INTERMED STAFF CODE OF CONDUCT
I. APPLICABLE DEFINITIONS:
“Appropriate behaviour” means any reasonable conduct to advocate for patients, to recommend improvements in patient care, to participate in the operations, leaders hip or activities of the organised staff, or to engage in professional practice including practice that may be in competition with the clinic.
Appropriate behaviour is not subject to discipline under these bylaws.
“Disruptive behaviour” means any abusive conduct including sexual or other forms of haras sment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.
“Harassment” means conduct toward others based on their race, religion, gender, gender identity, sexual orientation, nationality or ethnicity, which has the purpose or direct effect of unreasonably interfering with a person’s work performance or which creates an offensive, intimidating or otherwise hostile work environment.
“Inappropriate behaviour” means conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated inappropriate behavior can become a form of harassment and thereby become disruptive, and subject to treatment as “disruptive behavior.”
“Sexual harassment” means unwelcome sexual advances, requests for sexual favours, or verbal or physical activity through which submission to sexual advances is made an explicit or implicit condition of employment or future employment-related decisions; unwelcome conduct of a sexual nature which has the purpose or effect of unreasonably interfering with a person’s work performance or which creates an offensive intimidating or otherwise hostile work environment.
“Staff member” means all Intermed staff, including physicians and others and, for purposes of this Code, includes individuals with temporary clinical privileges.
II. TYPES OF CONDUCT
A. APPROPRIATE BEHAVIOR
Staff members cannot be subject to discipline for appropriate behavior. Examples of appropriate behaviour include, but are not limited to, the following:
•Criticism communicated in a reasonable manner and offered in good faith with the aim of improving patient care and safety;
•Encouraging clear communication;
•Expressions of concern about a patient’s care and safety ;
•Expressions of dissatisfaction with policies through appropriate grievance channels or other civil non-personal means of communication;
•Use of cooperative approach to problem resolution;
•Constructive criticism conveyed in a respectful and professional manner, without blame or shame for adverse outcomes;
•Professional comments to any professional, managerial, supervisory, or administrative staff, or members of the Board of Directors about patient care or safety provided by others;
•Active participation in staff and clinic meetings (i.e., comments made during or resulting from such meetings cannot
be used as the basis for a complaint under this Code of Conduct, referral to the Human Resources Department, economic sanctions, or the filing of an action before a state or central agency);
•Seeking legal advice or the initiation of legal action for cause.
B. INAPPROPRIATE BEHAVIOR
Inappropriate behavior by staff members is discouraged. Persistent inappropriate behavior can become a form of harassment and thereby become disruptive, and subject to treatment as “disruptive behaviour .” Examples of inappropriate behaviour include, but are not limited to, the following:
•Belittling or berating statements;
•Use of profanity or disrespectful language;
•Inappropriate comments written in any company documents;
•Blatant failure to respond to patient care needs or staff requests;
•Personal sarcasm or cynicism;
•Deliberate lack of cooperation without good cause;
•Deliberate refusal to return phone calls, pages, or other messages concerning company business;
•Intentionally condescending language; and
•Intentionally degrading or demeaning comments regarding patients and their families; nurses, physicians, company
personnel and/or the company and clinics.
C. DISRUPTIVE BEHAVIOR
Disruptive behaviour by staff members is prohibited. Examples of disruptive behaviour include, but are not limited to, the following:
•Physically threatening language directed at anyone in the clinic including physicians, nurses, other staff members, or any employee, administrator or member of the Board of Directors;
•Physical contact with another individual that is threatening or intimidating;
•Throwing instruments, charts or other things;
•Threats of violence or retribution;
•Sexual harassment; and,
•Other forms of harassment including, but not limited to, persistent inappropriate behaviour and repeated threats of litigation.
Interventions should initially be non-adversarial in nature, if possible, with the focus on restoring trust, placing accountability on and rehabilitating the offending staff member, and protecting patient care and safety. The staff supports tiered, non-confrontational intervention strategies, starting with informal discussion of the matter with the appropriate section chief or department chairperson. Further interventions can include an apology directly addressing the problem, a letter of admonition, a final written warning, or corrective action pursuant to the Human Resources Handbook, if the behaviour is or becomes disruptive. The use of summary suspension should be considered only where the staff member’s disruptive behaviour presents an imminent danger to the health of any individual. At
any time rehabilitation may be recommended. If there is reason to believe inappropriate or disruptive behaviour
is due to illness or impairment, the matter may be evaluated and managed confidentially according to the established procedures of the Human Resources department.
Complaints about a non-medical staff member regarding allegedly inappropriate or disruptive behaviour should be in writing, signed and directed to the Director of Human Resources. Compla ints about a medical staff member should be directed to the Chief of Medical Operations. If the complaint concerns these individuals, it should be sent to the Company Ombudsman. The complaint should include:
1.the date(s), time(s) and location of the inappropriate or disruptive behaviour;
2.a factual description of the inappropriate or disruptive behaviour;
3.the circumstances which precipitated the incident;
4.the name and medical record number of any patient or patient’s family member who was involved in or witnessed the incident;
5.the names of other witnesses to the incident;
6.the consequences, if any, of the inappropriate or disruptive behaviour as it relates to patient care or safety, or
clinic personnel or operations; and
7.any action taken to intervene in, or remedy, the incident, including the names of those intervening.
The complainant will be provided a written acknowledgement of the complaint. In all cases, the staff member subject of the complaint shall be provided a copy of this Code of Conduct and a copy of the complaint in a timely fashion, as determined by the organised staff, but in no case more than 30 days from receipt of the complaint by the Director of Human Resources. The staff member will be notified that attempts to confront, intimidate, or otherwise retaliate against the complainant is a violation of this Code of Conduct and may result in corrective action against the staff member.
An ad hoc committee, none of the members of which may be economic competitors of the staff member, onsisting of the Director of Human Resources and at least two additional elected members of the management, one of whom shall be the staff member’s department chairperson, provided the chairperson is not the subject of the complaint, shall make such investigation as appropriate in the circumstances which may include seeking to interview the complainant, any witnesses and the subject of the complaint. The subject staff member shall be provided an opportunity to respond in writing to the complaint. The ad hoc committee will make a determination of the authenticity and severity of the
complaint. The ad hoc committee shall dismiss any unfounded complaint and may dismiss any complaint if it is not possible to confirm its authenticity or severity, and will notify both the complainant and the
subject of the complaint of the decision reached. If the ad hoc committee determines the complaint is well founded, the complainant and the subject of the complaint will be informed of the decision, and the complaint will be addressed as follows:
1.If this is the first incident of inappropriate behavior, the appropriate section chief, or chairperson of the offending staff member’s assigned department, shall discuss the matter with the offending staff member, and emphasis that the behavior is inappropriate and must cease. The offending staff member may be asked to apologies to the complainant. The approach during this initial intervention should be collegial and helpful.
2.Further isolated incidents that do not constitute persistent, repeated inappropriate behaviour will be handled by providing the offending staff member with notification of each incident, and a reminder of the expectation the individual comply with this Code of Conduct.
3.If the ad hoc committee determines the offending staff member has demonstrated persistent, repeated inappropriate
behaviour, constituting harassment (a form of disruptive behaviour ), or has engaged in disruptive behaviour on the
first offense, a letter of admonition will be sent to the offending staff member, and, as appropriate, a rehabilitation action plan developed by the ad hoc committee, with the advice and counsel of the management.
4.If, in spite of this admonition and intervention, disruptive behaviour recurs, the ad hoc committee shall meet with and advise the offending staff member such behaviour must immediately cease or corrective action will be initiated. This “final warning” shall be sent to the offending staff member in writing.
5.If after the “final warning” the disruptive behaviour recurs, corrective action (including suspension or termination of privileges) shall be initiated pursuant to the Human Resources Handbook of which this Code of Conduct is a part, and the offending staff member shall have all of the due process rights set forth in the Human Resources Handbook.
6.If a single incident of disruptive behaviour or repeated incidents of disruptive behaviour constitute an imminent danger to the health of a n individual or individuals, the offending staff member may be summarily suspended as provided in the Human Resources Handbook. The staff member shall have all of the due process rights set forth in the
Human Resources Handbook.
7.If no corrective action is taken pursuant to the Human Resources Handbook, a confidential memorandum summarizing the disposition of the complaint, along with copies of any written warnings, letters of apology, and written responses from the offending staff member, shall be retained in the staff member’s credentials file for two (2)
years, and then must be expunged if no related action is taken or pending. Informal
rehabilitation, a written apology, issuance of a warning, or referral to the Health and Well being Committee (or equivalent committee) will not constitute corrective action.
8.At any time during this procedure the staff member has a right to personally retain and be represented by legal counsel.
IV. INAPPROPRIATE OR DISRUPTIVE BEHAVIOR AGAINST A STAFF MEMBER
Inappropriate or disruptive behaviour which is directed against the organised staff or directed against a staff member by an employee, administrator, board member, contractor, or other member of the community shall be reported by the staff member to the clinic pursuant to policy or code of conduct, or directly to the governing board, the state or central government, or relevant accrediting body, as appropriate.
V. ABUSE OF PROCESS
Threats or actions directed against the complainant by the subject of the complaint will not be tolerated under any circumstance. Retaliation or attempted retaliation by staff members against complainants will give rise to corrective action pursuant to the Human Resources Handbook. Individuals who falsely submit a complaint shall be subject to corrective action under the Human Resources Handbook or employment policies, whichever applies to the individual.
VI.PROMOTING AWARENESS OF CODE OF CONDUCT
The staff shall, in cooperation with the company, promote continuing awareness of this Code of Conduct among the staff and the community, by :
1.sponsoring or supporting educational programs on disruptive behaviour to be offered to physicians, staff members and clinic employees;
2.disseminating this Code of Conduct to all current staff members upon its adoption and to all new employees.
3.encouraging the Human Resources Department to assist members of the staff exhibiting inappropriate or disruptive
behaviour to obtain education, behaviour modification, or other treatment to prevent further infractions.
4.informing the members and the staff of the procedures the company has put into place for effective communication to administration of any staff member’s concerns, complaints and suggestions regarding clinic personnel, equipment, and systems.