Cases & Commentaries

Difficult Encounters: A CMO and CNO Respond

Spotlight Case
Commentary By Ernest J. Ring, MD; Jane E. Hirsch, RN, MS

Case Objectives

  • Appreciate the risk of disruptive
    behavior and understand institutional response to such
    behavior.
  • Describe characteristics of a culture
    that encourages open communication, respect, and opportunities for
    interprofessional learning and teamwork.

The Case

 

An 89-year-old man was
admitted to the orthopedic service after sustaining a hip fracture.
The patient's family physician requested a cardiology evaluation.
Surgery was delayed while the consultant evaluated the patient. The
cardiologist identified severe aortic stenosis (echocardiogram
showed an aortic valve area of 0.9 cm2) and recommended
that the patient not go to surgery. On the late afternoon following
the cardiologist's report, the orthopedic resident called the
operating room to schedule the patient for surgery later that
evening. The nurse on the floor paged the orthopedic resident and
read the cardiologist's conclusions and recommendations over the
phone. The resident came to the floor, told the nurse that she was
"stupid" and confidently explained that the case would be done
under spinal anesthesia, so the cardiologist's concerns were
nothing to worry about.

Spinal anesthesia can cause unexpected and sudden
hypotension resulting in hypoperfusion of the coronary arteries and
sudden death. At 7:00 PM, the nurse called the hospital's Chief
Medical Officer (CMO), who was getting ready to leave for the day.
The CMO promptly paged the orthopedic resident, who was meeting
with the attending orthopedic surgeon to review x-rays of the case.
The CMO went to the x-ray department and talked with two residents
and the attending. The CMO patiently explained the risk of
perioperative death associated with hypotension in the presence of
severe aortic stenosis. The attending then called the operating
room to cancel the case. The following day, the CMO reviewed the
nurse's intervention with the Chief Nursing Officer (CNO).

Two days later, the patient suddenly arrested on
the floor. Resuscitation efforts were unsuccessful.

The Commentary: Part 1

Commentary by Ernest J. Ring,
MD, former Chief Medical Officer, UCSF Medical
Center

This incident highlights the problem of
unprofessional physician behavior and the increasing recognition
that caregiver incivility can directly jeopardize patient safety.
In this case, a resident was rude and disrespectful to a nurse for
pointing out a consulting cardiologist's concern about a patient's
high risk for surgery. The resident responded by demeaning the
nurse. Furthermore, he ignored her warning, moving ahead to
schedule the surgery. This prompted the nurse to take immediate
action by contacting the CMO and asking him to intervene and stop
the surgery.

The CMO's most important responsibility is
protecting patient safety. Had I been the CMO in this case, I would
have quickly evaluated the clinical facts and confirmed that
immediate cancellation of the hip surgery was warranted. It's
highly unusual for a CMO to be asked to second-guess a surgeon's
clinical judgment in matters directly related to the surgeon's
specialty expertise. If the nature of the operation had been the
issue, I would have sought the opinion of the Chief of Orthopedic
Surgery. However, in this case the concern was about the risk of
spinal anesthesia, so I would have met with the attending
anesthesiologist to review the cardiologist's findings. If the
anesthesiologist agreed that the patient's condition was so poor
that he would not tolerate the anesthesia, we would have gone
together to confer with the orthopedic surgeon and cancel the
operation.

Once the immediate safety issue was resolved, I
would have handled the complaint about the resident's behavior
toward the nurse in the same manner I investigated all
unprofessional behavior incident reports involving
physicians—interview any witnesses and try to understand both
sides of the story, including that of the physician. Typically,
when a complaint involves a resident's behavior at a "name-calling"
level, I would refer the matter to the resident's training program
director. As with most training hospitals, residents are not
credentialed by the medical center and their behavior is not
tracked by our Medical Staff Office. Instead, the residency program
director and department chair have direct authority over the
residents and maintain records of their performance in each of the
hospitals in which they rotate. They would therefore be in the best
position to know whether this incident was an isolated event or
part of a more worrisome pattern of unprofessional behavior.

Both our medical center and University have
written codes of conduct concerning intimidating or disruptive
behavior. Clearly, acts involving physical contact, throwing
equipment, or the use of very threatening language are never
tolerated and have to be dealt with at the highest leadership
level. If this resident's behavior had been that serious, I would
have met with him along with his program director and department
chair and likely the Associate Dean for Graduate Medical Education.
Depending on the history of previous complaints about this
resident, the actions taken could range from referral to an anger
management program to immediate dismissal from the residency. If
this was a first complaint, I would ask the department leadership
to take the lead and counsel him about the importance of good
communication and a collaborative work environment for safe and
high-quality patient care. I would also expect them to warn him
that insulting behavior toward nurses or any other hospital staff
is never acceptable and that any further complaints about his
behavior could jeopardize his status in the residency program.
Finally, I would require that he apologize to the nurse.

Our medical center expects no less civility in
the behavior of attending physicians than from our residents.
Surely, the more authoritative position of an attending physician,
especially a senior faculty member, creates a much more threatening
power perception, and the impact of any improper attending behavior
on the health care team would be substantially greater. As CMO, I
responded to every complaint I received about unprofessional
attending physician behavior. My first step was to send an email to
the person who reported the incident, thanking them for taking the
time to submit the report and assuring them that I would follow up.
I would then arrange for the physician-subject of the complaint to
come to my office to discuss his or her perception of the events
surrounding the incident. Interestingly, when I met with physicians
to discuss an incident, they virtually always wanted to focus first
on whatever underlying issue triggered their behavior. I would
always patiently hear them out but explain that things cannot
always go perfectly in a complex medical center environment. No
matter what prompted it, I'd add, their reaction was inappropriate
and they must find a better way to deal with their frustrations in
the future. I would also inform them that a letter describing their
behavior was going to be placed in their credentials file with a
copy to the chairman of their department.

The great difference between enforcing rules on
faculty behavior compared with incidents involving residents is the
limited authority that CMOs and hospitals have over attending
physicians. As mentioned previously, resident behavior can be
addressed at the department level in multiple ways, up to and
including discharge from the program. Governance over attending
physician behavior is much more complicated. Attending physicians
are credentialed members of the Medical Staff and are governed by
the Medical Staff bylaws, which provide them numerous rights and
extensive due process guarantees. The medical center leadership,
including the CMO, can summarily restrict or suspend privileges "to
protect the life of any patient or to reduce the likelihood of
imminent danger to the health or safety of any individual," but
physician behavior is only rarely threatening enough to warrant
this action. Summary suspensions are also time limited and must be
rapidly ratified by a senior governance body, in our case the
Executive Medical Board.

More commonly, the problem is an ongoing pattern
of unprofessional behavior that continues despite counseling by the
department chair or CMO. When this occurs, implementing corrective
action is very difficult and time consuming and must follow a
highly proscribed legal process. I'll describe the process at UCSF
Medical Center—although the process may vary in a few of its
details from hospital to hospital or state to state, in my
experience, the overall flavor is similar. First, a written request
must be submitted to the President of the Medical Staff. The
President then appoints an ad hoc committee of the Medical Staff to
investigate the allegations. They meet several times to interview
individuals who have direct knowledge of the physician's behavior
and talk to the physician-subject of the investigation. When they
have completed their investigation, the committee chair makes a
presentation to the Executive Medical Board with the committee's
findings and any recommendations on appropriate actions. The
subject of the investigation is invited to provide a written
response and may attend the Executive Medical Board meeting when
the ad hoc report is presented.

The Executive Medical Board then deliberates to
decide whether the physician's actions warrant a reduction,
modification, or suspension of clinical privileges. If so, the
physician is still allowed to maintain full privileges until a
"fair hearing" is held. The fair hearing panel is appointed by the
President of the Medical Staff and can only include individuals not
involved with the Executive Medical Board or the ad hoc committee.
The physician is allowed to have legal representation. If the fair
hearing panel agrees with the Executive Medical Board decision, a
corrective action can finally be taken.

During my tenure as CMO, we went through this
process on several occasions with several different physicians.
Each time, the ad hoc committee meetings were difficult to schedule
because of committee members' busy schedules, so the process took
many months—nearly 2 years in one case. The committees and
the Executive Medical Board tended toward conflict avoidance and
often recommended the physician be given another chance and not
have privileges limited unless he or she "did it" one more time. In
the few cases in which the Executive Medical Board recommended
termination or limitation of privileges, the physician resigned
from the medical staff before a fair hearing could be
completed.

It seems very clear to me that in order for a
medical center to oversee disruptive physician behavior, there must
be a series of punishments available that actually fit the crimes.
Currently, the only punishments we have at hand are too severe and
cumbersome to be applied, except in the most extreme situations.
This leaves the medical center legally responsible for protecting
its employees from a hostile work environment (and its patients
from problem physicians) without adequate control over the
physician staff. Fortunately, almost all the physicians on our
medical staff are dedicated clinicians and scientists and are never
the subject of behavior complaints. That allows the CMO and the
Executive Medical Board the time to keep after the few who seem to
cause all the trouble.

The Commentary: Part 2

Commentary by Jane E. Hirsch,
RN, MS, former Chief Nursing Officer, UCSF Medical
Center

Although efforts to improve relationships among
health care professionals have been underway for many years, the
patient safety movement has given them greater urgency. It is clear
that teamwork, communication, and collaboration enhance patient
safety and quality. Yet patterns of disrespectful, disruptive, or
hostile behavior remain significant issues in health care, leading
to increased medical errors and sentinel events. On July 9, 2008,
The Joint Commission issued a Sentinel Event Alert stating that
"intimidating and disruptive behaviors can foster medical errors,
contribute to poor and preventable adverse outcomes, [and] increase
the cost of care...."(1)

Because of these concerns, The Joint Commission
developed a leadership standard (LD.03.01.01) that now requires
hospitals to address disruptive and inappropriate behaviors and to
develop a comprehensive approach for managing unacceptable
behavior.

This case highlights the type of adverse event
that can occur as a result of unprofessional communication and poor
teamwork. From the beginning, it would have helped had the
cardiologist communicated his or her conclusions directly to either
the orthopedic resident or attending, rather than leaving written
recommendations that the nurse had to read over the phone to the
resident. Questions regarding this patient's risk of perioperative
death could have been discussed at this time. When the resident
called the nurse "stupid," an immediate breakdown in respect,
communication, and trust occurred. It is well documented that
intimidating, hostile behavior can lead to conflict avoidance,
silence, or poor morale that can have a devastating effect on
patient safety—particularly if a caregiver, in this case a
nurse, decides not to challenge the behavior.(2)

In this scenario, the nurse decided,
appropriately, to speak up, and contacted the CMO after the
conversation with the orthopedic resident. Although it appears that
the nurse "jumped" several levels in the chain of command and
communication, she is to be commended for ensuring that the
cardiologist's recommendations were reviewed further and that the
patient be prevented from having surgery that evening.
Impressively, the CMO acted promptly, by calling the resident and
physically going to the radiology department to meet with the
resident and attending. (It was also fortunate that the CMO was
knowledgeable about the risks of spinal anesthesia in patients with
severe aortic stenosis, since apparently the orthopedic attending
was unaware of this.) However, it is not clear whether the CMO also
addressed the resident's inappropriate comment to the nurse at that
time; it would be important for the orthopedic attending to be made
aware of the resident's behavior. Since the CMO and CNO reviewed
the nurse's intervention the following day, it would be appropriate
if both chain of command communication and the resident's
disrespectful comment were discussed and handled.

Development of a culture that
encourages open communication, trust, and respectful behavior, even
when it involves challenging or questioning a colleague, is
critical. There is evidence that interpersonal dynamics within
teams are key contributors to good outcomes and decreased patient
care errors.(3)
Promoting behaviors that facilitate effective interpersonal
interactions among health professionals can help improve safety at
a foundational level. Organizations that aspire to create cultures
of safety must address the pervasive behavioral patterns that
undermine effective communication and team performance.(2) The
CNO and CMO are important purveyors of this message, and by
role-modeling professional collaborative behavior, problem-solving,
and strong teamwork, the two can create a productive collegial
relationship and culture that set the tone for the other health
care professionals within the organization.

Development of a culture such as
this, however, requires more than role-modeling. There must be an
organizational commitment to skills training in conflict
resolution, opportunities for interprofessional learning and
teamwork, and an emphasis on conflict engagement, which is learning
to deal with conflict constructively and accepting the challenges
of addressing conflict with an understanding that resolution may
not be possible (4), so
that safe patient care is supported and enhanced. The CNO must
ensure that nursing staff are adequately prepared, encouraged, and
commended when patient care questions are brought forward. Nurses
who are intimidated or feel that they lack the skills to intervene
or question a situation are unlikely to handle conflict in the most
optimal way. This makes it important to emphasize that appropriate
conflict engagement, communication, and teamwork have a major
impact on patient safety and that these are expected competencies.
Educational interventions, preferably via interprofessional
training, may be needed to enhance these skills. Examples of these
educational offerings might include Conflict Management/Engagement,
Engaging in Collaborative Practice, Difficult Conversations, and
Teamwork and Decision-Making.

Early in my career, as a staff
nurse, I was comfortable questioning physicians, nurses, or
administrators about decisions that I thought might compromise
quality of care or patient safety. When I became CNO and had a
broader view of care across an entire institution—even in a
place with as many excellent people as UCSF—I was surprised
by the degree and depth of unprofessional, disrespectful, and
intimidating behavior among professional colleagues. Just as the
staff nurse needs to learn to speak up to defend patient safety, so
too does the effective nurse administrator, and this tone is set by
the CNO. I came to rapidly appreciate the importance of early
intervention, appropriate conflict engagement, and teamwork in
addressing these critical issues. I also learned that this work
depended on having strong collaboration with physician leaders and
so I was most fortunate to have an excellent relationship with a
wonderful CMO!

The Commentary: Part 3

Dr. Ring
responds:

It seems to me that our medical
center's culture has evolved considerably over the past few years.
Today, it is much less likely that a patient would be harmed by the
kind of events described in this scenario. Safety and quality
innovations that were incorporated into our daily hospital
operations (eg, rapid response teams, time outs, and intra-service
handoff protocols, to name a few) have not only improved caregiver
communication but also led to increased appreciation of the value
of interdisciplinary teamwork. Teamwork training
programs—which brought together physicians, nurses,
pharmacists, and other staff from high-risk environments such as
the operating rooms and medicine wards—gave providers a clear
message that anyone suspecting that a patient is in jeopardy for
any reason has an obligation to bring their concern to the
attention of the nursing leadership, an attending physician, a
department chair, or, as in this case, even to the
CMO.

I fully realize that the kind of
rude behavior displayed by the resident in this case still occurs
sometimes—even in our medical center—but it is clearly
happening much less often. Our clinical departments are now
required by The Joint Commission and the ACGME to regularly
evaluate both their attending physicians and residents for
competencies including professionalism and interpersonal and
communication skills. In my experience, department chairs take
incident reports and complaints about their faculty and residents
very seriously and generally act on them. Moreover, the word is out
that physicians are being held accountable for inappropriate
behavior and that even senior faculty have lost clinical
privileges. Unfortunately, our governance mechanisms for dealing
with problem physicians remain very cumbersome. They leave us with
too few alternatives for remediation, which means that legal
counsel still has to oversee every step for anything more serious
than a reprimand.

Ms. Hirsch
responds:

Dr. Ring's remarks describe his
commitment, as CMO, to handling issues of unprofessional conduct
with physicians. I respect his view that patient safety is a CMO's
first responsibility, and his description of how he would have
handled this particular situation is thoughtful and comprehensive.
He has also identified that there is increasing recognition that
incivility, especially interprofessional disrespect, can directly
jeopardize patient safety. I am particularly pleased that he would
contact the individual reporting a complaint against a physician,
assuring them that there would be follow up. Often, individuals
feel that their complaints fall into a black hole, are not taken
seriously, or will not be addressed because of the "power
perception" that he mentions
.

Notwithstanding Dr. Ring's
leadership, there is clearly a perception in our institution that
there is a double standard in this area: employees (particularly
nurses) can be disciplined and terminated for problematic behavior,
but the perception is that such behavior by physicians is often
tolerated.

Dr. Ring's commentary highlights
the difficulty in addressing unprofessional conduct issues with
medical staff, including house staff. Medical centers often have
limited authority over house staff and attending physicians and
must utilize lengthy and cumbersome Medical Staff processes to
effectively address these issues. While Medical Staff bylaws are
designed to protect medical staff, their "numerous rights and
extensive due process guarantees" mean that implementing corrective
action is extraordinarily time-consuming and cumbersome and often
results in no action being taken, even in cases of problematic
patterns of behavior. Not only is the lack of action a problem for
other caregivers and patients who interact with the physician in
question, but in a teaching setting, attending physicians'
unchecked unprofessional behavior can serve as a negative
role-model for junior physicians and house staff—the
perception spreads that disruptive, disrespectful behavior is
acceptable.

I wholeheartedly agree with Dr.
Ring's comment that the Executive Medical Board at our facility has
tended toward conflict avoidance, often recommending that problem
physicians be given yet one more chance; I suspect this is true in
most institutions. I appreciate that the leadership of individuals
like Dr. Ring is increasing the chances of prompt and direct action
in cases of unprofessional conduct, but in my view, this is
happening far too slowly. As Dr. Ring says, fortunately most
physicians are dedicated clinicians, as are most health care
professionals, but the potential impact on patient safety and staff
satisfaction caused by problematic individuals is significant. It
seems time for CNOs and CMOs to work together to ensure that their
health care institutions develop timely and thorough processes to
adequately address disrespectful, disruptive behavior by physicians
as well as by other providers.

Ernest J. Ring,
MD

Professor Emeritus, Department
of Radiology

University of California,
San Francisco

Jane E. Hirsch,
RN, MS

Clinical
Professor

Director, Nursing & Health
Systems Leadership (Administration) Masters Specialty
Area

UCSF School of
Nursing

Faculty
Disclosure:
Dr. Ring and Ms. Hirsch have declared that
neither they, nor any immediate member of their families, have a
financial arrangement or other relationship with the manufacturers
of any commercial products discussed in this continuing medical
education activity. In addition, his commentary does not include
information regarding investigational or off-label use of
pharmaceutical products or medical
devices
.

References

1. The Joint Commission. Behaviors that undermine
a culture of safety. Sentinel Event Alert. July 9, 2008. [Available at]

2. Gerardi D, Forse A. Conflict
Engagement—An Essential Competency for Addressing Behaviors
that Undermine Safe Patient Care and Contribute to Unhealthy Work
Environments, unpublished manuscript.

3. Keeping Patients Safe: Transforming the Work
Environment of Nurses, Institute of Medicine. Washington, DC:
National Academies Press; 2004. ISBN: 9780309090674. [Available at]

4. Mayer B. Beyond Neutrality: Confronting the
Crisis in Conflict Resolution. San Francisco, CA: Jossey-Bass;
2004. ISBN: 9780787968069.