University Hospital - Draft

UNIVERSITYHOSPITAL

POLICY:

1. Collaboration, communication, and collegiality are essential for the provision of safe and competent patient care. Therefore, all Medical Staff members, Allied Health Professionals, Medical Students, Interns, Residents, and Fellows (House Staff) in the Hospital must treat others with respect, courtesy, and dignity while conducting themselves in a professional and cooperative manner.

1. This policy outlines collegial and educational efforts that can be used by Medical Staff leaders to address allegations of conduct that do not meet this standard including sexual harassment. The goals of these efforts are to arrive at responsive actions by the individual to resolve concerns which have been raised and minimize the necessity of proceeding through any formal corrective action proceeding under the Medical Staff Bylaws.

1. In dealing with all incidents of alleged inappropriate conduct, the protection of patients, employees, physicians, allied health professionals, and all others in the Hospital is of the utmost concern.

1. All efforts undertaken pursuant to the Policy shall be an integral part of the Hospital’s performance improvement and peer review activities.

5.No person shall be retaliated against by UniversityHospital or the Medical Staff for making a good faith report in accordance with this policy. A decision that a report of an incident perceived to be inappropriate conduct was in fact not inappropriate conduct does not indicate that the report was initiated in bad faith, as for example, facts and circumstances unknown to the person making the report may explain the questioned behavior.

BEHAVIOR EXPECTATIONS:

No Medical Staff members, Allied Health Professionals, Medical Students, Interns, Residents, or Fellows (House Staff) may provide patient careservices at UniversityHospital until they receive written approval and effective appointment date from the hospital CEO or the Board of Directors.

Each University Hospital Medical Staff member is expected to conform to the behaviors specified in the code of conduct as listed below:

1. Behavior reflects that the patient always comes first.

1. Treats patients and visitors, staff members, and healthcare providers with dignity and respect and holds team members accountable to do the same.

1. Sets a positive example with quality of work.

1. Helps other team members to grasp and understand issues. Communicates information clearly and professionally.

1. Ensures that patient’s privacy and confidentiality are maintained.

1. Respects different points of view and shares positive ideas and thoughts about work. Avoids gossip and other negative styles of communication.

1. Accepts constructive criticism and suggestions about job performance and behavior in a positive manner. Is receptive to change.

1. Addresses concerns and conflicts in a constructive manner. Focuses on issues and not personalities.

1. Recognizes the value of each healthcare provider, including support staff, and treats each individual with dignity and respect at all times.

1. Interacts positively with hospital staff by informing them of expectations, providing feedback and paying compliments as appropriate.

1. Projects a positive, professional image.

1. Uses resources and materials efficiently and effectively.

1. Is committed to continuously improving. Stays current with profession as well as hospital and regulatory policies.

1. Complies with hospital policies and regulatory standards (TJC, OSHA, Medicare, Medicaid, etc.) in delivering the best possible care, maintaining a safe work environment, and documenting the delivery of service.

1. Respects the rights of patients by identifying him/herself upon entering a patient's room. Contacts the Speech and Hearing Department or Administrative Nurse Supervisor if having difficulty communicating with a sensorially deprived or low English proficiency patient.

INAPPROPRIATE CONDUCT:

As means of education and the enforcement of this policy, examples of inappropriate conduct include but are not limited to the following:

1. Threatening/offensive or abusive language/behavior directed at patients or their family members, nurses, Hospital personnel, House Staff, or other physicians.

2.Inappropriate physical contact with another individual that is threatening or intimidating.

3.Refusal to abide by the Medical Staff requirements as delineated in the Medical Staff Bylaws, Rules and Regulations, and Policies and Procedures.

4.Sexual harassment, which is defined as any verbal and/or physical conduct of a sexual nature that is unwelcome and offensive to those who are subjected to it or witness it.

GENERAL GUIDELINES:

1. Issues of employee conduct will be dealt with in accordance with the Hospital’s Human Resources Policies and Procedures. Issues of conduct by members of the Medical Staff and Allied Health Professionals (hereinafter referred to as practitioners) will be addressed in accordance to this policy. If the issue involves an employed practitioner, hospital management in consultation with appropriate medical staff leaders and legal counsel will determine which applicable policies will apply, including possibly both Human Resources and Medical Staff.

1. This policy addresses various steps (i.e. counseling, warnings, and meetings with a practitioner) that can be taken to addressreports about inappropriate conduct. However, a single incident of inappropriate conduct or a pattern of inappropriate conduct may be completely unacceptable, and therefore, immediate formal corrective action is warranted.

1. The Medical Staff leadership and Hospital Administration shall provide education to practitioners regarding appropriate professional behavior. The Medical Staff Leadership and Hospital Administration shall make employees, members of the Medical Staff, and other personnel in the Hospital aware of this policy and shall institute procedures to facilitate prompt reporting of perceived to be inappropriate conduct.

REPORTING OF CONDUCT PERCEIVED TO BE INAPPROPRIATE:

1. Hospital staff or medical staff members who observe, or are subjected toconduct by a practitioner perceived to be inappropriate are encouraged to report the incidentto the Chief Medical Officer.

2.A hospital staff member or medical staff member shall initiate the review process under this policy bysigned letter to the CMO. The letter shall, as applicable, address the information described at 3 below. Complaints from patients and individuals associated with patients will be accepted as described in University Policy G-111 (Management of Patient Complaints). Anonymous verbal or writtenreports will be a considered, but an anonymous report shall not be included in a practitioner specific peer review file unless at least two members of the Professional Review Committee determine, after giving the practitioner an opportunity to respond in writing, that the report should be so filed. The Professional Review Committee shall consist of any two or more of the Medical Staff’s Immediate Past President, President, and President-Elect.

3. The documentation should include the following:

1. the date and time of the incident;
2. a factual description of what happened;
3. the name of any patients or patient’s family members who may have been involved or witnessed the behaviorperceived to be questionable;
4. the names of any other witnesses;
5. consequences of the perceivedquestionable behavior as it relates to patient care, personnel, or Hospital operations;

1. The Chief Medical Officer shall follow-up with the individual who made the report, when that information is available. The Chief Medical Officer will thank the individual for submitting the report and will ask the individual to report any further incidents of conduct perceived to be inappropriate. The Chief Medical Officer shall also inform the individual, due to confidentiality policies, no information will be provided regarding the review of the incident. In the event the CMO determines there was no inappropriate conduct, the CMO may share information with the reporter in order to resolve the reporter’s misperception.

INITIAL PROCEDURE:

1. The Chief Medical Officer shall review the report and may meet with the individual who prepared it and/or any witnesses to the incident.

2. If the Chief Medical Officer determines that there was no inappropriate conduct, the CMO shall file report in a confidential not practitioner specific peer review file. Such reports will be retained for the remainder of the calendar year in which received plus the next two calendar years.

3. If the Chief Medical Officer determines that an incident of inappropriate conduct has likely occurred, the following may occur:

1. In every event, notify the affected practitioner that a report of inappropriate conducthas been received and invite the practitioner to meet with the Chief Medical Officer and/or Department Chief.
2. Notify the practitioner’s Department Chief regarding the report.
3. Send the practitioner a letter of guidance about the incident.
4. Educate the practitioner about the administrative channels available for registering concernsabout quality or services, if the practitioner’s conduct suggests that such concerns led to the behavior.
5. Send the practitioner a letter of counseling, particularly if there have been prior incidents and/or a pattern which may be developing.
6. All correspondence will be confidential and maintained in the practitioner’s peer file, unless the CMO and practitioner’s Department Chief agree that the issue was minor and adequately addressed through discussion with the practitioner. In that event the CMO shall file the report in a confidential not practitioner specific peer review file retained for the remainder of the calendar year in which received plus the next two calendar years. In either event, the practitioner will be given the opportunity to respond in writing to the report. The practitioner’s response, if any, shall be filed with the report.

4. Allegations that appear credible, unless resolved by discussion with the practitioner as discussed in 3 f above,will be submitted in writing to the President of the Medical Staff in accordance with Article XVIII of the Medical Staff Bylaws. The President of the Medical Staff shall review the screened written concerns with the Medical Executive Committee.

5.The identity of the individual making thereportwill generally not be disclosed to the practitioner. However, if the practitioner discovers or thinks he or she knows who made thereport, the practitioner shall be advised that any retaliation against the personwho made the report, whether the specific identify is disclosed or not, will be grounds for immediate referral to the President of the Medical Staff and Medical Executive Committee.

REFERRAL TO THE MEDICAL EXECUTIVE COMMITTEE:

1. A matter may be referred to the Medical Executive Committee for review and action as described in Article XVIII of the Medical Staff Bylaws.

1. The Medical Executive Committee options under the Bylaws include, but are not limited to:
2. Require the practitioner to meet with the Medical Executive Committee or Ad Hoc Committee appointed by the President of the Medical Staff.
3. Issue a letter of warning or reprimand.
4. Require the practitioner to receive some type of counseling or complete a behavior modification course.
5. Impose a “personal” code of conduct on the practitioner and make continued appointment and clinical privileges contingent on the practitioner’s adherence to it.

The imposition of any of the above actions does not entitle the practitioner to a hearing or appeal unless the Medical Executive Committee recommends an action which limits a practitioner’s exercise of the practitioner’s clinical privileges. All correspondence will be confidential and maintained in the practitioner’s peer file.

1. At any time, the Medical Executive Committee may make an adverse recommendation regarding the practitioner’s continued appointment and clinical privileges to the Board of Directors. At such time, the practitioner would be entitled to a hearing or appeal in accordance with applicable Medical Staff Policies and Procedures, Rules and Regulations, and Bylaws.

RELATIONSHIP TO THE MEDICAL STAFF BYLAWS:

1.Nothing in this policy limits or restricts the authority or processes established under Article XVIII of the Medical Staff Bylaws or the rights of a practitioner to a hearing or appeal under Article IXX of the Medical Staff Bylaws.

I acknowledge that I have read the above Code of Conduct Policy in full and agree to abide by and conform to all behaviors listed.

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SignaturePrinted NameDate

APPROVAL:

MEC: 2/20/07; 3/17/09, 10/26/2010

Board: 2/22/07; 3/26/09, 10/28/2010

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