Disruptive behavior: Why this dog don't hunt

A hound dog lays in the yard and an old man in overalls sits on the porch. "Excuse me, sir, but does your dog bite?" a jogger asks. The old man looks over his newspaper and replies, "Nope." As soon as the jogger enters the yard, the dog begins snarling and growling, and then attacks the jogger's legs. As the jogger flails around in the yard, he yells, "I thought you said your dog didn't bite!" The old man mutters, "Ain't my dog."

That's disruptive behavior.

Since January 1, 2009 , The Joint Commission has begun addressing hostile behaviors using two new performance expectations:

• The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.


• Leaders create and implement a process for managing disruptive and inappropriate behaviors.

Disruptive behaviors include the easy-to-recognize ("you-better-duck") kinds as well as passive-aggressive varieties that tend to dog morale, undercutting intention and outcomes. A short, but salient, discussion of disruptive behaviors can be found in "Behaviors that undermine a culture of safety," a Joint Commission Sentinel Event Alert published last summer. The document (and reference list) is chock-full of negative organizational outcomes that can be predicted to arise from disruptive behavior. Irrespective of your stake in the healthcare system, you'll recognize them: medical error; patient dissatisfaction; diminished recruitment and retention; litigation; and increased costs. The document also acknowledges that disruptive behavior is endemic in healthcare settings.

The relationship between disruptive behaviors and highly reliable performance is interesting to me, as are most variables that inform patient safety. I think there are valid reasons, rooted in what's good, right, and just, for people to treat one another with civility and respect. But what "respect," "civility," and "disruptive" look like to large populations of diverse people is subject to cultural nuance, and has always struck me as being exceedingly difficult to operationalize. (I was once a participant in a focus group where someone defined a "nice family meal" as one in which no one stabbed another diner.)

So my engineer's mind wanted to know this about disruptive behavior: "Does managing it lead to better performance?"

Significant barriers prevent this question from being studied in a linear fashion, but work done in commercial aviation over the past 30 years suggests that it does. The analyses of a series of fatal airline crashes in the 1970's led aviation safety experts to understand that human error is causally linked to failures of interpersonal communications, decision making, and leadership. To manage risks associated with human performance, a series of high level communication-oriented behaviors and performance activities, termed Crew Resource Management (CRM), evolved.

Normalizing behaviors within crews has improved the safety of air travel. Malcolm Gladwell tells riveting stories about why and how CRM works in his book Outliers. And a classic scholarly (but easy-to-read) 1999 analysis The Evolution of Crew Resource Management by Helmreich, Merritt, and Wilheim says more and is available online.

Crew resource management is emerging in healthcare with early AHRQ-funded projects now reporting and organizational templates, like TeamSTEPPS now available. The Joint Commission's acknowledgement that disruptive behavior creates breakdowns in the teamwork necessary to deliver safe patient care is an important foundational step in nurturing cultures in which safety is paramount.

Taking on disruptive behavior as the "safety-negative" bully it is, codifies something healthcare providers intuitively know but may have forgotten: If you stab people at the dinner table, they're unlikely to leap to their feet, performing the Heimlich maneuver with efficiency and aplomb when you choke.