<p>______HOSPITAL MEDICAL STAFF POLICY ______SUBJECT: DISRUPTIVE BEHAVIOR</p><p>A. It is the policy of ______Hospital that all individuals be treated with courtesy, respect, and dignity. To that end, the Board requires that all individuals, employees, physicians, and other independent practitioners conduct themselves in a professional and cooperative manner in the Hospital. B. If a physician or other privileged independent practitioner fails to conduct himself or herself appropriately, the matter shall be addressed in accordance with this policy and/or per the Medical Staff Bylaws, Article VII, Corrective Action. It is the intention of this Hospital that this policy be enforced in a firm, fair, and equitable manner. C. Disruptive behavior by physicians and other privileged independent practitioners will be addressed by the Board of Directors. A single egregious incident which includes but is not limited to physical or sexual harassment, assault, a felony conviction, a fraudulent act, stealing, damaging Hospital property, or inappropriate physical behavior may result in immediate termination of employment or Medical Staff membership and/or clinical privileges. The Board may, at its discretion, refer such issues to the Medical Executive Committee for investigation and recommendation. D. Unacceptable disruptive conduct may include, but is not limited to, behavior such as:</p><p>1. Attacks-verbal or physical-leveled at other Medical Staff, Hospital personnel, or patients, that are personal, irrelevant, or beyond the bounds of fair professional conduct. 2. 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. 3. Non-constructive criticism that is directly addressed to its recipient in such a way and with the intent to intimidate, undermine confidence, belittle, or imply stupidity or incompetence. 4. Refusal to accept-or disruptive acceptance of-Medical Staff assignments or participation in committee or departmental affairs which the Division/Department Head deems to be essential to the functioning of the Division/Department of the Hospital. </p><p>Disruptive Behavior 1 Purpose</p><p>The purpose of this policy is 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 </p><p> disrupts the operation of the Hospital;  affects the ability of others to do their jobs;  creates a "hostile work environment" for Hospital employees or other Medical Staff;  interferes with an individual's ability to practice competently; or  adversely affects or impacts the community's confidence in the Hospital's ability to provide quality patient care. </p><p>Procedure </p><p>A. Documentation of disruptive conduct is critical because it is ordinarily not one incident that leads to disciplinary action, but rather a pattern of inappropriate conduct. Such documentation should include: </p><p> the date and time of the questionable behavior; </p><p> a statement of whether the behavior affected or involved a patient in any way, and, if so, the name of the patient; </p><p> the circumstances that precipitated the situation; </p><p> a description of the questionable behavior that is limited to factual, objective language; </p><p> the consequences, if any, of the disruptive behavior as it relates to patient care or Hospital operations; and </p><p> a record of any action taken to remedy the situation, including the date, time, place, action, and name(s) of those intervening. </p><p>B. Any practitioner, employee, patient, or visitor may report potentially disruptive conduct. The report shall be submitted to the Vice President Medical Affairs [VPMA] (or in his/her absence to the President/Chief Executive Officer [CEO]). C. Once received, a report will be investigated by the VPMA. The evaluation of the report will be completed within 10 business days. This investigation is not a "hearing" as used in the Medical Staff Bylaws, Article VIII. Unfounded reports may be dismissed by the VPMA. The individual initiating such report will be </p><p>Disruptive Behavior 2 appraised whether the report is unfounded or whether further action by the VPMA will be undertaken. Those reports considered accurate will be addressed as follows: </p><p>1. A single confirmed incident warrants a discussion with the offending physician/practitioner; the VPMA or designee (generally the Department Head) shall initiate such a discussion and emphasize that such conduct is inappropriate and must cease. The Code of Conduct Policy and Article VII, Corrective Action will be reviewed with the physician/practitioner. The initial approach should be collegial and helpful to the physician and the Hospital. 2. If there is a second report of potentially disruptive conduct, the report shall be submitted to the VPMA (or in his/her absence to the President/CEO) as per the Medical Staff Bylaws, Article VII Corrective Action. 3. Once received, a second report will be investigated by the VPMA. The evaluation of the report will be completed with 10 business days. Unfounded reports may be dismissed by the VPMA. The individual initiating such report will be appraised whether the report is unfounded or whether further action by the VPMA will be undertaken. Those reports considered accurate will be addressed as follows: </p><p> a. The VPMA shall meet with the physician/practitioner. The physician/practitioner will be counseled that such behavior is inappropriate and will not be tolerated and must cease. The disruptive practitioner policy will be reviewed with the physician/practitioner again. b. The VPMA may, at her/his discretion, suggest appropriate helpful measures to aid the physician/practitioner in preventing further occurrences of this behavior. The physician/practitioner will be advised that a letter summarizing the meeting will be forwarded to the President/ CEO, the subject physician/practitioner, and a copy placed in his/her credentials file along with the report(s) of the occurrence(s). The letter will inform the physician/practitioner that she/he is required to behave professionally and cooperatively within the Hospital. The involved physician/practitioner may submit a rebuttal to the charge. Such rebuttal will be maintained as a permanent part of the record. </p><p>Disruptive Behavior 3 4. If the same or similar disruptive behavior recurs the report will be investigated by the VPMA. The evaluation of the report will be completed within 10 business days. Unfounded reports may be dismissed by the VPMA. Those reports considered accurate will be addressed as follows: </p><p> a. The VPMA shall meet with and advise the physician/practitioner that such conduct is intolerable, and must stop immediately. b. This meeting is not a discussion, but rather constitutes the physician's/practitioner's final warning. The meeting shall be followed by a letter to the physician/practitioner reiterating the final warning, and a copy placed in his/her credentials file along with the report (s) of the occurrence (s). c. The involved physician/practitioner may submit a rebuttal to the charges. Such rebuttal will be maintained as a permanent part of the record, and a copy placed in his/her credentials file along with the report (s) of the occurrence (s).</p><p>5. In the event of repeated reports of disruptive behavior, the VPMA may mandate that the individual be evaluated for mental/physical health status by an appropriate physician/practitioner with a report back to the VPMA. Summary Suspension as defined in the Medical Staff Bylaws, Article VII, Corrective Action may be imposed during this process. </p><p>D. A single egregious incident occurring on Hospital property, or its facilities, or repeated incidents as defined and described in this policy shall initiate investigatory action according to, and shall be interpreted and enforced by the Board consistent with the Medical Staff Bylaws. No other policy or procedure shall be applicable to egregious incidents or unacceptable disruptive behavior except as designated by the Board. E. In the event a practitioner is suspended for a single egregious incident, or a clearly defined and investigated pattern of incidents, he/she may be afforded a hearing before the Board or an Appellate Committee of the Board as defined in the Medical Staff Bylaws, Article VIII, Hearings and Appellate Review. If it is unclear whether the conduct was actually disruptive, the Board may in such circumstance seek the expert opinion of an impartial individual experienced in such matters. </p><p>Original: 4/5/04</p><p>Disruptive Behavior 4 ______Chairman, Credentials Committee Date</p><p>______President of the Medical Staff Date</p><p>______President, CEO Date</p><p>______President, Board of Directors Date</p><p>Disruptive Behavior 5</p>