POLICY & PROCEDURE MANUAL
/ SECTION: 300 - PERSONNEL
SUBJECT: DISRUPTIVE BEHAVIOR
PURPOSE
· To uphold the goal of the Public Health Trust (PHT) and Jackson Health System (JHS) to create and maintain a culture of safety, and quality. This policy is intended to define and describe actions and behaviors which hinder or do not contribute to that goal, and to describe the means by which such actions and behaviors will be addressed.
· To establish the general policies and procedures regarding personal conduct that all JHS employees must follow as a condition of employment.
· To ensure that all individuals working at the Jackson Health System (JHS) (including management and non-management, clinical and administrative staff, licensed independent practitioners, governing body members, contract/agency workers, students, volunteers, physicians, residents, other practitioners as defined by the Medical Staff Bylaws, and all others who represent JHS conduct themselves in a professional, collaborative and appropriate manner while providing services to patients and the public.
· To provide a formal procedure for further investigation and resolution of inappropriate conduct and disruptive behavior displayed in the work place.
POLICY
This policy requires that all individuals working at the Jackson Health System treat others with respect, courtesy, and dignity through teamwork and to conduct themselves in a professional manner. These standards of behavior safeguard the JHS tradition of strong moral and legal standards. Behavior resulting in a complaint from a medical staff member, a member of the hospital clinical or administrative staff, individuals in contact with the medical staff members, employees at the hospital, visitors or patients and their family members, will be responded to according to this policy. JHS maintains a zero tolerance approach towards intimidating, disruptive, and illegal behaviors that may contribute to a work environment that may impact staff or patient safety quality of patient care or represent criminal acts.
JHS leadership is committed to providing education to all individuals working at the JHS on safety and quality as well as defining acceptable versus disruptive and inappropriate behavior during new hire orientation, department/unit specific orientation, via corporate intranet communications, during annual mandatory testing and reinforcement during annual performance reviews.
JHS is committed to holding all individuals working at the JHS accountable for their behavior, and is committed to enforcing the Disruptive Behavior policy in a consistent and equitable manner.
JHS will maintain a system to detect and receive reports of unprofessional and disruptive behavior within the context of organizational commitment to the health and well-being of all staff and patients.
BEHAVIORAL EXPECTATIONS
Basic performance and behavioral expectations of all health care employees are based on generally accepted standards of professional conduct, federal, state, and local laws; standards set by regulatory and accrediting bodies such as the Centers for Disease Control/NIOSH, The Department of Labor/OSHA, the Joint Commission, the Centers for Medicare & Medicaid (CMS), the American Medical Association, the American Association of Medical Colleges, the Office of Inspector General (OIG) and the JHS Medical Staff Bylaws and corporate policy.
The Jackson Health System’s Mission, Vision, Values and Credo uphold these basic standards and govern the additional expectation that governance, leadership and all employees will work collaboratively toward the goal stated in our organizational principles: to make Jackson a place where patients want to come for service, a place where physicians want to refer patients, and a great place to work, by putting the needs of all people we serve – internally and externally – first. All individuals working at the JHS will help achieve this goal by maintaining a focus on safety, teamwork, courtesy, professionalism, competence and compliance while living the Jackson Values.
Disruptive Behavior Defined
All individuals working at the JHS are expected to conduct themselves in a manner supportive of a safe working environment. Contrary and disruptive behaviors will be addressed according to JHS policy. Disruptive behavior is defined as behavior that has a negative impact on the workplace environment. This includes, but is not limited to, verbal or non-verbal conduct that: (1) is violent or threatening to any other person, (2) negatively affects quality of patient care and/or disrupts the operation of the healthcare setting, (3) affects the ability of others to do their jobs, (4) creates a hostile work and/or care environment for JHS employees, medical staff or patients, (5) interferes with an individual’s ability to practice competently, or (6) adversely affects or impacts the community’s confidence in JHS’ ability to provide quality patient care.
Specific examples of “inappropriate conduct” include, but are not limited to, a pattern or series of related factors that can be either the result of conscious intention, unconscious neglect, and/or a lack of knowledge that disturbs another employee’s day-to-day interpersonal surroundings and as supported by facts and circumstances, such as:
1. Overtly negative attitudes, communications, and behaviors that result in others feeling threatened, belittled, devalued, humiliated, frightened, intimidated, or demoralized, or which undermines an individual’s confidence in his/her own ability to provide quality patient care.
2. Inappropriate comments or behaviors directed toward others, inconsiderate responses to patient needs, staff requests, or derogatory comments about organizational requirements and policies.
3. Behavior which jeopardizes quality patient care or the ability of others to provide quality patient care, including physical or verbal abuse of patients, employees, physicians and/or others involved in the provision of patient care.
4. Deliberate violation of organizational policies without adequate evidence to support the alternative chosen.
5. Profane or disrespectful language that has the effect of intimidating or suppressing input from other members of the healthcare team, or the use of such language while on JHS premises, or while speaking with other JHS personnel.
6. Sexual harassment including, but not limited to; sexual comments or innuendos or inappropriate physical contact with another individual.
7. Racial or ethnic jokes, slurs, or comments.
8. Demeaning behavior consisting of name calling, degrading or demeaning comments to patients, their families, or JHS medical staff or employees derogatory comments about the quality of care provided by other staff or by the JHS.
9. Outbursts of anger by themselves or eruptions which lead to acts of violence toward others (such as physical contact or throwing of objects) or destruction of property.
10. Retaliation, as described in the Non-Retaliation section of this policy.
11. Workplace Bullying, defined as the tendency of individuals or groups to use persistent aggressive or unreasonable behavior against a co-worker or subordinate including systematic aggressive communication, manipulation of work, and acts aimed at humiliating or degrading one or more individuals.
12. A dissenting opinion, in itself, does not constitute disruptive behavior.
A. RESPONSIBILITIES/PERFORMANCE IMPROVEMENT
It is the responsibility of all individuals working at the JHS who are witnesses to the type of behavior described in this policy to report the behavior according to the process outlined in the Reporting Procedures section below.
The medical and hospital leadership are expected to promote continuing awareness of this policy among the medical staff and other hospital staff, to include the following efforts:
· Sponsoring or supporting educational programs on disruptive behavior to be offered to medical staff members and hospital employees.
· Disseminating this policy to all current hospital employees and medical staff members upon the adoption of the policy and to all new hospital employees and members of the medical staff upon beginning employment or joining the medical staff.
· Disruptive behavior complaints brought against non JHS/PHT medical staff members will be processed according to the Medical Staff Bylaws. Complaints against JHS hospital employees or any other individuals providing services at Jackson or for Jackson will be processed through Human Resources Capital Management according to this policy.
· JHS leadership, through the Quality Division, will monitor and evaluate the effectiveness of this policy on an ongoing basis. Evaluation may involve review of data assessments and analysis from Incident Reporting and Satisfaction Surveys.
B. REPORTING PROCEDURES
The incident reporting process may be used to report complaints involving disruptive behavior.
1. Complaints about a non JHS/PHT medical staff employee regarding alleged disruptive behavior should be provided in writing, signed, and directed to the Chief Medical Officer.
2. Patients, patient family members, visitors, students, and volunteers may bring a complaint against a JHS employee to the employee’s immediate supervisor (if known), or to the Patient Relations Department. A written report by the complainant will be encouraged. If the complainant is unable or unwilling to provide the complaint in writing, then the immediate supervisor or Patient Relations will prepare a written report which (1) indicates that the complainant was unable or unwilling to prepare a written report and provides the reasons given for the inability or unwillingness on the part of the complainant; and (2) includes a description of the issue/events as verbally reported.
· Patient Relations shall coordinate its inquiry efforts with Employee Labor Relations.
C. EMPLOYEE AND SUPERVISOR RESPONSIBLITIES FOR HANDLING COMPLAINTS
1. In the case of disruptive behavior or allegations of discrimination, sexual harassment, sexual misconduct or retaliation, the employee or supervisor should:
a. Contact Employee Labor Relations as soon as possible. Employee/Labor Relations will provide the employee with a complaint form to be completed and signed by the employee and enter the information into an electronic tracking system. They will determine if an investigation is warranted, and who should conduct the investigation. (Attachment A – Complaint Form), or
b. Call the Compliance Hotline.
2. Employee/Labor Relations will collaborate with Risk Management in accordance with applicable procedure.
3. If it is determined by Employee/Labor Relations that the departmental supervisor is to complete the internal inquiry, the complaint inquiry process will include a full review of the situation including the performance history of the parties involved (the individual bringing the complaint as well as the person named in the complaint), interviews with witnesses and involved parties, and a consideration of all factors which are deemed relevant to the inquiry.
4. At the conclusion of the inquiry process, Employee/Labor Relations will prepare a “Disposition of Complaint Summary” as set forth in Attachment C which will provide a Summary of the Complaint, Alleged Rule Violations(s), Disposition of the Complaint and Recommendations, and forward the Memorandum to the respective Vice President or designee.
The memorandum should include the following details:
· Summary of Complaint: Brief summary of the incident. Must set forth the date the complaint was received, date(s) of alleged incident(s); the complainant and subject names; witness name(s), written reports/statements and all facts pertinent to the disposition of the inquiry.
· Alleged Policy Violation(s): Cite the policy, rule or procedure violation.
· Disposition of the Complaint: The following classifications will be used:
a. Sustained: The allegation is supported by sufficient evidence to indicate that the employee committed one or more of the alleged acts, or the inquiry disclosed other acts of misconduct.
b. Not Sustained: There is insufficient evidence to sustain the complaint.
c. Unfounded: The complainant admits to making a false allegation, the charge is false or not factual or the accused employee was not involved in the incident.
d. Policy Failure: The allegation is true, but the employee was acting in a manner consistent with JHS Policies, necessitating a review and revision of the policy as written. A finding of policy failure must clearly detail how the policy is incorrect and make recommendations for correcting that policy.
· Additional Findings: If during the inquiry, additional information or other administrative issues that need to be resolved are uncovered, this new information should be reported.
· Performance History of Parties: (subject and complainant): Check personnel file, Employee/Labor Relations, and Risk Management for similar complaints that have been sustained. If yes, then list complaints, date and disciplinary actions awarded to the employee(s).
· Recommended Corrective Action:
a. If discipline is to be recommended in accordance with Policy #305, list the name of each concerned employee and the disciplinary action recommended.
b. If remedial action is to be recommended (e.g. informal or formal counseling, performance improvement plan, training), list the name of each employee and the remedial action recommended.
D. GUIDELINES FOR HANDLING DISRUPTIVE AND INTIMIDATING BEHAVIOR IN THE WORKPLACE
In addition to taking the above steps, supervisors can use the following as a guide for classifying disruptive behavior and possible interventions:
Types of Disruptive Behavior and Available Interventions:* (See Attachment D)
*If there is doubt about how to address any type of disruptive behavior, consult with Security and/or Employee/Labor Relations.
1. Disruptive personal or professional disagreements that do not harm the integrity of the relationship.
a. Intervention: Direct coaching, mediation, workplace consultation, Employee Work/Life Services-EAP assistance available as appropriate to the situation.
2. Offensive jokes, graffiti, off-color language, gestures, unusual silence or angry outbursts, blaming.
a. Intervention: Performance management, Leadership and Organizational Training, Consultation with Security, Employee/Labor Relations and/ or Employee Work/Life Services-EAP appropriate to situation.
3. Odd or bizarre behavior, reports of “fear from staff”, but no specific threats.
a. Intervention: Contact Employee/Labor Relations to determine next steps. Discretionary contact of the Behavioral Risk Management Team to determine the next step depending upon the severity of the situation, or consider Performance Management, Leadership and Organizational Training, Employee Labor Relations, Employee Work/Life Services-EAP and/or Occupational Health Services consultation, and/or refer for a fitness-for-duty evaluation as indicated.
b. Any employee who engages in explosive outbursts or who makes verbal non-specific threats that put others around them in fear of harm and/or disruption to the workplace, may be placed on administrative leave and is subject to disciplinary action up to and including termination.
4. Harassment and discrimination, verbal, physical, and written threats, exhibiting unwanted attention toward another individual via phone, electronic mail, fax, etc., or conduct behaviors that constitute stalking.