Policies and Procedures for Medical Staffs and Medical Groups Behaviors that Undermine a Culture of Safety A Guideline from California Public Protection & Physician Health © 2017 CPPPH CPPPH Guideline on Behaviors that Undermine a Culture of Safety Page 2 of 62 Table of Contents INTRODUCTION ................................................................................................................................... 4 STATEMENT OF PURPOSE .................................................................................................................... 5 THE EVIDENCE ON WHICH THIS DOCUMENT IS BASED .......................................................................... 5 DISCLAIMERS ....................................................................................................................................... 5 DEFINITIONS ........................................................................................................................................ 6 WELLBEING COMMITTEE ............................................................................................................................... 6 DISRUPTIVE BEHAVIOR .................................................................................................................................. 6 CONSIDERING DISRUPTIVE BEHAVIOR .................................................................................................. 8 WHAT FALLS OUTSIDE THE DEFINITION ............................................................................................................. 8 WHAT IS THE DISTINCTION BETWEEN DISRUPTIVE BEHAVIOR AND WHISTLE BLOWING? .............................................. 9 EXAMPLES OF INAPPROPRIATE CONDUCT ....................................................................................................... 10 FAILURE TO COMPLY ................................................................................................................................... 11 LEVELS OF BEHAVIOR THAT ARE DEFINED AS PROBLEMATIC .............................................................. 12 RESPONSES OF THE MEDICAL STAFF ................................................................................................... 13 THREE LEVELS OF GRADUATED, GRADED RESPONSES OF THE MEDICAL STAFF ......................................................... 13 Level 1: Early response ....................................................................................................................... 14 Level 2: Response to multiple significant episodes ............................................................................ 15 Level 3: Response to multiple significant episodes and failure to respond to interventions .............. 17 ACTIONS OF THE MEDICAL STAFF .................................................................................................................. 17 CORRECTIVE ACTION, INCLUDING SUMMARY SUSPENSION, WHEN INDICATED ........................................................ 18 CONCERNS THAT ERECT BARRIERS TO APPROPRIATE ACTION OF THE MEDICAL STAFF ....................... 18 ELEMENTS THAT SHOULD BE IN PLACE TO SUPPORT THE ACTION OF THE MEDICAL STAFF ................. 19 Policies and procedures regarding complaints .................................................................................. 19 Anonymous complaints? .................................................................................................................... 19 Notifying the physician ...................................................................................................................... 19 Potential retaliation ........................................................................................................................... 19 PROCEDURES FOR RAISING SAFETY CONCERNS AND MAKING COMPLAINTS ............................................................ 20 LEGAL COUNSEL INVOLVEMENT ..................................................................................................................... 20 ORGANIZATIONAL STRUCTURE OF THE MEDICAL STAFF ...................................................................................... 20 POLICIES AND PROCEDURES FOR SHARING INFORMATION .................................................................................. 20 EDUCATIONAL EFFORTS ............................................................................................................................... 21 RESOURCES ............................................................................................................................................... 21 LEGAL CONSIDERATIONS ON WHICH POLICIES ARE BASED ................................................................. 21 THE JOINT COMMISSION ....................................................................................................................... 21 CALIFORNIA LAW: A BRIEF HISTORY .......................................................................................................... 22 THE DUTY TO ACT ................................................................................................................................... 23 THE IMPACT OF EMPLOYMENT STATUTES ............................................................................................. 23 LIMITATION OF PRIVILEGES/SUMMARY SUSPENSION ........................................................................... 25 THE IMPACT OF THE WHISTLEBLOWER STATUTES ................................................................................. 25 THE ROLE OF THE WELLBEING COMMITTEE ........................................................................................... 26 REASONABLE ACCOMMODATION ......................................................................................................... 26 REPORTING TO THE MBC AND THE NPDB .............................................................................................. 27 SUGGESTED BYLAW PROVISIONS ........................................................................................................... 28 RESTATEMENT OF PURPOSE ............................................................................................................... 28 © 2017 CPPPH Page 2 of 62 CPPPH Guideline on Behaviors that Undermine a Culture of Safety Page 3 of 62 REFERENCES ....................................................................................................................................... 29 WORKGROUP ..................................................................................................................................... 30 APPENDIX A: ACGME CORE COMPETENCIES ADDRESS BEHAVIOR ...................................................... 32 DEFINITIONS FROM THE ACCREDITATION COUNCIL ON GRADUATE MEDICAL EDUCATION (ACGME) ........................ 32 DESCRIPTION AND DISCUSSION ..................................................................................................................... 32 Patient Care ....................................................................................................................................... 32 Medical Knowledge ............................................................................................................................ 33 Interpersonal and Communication SKills ............................................................................................ 33 Professionalism .................................................................................................................................. 33 Practice-Based Learning and Improvement (PBLI) ............................................................................. 34 Systems-Based Practice (SBP) ............................................................................................................ 34 APPENDIX B: MECHANISMS FOR COMMUNICATING PHYSICIAN CONCERNS ....................................... 35 FROM CALIFORNIA HOSPITAL ASSOCIATION .................................................................................................... 35 Processing the Complaint .................................................................................................................. 35 Responding to the Complaint ............................................................................................................ 35 Documentation .................................................................................................................................. 36 EXAMPLE OF A MECHANISM FOR COMMUNICATING PHYSICIAN CONCERNS: A PHYSICIAN COMMENT LINE ........................................................................................................................................................ 37 APPENDIX C: SAMPLE CODES OF CONDUCT ........................................................................................ 39 SAMPLE #1 ............................................................................................................................................... 39 Code Of Conduct ................................................................................................................................ 39 Policy For Failure To Comply With The Code Of Conduct ................................................................... 40 SAMPLE #2 ............................................................................................................................................... 41 Code of Conduct ................................................................................................................................