MedicalCenter
Medical Staff
POLICY AND PROCEDURE MANUAL
EFF. DATE: 11/24/97 POLICY: MS 5.1.3
RVSD/RVWD DATE:PAGE 1 of 3
2/01, 11/03DEPT.: Medical
TITLE:DISRUPTIVE MEDICAL STAFF MEMBER
PURPOSE:To ensure optimum patient care by promoting a safe, cooperative and professional health care environment; and, to prevent or eliminate, to the extent possible, conduct that disrupts the operation of ______Medical Center or affects the ability of others to do their jobs, creates a “hostile work environment” for Hospital employees or other Medical Staff Members, or interferes with an individual’s ability to practice competently.
POLICY:______MedicalCenter is committed to fostering a collegial work environment in which all individuals within its facilities are treated courteously, respectfully, and with dignity. To that end, the Hospital Board requires that all individuals, employees, and Medical Staff Members conduct themselves in a professional and cooperative manner at the Hospital. Egregious incidents such as assault, battery, felonious acts, fraudulent acts, stealing, throwing equipment/records, or inappropriate physical or verbal behavior may subject a Medical Staff member to immediate disciplinary action or termination of Medical Staff Membership. This policy outlines the procedures dealing with the disruptive conduct of Medical Staff Members.
GUIDELINES:
Incidents will be initially handled as provided in this policy, although, a single egregious incident or repeated incidents can result in initiation of investigatory action pursuant to Article VIII, Part D, of the Medical Staff Bylaws.
Unacceptable disruptive conduct may include, but is not limited to, behavior such as:
- Attacks (verbal or physical) leveled at other appointees to the Medical Staff, Hospital personnel or patients which are personal, irrelevant or go beyond the bounds of fair professional conduct;
- Impertinent and inappropriate comments (or illustrations) made in patient medical records or other official documents, impugning the quality of care in the Hospital, or attacking particular physicians, nurses, or Hospital policies;
- Non-constructive criticism, addressed to it’s recipient in such a way as to intimidate, undermine confidence, belittle or imply stupidity or incompetence; and
- Refusal to accept medical staff assignments, or to participate in committee or departmental affairs.
______MedicalCenter
Medical Staff
POLICY AND PROCEDURE MANUAL
EFF. DATE: 11/24/97 POLICY: MS 5.1.3
RVSD/RVWD DATE:PAGE 2 of 3
2/01, 11/03DEPT.: Medical
PROCEDURE:
Any physician, hospital employee, patient, or visitor that has observed or been the victim of conduct that constitute disruptive conduct may report the matter and the following steps should be taken:
Step One: Use the attached form to report all incidents of questionable behavior. Answer all questions in as much detail as possible. All reports will be kept confidential and shall include the following:
- the date and time of the disruptive behavior;
- the name of the patient if the disruptive behavior affected or involved a patient in any way;
- the circumstances which precipitated the situation;
- a description of the disruptive behavior limited to factual, objective language as much as possible;
- the consequences, if any, of the disruptive behavior as it relates to patient care or hospital operations;
- a description of any action taken to remedy the situation including date, time place of action, and name(s) of those intervening.
- a recording of known witnesses to the event(s)
Step Two:
All reports should be submitted to the Medical Staff Office, Chief Medical Officer (CMO) or Department Manager. Once received, any reports not initially submitted to the CMO shall be forwarded to the CMO. The Chief Medical Officer, in consultation with the President of the Medical Staff, will investigate any report. The Chief Medical Officer may dismiss reports that are not founded. The individual initiating the report will be apprised within 30 days. In situations where the report is found to constitute a credible report of disruptive behavior, the physician shall be required to meet with the Chief Medical Officer or his designee.
Step Three:
At the meeting, the physician shall be advised of the complaint(s) and shall be given an opportunity to respond. If at the conclusion of that discussion, the Chief Medical Officer or his designee is convinced that the reported act(s) did occur, the physician shall be advised that such disruptive conduct is inappropriate and must cease. The initial approach should be collegial and designed to be helpful to the physician and the Hospital. The physician should be given an opportunity to voluntarily cease the disruptive conduct that gave rise to the complaint(s) and, if appropriate, to apologize to the individual(s) involved. The individual who reported the disruptive conduct shall be informed of the corrective action taken within 30 days.
______MedicalCenter
Medical Staff
POLICY AND PROCEDURE MANUAL
EFF. DATE: 11/24/97 POLICY: MS 5.1.3
RVSD/RVWD DATE:PAGE 3 of 3
2/01, 11/03DEPT.: Medical
Step Four:
If it appears to the Chief Medical Officer and/or President of the Medical Staff that a pattern of disruptive behavior is developing, the Chief Medical Officer or his designee shall meet with the physician and emphasize that if such repeated behavior continues, more formal action will be taken to stop it. All such meetings shall be documented and the Medical Staff Executive Committee and the Chief Executive Officer will be notified. A follow-up letter to the physician shall state the problem and shall instruct the physician that he/she is required to behave professionally and cooperatively within the Hospital. The physician may submit a written rebuttal to the charge, which shall be maintained as a permanent part of the quality file.
Step Five:
Any further confirmed incidents of disruptive behavior shall result in the institution of formal action in accordance with Article VIII – Part D of the Medical Staff Bylaws.
Documentation:
Records of reports,actions and resolutions, will be maintained in the quality file.
______MedicalCenter
Medical Staff
DISRUPTIVE MEDICAL STAFF MEMBERPOLICY AND INCIDENT REPORT
POLICY:
______MedicalCenter is committed to fostering a collegial work environment in which all individuals within its facilities are treated courteously, respectfully, and with dignity. To that end, the Hospital Board requires that all individuals, employees, and Medical Staff Members conduct themselves in a professional and cooperative manner at the Hospital. / ______MedicalCenter will not tolerate any form of retaliation against reporting individuals by the subject of the report or any other individual. All reports of retaliation will be investigated and penalties imposed against any individual taking any form of retaliation against a reporting individual.
INCIDENT REPORT
Instructions: Use this form to report all incidents of questionable behavior. Answer all
questions in as much detail as possible. Attach additional sheets if necessary.
All reports will be kept confidential.
Date of Report: Date and Time of the behavior:______Name of person committing the behavior:______
Name of any patient(s) that the behavior affected or involved in any way: ______
Describe the circumstances which precipitated the situation:______
______
______
______
Describe the behavior limited to factual, objective language as much as possible: ______
______
______
Describe the consequences, if any, of the behavior as it relates to patient care or
hospital operations:______
______
______
Provide the names of all witnesses to the behavior: :______
______
Describe any action taken to remedy the situation including date, time place of action, and
name(s) of those intervening:______
______
______
______
______