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Disruptive Behavior

I. Purpose of Policy

This policy affirms Dartmouth-Hitchcock’s commitment to attaining ever increasing levels of excellence by establishing a just culture and an environment of safety, quality, professionalism, respect, collegiality and teamwork at all times, prohibiting behaviors that undermine a safe and collegial environment, and identifying appropriate responses to such disruptive behaviors.

II. Policy Scope

This policy applies to the following positions at Dartmouth-Hitchcock Clinic and Mary Hitchcock Memorial Hospital (collectively, “Dartmouth-Hitchcock” or “D-H”): Physicians/Fellows/Residents, Associate Providers, Non-Provider Staff, Temporary Staff, Per Diem/PRN Staff, Volunteers, Travelers, Students, Independent Contractors and Leased employees.

Nothing in this policy provides any contractual rights regarding employee privacy, nor does anything in this policy alter or modify the employment-at-will relationship between D-H and its employees.

III. Definitions

Awareness Conversation: A conversation that any person can have with any other person in which the first describes an observed behavior by the latter that is not consistent with the standards and expectations for professional conduct described in the D-H Code of Ethical Conduct. Awareness conversations may take place, for example, between D-H physicians and/or staff, and other covered individuals including peers, co-workers and colleagues, and do not have to be documented or reported.


Disruptive Behavior: Behavior that includes, but is not limited to, words or actions that create or have the potential to create an unsafe or hostile environment for patients, families, or other staff, to interfere with patient care, or to disrupt Dartmouth-Hitchcock operations. It includes behavior that interferes with or undermines the level of teamwork and collegial respect that are critical to a safe environment. See the Appendix at the end of this policy for some specific examples of disruptive behaviors. Disruptive Behavior includes “egregious behavior” as defined below.


Egregious Behaviors: Highly offensive and/or aggressive acts (including those that could also constitute criminal acts such as assault or theft), discrimination, boundary violations, or working while under the influence of a substance or alcohol (refer to the Substance Abuse and Drug-Free Workplace Policy and the Fitness for Duty Policy).


IV. Policy Statement

Dartmouth-Hitchcock is committed to excellence in patient care and to providing a healing environment for our patients and families and a safe and secure environment for our work force. The goal is to enable D-H physicians and staff to attain ever-increasing levels of excellence by establishing environments of safety, quality, continuous learning and accountability (see References 7, 8). As such, all D-H physicians and staff (and all others identified as “covered individuals” above) shall act in a professional, collaborative and respectful manner at all times, consistent with applicable D-H policies and procedures and the Code of Ethical Conduct. D-H shall respond to all reported incidents of disruptive behavior in a manner intended to remedy the situation based on the particular facts and circumstances.

  1. Covered Individual Responsibility
    • Each member of the D-H community (to include all “covered individuals” identified above) is accountable for adhering to D-H’s expectations of professional, respectful, and safe conduct. In addition, each member of the D-H community is responsible for reporting incidents of disruptive behavior using the process outlined below.

    • When a covered individual observes another member of the community engaging in disruptive behavior that appears to be a first instance for which timely, direct feedback would likely prevent recurrence, and if the behavior or conduct is not egregious, the covered individual – if comfortable doing so – may, and is encouraged to, conduct an “awareness conversation” to address the behavior. Employees may contact Employee Relations for guidance and/or assistance with such discussions, or to request that the behavior be addressed by Employee Relations.

    • If a covered individual chooses not to engage in an awareness conversation with the person engaging in disruptive behavior, the covered individual is strongly encouraged to report his or her observations using the process below.

    • When a covered individual observes another member of the community engaging in disruptive behavior that the individual believes rises above minor instances of disruptive behavior or conduct (i.e., of the type appropriate for an awareness conversation), the covered individual is required to report the incident using the process outlined below.


  2. Reporting Disruptive Behavior
    • Covered individuals are responsible for promptly reporting any disruptive behavior (other than minor instances as addressed above in Paragraph 1), including all instances of egregious behavior, by notifying or contacting the following:
      • A supervisor or any other person in management
      • D-H’s Occurrence or Incident Reporting System
      • Employee Relations at (603) 653-1570 or employee.relations@hitchcock.org
      • D-H’s Compliance Help Line at (888) 422-2084

    • In addition, if a covered individual is informed of an instance of disruptive behavior by a patient or visitor, the covered individual must inform his or her supervisor or other person in management at D-H. Any reported incident of egregious behavior must be reported immediately.

    • The individual who is reporting a disruptive behavior incident may remain anonymous and will be asked to provide the following:
      • The date and time of the incident
      • The name of the person exhibiting disruptive behavior
      • Information about who was involved, including patients, if any, and the circumstances that precipitated the situation
      • A factual and objective description of the behavior
      • Identification of others who might have observed the incident

    • All reports will be treated as confidential to the greatest extent possible and consistent with applicable laws.

    • If a behavior poses or appears to pose an immediate threat of harm to any individual, e.g. assault or threat of assault, or other behavior that may result in bodily harm, D-H Security (when Security is available on site) or local law enforcement should be contacted.

    • If a covered individual is concerned that his or her report has not been appropriately handled, he or she should contact Employee Relations or, if the event was reported to Employee Relations, the covered individual may contact his/her supervisor or the Office of General Counsel.

  3. Organizational Response
    • Employee Relations or other D-H department, as appropriate to the type of behavior at issue and the category of covered individual, will review each complaint of disruptive behavior and advise departmental leadership on the appropriate response based on the specific facts and circumstances.

    • Response to the disruptive behavior may take a variety of forms, including without limitation informal counseling, affirmation of expectations of employment, corrective action, performance improvement plan, fitness for duty evaluation, and disciplinary action up to and including immediate termination in accordance with D-H policies and practices, and in accordance, as applicable, with the Dartmouth-Hitchcock Professional Staff Bylaws.

    • D-H takes egregious behaviors seriously and adopts a “zero tolerance” approach. Any egregious behavior may result in immediate dismissal from employment (subject, as applicable, to requirements for physicians and others Professional Staff members as set forth in the Dartmouth- Hitchcock Professional Staff Bylaws, and to requirements for graduate medical education trainees set forth in applicable GME policies, including due process rights set forth therein) and reporting to applicable professional boards or regulatory agencies.

    • As may be appropriate depending on the specific facts and circumstances, resources which may be offered to help the employee include but are not limited to Employee Relations, Employee Assistance Program, and the New Hampshire Professionals Health Program.

    • All corrective action and disciplinary action will be taken in a manner consistent with the Corrective Action Policy and/or the Bylaws, Rules and Regulations of the Dartmouth-Hitchcock Professional Staff, as applicable.

    • Documentation of the organizational response will be provided to the employee who was the subject of the review and a copy sent to Human Resources for inclusion in the employee file and/or included in the professional staff member credentialing file, maintained in the Medical Staff Office, as appropriate. Such documentation will be considered along with other feedback, in connection with an employee performance evaluation process and, with respect to professional staff members, in connection with the professional staff reappointment process and related credentialing and privileging processes. Employee Relations shall maintain documentation of all incidents of disruptive behavior investigated by Employee Relations, pursuant to Human Resources policies and practices.


  4. Employee Protection
    • D-H prohibits retaliation and will take no adverse action against any person for making a disruptive behavior report in good faith. Retaliation and adverse action in response to reporting any incident of disruptive behavior would include but are not limited to the following: discharge, demotion, suspension, harassment, denial of promotion, transfer or in any other manner discriminating or threatening to discriminate against a D-H employee in the terms and conditions of the D-H employee’s employment.

    • Any D-H employee who believes that he or she has been subjected to retaliatory conduct for reporting an incident of disruptive behavior may report the concern to Employee Relations at 653- 1570, Compliance and Audit Services at (603) 650-3480 or the Compliance Helpline at (888) 422- 2084 for timely investigation of such concern of retaliatory conduct.


  5. Examples of Disruptive Behaviors
    • The following list is a small subset of the types of behaviors and communications that undermine a culture of safety and are in direct conflict with the Code of Ethical Conduct. These are examples and by no means meant to be an exhaustive list.

    • Examples of overt disruptive behavior include:
      • Outbursts of anger, such as throwing instruments, charts or other objects
      • Intimidation/threats
      • Unnecessary/inappropriate touching or contact
      • Harassment, innuendoes or use of obscene gestures
      • Racial, ethnic, or sexual orientation jokes or comments
      • Unwillingness to adhere to D-H or section/department standards of practice or policies or refusing to perform assigned tasks
      • Frivolous, retaliatory or intentionally misleading (“bad faith”) reports of disruptive behavior or other policy violation
      • Use of derogatory or foul language
      • Inappropriate expressions of anger
      • Comments intended to undermine another D-H physician, trainee, and/or staff member’s selfconfidence in providing care
      • Condescending or disrespectful language
      • Showing up to work impaired by alcohol or other substance

    • Examples of covert disruptive behavior include repetitive instances of:
      • Unfair/unreasonable delegation of tasks or assignments (e.g. outside scope of practice or job description)
      • Sarcastic or impatient responses directed at another individual
      • Sabotage
      • Comments that undermine a patient’s trust in other caregivers or the institution
      • Refusal to answer questions, respond to calls, or return pages in a timely manner


V. References

Rosenstein, AH and O’Daniel, M: Disruptive behavior and clinical outcomes: Perception of nurses and physicians. American Journal of Nursing, 2005, 105, 1, 54-64

Institute for Safe Medication Practices: Survey on workplace intimidation. 2003. Available online: http://ismp.org/survye/surveyresults/survey0311.asp (accessed April 14, 2008)

Morrissey, J: Encyclopedia of errors; Growing database of medication errors allows hospitals to compare their track records with facilities nationwide in a non-punitive setting. Modern Healthcare, March 24, 2003, 33 (12): 40, 42

Gerardi, D: Effective strategies for addressing “disruptive” behavior: Moving from avoidance to engagement. Medical Group Management Association Webcast, 2007; and Gerardi, D: Creating Cultures of Engagement: Effective Strategies for Addressing Conflict and “Disruptive” Behavior. Arizona Hospital Association Annual Patient Safety Forum, 2008

Ransom, SB and Neff, HE, et al: Enhancing physician performance. American College of Physician Executives, Tampa, FL, 2000, chapter 4, p. 45-72

Rosenstein, A, et al: Disruptive physician behavior contributes to nursing shortage: Study links bad behavior by doctors to nurses leaving the profession. Physician Executive, November/December 2002, 28 (6): 8-11. Available online: http://findarticles.com/p/articles/mi_0843/is_6_28/ai_94590407 (accessed April 14, 2008)

Wheeler, Susan A, et al: The Link Between Teamwork and Patients’ Outcomes in Intensive Care Units. American Journal of Critical Care, November 2003, 12 (6): 527-534

Hickson, Gerald B, et al: A Complementary Approach to Promoting Professionalism: Identifying, Measuring, and Addressing Unprofessional Behaviors. Academic Medicine, November 2007 82 (11): 1040-1048

The Joint Commission Sentinel Event Alert – “Intimidating and disruptive behaviors can foster medical errors (see references 1, 2, 3), contribute to poor patient satisfaction and to preventable adverse outcomes (see references 1, 4, 5), increase the cost of care (see reference 4, 5), and cause qualified clinicians, administrators and managers to seek new positions in more professional environments (see references 1, 6). Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment.” “To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.”]


D-H Policy ID: 6587

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