Board Policy No. 22 / Subject: Board Code of Conduct
Effective Date: May 26, 2009;
Updated: June 28, 2011; November 27, 2012
Purposes and Policy
The attached Code of Conduct has been adopted as a Medical Staff and an Administrative policy. The members of the Governing Board are covered within the scope of this statement. By Board approval, the Administrative Policy Statement is hereby included in the official policies and procedures of the Board of Directors of Emerson Hospital. The Board affirms the ideals and behaviors in this policy and further agrees to implement the following procedures in a situation where a Board member violates this policy.
Procedure
Any action by a Board member in violation of this policy may subject such individual to disciplinary action, including removal from the Board. The Chairman of the Board shall be responsible to address violations of the terms of the Code of Conduct and to take action to remedy an initial infraction, unless he or she deems such infraction to be substantially harmful to the Corporation. Upon the occurrence of a second or subsequent infraction, or of an initial infraction that the Chairman deems to be substantially harmful to the Corporation, action will be taken by the Board upon recommendation of the Chairman. The Chairman may rely on the assistance of the Governance Committee in devising and recommending a course of action. This may include disciplinary action up to and including dismissal if the board member is also an employee. If the person is a member of the board of the Corporation but not an employee of the Corporation, the Covered Person may be removed in accordance with the applicable By-Laws.
Board members will be granted access to Outside Counsel through the Board Chairman for any questions they may have with respect to the application of this Policy.
The Code of Conduct is the responsibility of all hospital Governing Board members. The Code and this policy shall be reviewed and the attached form signed by every Governing Board member upon acceptance of their position and annually.
Board Policy Manual for Emerson Health System, its Affiliates and Emerson Hospital
Board Policy No.: 22 / Subject: Code of Conduct
Effective Date: May 26, 2009
Renewed: June 28, 2011 / Exhibit 1: Signature Form for Board
Code of Conduct Agreement
PLEASE RETURN BY JANUARY 15TH TO: OFFICE OF THE PRESIDENT
EMERSON HEALTH SYSTEM, INC.
133 ORNAC
CONCORD, MA 01742
Failure to complete and return this form is considered a violation of this policy.
The undersigned recognizes the importance attached by the Board to the Code of Conduct. In light of this acknowledgment, the undersigned understands that as a leader they will be expected to be role modelsby their actions and by their enforcement of the Code of Conduct.
I agree that the Chairman of the Board shall be responsible to address violations of the terms of the Code of Conduct and to take action to remedy an initial infraction, unless he or she deems such infraction to be substantially harmful to the Corporation. I further agree that, upon the occurrence of a second or subsequent infraction, or of an initial infraction that the Chairman deems to be substantially harmful to the Corporation, I agree to comply with any action taken by the Board upon recommendation of the Chairman, which action may include disciplinary action up to and including my dismissal, subject to the terms of any applicable employment agreement that I have with the Corporation, or, if I am a member of a board of the Corporation but not an employee of the Corporation, that I may be removed in accordance with the applicable By-Laws.
I hereby affirm I have read and agree to abide by and to enforce the principles and procedures associated with the Board Code of Conduct policy.
______Date: ______
Covered Person’s signature
______
Print name
EMERSON HOSPITAL
ADMINISTRATIVE POLICY
TOPIC: Code of ConductStatement Of Policy:
It is the mission of Emerson Hospital to deliver high quality, safe and cost-effective care to our patients and to maintain a professional and respectful environment for all members of the Emerson Hospital community. In keeping with that mission, this Code Of Conduct policy supports our goal of maintaining a respectful environment by defining acceptable, disruptive and inappropriate behavior and setting forth a clear process for addressing and resolvingdisruptive and inappropriate behavior.
Scope:
All hospital and medical staff, volunteers, Governing Board members and contract employees who work at Emerson Hospital or the hospital's satellites. Patients, families and visitors who are involved in or witness intimidatingand/or disruptive behavior.
Purpose:
1. To define acceptable, disruptive and inappropriate behavior.
2. To identify the process for managing disruptive and inappropriate behavior.
3. To support a culture in which respect and teamwork are recognized as essential in the provision of patient care and services at all levels of the organization.
4. To recognize disruptive and inappropriate behavior and utilize staff education and management support to address these behaviors in a reasonable and effective manner.
5. To consistently enforce the Code of Conduct policy regardless of position, seniority or clinical discipline through positive reinforcement and, if necessary, appropriate disciplinary actions.
6. To effectively develop a culture of "zero tolerance" for intimidation and/or disruptive behaviors through staff education and accountability and the implementation of effective policies and procedures and Medical Staff Bylaws.
Code of Conduct:
We affirm the following ideals and behaviors:
I will always put the interests of patients first.
I will follow the rule of treating others as I would like to be treated.
I will treat all staff with respect by:
- introducing myself and acknowledging others
- making requests in a respectful manner
- responding to pages, calls and requests for assistance or consultation in a timely manner
I am a member of a patient care team and I will:
- listen with patience
- consider the perspectives of others
- collaborate with team members to provide safe and quality care to our patients.
We recognize that we all experience stresses and frustrations in trying to deliver the best care for our patients; however, certain behaviors may negatively impact patient care. We agree not to tolerate disrespectful or abusive conduct, including, but not limited to:
- verbal outbursts or physical threats
- intimidating behavior or words directed at another person
- mocking, insulting or humiliating another person, especially in the presence of others
- refusing to answer questions or return calls for assistance.
This code will be reviewed at least annually by the Medical Executive Committee and Senior Leadership.
Process:
The Code of Conduct is the responsibility of all hospital and medical staff, volunteers, Governing Board members and contract employees. The Code and this policy shall be reviewed and signed:
a) by every employee upon hire and at least once a year during annual Healthstream education.
b) by every physician and LIP upon appointment to the medical staff and upon reappointment
c) by every volunteer upon acceptance of a position and annually
d) by every contract employee at orientation and annually
e) by every Governing Board member upon acceptance of their position and annually
The hospital and medical staff leadership will engage and support education of this policy as well as how to address intimidating and disruptive behaviors to include skills training. These leaders will be expected to be role modelsby their actions and their enforcement of the Code of Conduct.
Procedure for addressing disruptive/inappropriate behavior:
When disruptive/inappropriate behavior is identified or staff believe it has occurred, the following steps shouldbe taken:
1. Staff may immediately address the person causing the disruptive behavior. This maybe most effectivein a "peer to peer" situation and only when the staff feel safe addressing the person and the situation. OR
2. Staff shall inform their manager or department chair/service chief within one business day after the occurrence.
3. The manager or department chair/service chief shall meet with the person identified as disruptive and the person(s) involved in the situationas soon as possible after the event occurred to discuss the situation andagree upon anacceptable resolution. If resolution is not achieved go to step 4.
4. The above parties shall meet with the appropriate Vice-President(s) and/or the President of the Medical Staff and/or Chief Medical Officer. Upon acceptable resolution of the situation, the appropriate hospital and medical staff leadership currently involved shall be responsible for assuring that recommendations made in the resolution of the situation will be implemented and enforced and that there is no recurrence of a similar situation involving the disruptive staff. (see "Retaliation" section below)
5. If an issue cannot be resolved in steps 1 through 4 the following actions shall be taken:
a. For employees, volunteers and contract staff: If recommendations for disciplinary actions are made with input from the involved Vice President(s), the Vice President of Human Resources must be contacted and relevant HR policies will be followed.
b. For physicians and other LIPs: The department chair, President of the Medical Staff or Chief Medical Officer shall refer the situation to the Professional Review Committee (PRC) for further review and resolution. Recommendations made by the PRC may be cause for corrective action and the process in the Medical Staff Bylaws will be followed.
Issues involving members of the Governing Body will be addressed by the CEO and the Chairman of the Board or designee.
Documentation:
All situations of disruptive behavior must be documented. Supervisors, managers and/or medical staff leaders shall assist hospital and medical staff with the documentation as necessary. Any witness to the situation will also document what they witnessed and those statements will be attached to the original form. The original documents will be filed with the manageror department chair as appropriate. If steps 5 a or b are necessary, all documentation shall be filed in the employee file in HR Department or in the PCA Department if a physician or LIP is involved.
No Retaliation:
Any hospital or medical staff, volunteer, Governing Board member, contract staff, patient or visitor has the right and responsibility to address disruptive and inappropriate behavior as detailed in this policy. Anyone who believes that as a result of addressing disruptive or inappropriate behavior they see or have experienced retaliatory behavior (for example, threats, angry exchanges, negative comments, refusal to answer a question) must immediately inform the HR Department if the behavior is related to an employee, volunteer, contract staff or Governing Board member or the PCA Department if the behavior involves a physician or LIP. Retaliatory behavior will not be tolerated and may result in disciplinary action for employees or members of the medical staff.
Reference:
The Joint Commission Comprehensive Accreditation Manual for Hospitals, 2009 Edition
The Joint Commission Sentinel Event Alert, Issue 40, July 9, 2008
“Disruptive Clinician Behavior: A Persistent Threat to Patient Safety”, Patient Safety & Quality Health Care; July/August 2006
Emerson Hospital Medical Staff Compact, January 13, 2009
Relevant Policies:
Code of Organizational Behavior & Ethics, Emerson Hospital Administrative Manual
Disciplinary Procedure; Emerson Hospital Human Resource Manual
Harassment/Sexual Harassment; Emerson Hospital Human Resource Manual
DATES:
Implemented:
Administrative Policy Approvals:
Quality and Patient Safety Council: February 26, 2009
Medical Executive Committee: March 17, 2009
Board of Directors: April 28, 2009;
Adopted Board Policy & Procedure: May 26, 2009
Documentation for Addressing Inappropriate Behavior
Date of Occurrence: Unit/Department:
Staff/Physician/Board Member Involved:
Description of Incident: ______
Statement of Concerns: ______
______
______
Action(s) Taken To Address Concerns:
______
Board Member/Manager/Chief/Chair Completing Report:
Copies sent to:
Additional follow-up necessary: _____yes _____no
Person assigned to follow-up: ______
If yes, detail follow-up/actions
______
WHEN THE ISSUE IS DOCUMENTED PLEASE SEND TO THE BOARD CHAIRMAN. IF RECOMMENDATIONS FOR DISCIPLINARY ACTIONS ARE MADE AND THE FORM IS COMPLETED, FORWARD TO THE PATIENT CARE ASSESSMENT DEPARTMENT IF IT IS TO BE REFERRED TO THE PROFESSIONAL REVIEW COMMITTEE.
Board Policy #22. Board Code of Conduct
Effective Date: May 26, 2009; Updated: June 28, 2011; November 27, 2012
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