EPIC/AIM

POLICY DESCRIPTION: Inappropriate Conduct / CATEGORY:
APPROVED DATE: / REFERENCE NUMBER:
APPROVED BY: / REVISION DATE:
EFFECTIVE DATE: / PAGE: 1 of 3
WRITTEN DATE:May 11, 2005 / RETIRED:
SCOPE:All independent contractors and employed physician/mid level providers working at facilities that EPIC/AIM staffs. All employees and/or independent contractors employed by EPIC/AIM performing administrative duties.
PURPOSE: The purpose of this policy is to reaffirm EPIC/AIM’s ongoing commitment to non-discriminatory practices and to specifically address the issue of inappropriate conduct.
POLICY:
  1. All physicians and employees of EPIC/AIM must treat others with respect, courtesy and dignity and conduct themselves in a professional and cooperative manner. This policy is intended to address conduct, which does not meet the standards. In dealing with incidents of inappropriate conduct, the protection of patients, employees, physicians and others in the hospitals and within EPIC/AIM is paramount.
  2. For purposes of this policy examples or “inappropriate conduct” include, but are not limited to, the following:
a)Threatening or abusive language directed at nurses, hospital personnel, EPIC/AIM employees or other physicians (e.g. belittling, berating, and/or threatening another individual);
b)Degrading or demeaning comments regarding patients, families, nurses, physicians, EPIC/AIM employees, hospital personnel or the hospitals;
c)Profanity or similarly offensive language while in the hospital and/or while speaking with nurses or other hospital personnel;
d)Inappropriate physical contact with another individual that is threatening or intimidating.
e)Public derogatory comments about the quality of care being provided by other physicians, nursing personnel or the hospitals; and/or
f)Inappropriate medical record entries concerning the quality of care being provided by the hospital or any other individual.
  1. Conduct that may constitute sexual harassment shall be addressed pursuant to EPIC’s Sexual Harassment Policy.
  2. The policy outlines collegial steps (i.e. warnings and meetings with a practitioner) that can be taken in an attempt to resolve complaints about inappropriate conduct exhibited by practitioners. However, there may be a single incident of inappropriate conduct, or a continuation of conduct, that is so unacceptable as to make such collegial steps inappropriate and that requires immediate disciplinary action. Therefore, nothing in this policy precludes immediate referral to the CEO, CCO or EPIC Board or elimination of any particular step in the policy in dealing with a complaint about inappropriate conduct.
  3. This policy is intended to be supportive of all individual hospital policies and shall not supercede any hospital policy or medical staff bylaws.

PROCEDURE:
  1. Any individual who observes or is subjected to inappropriate conduct by any EPIC/AIM physician or employee shall immediately notify the EPIC CEO, CCO or appropriate Emergency Department Chief. Upon learning of such conduct the CEO, CCO or Department Chief shall request that the individual who reported the incident document it in writing.
  2. The documentation shall include:
a)The date and time of the incident;
b)Factual description of the questionable behavior;
c)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;
d)The circumstances which precipitated the incident;
e)The names of other witnesses to the incident
f)Consequences, if any, of the behavior as it relates to patient care personnel, or hospital operations; and
g)Any action taken to intervene in, or remedy the incident.
  1. The report shall immediately be forwarded to the CEO, CCO, Compliance Committee and the appropriate Emergency Department Chief. Under the direction of the CEO, an investigation of the incident and allegations will be undertaken immediately.
  2. if it is determined that an incident of inappropriate conduct has occurred, the CEO and/or the CCO (or their respective designees) and the appropriate Department Chief shall meet with the practitioner or employee. This initial meeting shall be collegial, with the goal of being helpful to the practitioner in understanding that certain conduct is inappropriate and unacceptable. During the meeting, the practitioner shall be advised of the nature of the incident that was reported and shall be requested in provide his/her response concerning the incident. The practitioner shall also be advised that if the incident occurred as reported, his/her conduct was inconsistent with standards of the hospital. The identity of the individual preparing the report of inappropriate conduct will not be disclosed at this time, unless the CEO and the Department Chief agree in advance that it is appropriated to do so. In this case, the practitioner shall be advised that any retaliation against the person reporting the incident will be grounds for immediate exclusion from all EPIC/AIM facilities.
  3. This initial meeting can also be used to educate the practitioner about administrative channels that are available for registering complaints or concerns about quality or services, if the individual’s explanation suggests that such concerns led to the behavior. Other sources of support or counseling can also be identified for the practitioner, as appropriate.
  4. the practitioner shall be advised that a summary of the meeting will be prepared and a copy provided to him/her. The practitioner may prepare a written response to the summary, both of which shall be kept in the confidential portion of the physician’s credentialing file.
  5. The EPIC Board shall be concurrently apprised of all incidents, investigations and conclusions.
  6. If another report of inappropriate conduct involving the practitioner is received, and after investigation is found to have merit, a second meeting shall be held. It is advisable that at least three people (e.g. the CEO, CCO, Department Chief, EPIC Board member, or other physician) be present to meet with the practitioner. At this meeting the practitioner shall be informed of the nature of the incident and be advised that such conduct in unacceptable. The practitioner shall be advised that if there is a future complaint about inappropriate conduct, the matter will be referred to the EPIC Board and to the Compliance Committee for more formal action. A Letter shall be sent to the practitioner confirming the substance of the meeting, a copy of which shall be kept in the confidential portion of the practitioner’s credentialing file (along with any response submitted).
  7. In the event there is a third established incident of inappropriate conduct, the practitioner shall be given a final written warning that the inappropriate conduct will not be tolerated. (A meeting may, but is not required to be held with the practitioner and appropriate leaders.) The letter shall describe the inappropriate conduct, outline the steps that have been taken in the past to correct that conduct, and detail the kind of behavior that is acceptable and unacceptable. The letter should also confirm the consequences of an additional incident of inappropriate conduct, including, but not limited to probation, exclusion from all EPIC/AIM facilities for a period of time and/or a request that a formal investigation be commenced by the EPIC board. The letter will define the conditions of continued practice at the EPIC/AIM facilities. The practitioner shall be required to sign the letter. If the practitioner refuses to sign the letter, the CEO or CCO shall request that a formal investigation be commenced by the EPIC board.
  8. A single additional incident may result in immediate exclusion from all EPIC/AIM facilities or other disciplinary action as deemed appropriate by the CEO, CCO and the EPIC Board of Directors. A formal investigation by the EPIC board will be commenced at this time. Any further action, including any hearing or appeal shall be conducted under the direction of the EPIC board.
  9. If the practitioner continues to engage in a pattern of inappropriate conduct, the practitioner may be excluded from all EPIC/AIM facilities pending the formal investigation by the EPIC board and any related hearing and appeal that may result. Such exclusion is not a suspension of clinical privileges, even though the effect is the same. Rather, the action is taken to protect patients, employees, physicians and others on the hospital’s premises from inappropriate conduct and to emphasize to the practitioner the most serious nature of the problem created by such conduct. Before any such exclusion, the practitioner shall be notified of the event or events precipitating the exclusion and shall be given an opportunity to respond in writing and to demonstrate that acceptable standards of conduct have not been violated. However, to ensure that there is not inappropriate delay in addressing the concerns, the practitioner must submit any response within three days of being notified.
  10. In order to effectuate the objectives of this policy and except as otherwise may be determined by the CEO and CCO the practitioner has no right to have counsel attend any of the meetings described above.

REFERENCE: