Olympic hockey vs. the Stanley Cup: How rules drive behavior

I am currently entranced by the professional hockey Stanley Cup Finals, just as I was by the 2010 Olympic hockey games. I find it remarkable that many of the players who participated in both games behave so differently on the ice depending on the competition. In professional hockey, fighting is allowed (most would say encouraged). In Olympic hockey, fighting results in an automatic ejection.
The contrast between the Stanley Cup and the Olympics provides a clear example of how you can define your medical staff’s peer review culture regarding physician behavior. I am not suggesting that anyone encourage disruptive behavior for entertainment value, but like in professional hockey, medical staffs certainly enable it by not setting or enforcing a clear set of rules.

I believe that medical staff behavior issues are not entirely physicians’ faults. Although as a profession we have been slower than we should have been to address this issue, the desire of many well-meaning physician leaders has been undermined by management and the board’s lack of clear support.  However, I believe this trend is changing. I find many physician leaders today who desire to address inappropriate physician behavior by getting the support from administration and the board. To do so fairly, those leaders need to establish a clear set of rules in advance. The players who tried out for the Olympic team all knew the no-fighting rule before the first team practice; they didn’t find out about it minutes before the first game.

We need to remember our goal in addressing disruptive behavior is not to play “gotcha.” It is to move to change behavior for the future. Here are some steps to do so:
 

1. Define appropriate behavior as a physician competency defined by the Accreditation Council for Graduate Medical Education, the American Board of Medical Specialties, and the Joint Commission. Behavior falls under the categories of professionalism and communication and interpersonal skills.
2. Clearly articulate what the medical staff defines as inappropriate behavior. Most medical staff code of conduct policies define poor conduct as conduct that:
   • disrupts the operation of the hospital
   • affects the ability of others to do their jobs
   • creates a hostile work environment for hospital employees or medical staff members
   • interferes with an individual’s ability to practice competently
   • adversely affects the community’s confidence in the hospital’s ability to provide quality patient care.

   But you also need to clearly describe the inappropriate behaviors, such as:

   • Attacks—verbal or physical—leveled at other appointees to the medical staff, hospital personnel, patients or patients’ families that are personal, irrelevant, or beyond the bounds of appropriate, professional conduct
   • Impertinent and inappropriate comments or illustrations made in patient medical records, other official documents, or directly to patients that impugn the quality of care in the hospital or attack particular physicians, nurses, or hospital policies
   • Inappropriate comments leveled at the recipient with the intention to intimidate, undermine confidence, or belittle the individual 
   • Behavior in committee, department, or other medical staff or hospital affairs that is disrespectful, threatening, or otherwise unprofessional or inappropriate

   Disruptive conduct shall not include constructive concerns regarding patient care and the system of care that are communicated through appropriate channels in a good faith effort to improve the quality of care and services throughout the organization.

3. Clearly define how the medical staff validates the incidents of reported behavior in the least biased way. Although we must be fair to physicians, we also must recognize the potential that our own professional biases might lead us to dismiss real concerns. Include a non-physician investigator in the medical staff’s validation process, such as a risk manager, and use a physician leadership group rather than the department chair alone to make final determinations regarding the validity of incidents.
4. Determine how the medical staff can identify and quantify less egregious incidents to detect patterns of behavior that need to be addressed before they get out of control. Use rule indicators to educate individual physicians regarding the code of conduct after each incident via a rule letter. Also use a tracking system to determine when the number of incidents exceeds the medical staff’s defined target and requires further action. Typical targets are two to three incidents during a 12-month period. 
5. Clearly define how the medical staff will address both individual incidents and patterns of inappropriate behavior and hold physician leaders accountable. This is done through a series of well-defined, documented progressive interventions. This process is described on the Greeley Company’s White Paper, Managing Disruptive Behavior: Balancing Patient Safety with the Rights and Dignity of Physicians.

The no-fighting rule in Olympic hockey would be of no value if the referees didn’t enforce it.  But if hockey players can change their behavior by changing the rules and enforcing them, so can physicians.
 

Robert Marder, MD, CMSL, is vice president of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.