In today’s health care environment of collaborative patient care and an emphasis on the safety of patients, staff and others, health care institutions are expected to be proactive in identifying, preventing and managing disruptive behaviour. Disruptive behaviour by anyone in a health care setting can have significant implications for safety and the provision of quality patient care. Depending on the nature of the conduct, disruptive behaviour may also constitute workplace violence or harassment under the Occupational Health and Safety Act, or discrimination under Ontario’s Human Rights Code.

In May 2016, the College of Physicians and Surgeons of Ontario (CPSO) updated its policy on Physician Behaviour in the Professional Environment. Originally passed in 2007, this policy was developed in conjunction with a broader initiative by the CPSO, the Ontario Hospital Association and other stakeholders to develop a framework, resources and tools to identify, prevent and manage disruptive physician behaviour and its consequences. The amended CPSO policy clarifies, but does not fundamentally alter, the CPSO’s expectations for physician conduct in the professional environment.

The most significant policy revision is the broadening of the CPSO’s characterization of disruptive behaviour to explicitly recognize the negative effects that such behaviour can have on quality of care, patient outcomes and the safety of patients and others. Beyond being simply “unprofessional”, disruptive behaviour erodes trust, communication and collaboration within the patient care team and with the patient/family.

Just prior to the release of the revised policy, the CPSO’s Discipline Committee temporarily suspended a physician, having found that his disruptive behaviour, in and of itself, constituted professional misconduct. The physician, who had held a number of prominent roles in a hospital, had a history of disruptive, unprofessional and inappropriate behaviour towards colleagues, staff and patients. The physician failed to make any changes despite repeated efforts by the hospital to address the conduct.

In suspending the physician, the Committee noted that neither patients nor staff should have to endure such conduct, which can result in a poisoned workplace. Accordingly, the Committee imposed various terms, conditions, and limitations on the physician’s certificate of registration. These steps were taken in an attempt at remediation and to protect patients and staff from similar conduct in the future. This decision demonstrates the CPSO’s willingness to take action where a physician’s conduct is disruptive, even in the absence of clinical deficiencies.

What to Do When Physicians or Other Staff Exhibit Disruptive Behaviour?

Health care institutions are increasingly seeking guidance in addressing issues such as: What conduct constitutes “disruptive” behaviour? Does this behaviour have to impact patients or put patient safety at risk to be considered disruptive? What tools should we have in place to address disruptive behaviour? How many complaints are needed before action can be reasonably taken? What reliance can be placed on regulatory Colleges’ investigations? What type of action is appropriate?

Health care institutions ought to be proactive by ensuring their by-laws, policies, and credentialing and re-credentialing processes clearly establish expectations for conduct and are consistent with current best practices for addressing disruptive behaviour. Conduct expectations should be entrenched in an institution-wide Code of Conduct policy that is applicable to everyone who works within the institution, including physicians and other professional staff, management, employees, contractors, Board members and volunteers and should also set forth a clear process for identifying and addressing conduct issues.

Specific actions available will vary depending on the nature of the relationship between the organization and the health care professional, as well as the nature and frequency of the conduct. It is never too early to consider what steps should be taken when this conduct begins to emerge. It is also important to keep a record of concerning conduct to evaluate whether a pattern is emerging. Where conduct issues do arise, it is important to ensure they are dealt with in a timely manner and in accordance with due process, using the tools that are available including, for example, workplace monitoring agreements.