Knowing when to pull the plug on a disruptive physician
One of the most difficult questions that a medical staff leader asks is, “When should we pull the plug on a disruptive or impaired medical staff colleague who has not responded to any of our efforts to help?”
Unfortunately, this question does not have a single answer; rather, it must be answered individually as it requires the medical staff to consider multiple factors. Medical staff leaders must have a sense as to whether the practitioner has the potential to improve and whether the organization should put in more time, effort, and resources to help an individual who may or may not wish to be helped.
The only short answer is that the medical staff must “pull the plug” when a physician commits an egregious act and there is no other reasonable option. What is egregious behavior? Typical examples may include:
- Statutory rape
- Obvious incompetence that leads to unexpected patient harm, often to multiple individuals
- Aggravated assault and battery
- Other behavior that places patients, employees, colleagues, and staff members in danger
Other than these rare events, there is a much better way than pulling the plug, and this is dealing with the performance issue head-on through our old friend the “performance pyramid.”
How is this done? One layer at a time as follows:
- Conduct thorough credentialing and privileging: When a performance issue is identified, only appoint or reappoint the physician contingent on the creation of an improvement plan between leadership and the practitioner. That plan should include:
- A clear statement of the performance issue
- What the practitioner commits to do to remedy the performance issue
- What leadership commits to do to support the physician
- Explicit positive and negative consequences based on a measurable outcome within a specific time frame, and an opportunity to revisit the performance issue in the near future.
- Set, communicate, and achieve buy-in to expectations: Have a frank discussion so that the practitioner understands the reasons why the performance issue is so important to leadership and what he or she can do to demonstrate his or her understanding (usually in writing).
- Contract to reinforce expectations: If there is a performance issue and the practitioner is under some form of contract (e.g., employment, personal services agreement, comanagement agreement, etc.), the terms of the performance expectations and improvement plan should be written directly in the contract with explicit positive and negative consequences.
- Measure performance against expectations: Create a measurable indicator with two targets (i.e., satisfactory and excellent) to objectively measure whether the practitioner and others are meeting the medical staff’s expectations around this specific performance issue and to what extent.
- Provide periodic feedback: Let the practitioner know how he or she is doing in a timely, objective, and meaningful way to enable optimum compliance and self-management.
- Manage poor and marginal performance: Take incrementally increasing steps to reduce variation from expectations, such as collegial intervention, voluntary improvement plan, mandatory improvement plan, and final warning.
- Take corrective action: Under the Health Care Quality Improvement Act of 1986, a healthcare entity will not lose its federal immunity if corrective action is taken for under 14 days unless the entity is in a state that requires mandatory reporting of all corrective action to the state licensing board (e.g., Oregon or New York). This is sometimes a drastic but effective action to let the practitioner know that the medical staff is serious about addressing a recalcitrant performance issue.
If the medical staff has gone through all of these steps to the best of its ability, when does it pull the plug? It depends on several factors, including the famous five questions by late Dick Hoerl, an admired and respected former clinical psychologist, hospital CEO, and organizational consultant:
- Does the person know they have a problem?
- Is he or she willing to take personal responsibility for the problem?
- Is he or she willing to change?
- Is he or she able to change?
- Will the “system” permit him or her to change?
What does the last question mean? Sometimes an individual is willing and able to change; however, there has been so much damage to others within the organization that the physician is unable or unwilling to forgive. Thus, that individual has to go somewhere else to start anew.
Dick used to say that if the answer to any of the five questions is unequivocally “no,” then the best thing leadership can do is to help orchestrate an individual’s exit from the organization. This might be in the form of voluntary outplacement (I often helped emergency physicians find other jobs that were a better fit for them). It might be gradual termination (e.g., near retirement or after planning a relocation). Or it might even be short term if the issues are particularly difficult and there is a lot of bad blood.
In the end, medical staff leadership must ask the question, “Should we continue to work with this individual, or is there a high likelihood that extending ourselves further will only damage the organization even more?” This is a tough question to ask oneself; however, sometimes it is the only question left to answer.
When to pull the plug? It depends. Listen to your head; listen to your heart; listen to your sixth sense. The majority of the time, you will act in the best interests of your staff, your patients, and even the practitioner in question who may be in irreconcilable conflict with him or herself.
Wishing you continued success.
Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, is a senior consultant at The Greeley Company, a division of HCPro, Inc., in Danvers, MA