Revised: 7.19.2012

Manual:Human Resources

Policy #:HR-P450

Approval Date:

Effective Date:9/1/2012

Revision Date:7/2/2012

PHYSICIAN PROFESSIONAL CONDUCT

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  1. PURPOSE

IU Health Physicians (IUHP) values the immeasurable contributions of the outstanding physicians who model the organization’s Mission to deliver preeminent medical care and services to our patients. With such commitment to the Mission, IUHP is becoming a premier academic multi-specialty physician group. However, in those instances when conduct occurs that is in opposition to preeminent service, the organization may find it necessary to intervene. The purpose of such intervention is topromote a culture of professional conduct for all physicians to support teamwork, to create a positive workplace environment, to foster the effective delivery of safe, compassionate, and quality patient care, and to establish a consistent and effective approach for addressing disruptive conduct in the workplace.

  1. SCOPE

AllPhysicians are covered by the scope of this policy. The Physician Professional Conduct policy addresses the behavior and conduct of physicians. Any issues with professional competence or patient care are addressed in the credentialing policy IU Health Physicians Provider Corrective Action, Fair Hearing and Appeal policy (CR-11119).

  1. DEFINITIONS
  2. Cup of Coffee Conversation – a brief, respectful, and non-judgmental informal conversation between colleagues that occurs when an episode of perceived unprofessional behavior occurs. The intent of the “cup of coffee conversation” is to create an awareness of the incident and the behavior that was inconsistent with IUHP Mission, Vision, Values and “Our Commitment” and thus minimize/eliminate such behavior.
  3. Disruptive Behavior includes, but is not limited to, words or actions that:
  4. Prevent or interfere with an individual’s or group’s work, performance, or ability to achieve intended outcomes. Examples include intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or criticizing other members of the team or the institution;
  5. A pattern of behavior that collectively leads to disruptive behavior;
  6. Include ‘passive/aggressive’ behavior as demonstrated by subtle verbal and non-verbal actions;
  7. Make inappropriate comments or actions about or directed toward anyone which are unethical;
  8. Include unprofessional conduct toward patients or their families or friends or visitors, including outbursts or language or attitude directed toward such individuals that are demeaning or insensitive;
  9. Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe environment including, but not limited to, use of language that is profane, vulgar, sexually suggestive or explicit, degrading, or racially/ethnically/religiously slurring in any professional setting; any unwanted touching or communication, sexually-oriented or degrading jokes or comments; obscene gestures;
  10. Any behavior which constitutes the physical or verbal abuse of others ;
  11. Threaten personal or group safety, such as aggressive or violent physical actions; physical throwing of objects; oral or written threats to a person or property, whether in person, over the telephone, by email or through other means of communication with anyone employed, affiliated with, or seeking services from or providing services to the IU Health System; or
  12. Involve inappropriate relationships with patients or staff.

For purposes of this policy, ”disruptive behavior” does not include issues involving professional competence or patient care that are directly covered by IUHP’s Provider Corrective Action, Fair Hearing and Appeal Policy (CR-11119).

  1. POLICY STATEMENTS
  2. IUHP appreciates and values the preeminent medical care and services our physicians provide to our patients and communities.
  3. IUHPexpects physicians will behave in a manner that is courteous, cooperative and professional which is consistent with the Mission, Vision, Values and “Our Commitment” statement of the organization. It is further expected that everyone treat patients, visitors, associates, medical staff, students, personnel, contractors and others, and each other with courtesy, respect and dignity.
  4. IUHP’s physicians are encouraged to engage each other in timely informal co-worker/collegial conversations (also known as “Cup of Coffee Conversations”) that describe observed or otherwise noted behaviors that appear to be inconsistent with IUHP’s Mission, Vision, Values, or “Our Commitment”, which are isolated and do not rise to the level of behaviors that would result in corrective action.
  5. IUHP fosters a culture that disapproves of and addresses unprofessional, inappropriate, intimidating, retaliatory, disruptive, threatening and violent behavior, or ‘disruptive behavior’ by its physicians. IUHP does not tolerate such behaviors and appropriately addresses suchbehavior through corrective action, including in certain instances termination of employment,to promote insight,accountability, and appropriate changes in behavior that support IUHP’s Mission, Vision, Values and goals.
  6. Disruptive behavior, or refusal to cooperate with the procedures described in this Policy,as well as failure to comply with contractual obligations or performance expectations outlined in each IUHP “Employment Agreement”,may result in corrective action and/or termination.
  7. Disruptive behavior occurs in varying degrees, which are classified into threelevels of severity. Level III behavior is the most severe violation of this Policy. Any intervention will be commensurate with the nature and severity of the disruptive behavior, as defined in Procedure Section V.b. Repeated instances of disruptive behavior will be considered cumulatively and action taken accordingly.
  8. Levels of disruptive behavior include:
  9. “Informal” Cup of Coffee – Collegial discussion between two peers to provide quick, non-judgmental feedback concerning a single episode of disruptive behavior.
  10. Level I “Awareness Intervention” – Single serious incident or repeated incidents of various disruptive behaviors.
  11. Level II “Guided Intervention” – Pattern of disruptive behaviors which have continued or increased in severity.
  12. Level III “Disciplinary Intervention – No change in pattern of disruptive behavioror a single egregious incident of disruptive behavior.
  13. Any IUHP associate, patient, or employee of an affiliate organization, including the Indiana UniversitySchool of Medicine (the “School”) may report disruptive physician behavior(s) by utilizing the “Confidential Report of Incident of Disruptive Behavior” form attached to this policy. IUHP prohibits retaliation against anyone who reports disruptive physician behavior(s). Any IUHP associate who believes he/she has been subject to or affected by retaliatory conduct should report his/her concern to the Executive Director of Human Resources or his/her designee.
  14. Any physician, who is placed on disciplinary action as outlined in Section V of this policy, will lose eligibility for the next Quality or Citizenship Bonus, which is typically earned in the current calendar year but payable in the following calendar year.
  15. Except for behaviors that may be addressed through Cup of Coffee Conversations, a physician’s Service Line Chief (SLC) or other appropriate IUHP representative is designated as the individual(s) in charge of addressing disruptive behavior. The SLC shall consult with Human Resources and/or Legal regarding disruptive behavior at Level I, Level II or Level III or that may warrant action resulting in a change in a physician’s assignment (e.g., suspension).
  16. In instances where IUHP physicians are assigned to work in a hospital setting that has clearly established protocol for addressing disruptive behavior, the hospital may investigate allegations that a physician has violated hospital policy in accordance with its procedures. However, IUHP reserves the right to evaluate, make independent judgment and take appropriate action about such disruptive behavior regardless of the hospital investigation and outcome.
  17. This policy shall not preclude the application of necessary actions to ensure a safe working environment or to prevent unlawful conduct.
  18. Depending upon the seriousness of the violation, the corrective action taken may lead to immediate suspension or be in the form of termination.
  19. For serious issues (some Level II and all Level III), IUHP may inform relevant partner organizations of the disruptive behavior as the behavior is discovered and reviewed. The outcome of the investigation may be shared with partner organizations.
  1. PROCEDURE
  1. Minor complaints or observed unprofessional behavior may be addressed directly by a peer or authority figure through a Cup of Coffee Conversation. More serious complaints about a physician regarding disruptivebehavior or a complaint about a pattern of disruptive behavior in violation of this policy must be in writing and directed to the Service Line Chief (or if the complaint is about the Service Line Chief then to such person’s supervisor) (see attached “Confidential Report of Incident of Disruptive Behavior” form). Based upon the severity and/or frequency, various disciplinary actions may result which include creating awareness, coaching, corrective action, zero tolerance letters, suspension, other mandated actions or referrals, or termination. Notwithstanding the procedures set forth in this Section V, the policies and procedures set forth herein shall not limit IUHP’s ability to assert and take action enforcing its contractual rights set forth in physician Employment Agreements nor restrict or prevent IUHP management from taking all steps it deems necessary and appropriate to respond to physician conduct, including without limitation termination of employment without application of the procedures set forth in this policy.
  2. The following levels of intervention are sanctioned by IU Health Physicians as appropriate responses to provide feedback to eliminate disruptive behavior:
  1. “Informal” Cup of Coffee Conversations where peers provide quick feedback concerning a single episode of unprofessional behavior. The intent of this conversation is to create an awareness of the incident and the behavior that was inconsistent with IUHP Mission, Vision, Values and “Our Commitment”, and, thus, minimize or eliminate the unprofessional behavior.
  2. Level I –“Awareness Intervention” includesa single serious incident or repeated incidents of various disruptive behaviors. These incidents will be addressed by the Service Line Chief, in consultation with Human Resources and Legal Counsel. The purpose of this intervention is to call awareness of the disruptive behavior and set expectations that the disruptive behavior not continue. If through discussion or investigation of Level I incidents it is determined that the incident is of such a serious or egregious nature, it may be elevated directly to Level III below.
  3. Level II – “Guided Intervention” includesincidents of disruptive behavior which have continued or increased in severity. These incidents will be addressed by the Service Line Chief, in consultation with Human Resources and Legal Counsel. Findings of such conduct will result in sanctions including some form of disciplinary action.
  4. Level III – “Disciplinary Intervention” includes a persistent pattern of disruptive behavior or a single egregious disruptive incident and will be reviewed and addressed by the Service Line Chief, in consultation with Human Resources and/or Legal. Findings of such conduct will result in sanctions including some form of disciplinary action (which may include termination). Level III incidents may be referred to the Medical Staff Office.
  1. At IUHP’s discretion, IUHP will coordinate with the School a response to disruptive behavior by a Physician who has an appropriate level faculty appointment with the School.
  1. RESPONSIBILITY

Service Line Chiefs and the Executive Director of Human Resources are responsible for the consistent application of this policy throughout the organization.

  1. AMENDMENTS

Amendments to this policy require authorization by the CEO and Chief Medical Executive.

VIII.CROSS REFERENCE

Credentialing Policy CR-11119 “Provider Corrective Action, Fair Hearing, Appeal”

IX.APPROVAL BODY

Administration

X.APPROVAL SIGNATURES

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John Kohne, MDDate

Chief Medical Executive

John Fitzgerald, MDDate

President and Chief Executive Officer

XI DATES

Approval Date:

CONFIDENTIAL

REPORT OF INCIDENT OF DISRUPTIVE BEHAVIOR

(Complete this form in its entirety and submit it to the Service Line Chief)

Date, Time and location of Incident

Date: ______

Time: ______

Location: ______

Description of Incident

Please describe the behavior observed as factually and objectively as possible, including the events, which precipitated the behavior, if known. Provide all relevant details. (Please continue on a separate page as needed)

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Others Present (include name(s), position, department, and contact information if known):

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Effect on Others Involved

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Did the behavior affect or involve a patient? ______Yes ______No

Please describe the effect of the clinician’s behavior on patient care.

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Action Taken

Was a supervisor, management, or any other person notified of the incident?

______Yes Name of person notified: ______

______No

Was any further action taken? ______Yes ______No

If yes, please provide date, time and description of action taken.

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Name of Person Reporting (optional): ______

Position ______

Date: ______

NDS01 1345223v1

Physician Professional Conduct

HR-P450

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