Why It Matters
There's been a big pendulum swing in the world of patient safety — away from blaming individuals to blaming systems. But people who recklessly violate protocol must be held accountable.
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Dear IHI: What Would You Do about the Aggravating Surgeon Who Won’t Wash His Hands?

By Jennifer Lenoci-Edwards | Thursday, April 28, 2016

Dear IHI —

There’s a surgeon on my team who thinks he’s an exception to every rule because he brings in millions of dollars in revenue. I’ve seen him skip hand hygiene protocol several times, even though other staff have directly asked him to follow it. I’m concerned for our patients and the culture of our organization with his bad example. What would you do? – AGGRAVATED


You’re in a quite a predicament. You may have a disruptive staff member on your hands. These infuriating colleagues can come from all departments and disciplines, not just surgery, and they can cause big roadblocks to building effective teams and a strong culture of safety.

You may already know that there has been a big pendulum swing in the world of patient safety — away from blaming individuals to blaming systems. We always try to understand where we can improve our systems and make it easier for people to do the right thing. At the same time, the system cannot be responsible for all cases of people acting carelessly or otherwise purposefully violating norms.

First, we need to determine if this is a system problem. Are many staff or surgeons not washing their hands? Or is your surgeon, who I’ll call Dr. Disruptive, the only one? If you look to James Reason’s decision tree for determining culpability for unsafe acts, you can find some great insight on how to formally assess your staff.

If you decide that Dr. Disruptive is in fact out of line, you need a plan that involves awareness and education. Does he understand what is asked of him? Does he know he is missing the step of handwashing? Does he know how uncomfortable he’s making his colleagues, and how his actions are potentially impacting patients? With the right staff member, awareness and acknowledgment can be enough to set some expectations of “how we do business here.”

But if awareness and education aren’t enough, your organization then needs to explain that there are consequences for failing to meet these expectations. This means the surgeon’s supervisor should be constantly assessing the behavior in question and regularly checking in with Dr. Disruptive to address his progress.

If all else fails — and this is the hardest step — your organization needs to be willing to take punitive action. That includes asking Dr. Disruptive to step down, if that’s what it comes to. It’s hard to imagine losing the revenue that he’s bringing in. But to counter those costs, think about these costs: the cost of potential infections for the patient, the cost to your reputation, and the cost of turnover of your best staff. Unhappy team members will move across the street to your competitors, where they can work on teams that bring them joy and best outcomes for patients.

Challenging a powerful staff member takes courage. It still isn’t safe in every organization, and you may have to consider whether you will face retribution for speaking up and how you might handle that. But keep in mind that every person who has the courage to speak up is making your system that much safer for others — both staff and patients.

Good luck,


Jennifer Lenoci-Edwards, RN, MPH, Director of Patient Safety at IHI

Have you dealt with a disruptive staff member? Leave your advice in the comments.

Editor's Note: "Dear IHI" is an advice column in which IHI experts answer questions from health care change agents in the field. Have a question for "Dear IHI"? Send it to info@ihi.org or on Twitter using the hashtag #DearIHI and @theihi.

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