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Cultural Change: Address Disruptive Behavior and Improve Patient Outcome

Employee engagement, fiscal performance and clinical outcome drive the need to eliminate disruptive behavior; four approaches help create the culture to do so.


When a life hangs in the balance and those charged with saving it are under pressure, one can understand how tempers may flare, words might be exchanged, and manners fall by the wayside. But these behaviors—or even worse ones—are observed frequently in health care settings. Even when no life is on the line. A whopping 97 percent of doctors and nurses who participated in a survey by the American College of Physician Executives reported experiencing them.

If demonstrated by even just a few associates in a health care setting, these disruptive behaviors lead to problems between staff that affect the quality of patient care overall. With these concerns in mind, The Joint Commission introduced leadership standards for all its accreditation programs in January of 2009. The Joint Commission also released 11 suggestions to help health care organizations address disruptive behaviors. Scrutinizing this list, one finds that many of the suggestions address not just the behaviors, but the very cultures of the organizations in which they are displayed.

The best way to drive out disruptive behaviors is by creating and sustaining a culture in which the norm is appropriate and productive behaviors. Making such an improvement has clear benefits in areas such as employee engagement, retention, fiscal performance, and of course, positive clinical outcomes for patients. In this article, we’ll discuss what’s driving the need to eliminate disruptive behaviors, and detail four approaches that create the culture to do so.

THE IMPERATIVES TO ELIMINATE DISRUPTIVE BEHAVIORS
It’s ironic that a profession that prides itself on treating patients with care, dignity and respect needs to worry about how its professionals treat each other. ‘Don’t’ lists read like the rules in a particularly aggressive kindergarten classroom, except that “don’t throw” is followed by “sharp objects across the ER at your coworker,” and disrespectful language covers vocabulary a little more sophisticated than what’s found in a typical five-year-old’s vernacular. The playground bully may grow up and bring his bad adolescent behaviors to work. And sadly, adult bullies are more skilled than kids at disguising bad behavior by using passiveaggressive methods . . . harder to observe, but potentially just as damaging.

The results of disruptive behaviors manifest in a number of measures and situations that health care organizations care deeply about:

  • They are reflected in patient satisfaction metrics, such as HCAHPS, which indicate patient loyalty and can influence reimbursements. Retaining patients and payfor- performance both affect an organization’s bottom line.
  • Disruptive behaviors are likely to increase turnover rates while decreasing engagement, as associates leave hostile colleagues behind to find more amiable work environments.
  • There’s no room in today’s health care environment for a lone operator because treating each patient is more of a team effort, and more complex, than it’s ever been. As patient care is handed off from, say, an emergency room, to intermediate care, to therapy or radiology, there are many points at which poor communication and an inability to work as part of a team threatens continuous quality care.
  • When The Joint Commission performed a root-cause analysis of sentinel events, 70 percent were attributed to communication failures. This is just one indication of how disruptive behaviors present a sizable legal liability for health care organizations.
  • Most importantly, these behaviors are reflected in patient safety statistics, as these behaviors contribute to mistakes that cost lives.

 

When patients and staff are choosing not to tolerate these behaviors, why are organizations accepting them? For all the reasons detailed above, health care organizations have no choice but to eliminate dysfunctional interpersonal interactions. To do this, they must redefine the corporate culture that has allowed these behaviors to exist. There are four areas that need to be addressed in order to accomplish this goal: defining the right behaviors, hiring right, developing excellent leaders, and holding everyone accountable for results using evaluation and measurement.

DEFINE THE DESIRED BEHAVIORS
Defining—and discouraging—disruptive behaviors will have little effect without other changes. A far more effective approach is to define appropriate behaviors, and hard wire them into the corporate culture. This is one of the key points made by Dr. Thomas Lee in an April 2010 article titled “Turning Doctors into Leaders” for Harvard Business Review. He advocates for systems that enable everyone to speak, as he says, “the same ‘language’—that is, to measure the same things in the same way. Otherwise it’s easy, and understandable, for resisters to challenge the validity of apparent differences. But once [care] providers believe that apples are being accurately compared with apples, peer pressure and other incentives will help spread best practices. ”

The best way to get everyone speaking the same language is to use competencies. Some that focus on appropriate behaviors include Engagement Readiness, Patient Focus, and Collaboration. For example, “Engagement Readiness” is defined by “demonstrating a willingness to actively commit to one’s work and to invest one’s time, talent, and best efforts to accomplish organizational goals.” Key actions that support this include:

  • Expressing a sense of loyalty and attachment to the organization.
  • Working collaboratively with others to establish and maintain positive work relationships.
  • Demonstrating resilience and flexibility in the face of obstacles.
  • Welcoming new learning opportunities.
  • Seeking opportunities to solve work problems and accomplish challenging work goals.
  • Approaching work challenges with a “can do” mind-set.

 

When these positive behaviors are formally encouraged and widely modeled by many associates, they lessen the opportunity for their colleagues to act inappropriately. It becomes unacceptable, even taboo.

HIRE RIGHT
The greatest opportunity to change is to hire or promote a different kind of person. When competencies that support appropriate behaviors are used as part of a selection process, organizations lessen the incidence of disruptive behaviors by hiring and promoting people who are less likely to display them. In DDI’s experience, we frequently uncover the signs of a weak selection system when talking to health care organizations about a need for leadership development. The caliber and motivation of the people being trained is often one of the barriers to the success of a leadership development initiative. No amount of training can address motivation or improve a bad attitude. These factors must be screened during the selection process.

Moving past technical skills to also evaluate personality attributes and motivational fit is a best practice. Using tests and behavioral interviewing questions during the selection process uncovers a candidate’s likelihood of exhibiting disruptive behaviors down the road. For example, a test used early in the selection process can evaluate a candidate’s tendency to be patient service oriented, to collaborate with others, and to prioritize safety in the work environment. Measuring motivational fit—or a candidate’s interest in performing the duties associated with a particular position—ties to engagement. Highly engaged associates are less likely to perform unprofessionally on the job. Promoting associates requires special consideration.

Especially in the health care field, the tendency is to reward those with the best technical skills. However, top performers need to balance clinical excellence with interpersonal excellence. It’s the interpersonal skills that enable an associate to navigate his or her workplace without displaying disruptive behaviors. Promoting physicians into leadership roles is of special concern. One small example of the issue is offered in an article that asks, “Are Your Docs Management Ready?” from Hospitals & Health Networks magazine. “Physicians don't delegate in the way that you think of managers delegating—they give orders,” says the article. Additional development is necessary to make an excellent physician into an excellent leader of others.

If you don’t change what you are looking for in new hires, the only people available to promote will be people with the ‘old culture’ mind-set—leaders who may tolerate, model, and propagate disruptive behaviors. Starting by hiring for key behaviors, like quality orientation or collaboration, opens the door to a selection system overhaul that will stick down the road and bring the caliber of employee needed for a positive culture. One final way to “hire right” is to start new hires off with a heavy focus on “inculturation.”

Many of the best places to work organizations spend the majority of onboarding time on culture, rather than administrative concerns. High quality on-boarding programs equip associates with a clear set of expectations around appropriate behavior. These programs offer new talent a strong start on the job.

DEVELOP THE RIGHT BEHAVIORS
Your leaders are the model of what behaviors your organization expects. When they demonstrate disruptive behaviors, their teams will too. Leadership development is among the recommendations made by The Joint Commission, and we agree. We frequently see leaders in health care settings facing considerable challenges, from a lack of formal training, learning from leaders who display disruptive behaviors, or a combination of both.

When built on competencies that encourage appropriate behaviors, a training and development program further supports a positive culture. Whether disruptive behaviors are hardly seen, or the issue is on the rise, training all associates in communication, customer service, and team-building skills will set the bar. Training offerings will differ by level, but the core skills are complementary and support a language based on desirable interpersonal skills among all associates. Leaders need to demonstrate the right behaviors, and training can help them understand how to be effective models. In a culture where disruptive behaviors are minimal, topic areas that address disruptive behaviors include building trust and using personal influence. When disruptive behaviors are already an identified problem and need to be extinguished, development for leaders might address skills such as conflict resolution, feedback, coaching, and managing performance problems.

At the executive level of leadership, if arrogance, bullying, and other derailers are an issue, an executive coaching intervention is a valuable tool. A one-on-one coach provides guidance for leaders to focus on very specific needs. It’s especially useful to help a top leader improve his or her ability to model and use appropriate behaviors.

DRIVE ACCOUNTABILITY THROUGH EVALUATION AND MEASUREMENT
What gets measured gets done, which is why individual accountability is key. In Dr. Lee’s article for Harvard Business Review, he provides an example where evaluation and measurement drove accountability and impressive results. Dr. Delos Cosgrove took the leadership reigns at the Cleveland Clinic in 2004. “If the clinic was committed to the idea of ‘patients first,’ he argued, it had to not only make a serious commitment to measuring patient outcomes but also demonstrate that commitment to the world.” Dr. Cosgrove made performance measurements publicly available for the first time. The bold step angered many physicians, but also changed behavior.

Accountability is a common recommendation, made by The Joint Commission and others. We find organizations know what they need to do, but struggle with how to do it. Weaving accountability for demonstrating appropriate behaviors into a leader’s performance plan is an effective way to drive change—and ensure those changes stick. These plans need to define what people are expected to do using clear objectives, while telling them how to do it using behavioral competencies. To cite a real example, nurse leaders are commonly charged with achieving good clinical outcomes. What they need to do to successfully meet this goal includes completing rounds, updating records, and ensuring smooth shift changes. Competencies that are important in how that is done include commitment to ensuring patient safety in their units, employee engagement, safety intervention, or building a successful team.

Employee engagement surveys can be customized to seek information about the incidence of disruptive behaviors. There are tools to evaluate individuals, as well. For example, a multirater (360) tool reaches out to an associate’s coworkers to collect data on how they use key competencies for their positions. When those competencies are linked to the desired behaviors, surveys can help organizations identify individuals who are hard to partner and work with. Development plans can help drive people to improve their abilities.

When these surveys are deployed to a large number of individuals, organizations often see a gap that is common to many individuals in the group. When gaps are uncovered across a number of people, it’s time to consider a more thorough approach that includes development tied to the appropriate behaviors.

CATALYZING THE CHANGE
Many organizations are “checking the box” when it comes to disruptive behaviors. They’re putting in a process, a definition, and a code of conduct to address them. But if they stop there, organizations will not succeed in eliminating disruptive behavior. The only enduring solution is culture change that makes sure these behaviors are unacceptable.

Culture change is daunting. Culture change in the midst of 24/7 crises where lives are on the line, even more so. A culture isn’t going to fix itself. And measurable, sustainable change takes a fair amount of time to achieve. The four main suggestions made here—define the desired behaviors, hire right, develop the right behaviors, and drive accountability—converge to accomplish this goal. With increased pressure to eliminate disruptive behaviors, organizations will make the improvements necessary to ensure they’ll survive and thrive in today’s market.

ABOUT THE AUTHORS
Debra Walker is vice president of DDI’s health care practice. Debra works with health care organizations and leaders to align talent strategies with business priorities. Contact her at debra.walker@ddiworld.com.

Janice Burns is a senior consultant for DDI’s Leadership Solutions and consults with clients on leadership curriculum development and implementation strategies. Contact her at janice.burns@ddiworld.com.