UPMC Passavant. Medical Staff & Other Health Professional Staff. Standards of Conduct and Professional Ethics

UPMC Passavant Medical Staff & Other Health Professional Staff Standards of Conduct and Professional Ethics

STANDARDS OF CONDUCT AND PROFESSIONAL ETHICS Each member of the Medical Staff and Other Health Professional Staff (collectively, the Credentialed Staff ) is responsible for maintaining the highest professional standards. Credentialed Staff members are expected to conduct themselves in a manner that reflects positively on themselves and UPMC Passavant. Respectful behavior toward colleagues, hospital staff, patients, family members, and visitors is appropriate at all times. UPMC recognizes the importance of open communication between healthcare providers and its direct correlation with patient safety and successful patient outcomes. All staff are to feel empowered to stop others and use the phrase, I need some clarity (System initiative) in the event that there is confusion or flawed communication. Condition Stop, a Department of Surgery policy, allows for the ability of any member of the surgical team to call condition stop when he or she believes that there is an issue with any part of the surgical events. However, any staff member may utilize this policy when he or she deems it appropriate during a procedure in any patient care setting. Members of the Medical Staff are required to comply with American Medical Association s Principles of Medical Ethics and the UPMC Physician Ethics Policy HS-PS0490. For all Credentialed Staff, honesty and cooperation in the peer review process are expected and required. In accordance with Article 2 of the Credentials Policy of the UPMC Passavant Professional Staff Bylaws, an application for appointment, reappointment, and/or clinical privileges will not be processed and the applicant will be ineligible to reapply if it is discovered that an applicant has made a misrepresentation or omission during the course of the application process. Further, should the misrepresentation or omission be discovered after the individual has been granted appointment and clinical privileges, such appointment and clinical privileges will be automatically relinquished. COMPLIANCE WITH THE LAW It is the responsibility of each member or the Credentialed Staff to follow, in the course and scope of their activities at UPMC Passavant, all applicable laws, rules, regulations, and hospital policies, and to maintain a healthcare and business environment that is committed to integrity and ethical conduct. PATIENTS Patient-Physician Relationship Credentialed Staff members must at all times maintain a professional relationship with patients, and must act in strict accordance with all professional guidelines (such as the American Medical Association, state licensing board, and board certifying society) regarding the relationship between patients and caregivers. Credentialed Staff members must abstain from obtaining personal gain at the patient s expense and refrain from inappropriate involvement in a patient s personal life. Credentialed Staff members must not deceive a patient as to the identity of any practitioner providing medical services. Credentialed Staff members must not delegate the responsibility for diagnosis or care of patients to another practitioner unless the practitioner is qualified to undertake this responsibility under the practitioner s scope of practice. 1

Patient Referrals If a referring physician, or his or her immediate family member, has an ownership or investment interest in, or a compensation arrangement with, the entity to which a patient is referred, and payment for the referred services will be made from a federal or state health care program, such as Medicare or Medicaid, a federal law, commonly referred to as the Stark Law, may prohibit the referral. No UPMC Passavant physician shall refer a patient for services in violation of the law. If a physician has questions about referrals, he or she may consult with the UPMC Legal Department. MEDICAL RECORDS AND BILLING Billing Claims should only be submitted for services that are believed to be medically necessary and have been ordered by a physician or other appropriately licensed professional. The Credentialed Staff shall provide for proper, accurate, and timely documentation of all physician and other professional services prior to billing to ensure that only accurate and properly documented services are billed. The diagnosis and procedures reported on a payment claim should be based on the medical record and other documentation, and the documentation necessary for accurate code assignment should be available to the coding staff. Appropriate Medical Record Documentation The medical records of patients must be maintained accurately to assist in providing quality patient care and to meet applicable regulatory requirements. The diagnosis sheet must be completed in a timely manner by the physician or designee and the diagnosis should reflect the diseases for which the admission and hospitalization was prompted, and those diseases which are pertinent to the hospitalization. Medical Record documentation is expected to maintain the highest standards of personal, professional, and institutional responsibility. Medical record documentation should be limited to appropriate details pertaining to the patient and the patient s medical care and treatment. The medical records are not to contain derogatory or slanderous remarks about other practitioners or other institutions. Sarcasm and argumentative language does not belong in the patient s medical record. Medical records are to be completed promptly. Delinquent medical records completion can result in fining and progressive corrective action leading up to suspension or non-renewal of privileges from the Medical Staff. Live signatures for orders should be legible, and contact names and contact numbers should be printed below the signature. Confidential Patient Information Medical records are strictly confidential and should not be released without the authorization of the patient or his or her legally authorized representative. UPMC Passavant prohibits disclosure of patient information to anyone other that authorized personnel. Practitioners may not discuss patients or their conditions or treatments with anyone not involved in the care of the patient. Practitioners may not access protected health information, including electronic health records, of persons (including spouses, children, relatives, and others) except as part of their patient care or job responsibilities or as appropriately authorized. Relevant Policies: HS-MR1000 Release of Protected Health Information HS-EC1602 Minimum Necessary Standard for the Use and Disclosure or Protected Health Information 2

Accuracy of Reports Licensed practitioners must exercise great care in verifying the accuracy of any written or oral report made to any entity paying for UPMC Passavant services, whether a governmental agency or other payer. Inaccurate reports to payers may expose the Institution, as well as the practitioner preparing the inaccurate report, to civil and criminal penalties. Documentation in the Teaching Setting Physicians involved in teaching residents should ensure that billings for professional services performed with resident involvement are in full accord with Medicare requirements regarding teaching physicians, including requirements as to documentation of personal involvement in the services provided. Relevant Policies: HS-PS0494 Professional Services Provided Incident to Medical Resident Education 42 Code of Federal Regulations, Section 412.1 and following COLLEAGUES AND HOSPITAL STAFF Required Communications On transferring unstable patients to UPMC Passavant, or transferring unstable patients within the hospital, communication with the accepting physician is required. Licensed practitioners are expected to cooperate in a professional manner with the Care Management Department and its representatives. Physicians who are on the UPMC Passavant Medical Staff are expected to be readily accessible for calls regarding patients in the hospital and to provide accurate contact information. THE WORKPLACE Drugs and Alcohol The unlawful manufacture, distribution, possession or use of a controlled substance on UPMC Passavant premises or while conducting UPMC Passavant business off premises is prohibited. Consumption of alcoholic beverages on UPMC Passavant premises is limited by policy. Health care professionals, including those who maintain Drug Enforcement Agency (DEA) registration, must comply with all federal and state laws regulating controlled substances. Any individual suspected of working under the influence of drugs or alcohol should be reported to a supervising individual immediately. The UPMC Employee Assistance Program and the Pennsylvania Medical Society Physician Health Program are resources available to assist. Relevant Policies: HS-HR0703 Drug Free Workplace HS-HR0743 Use of Alcoholic Beverages on UPMC Premises Harassment Harassment in any form is prohibited including harassment based on race, color, religion, sex, sexual orientation, national origin, age, or disability. Instances of any type of harassment should be reported to Hospital Administration. Relevant Policy: HS-HR0705 Harassment-free Workplace Workplace Violence Threatening acts and behavior in the workplace are prohibited. Firearms and weapons are generally prohibited on UPMC Passavant property. Threatening or hostile activity or behavior 3

should be reported to Hospital Administration. Regardless of how minor the situation might seem, you should report any suspicious activity. Relevant Policy: HS-HR0745 Workplace Violence Bronze Policy BUSINESS STANDARD Bribes/Kickbacks When someone who can influence purchasing decisions made at UPMC Passavant takes money or anything of value from a vendor, it can be considered a kickback which is illegal. Bribes and kickbacks of any kind are prohibited. Additionally, members of the UPMC Passavant community should be aware that if someone refers a patient to another provider and receives something of value in exchange, it can be considered a kickback. Anti-kickback rules also apply to the recruitment of physicians, recruitment of research subjects, the acquisition of physicians practices, and other contractual arrangements. The anti-kickback laws are extremely broad and the penalties are severe. You may contact UPMC Corporate Legal Department if you have any questions. Relevant Policies: HS-MM0300 Guidelines for Purchasing HS-LE0003 Contracted Services Legal Review of Contractual Agreements Conflict of Interest Members of the Credentialed Staff who interact with persons or companies doing business with UPMC Passavant must do so in a reputable, professional, and legal manner. You have an obligation to disclose conflicts of interest, as well as situations that may appear to be a conflict. Relevant Policy: HS-EC1700 Conflict of Interest-General Obligations HS-EC1702 Policy on Conflicts of Interest and Interactions between Representatives of Certain Industries and Faculty, Staff, and Students of the Schools of the Health Sciences and Personnel Employed by UPMC at all Domestic Locations Research Integrity Members of the Credentialed Staff who participate in research involving UPMC Passavant facilities or UPMC Passavant patients must abide by legal requirements concerning conduct of research and the requirements of the University of Pittsburgh Institutional Review Board. Credentialed Staff participating in US Public Health Service extramural research awards must abide by federal requirements related to such awards. Credentialed Staff must be aware of and disclose potential conflicts of interest in research. Examples of such conflict include undertaking research when the investigator or his or her immediate family member has a financial, managerial, or ownership interest in the sponsoring company or in the company producing the product tested. Relevant Policy: HS-EC1701 Conflicts of Interest in Clinical Research Confidentiality Confidential or proprietary information developed or acquired by UPMC Passavant that is not generally available to others is an asset of the Institution and must be kept confidential and protected against theft, loss, or improper disclosure. Relevant Policy: HS-HR0736 Confidential Information 4

UPMC ETHICS AND COMPLIANCE OFFICE UPMC Passavant, through the UPMC Ethics and Compliance Office, maintains a help and reporting phone line (1-877-983-8442) to enable Credentialed Staff to report violations and to discuss any questions. To assist the Institution with its commitment to appropriate conduct, all Credentialed Staff are encouraged to report violations of any law or policy to a supervisor or a Compliance Officer. It is the duty of all Credentialed Staff to report job-related criminal conduct of which they have actual knowledge or job-related situations that endanger the health and safety of any individual to the appropriate supervisor or the Compliance Office. All persons making such reports are assured that such reports will be treated as confidential; such reports will be shared with others only on a bona fide need-to-know basis. UPMC Passavant will take no adverse action against persons making such reports in good faith. UPMC Passavant prohibits retaliation against persons who make such reports in good faith. False accusations made with the intent of harming or retaliating against another person can subject the accuser to disciplinary action. Code of Conduct Reporting and Corrective Action The following procedure outlines collegial and educational efforts that may be followed in an attempt to resolve complaints about inappropriate conduct exhibited by Credentialed Staff. However, there may be a single incident of inappropriate conduct, or a pattern of conduct, in response to which this informal collegial process may be deemed inappropriate and that warrants immediate disciplinary or other action that varies from the procedures set forth in this policy. Therefore, this procedure is to be construed as only one of many possible ways in which to deal with inappropriate conduct and does not establish any right on the part of any Credentialed Staff to be dealt with in compliance with this policy or procedure in whole or in part. Nothing in this policy precludes a referral to the Medical Staff Executive Committee of the Board at any time, the elimination or modification of any particular step in the process outlined in this policy or any other action by the hospital or medical staff in response to a complaint of inappropriate conduct. Conflicts will be addressed by Medical Staff Leadership (MSL), which includes Medical Staff President, Medical Staff President Elect, Immediate Past President, Department and Division Chairs, Hospital President, Vice President of Operations, Chief Nursing Officer, Chief Medical Officer, and additional others as appropriate. Conflicts should be handled quietly and privately at appropriate times when all parties can speak respectfully and courteously to one another, and if necessary, a mediator can be present. Behaviors That Undermine a Culture of Safety Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. 5

To aid in the education of Credentialed Staff, examples of inappropriate conduct include but are not limited to: threatening, intimidating, profane or abusive language, gestures or conduct (including inappropriate physical contact) loud vocalization within any patient care area of the hospital degrading, demeaning or discriminatory comments, gestures or conduct (e.g., comments based on gender, race, religion or national origin that would be offensive to a reasonable person); disparaging remarks about others discussed in open derogatory comments made in or to the public about the quality of care being provided by the hospital, another Credentialed Staff member, or other health care providers; throwing objects in any setting or situation inappropriate medical records entries concerning the quality of care being provided by, or that are otherwise critical of, the Hospital, another Credentialed Staff member, or any other individual; refusal to abide by Medical Staff requirements as delineated in the Professional Staff Bylaws, including but not limited to; emergency call issues, response times, medical record keeping, and other patient care responsibilities, and an unwillingness to work cooperatively with others in the Hospital. Reporting of Concerns regarding Inappropriate Conduct 1. Complaints of alleged inappropriate conduct should be submitted to the Medical Staff Services Department, President of Medical Staff and/or to the Chairman of the department in which the Credentialed Staff member holds privileges/clinical functions. The complaint may be forwarded to the Hospital President/Designee in the absence of the Medical Staff President or Chair. If complaints are submitted directly to the Hospital President, he/she will notify the Department /Division Chair through Medical Staff Services. Complaints must be documented and should be entered into Risk Master and disseminated to MSL as appropriate. 2. The individual who reports a concern will be requested to document the concern in writing. If the individual does not wish to do so, his/her supervisor or department chair may document the concern after attempting to ascertain the individual s reasons for declining and encouraging the individual to do so. If the report of alleged inappropriate conduct is reported by a visitor, patient, vendor, volunteer, or others who are not defined in this policy, the person receiving the complaint is responsible for submitting the report into Risk Master and to Medical Staff Services. 3. Documentation of the complaint should include: a. The date and time of the alleged inappropriate conduct/incident b. A factual description of the sequence of event (s) describing the incident c. The name of any person (s) who was involved in or witnessed the alleged inappropriate conduct/ incident(including any patient, family member, or staff member) d. The circumstances which precipitated the alleged inappropriate conduct/incident 6

e. The consequences, if any, of the alleged inappropriate conduct as it relates to patient care, personnel or hospital operations f. Any action already taken to intervene in or remedy the alleged inappropriate conduct If after the review of the report and investigation, MSL determines that the report is unfounded, no further action shall be taken. The individual initiating such report will be notified verbally of such determination and action. Appropriate documentation of such determination and notification shall be retained in a confidential manner in the credentials file of the Credentialed Staff member. 4. If it is determined that an incident of inappropriate conduct has likely occurred, the MSL has several options including but not limited to the following; notify the Credentialed Staff member that a complaint has been received and invite the Credentialed Staff member to discuss, or provide his/her explanation of the incident. meet with the individual who prepared the report and/or any witnesses to the alleged incident send the Credentialed Staff member a letter of guidance regarding the incident; educate the Credentialed Staff member 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 may also be identified for the Credentialed Staff member as appropriate; refer the matter to the President of the Medical Staff or Hospital President for investigation pursuant to the Credentialing policy. notify Hospital President at an appropriate time 5. Documentation to support that the collegial meeting has occurred will be maintained in the Credentialed Staff member s quality file. 6. The identity of an individual reporting a complaint of inappropriate conduct will generally not be disclosed to the Credentialed Staff member during initial efforts, unless, after consultation with at least two members of MSL determines that it is appropriate to do so. In any case, the Credentialed Staff member will be advised that there is zero tolerance for any retaliation against the person(s) reporting a concern, whether his/her identity is disclosed or not. Any retaliation will be grounds for immediate referral to the President of the Medical Staff and Hospital President for investigation pursuant to the Professional Staff Bylaws. No adverse action may be taken against an individual as a result of submitting a report. 7. The Credentialed Staff Member will have access to any documentation placed in his/her confidential file regarding the incident in accordance with MSO Policy 9.007. 7

8. MSL may continue to utilize the collegial and educational steps noted in this Policy as long as it is believed that there is still a reasonable likelihood that those efforts may resolve the concerns. 9. An additional founded claim of inappropriate conduct could result in: -formal reprimand -MSL may meet with the Credentialed Staff member to discuss a plan to change his or her behavior with a clear commitment to necessary change -a referral to the Medical Executive Committee for possible initiation of formal action pursuant to the Medical Staff Bylaws. Exclusion from the hospital s facilities may be appropriate pending this process. 10. Continued reports of inappropriate conduct will be referred to the Medical Executive Committee (MEC). Any further action, including any hearing or appeal, shall then be conducted under the direction of the Board in accordance with the Bylaws.. 11. After an incident is referred to the MEC, the Credentialed Staff member may be excluded from the hospital s facilities pending the formal investigation process pursuant to the Medical Staff Bylaws 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 Credentialed Staff member the most serious nature of the problem created by such conduct. 12. Prior to any exclusion, the Credentialed Staff member shall be notified of the event or events precipitating the exclusion and he/she shall be given the opportunity to respond in writing and to demonstrate that acceptable standards of conduct have not be violated. However, to ensure that there is no inappropriate delay in addressing the concerns, the Credentialed Staff member must submit any response within three days of being notified. 13. In order to effectuate the objectives of this policy and, except as otherwise permitted by the mutual agreement of the Hospital President and the Medical Staff President, the Credentialed Staff member shall have no right to have counsel attend any of the meetings described above. CROSS INDEX TO OTHER POLICIES: Other Health Professionals Policy Professional Staff Bylaws TJC Sentinel Event Alert 40 UPMC Code of Conduct HS-EC1900 Sponsor: Medical Staff Services Orig. Date: 12/94 Reviewed: 01/03, 7/10 Revised: 05/01, 09/03, 02/04, 8/06, 10/06, 06/07, 4/08, 7/10, 2/11, 8/2015 8

AFFIRMATION I understand that all members of the UPMC Passavant Credentialed Staff are expected to adhere fully to the practices and policies described in the booklet entitled Standards of Conduct and Professional Ethics. I further understand that each member of the Credentialed Staff will be asked to acknowledge in writing at the time of appointment and reappointment that they have read the policy and will comply with the standards set forth therein. As one seeking appointment or reappointment to Medical Staff or Other Health Professional Staff of UPMC Passavant, I hereby affirm that I have read Standards of Conduct and Professional Ethics and will comply with the standards set forth therein. Signature Date Print Name Received: Medical Staff Services Date 9