POLICY: The PHT is committed to providing medical care in an environment that is free from disruptive behavior. It is the responsibility of all members of the staff and medical staff of the Public Health Trust (PHT) to report any episodes of disruptive behavior that they have witnessed. It is the policy of the PHT that all personnel adhere to specific guidelines when handling complaints of disruptive behavior demonstrated by a Licensed Independent Practitioner (LIP) or other practitioner (MD, DO, Dentist, Oral Surgeon, Podiatrist, Chiropractor, Physician Assistant, Psychologist; or non-pht employed CRNA, ARNP, or CNM), hereafter known as: Practitioner. The initial goals of addressing disruptive behavior in a Practitioner are: (1) to help him or her take some responsibility for the behavior and acknowledge that he or she is at least part of the problem; and (2) to provide a safe environment for work and care for providers and patients in PHT facilities. This policy outlines the procedure through which disruptive behavior should be reported and appropriately recorded. While a single minor incident may not be sufficient for action other than collegial steps (counseling, warning, and meeting with the Practitioner), each individual report may help identify a pattern that requires intervention. However, a single egregious incident of inappropriate conduct, or continuation of conduct that is so unacceptable as to make such collegial steps inappropriate, may require immediate disciplinary action including immediate termination of the Practitioner or summary suspension of membership or clinical privileges of the Practitioner. Examples of such conduct include, but are not limited to, physical or sexual harassment, assault, a felony conviction, a fraudulent act, stealing, damaging hospital property, or inappropriate physical or verbal disruptive conduct. Further, this policy establishes a process to review or verify report of disruptive behavior and a means of monitoring whether a Practitioner s disruptive conduct improves after intervention. It is the intent of this policy to allow the Immediate by the Chief of Service), appropriate Director of Nursing, and/or Chief Medical Officer latitude to develop a plan for assessment and resolution that is deemed DATE: 02/2808/05 PAGE 1 of 7
appropriate, with the goal of achieving elimination of the Practitioner s disruptive behavior. DEFINITION: Disruptive behavior is defined as behavior that negatively impacts 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 Jackson Health System (JHS) employees, medical staff or patients, 5) interferes with an individual s ability to practice competently, 6) adversely affects or impacts the community s confidence in JHS s ability to provide quality patient care. Personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively constitutes disruptive behavior. This includes, but is not limited to, conduct that interferes with one s ability to work with other members of the health care team. However, constructive criticism that is offered in good faith through appropriate channels with the aim of improving patient care should not be construed as disruptive behavior. To aid in the definition of disruptive behavior, the collegial education of Practitioners, and in the enforcement of this Policy, specific examples of "inappropriate conduct" include, but are not limited to: a. Threatening or abusive language directed at patients, JHS personnel, or physicians (e.g., belittling, berating, and/or threatening another individual); b. Degrading or demeaning comments regarding patients, families, nurses, physicians, JHS personnel, or the Facility; c. Profanity or similarly offensive language while in JHS and/or while speaking with JHS personnel; d. Inappropriate physical contact with another individual; e. Derogatory or otherwise critical comments about the quality of care being provided, by JHS another Medical Staff member or any other individual, that are made outside of appropriate Medical Staff and/or administrative channels; DATE: 02/2808/05 PAGE 2 of 7
f. Inappropriate or otherwise critical medical record entries concerning the quality of care being provided by JHS or any other individual of JHS, other Healthcare Staff members or personnel; g. An unwillingness and/or inability to work cooperatively with other members of the Medical and Facility Staffs; and/or h. Making or threatening retaliation as a result of an individual s complaint about disruptive conduct. If a Practitioner fails to conduct himself/herself according to PHT Medical Staff Bylaws, Rules and Regulations, and/or PHT policies and procedures, the matter shall be addressed in accordance with the following policy. PROCEDURE: 1. All initial reports of alleged inappropriate Practitioner behavior should be written or verbalized to the appropriate Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer. 2. A written report by the complainant will be encouraged. If the reporter is unable or unwilling to do so, then the Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer will prepare a written report indicating that (1) the reporter was unable or unwilling to prepare a written report and the reasons; and (2) a description of the issue/event as verbally reported. The description shall include at a minimum: a. The date and time of the disruptive conduct; b. A statement of whether the disruptive conduct affected or involved a patient or a patient s family member in any way and, if so, the name of the patient, family member, and all witnesses; c. A description, limited to factual, objective language of the disruptive conduct and the circumstances involved; d. The consequences, if any, of the disruptive conduct as it relates to patient care or hospital operations; and e. A record of any action taken to remedy the situation, including date, time, place, action, and name(s) of those intervening. DATE: 02/2808/05 PAGE 3 of 7
3. The Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer will initiate an investigation into, or workplace assessment of, the occurrence to identify or rule out the existence of disruptive behavior. The Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer may seek the expert opinion of an impartial individual experienced in such matters. 4. The Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer has an affirmative duty to meet with the Practitioner to review the alleged behavior, the requirements of this policy and to allow the said Practitioner a forum to explain the alleged behavior. 5. At the completion of the investigation and/or assessment, the Immediate by the Chief of Service), Director of Nursing, and/or Chief Medical Officer shall determine whether the Practitioner engaged in disruptive behavior. If so, the Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer will assist the Practitioner in charting a course participating in an appropriate educational program (such as a healthcare-related anger management course) or other remediation plan for developing professional working relationships and resolving problems without disruptive behavior. The Immediate by the Chief of Service), Director of Nursing, and/or Chief Medical Officer will also develop a plan for monitoring the Practitioner s behavior and will document findings of these periodic reviews to the Practitioner s performance profile. a. The Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer may also educate the Practitioner about administrative channels that are available for registering complaints about quality or services, if the Practitioner's conduct suggests that such concerns led to the behavior. Field Code Ch DATE: 02/2808/05 PAGE 4 of 7
Other sources of support or counseling, such as the Employee Assistance Program, can also be identified for the Practitioner, as appropriate. b. The identity of an individual reporting a complaint of inappropriate conduct will generally not be disclosed to the Practitioner during these efforts, unless the Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer agrees in advance that it is appropriate to do so and obtains the consent of the person reporting the concerns. In any case, the Practitioner shall be advised that any retaliation against the person reporting a concern, whether the specific identity is disclosed or not, will be grounds for immediate disciplinary action pursuant to the PHT Medical Staff Bylaws, PHT Medical Staff Rules and Regulations, and PHT policies and procedures. 6. The Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer may meet with the person toward whom the disruptive behavior was directed, to advise that the situation has been addressed, without compromising the privacy and confidentiality of the Practitioner. 7. The Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service)/Director of Nursing/CMO shall prepare a written report of each meeting. 8. If any additional complaints are received or if it appears to the Immediate by the Chief of Service), Director of Nursing, and/or Chief Medical Officer that a pattern of disruptive behavior is developing with the Practitioner, the Immediate by the Chief of Service), Director of Nursing, and/or Chief Medical Officer shall: (1) designate a committee of appropriate practitioners to evaluate the behavior and make a recommendation as to how to deal with the behavior; and (2) shall meet with the Practitioner to discuss the matter as follows: a. Emphasize to the practitioner that such conduct is unacceptable and must stop immediately. DATE: 02/2808/05 PAGE 5 of 7
b. Notify the Practitioner that the committee will make a recommendation that the Practitioner will be notified of; 9. In addition, the Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service)/Director of Nursing/CMO shall insure that the following procedures will occur: a. The CEO and CMO will be notified; b. All meetings will be documented; All documentation of this meeting shall be placed in the performance profile of the Practitioner. Should the Practitioner refuse or fail to sign and return any documentation within a reasonable time, the Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, and/or Chief Medical Officer shall initiate further corrective action pursuant to the PHT Medical Staff Bylaws, PHT Rules and Regulations, and PHT policies and procedures, up to and including reporting to the state impaired practitioner program (Physician Recovery Network Program [PRN] or Intervention Project for Nurses [IPN]) and/or the State Medical Regulatory Agency/Board. Where a member of the medical staff is also a member of a collective bargaining unit, conflict in any provision of Articles VIII or IX of these Bylaws will be resolved in favor of the conflicting provision in the union contract; c. The Practitioner may submit a rebuttal to the charge, which shall be maintained in the Practitioner s permanent record; and d. The Practitioner may take other action in accordance with PHT Medical Staff By-laws, PHT Medical Staff Rules and Regulations and PHT policies and procedures, as appropriate given the severity of the behavior. 10. It may become necessary to refer the Practitioner for formal clinical and workplace assessment. Disruptive behavior may or may not overlap with psychiatric or medical diagnosis and/or other impairment, necessitating the evaluation. The evaluator will be required to develop a rehabilitative plan, if indicated, with which the Practitioner must comply. The Practitioner must also sign a release so that the Evaluator or other appropriate entity will provide periodic updates to the Immediate Supervisor, Chief of Service and/or Associate Chief of Service (if so designated by the Chief of Service), Director of Nursing, DATE: 02/2808/05 PAGE 6 of 7
and/or Chief Medical Officer to insure that Practitioner is complying fully with the rehabilitative plan. AUTHORIZATION: Marvin O Quinn, President, Public Health Trust DATE: 02/2808/05 PAGE 7 of 7