JCAHO standards help address disruptive physician behavior.

Author: Youssi, Michael D.


A medical staff’s ability to tackle the challenges of disruptive physician behavior may be related to its compliance with accreditation standards of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO).

A HOSPITAL’S MEDICAL staff is charged with assuring that patients receive quality medical care. But disruptive physician behavior can destabilize patient care at many levels. * At the governance level, it can trigger painful disciplinary action by the governing body. * At the physician level, it can strain referral, coverage, leadership and peer review activities. * For nurses, it can severely compromise nurse-physician communication, diminish morale and contribute to the nursing shortage. * For patients, the very quality of medical care we pledge to assure is threatened. * And for the disruptive physician, it can bring unwanted scrutiny, befuddlement, loss of stature and remorse. Standards set by the Joint Commission for Accreditation of Healthcare Organizations can help medical staffs deal with disruptive physician behavior in a fair, organized fashion. The standards impact medical staff bylaws and rules and regulations, executive committee structure and function, departmental leadership and the credentialing and performance improvement processes. Organization and bylaws standards These standards specify the mutual responsibilities and accountabilities that exist between the governing body and the medical staff on the one hand, and between the medical staff and its members on the other. Bylaws provide for the orderly conduct of medical staff business and empower the medical executive committee to act on the medical staffs behalf in bringing recommendations to the governing body. In matters of appointment to the medical staff and delineation of clinical privileges, the medical staff is accountable to the governing body. Importantly, the final credentialing decisions rest with the governing body. This, in effect, creates a firewall that clearly places responsibility for effectively dealing with disruptive physician behavior in the medical staffs lap. Should a physician’s disruptive behavior reflect a health problem, the JCAHO standards go further to require the medical staff to implement a process to identify and manage the individual physician’s health-related matters. In some cases disruptive behavior may be reasonably interpreted to require anger and/or stress management or formal behavioral counseling and monitoring. Medical executive committee standards The medical executive committee is accountable for recommending, for the governing body’s approval, six pivotal actions that help identify any physician with disruptive behavior: 1. Establishing mechanisms and criteria for reviewing credentials 2. Considering individuals for medical staff membership 3. Delineating clinical privileges 4. Ensuring participation of the medical staff in process improvement 5. Establishing ways for medical staff membership to be terminated 6. Creating a fair-hearing process These standards for accreditation empower the medical staff leadership to act on behalf of the governing body and the community to preserve the quality of patient care provided by credentialed physicians. Department chair leadership standards JCAHO standards require that the department director/chair is responsible for all clinical and administrative activities of the department and continuing surveillance of the professional performance of all department members. This gives the director/chair the opportunity to get to know the individual members of the department and become aware of any problems with disruptive behavior. Additionally, the department director/chair is responsible for recommending continued medical staff membership for each member of the department. This responsibility may become a flashpoint when dealing with disruptive physician behavior. It is also one reason to fairly and fully address behavior issues up front and manage the behavior formally and comprehensively. JACHO standards stipulate that each clinical department makes recommendations to the medical staff about the criteria for clinical privileges in that department. These criteria must pertain to competence and ability and are above and beyond those criteria set by the medical staff in general and could include results of appropriate performance improvement activities. It is wise to imbed specific language in the department’s credentialing and orienting processes to prevent and mitigate problems involving disruptive behavior. Credentialing standards JCAHO standards address, in specific detail, essential components of the processes of credentialing, appointment/reappointment and granting/revoking of clinical privileges. Here are some that target disruptive physician behavior: 1. Authority of the medical staff to define the information to be provided for consideration for membership or privileges 2. Information provided from monitoring professional performance, judgment and clinical/technical skills 3. Information required from peers 4. A requirement to submit any reasonable evidence of current ability to perform privileges that may be requested 5. A requirement for applicants to consent to the inspection of records and documents pertinent to competence and ability to perform Standards aid physician executives As the article by Alan Rosenstein (Disruptive Physician Behavior Contributes To Nursing Shortage page 8) shows, disruptive behavior by a physician poses a serious challenge to physicians in leadership positions. Equipping physician leaders to deal with the issue is a step in the right direction. At least in the hospital setting, JCAHO standards do give physician executives a blueprint for an empowered, professional and respectful approach to confronting and managing disruptive physician behavior. ACPE Resources ACPE offers an excellent course on how to manage disruptive physician behavior. To bring the course to your organization for an OnSite Educational Program call 800/562-8088 or visit http://www.acpe.org/onsite for more information. Michael Youssi, MD, MHA, is a consultant at Joint Commission Resources, Inc. in Oakbrook Terrace, Ill. He can be reached by phone at 630/268-7400 or by e-mail at info@jcrinc.com  


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