Disruptive behavior: How will you handle heavy admitters?

A disruptive physician who brings a large revenue stream to the hospital-through either direct admissions or referrals-pose one of  the biggest challenges faced by medical staff leaders. Such physicians may feel immune to the tactics typically employed in managing problem conduct. They are sure the hospital will not ultimately jeopardize the revenue they generate by taking action against their privileges. This certainty may be heightened in a hospital that has narrow margins or runs in the red.

And worse, staff may feel that this physician is untouchable, meaning whatever his or her behavior, nobody will do anything about it. Staff typically finds such a feeling demoralizing. In addition, there may be members of hospital management or the board who discourage action against a practitioner with disruptive behavior because of the potential economic effect. Medical staff members may also weigh in against corrective action if they feel they will lose significant referral business. It can be especially disheartening to medical staff leaders attempting to do "the right thing" and manage a disruptive colleague only to find themselves "sand-bagged" by those who elevate revenue generation above professionalism.

The best way to prepare for such circumstances is to anticipate them. In particular, there are two steps you should consider to avoid economic blackmail from problem physicians.

The first is to consider this issue when you initially develop a disruptive physician policy. When presenting a code of conduct for board approval, encourage discussion in which the board considers how it will handle such situations. Document the discussion in the meeting minutes to ensure there is no historical amnesia at a future date.

The second step is to start planning for revenue replacement at the first signs of disruptive behavior from a high-revenue-generating medical staff member. Even when early behavioral interventions are being undertaken, medical staff and hospital leaders should begin planning for the possibility this physician will not be responsive and may be asked to leave the staff. Such planning might involve the recruitment of additional physicians in a similar specialty, the identification and fostering of new sources of revenue generation to make up for lost business, conversations with payers, etc.

The financial impact of terminating the privileges of a high admitter is less scary if the scenario has been anticipated and appropriate preparations undertaken.