MEDICAL STAFF CODE OF CONDUCT POLICY

 

DISRUPTIVE BEHAVIOR INVOLVING MEMBERS OF THE MEDICAL STAFF

For purposes of this Policy, “member” and “medical staff member” shall also include individuals with temporary clinical privileges.

I. PURPOSE
To define disruptive behavior involving medical staff members and to delineate the response to be followed in all cases involving such behavior. 

Disruptive behavior by members of the medical staff, or refusal of members to cooperate with the procedures described in this Policy, may result in corrective action, which shall be carried out according to the medical staff bylaws.

II. POLICY
This policy emphasizes the need for all individuals working in  ____________________________ to treat others with respect, courtesy, and dignity and to conduct themselves in a professional manner.  Behavior by medical staff members that generates a complaint by another medical staff member, a member of the hospital clinical or administrative staff, or individuals in contact with the medical staff member at the hospital, other than patients, will be responded to according to this policy.   Behavior that indicates that the medical staff member suffers from a physical, mental or emotional condition will be referred to the Well-being Committee or otherwise evaluated to promote assisting the medical staff member.  Sexual harassment and other disruptive behavior are not acceptable to the medical staff and will be corrected, or if correction fails or the initial conduct warrants, disciplined.

For purposes of this policy, examples of disruptive conduct include, but are not limited to, the following:

    • Threatening or abusive language directed at nurses, hospital personnel, or other physicians (e.g., belittling, berating, and/or threatening another individual);
    • Degrading or demeaning comments regarding patients, families, nurses, physicians, hospital personnel, or the hospital;
    • Profanity or similarly offensive language while in the hospital and/or while speaking with nurses or other hospital personnel;
    • Inappropriate physical contact with another individual that is threatening or intimidating;
    • Public derogatory comments about the quality of care being provided by other physicians, nursing personnel, or the hospital; and/or
    • Inappropriate medical record entries concerning the quality of care being provided by the hospital or any other individual.

The medical staff shall promote continuing awareness of this Policy among the medical staff and the hospital community, including the following efforts:

i. sponsoring or supporting educational programs on disruptive behavior to be offered to medical staff members and hospital employees;

ii. disseminating this Policy to all current members upon the adoption of the Policy and to all new members of the medical staff upon joining the staff.

iii. requiring the Medical Staff Well-Being Committee to assist a member of the medical staff exhibiting disruptive behavior to obtain education, behavior modification, or other treatment to prevent further violations.

APPLICABLE DEFINITIONS:

A. "Disruptive behavior" means any conduct or behavior including, without limitation, sexual harassment or other forms of inappropriate behavior, which:

i. jeopardizes or is inconsistent with quality patient care or with the ability of others to provide quality patient care at the hospital;

ii. is unethical; or

iii. constitutes the physical or verbal abuse of patients or others involved with providing patient care at the hospital.

 

“Sexual harassment” is defined as unwelcome sexual advances, requests for sexual favors, or verbal or physical activity through which submission to sexual advances is made an explicit or implicit condition of employment or future employment-related decisions; unwelcome conduct of a sexual nature which has the purpose or effect of unreasonably interfering with a person’s work performance or which creates an offensive, intimidating or otherwise hostile work environment.

B. Disruptive behavior occurs in varying degrees, which are classified into three levels of severity.  Level I behavior is the most severe violation of this Policy. Any corrective action will be commensurate with the nature and severity of the disruptive behavior. Repeated instances of disruptive behavior will be considered cumulatively and action shall be taken accordingly. 

C. Classification of severity shall follow these guidelines:

Level I:   Physical violence or other physical abuse which is directed at people.  Sexual harassment involving physical contact.

Level II:   Verbal abuse such as unwarranted yelling, swearing or cursing; threatening, humiliating, sexual or otherwise inappropriate comments directed at a person or persons, or physical violence or abuse directed in anger at an inanimate object. 

Level III:   Verbal abuse which is directed at-large, but has been reasonably perceived by a witness to be disruptive behavior as defined above.

 

III. PROCEDURE

Complaints about a member of the medical staff regarding alleged disruptive behavior must be in writing, signed and directed to the President of the Medical Staff, and include:

  1. the date(s) and time(s) of the questionable behavior;
  2. a factual description of the questionable behavior;
  3. the name of any patient or patient’s family member who was involved in the incident, including any patient or family member who witnessed the incident;
  4. the circumstances which precipitated the incident;
  5. the names of other witnesses to the incident;
  6. consequences, if any, of the inappropriate conduct as it relates to patient care, personnel, or hospital operations; and
  7. any action taken to intervene in, or remedy, the incident.

The President of the Medical Staff, on receiving the complaint, shall interview the complainant and, if possible, any witnesses.  The President of the Medical Staff and another member of the medical executive committee shall then interview the medical staff member.  This shall be done within 1, 5, or 10 days, depending on whether the complaint is level I, II, or III.  The President of the Medical Staff shall provide the member the opportunity to respond in writing.  The President of the Medical Staff shall do one or more of the following:

i. determine that no action is warranted.
ii. issue a warning.
iii. require a written apology to the complainant.
iv. refer member to the Medical Staff Well-Being Committee.
v. initiate corrective action pursuant to the medical staff bylaws. 

IV. DISRUPTIVE BEHAVIOR AGAINST A MEDICAL STAFF MEMBER
Disruptive behavior which is directed against a medical staff member by a hospital employee, board member, contractor, or other member of the hospital community shall be reported by the member to the hospital pursuant to hospital policy governing conduct.

V. OTHER BEHAVIOR
Behavior by a medical staff member towards a hospital employee, board member, contractor or other member of the hospital community, which does not fall within the definition of disruptive behavior above, but violates hospital policy governing conduct, shall be dealt with according to that hospital policy, so long as the hospital policy has been approved by the medical executive committee.

VI. ABUSE OF PROCESS
Threats or actions directed against the complainant by the subject of the complaint will not be tolerated under any circumstance.    Retaliation or attempted retaliation by members against complainants will give rise to corrective action pursuant to the medical staff bylaws.  Individuals who submit a complaint or complaints which are determined to be false shall be subject to corrective action under the medical staff bylaws or hospital employment policies, whichever applies to the individual.

 

Adopted by the Medical Executive Committee______________, 200
Disseminated to Medical Staff Members and Privileges Holders___________, 200


JCAHO Standard MS. 2.6 states “The medical staff implements a process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function.”  This policy includes not only physicians but also non-physician members of the medical staff.  The TMF, in conjunction with the Tennessee Medical Association and the Tennessee Hospital Association, issued a model bylaw in January 2003 to help medical staffs set up Well Being Committees to address physician health issues.  To obtain a copy, call the TMF at 615-467-6411.

While this is a list of examples only, any behavior that appears to be disruptive must be measured and assessed according to the three part definition under II Policy; applicable definitions under section A on this page.

“Education of the medical staff and other organization staff about illness and impairment recognition issues specific to physicians” is to be included in the design of process under JCAHO Standard MS. 2.6, according to the standard’s Intent Statement.

The Medical Staff Well-Being Committee can be particularly helpful in monitoring a troubled member, enabling the member to be helped while preserving the member’s practice.  Further, under Joint Commission Standard MS.2.6,”the medical staff implements a process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function,” which is to include education of the medical staff, monitoring impaired members, and evaluation of complaints. A Medical Staff Well-being Committee should be designed to meet the JCAHO standard and maximize the legal protections available to medical staff committees in most states.

The TMF intends that questions about whether a physicians conduct is or is not ethical shall be determined by the definitions and guidance found in the current edition of the American Medical Association Code of Medical Ethics.  The Code can be accessed via the AMA web site: http://www.ama-assn.org

The behavior to be addressed by the medical staff has to fall within the purview of the medical staff organization-professionalism and patient care quality.   If the behavior is not related to patient care or professional ethics, the legal protections provided for peer review are not likely to apply. 

It is necessary that the medical executive committee screen and approve the hospital policy to prevent the hospital policy from conflicting with or circumventing the medical staff policy.  For example, hospital policy could be adopted to prevent medical staff members from writing letters to the newspaper editor.  The letter-writing would not violate this policy, but should not be subject to punishment by the hospital without medical staff involvement.  However, this clause is necessary to permit the hospital to take the action it needs to take to respond to medical staff member sexually harassing a gift shop worker, which is outside the patient-care related behavior covered by the medical staff policy.   

 

 
 
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