MEDICAL STAFF CODE OF CONDUCT POLICY

MEDICAL STAFF CODE OF CONDUCT POLICY I. POLICY STATEMENT 1. Collaboration, communication, and collegiality are essential for a Culture of Safety to exist and excellent patient care to occur. As such, all Medical Staff members and Allied Health Professionals practicing in the Medical Center must treat others with respect, courtesy, and dignity and conduct themselves in a professional and cooperative manner. The Medical Center has a zero tolerance policy for conduct that does not meet this standard, and any incidents of inappropriate conduct will be addressed in accordance with this Code of Conduct Policy. This will be enforced consistently for all staff members and in a timely fashion. 2. This Policy outlines progressive steps, beginning with collegial and educational efforts, that can be used by Medical Staff leaders to address conduct that does not meet this standard. The goal of these efforts is to arrive at voluntary, responsive actions by the individual to resolve the concerns that have been raised, and thus avoid the necessity of proceeding through the disciplinary process in the Credentials Policy. Individual professional accountability is at the foundation of this policy and all interventions will be educational in direction as long as the physician is open to learn. Remember activity that is permitted is in fact promoted and delays to curb unwanted activities make change harder. 3. This Policy also addresses sexual harassment of employees, patients, other members of the Medical Staff, and others, which will not be tolerated. 4. In dealing with all incidents of inappropriate conduct, the protection of patients, employees, physicians, and others in the Medical Center and the orderly operation of the Medical Staff and Medical Center are paramount concerns. Complying with the law and providing an environment free from sexual harassment are also critical. 5. All efforts undertaken pursuant to this Policy shall be part of the Medical Center s performance improvement and professional practice evaluation/peer review activities. II. EXAMPLES OF INAPPROPRIATE CONDUCT To aid in both the education of Medical Staff members and Allied Health Professionals and the enforcement of this Policy, examples of inappropriate conduct include, but are not limited to: threatening or abusive language directed at patients, nurses, other Medical Center personnel, Allied Health Professionals, or physicians (e.g., belittling, berating, and/or non-constructive criticism that intimidates, undermines confidence, or implies stupidity or incompetence); 1

degrading or demeaning comments regarding patients, families, nurses, physicians, Medical Center personnel, or the Medical Center; reluctance to answer questions, return phone calls or pages, condescending language or voice intonation, impatience with questions, answering with silence; profanity or similarly offensive language while in the Medical Center and/or while speaking with patients, nurses, or other Medical Center personnel; retaliating against any individual who may report a quality and/or behavior concern about a Medical Staff member or Allied Health Professional (this includes approaching and directly discussing the matter with the individual who reported the concern); physical contact with another individual that is threatening or intimidating; derogatory comments about the quality of care being provided by the Medical Center, another Medical Staff member, or any other individual outside of appropriate Medical Staff and/or administrative channels; medical record entries impugning the quality of care being provided by the Medical Center, Medical Staff members, or any other individual; medical record entries criticizing hospital policies or processes, or accreditation and regulatory requirements; inappropriate use, disclosure, or release of confidential patient information; refusal to abide by Medical Staff requirements as delineated in the Medical Staff Bylaws, Credentials Policy, Rules and Regulations, or other Medical Staff policies (including, but not limited to, emergency call issues, response times, medical recordkeeping, other patient care responsibilities, failure to participate on assigned committees, and an unwillingness to work cooperatively and harmoniously with other members of the Medical Staff and Medical Center employees); and/or sexual harassment, which is defined as any verbal and/or physical conduct of a sexual nature that is unwelcome and offensive to those individuals who are subjected to it or who witness it. Examples include, but are not limited to, the following: (a) Verbal: innuendoes, epithets, derogatory slurs, off-color jokes, propositions, graphic commentaries, threats, and/or suggestive or insulting sounds; 2

(b) Visual/Non-Verbal: derogatory posters, cartoons, or drawings; suggestive objects or pictures; leering; and/or obscene gestures; (c) Physical: unwanted physical contact, including touching, interference with an individual s normal work movement, and/or assault; and (d) Other: making or threatening retaliation as a result of an individual s complaint regarding harassing conduct. III. GENERAL GUIDELINES/PRINCIPLES 1. Issues of employee conduct will be addressed in accordance with the Medical Center s Human Resources Policies. Issues of conduct by members of the Medical Staff or Allied Health Professionals (hereinafter referred to as practitioners ) will be addressed in accordance with this Policy. If the matter involves an employed practitioner, Medical Center Administration, in consultation with appropriate Medical Staff leaders and legal counsel, will determine which of any applicable policies will be applied. 2. Every effort will be made to coordinate the actions contemplated in this Policy with the provisions of the Credentials Policy. In the event of any apparent or actual conflict between this Policy and the Credentials Policy, the provisions of this Policy shall control. 3. This Policy outlines collegial steps (e.g., counseling, warnings, and meetings with a practitioner) that can be taken to address concerns about inappropriate conduct by practitioners. However, a single incident of inappropriate conduct or a pattern of inappropriate conduct may be so unacceptable or egregious that more significant action is required. Therefore, nothing in this Policy precludes an immediate referral of a matter being addressed through this Policy to the Medical Executive Committee ( MEC ) or the elimination of any particular step in the Policy. 4. In order to promote the collegial and educational objectives of this Policy, all discussions and meetings with a practitioner whose conduct is at issue shall involve only the practitioner, the appropriate Medical Staff leader(s), and members of Medical Center Administration (unless the Medical Staff leader(s) or Medical Center Administration determine otherwise in a particular situation). No counsel for either the practitioner or the Medical Staff leaders or the Medical Center shall attend any of these meetings. 5. The Medical Staff leaders and Medical Center Administration shall provide education to all Medical Staff members and Allied Health Professionals regarding appropriate professional behavior. The Medical Staff leaders and Medical Center Administration shall also make employees, members of the Medical Staff, and other personnel in the Medical Center aware of this Policy and shall encourage the prompt reporting of inappropriate conduct. All Medical Staff will sign this policy at the time of appointment or reappointment and those members who have issues with this policy will be counseled by a medical staff leader. 3

IV. REPORTING OF INAPPROPRIATE CONDUCT 1. Any Medical Center employee who observes, or is subjected to, inappropriate conduct by a practitioner shall report the incident in a timely manner by submitting a completed Professional Behavior Report Form (see Appendix A) to his/her supervisor. (Form will be available in the CQO office). All such reports shall be forwarded to the Professional Conduct Committee ( PCC ) for review. The PCC shall consist of the Chief of Staff, the Immediate Past Chief of Staff, the appropriate Department Chair, and the CEO. The Chief Quality Officer is also a member of the Committee, without vote. Other committees tasked with evaluating physician behavior may also be appropriate such as the Wellness Committee or the MEC. The Professional Behavior report maybe filled out by the CQO but she/he must have had direct contact with the person with the complaint. The form must be signed by the CQO and the name of the person bringing the complaint/incident forward is placed on the form. Any practitioner who observes such behavior by another practitioner shall complete the Professional Behavior Report Form and provide it directly to the Chief of Staff or any other member of the PCC. (see above) 2. The Chief of Staff or the PCC, usually the CQO, ( or their designees) shall follow up with the individual who made the report by: informing him/her that the matter is being reviewed and that the Medical Staff leaders may or may not need further information from him/her; thanking him/her for reporting the matter; instructing him/her to report any further incidents of inappropriate conduct; and informing him/her that, due to legal confidentiality requirements, no further information can be provided regarding the outcome of the review. V. INITIAL PROCEDURE 1. The PCC shall review the report and, if necessary, may meet with the individual who prepared it and/or any witnesses to the incident to ascertain the details of the incident. It is important that more than one individual is appraised of the situation and that a record of the response by the PCC be kept, even if the incident as reported is concluded by the PCC to not represent inappropriate behavior. 2. If the PCC determines that an incident of inappropriate conduct has likely occurred, the PCC has several options available to it, including, but not limited to, one or more of the following: notify the practitioner that a report has been received and ask them to selfevaluate and give them the acknowledgement that you feel this will not happen 4

again, if appropriate invite the practitioner to provide a written response or to meet with one or more members of the PCC to provide his/her perspective; send the practitioner a letter of guidance or counsel about the incident; educate the practitioner about administrative channels that are available for registering concerns about quality or services, if the practitioner s conduct suggests that such concerns led to the behavior. Other sources of support may also be identified for the practitioner, as appropriate; send the practitioner a letter of warning or reprimand, particularly if there have been prior incidents and a pattern may be developing; and/or have a PCC member(s), or the PCC as a group, meet with the practitioner to counsel and educate the individual about the concerns and the necessity to modify the behavior in question. 3. The identity of an individual reporting inappropriate conduct will generally not be disclosed to the practitioner during these efforts, unless the PCC determines in advance that it is appropriate to do so. In any case, the practitioner shall be advised that any retaliation against the person reporting a concern, whether the specific identity is disclosed or not, will be grounds for immediate referral to the MEC for review pursuant to the Credentials Policy. 4. The PCC will prepare documentation for a practitioner s file regarding its efforts to address concerns with the practitioner, and the practitioner shall be apprised of that documentation and given an opportunity to respond in writing. Any such response shall then be kept in the practitioner s confidential file along with the original concern and the PCC s documentation. 5. If additional reports of inappropriate conduct are received concerning a practitioner, the PCC may continue to use the collegial and educational steps noted in this Section V as long as it believes that there is still a reasonable likelihood that those efforts will resolve the concerns. VI. REFERRAL TO THE MEDICAL EXECUTIVE COMMITTEE 1. At any point, the PCC may refer the matter to the MEC for review and action. The MEC shall be fully apprised of the actions taken by the PCC or others to address the concerns. When it makes such a referral, the PCC may also suggest a recommended course of action. 2. The MEC may take additional steps to address the concerns, including, but not limited to, the following: require the practitioner to meet with the full MEC or a designated subgroup; 5

require the practitioner to meet with specified individuals (including any combination of current or past Medical Staff leaders, an outside consultant(s), and/or the Board Chair or other Board members if Medical Staff leaders, Medical Center Administration, and/or legal counsel determine that Board member involvement is reasonably likely to impress upon the practitioner involved the seriousness of the matter and the necessity for voluntary steps to improve); issue a letter of warning or reprimand; require the physician to complete a professional improvement or behavior modification course that is acceptable to the MEC; the Administration and MEC should have on file modification courses that they will use if the need arises, the physician in question should not pick their own. These courses will be over a few days but usually 12 to 18 months of continued contact is necessary for best results as behavior modification takes time. impose a personal code of conduct on the practitioner and make continued appointment and clinical privileges contingent on the practitioner s adherence to it; and/or suspend the practitioner s clinical privileges for 30 days or less. This does not need to be reported to the data bank but can be very useful for both parties to decide steps going forward. The imposition of any of these actions does not entitle the practitioner to a hearing or appeal as described in the Credentials Policy. (Additional guidance regarding these and other performance improvement plan options for conduct and the related implementation issues is found in Appendix B to this Policy.) 3. The MEC may also direct that a matter be handled pursuant to the Medical Center s Policy on Practitioner Health Issues, if it has the reasonable belief that a health issue may be the reason for the inappropriate conduct. 4. At any point, the MEC may take appropriate action in accordance with the Credentials Policy, including referring the matter to the Board for review and action. VII. SEXUAL HARASSMENT CONCERNS All reports of inappropriate conduct that involve sexual harassment concerns will be reviewed by the PCC in the same manner as set forth above. However, because of the unique legal implications surrounding sexual harassment, a single confirmed incident requires the following actions: 1. A meeting shall be held with the practitioner by the PCC (or its designee) to discuss the incident. If the practitioner agrees to stop the conduct thought specifically to constitute 6

sexual harassment, the meeting shall be followed up with a formal letter of admonition and warning to be placed in the confidential portion of the practitioner s file. This letter shall also set forth those additional actions, if any, which result from the meeting. 2. If the practitioner refuses to stop the conduct immediately, this refusal shall result in the matter being referred to the MEC for review pursuant to the Credentials Policy. 3. Any reports of retaliation or any further reports of sexual harassment, after the practitioner has agreed to stop the improper conduct, shall result in an immediate investigation by the PCC (or its designee(s)). If the investigation results in a finding that further improper conduct took place, the PCC shall refer the matter to the MEC for a formal investigation or other steps in accordance with the Credentials Policy. Such referral shall not preclude other action under applicable Medical Center human resources policies. Should the MEC make a recommendation that entitles the individual to request a hearing under the Credentials Policy, the individual shall be provided with copies of all relevant reports so that he or she can prepare for the hearing. 7

APPENDIX A PROFESSIONAL BEHAVIOR REPORT FORM For Employees, Medical Staff Members, and Allied Health Professionals Instructions: Use this form to report all incidents of inappropriate conduct and unprofessional behavior. Attach additional sheets if necessary. Please provide the following information as specifically and as objectively as possible: 1. Date of the incident: 2. Time of incident: 3. Name of person exhibiting inappropriate conduct: 4. Name(s) of any patient(s) affected or involved. N/A (if no patient was affected, circle N/A): 5. Describe what happened as specifically and objectively as possible. 1

6. How do you think this behavior affected patient care, hospital operations, your work, or your team members work? 7. Provide the names of all witnesses to this behavior. 8. What did you or others do to address this behavior? Signature of person completing this form: ( may be person other than the person reporting the incident, but in that circumstance must be a member of the PCC) Date form completed: 2