negative group members and dysfunctional groups, Res Organ Behav, 27;175-222 (2006)
5. Hickson et al, Patient complaints and malpractice risk, JAMA, 287(22);2951-7 (2002)
6. Hickson et al, Obstetrician prior malpractice experience and patient satisfaction with care, JAMA, 272(20);1583-7 (1994)
7. Pejic AR. Verbal abuse: a problem for pediatric nurses. Pediatr Nurs 31;271–9 (2005)
8. Province W, The costs of disruptive physician behaviour, Harvard Business School (2010)
9. Roche et al, The rate and cost of nurse turnover in Australia, Aust J Nurs Pract, 21(2) (2014)
10. Hickson et al, Factors that prompted families to file malpractice claims following perinatal injuries, JAMA, 67;1359-63 (1992).
11. Rawson J, Thompson N, Sostre G, Deitte L, The cost of disruptive and unprofessional behaviors in health care, Acad Radiol, Sep;20(9):1074-6 (2013)