Intimidating behavior has been called the “healthcare equivalent of road rage.” As more and more healthcare organizations work on building a Culture of Safety, they’re forced to address this issue head on.

Intimidating Behavior and a Culture of Safety

A hallmark of a Culture of Safety is that it doesn’t tolerate intimidating behavior. Instead, it actively seeks to eliminate this type of behavior.

So, what’s the relationship between intimidating behavior and patient safety? Essentially, intimidating behavior fosters errors and increases the risk of harm to patients. How so?

Let’s say a nurse has a question about a medication order. But, she won’t’ ask the physician for fear of being yelled at. Well, that increases the chance of a medication error. The Institute for Safe Medication Practices did a study on this. They found that 40% of clinicians reported they had kept quiet during such an event rather than question a known intimidator.

Joint Commission Requirements

Leadership standard LD.03.01.01 requires that “Leaders create and maintain a culture of safety and quality throughout the hospital.” It also requires that “leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety.” (The same standard is in both the Hospital and Behavioral Health manuals.)

This code of conduct must be written. It must also define what constitutes unacceptable behavior. The best way to do that is to include examples. Strong polices we’ve seen clearly list the unacceptable behaviors. For example, verbal outbursts, throwing objects, not returning phone calls, profanity, condescending language, etc.

The final Joint Commission requirement is that “Leaders create and implement a process for managing behaviors that undermine a culture of safety.” This is the most challenging aspect. It typically includes verbal and written feedback and use of a formal disciplinary process.

Best Practices for Managing Intimidating Behavior

As your organization grapples with the challenge of managing intimidating behavior, here’s some best practices to keep in mind:

• Define acceptable and unacceptable behavior in a written code of conduct.
• Include examples of unacceptable behavior in your code of conduct.
• Formally educate all staff and licensed independent practitioners on the code of conduct.
• Establish a zero tolerance policy for intimidating behavior.
• Enforce the code consistently and equitably regardless of position or seniority.
• Provide a formal mechanism for reporting intimidating behavior.
• Encourage reporting.
• Provide support for those who do report.
• Develop a formal surveillance system for detecting intimidating behavior.

Joint Commission Guidance

In 2008, TJC published Sentinel Event Alert # 40: Behaviors that Undermine a Culture of Safety. The guidance in that article is still highly relevant today.

More recently, there was an interesting blog post on Dateline @ TJC. It’s titled “Cup of Coffee” Conversations’ Strong Role in Changing Behaviors.” 

The post talks about training employees to initiate “cup of coffee “conversations to make colleagues aware that unprofessional behavior was observed. There’s data from the Vanderbilt Center for Patient and Professional Advocacy that shows behaviors improve approximately 95% of the time following such conversations.

Survey Scrutiny

This year, we see a definite uptick in surveyors pursuing the topic of a Culture of Safety. They’re asking for the results of the organization’s evaluation of the culture of safety. And asking what leadership has done with the results. (For more on the Culture of Safety evaluation, see our post on Evaluating your Culture of Safety.)

We also see surveyors asking staff if there is a code of conduct. They also ask how staff were trained on it and how they would report intimidating behavior. We’ve incorporated these questions into our mock surveys  to heighten awareness on this topic.

So, now is the time to take a good hard look at your code of conduct and your process for dealing with intimidating behavior. Research the literature for best practices. If needed, update your approach to make sure it’s effective in tackling this all-important issue. As a result, your organization will be a safer place for both patients and staff!