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Tips for writing an effective code of conduct policy


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As of January 1, 2009, The Joint Commission (formerly JCAHO) will require hospitals to develop a formal process for defining and addressing unacceptable behavior for all healthcare professionals (LD.03.01.01, elements of performance 4 and 5). If your code of conduct policy is so onerous that staff are more likely to use it as a coaster than follow it, the following tips will make it a living, usable document:

Be specific. Your code of conduct policy should extend beyond simply defining disruptive behavior— it should connect the dots between disruptive behavior and patient care, says Jonathan Burroughs, MD, FACPE, CPE, FACEP, CMSL, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

For example, your disruptive behavior policy may define behavior that:

  • Undermines morale and creates turnover among professional and medical staffs
  • Leads nurses or other healthcare providers to avoid discussing patient care with the healthcare team for fear of being treated poorly
  • Is considered discriminatory under federal law

Policy language such as “This hospital does not tolerate disruptive behavior” is vague and not likely to engage staff, says Burroughs.

On the same note, a code of conduct policy should clearly define and address egregious violations, including rape, assault, and hate crimes.

Word wisely. Many hospitals use the word “investigation” improperly in their code of conduct policies when describing how an incident of disruptive behavior will be substantiated, Burroughs says. Those who draft the code may intend “investigation” to simply mean “look into,” but The Joint Commission and the Health Care Quality Improvement Act (HCQIA) define that word differently.

Using The Joint Commission’s and the HCQIA’s definition, physicians must be reported to the National Practitioner Data Bank when they lose their membership or privileges while under the threat of an investigation. Such reports can damage a physician’s career. “You don’t want to use the word ‘investigation’ unless you plan on potentially taking corrective action,” says Burroughs.

Tip: Burroughs suggests the following phrasing: “An inquiry will be made to verify the incident.”

Map it out. Policy development doesn’t end simply because you define disruptive behavior in the code of conduct policy. Healthcare leaders must map out a plan for addressing such behavior. For example, a hospital may require a staff member who has violated the code of conduct policy for the first time to sit down with a nurse leader for a collegial discussion.

Although the word collegial implies casualness, you should document all discussions relating to an individual’s behavior, Burroughs says, adding that if these discussions aren’t documented, there is no way to prove they’ve taken place.

The second violation may require the staff member in question to create a voluntary action plan to improve professional conduct, and so on.

Your goal must be to create a code of conduct policy that eliminates variation and ensures consistency even when leadership changes. In the past, various disruptive behaviors were swept under the rug, and new leaders disregarded policies their predecessors had put in place, Burroughs explains. “From one leader to another, you should be able to say, ‘We are on the third intervention with this [staff member], and if there any further violations, this is what you need to do,’ ” he says.

Of course, an incremental disciplinary approach is not appropriate when staff commit an egregious act.

Think small. “Most policies I read are too big,” says Burroughs. Aim for a succinct, easy-to-use document that provides users with specific pathways to follow when they are faced with disruptive behavior.

Encourage reporting. The code of conduct policy at Lakeview Medical Center in Rice Lake, WI, applies to everyone from volunteers to medical staff leaders, says Mary O’Donnell, CPCS, medical staff coordinator at the facility.

Witnesses to inappropriate behavior are encouraged to fill out a behavioral code of conduct report, which is patterned on the inappropriate behaviors listed in the code of conduct policy. The list of inappropriate behaviors was created during a brainstorming session among department directors.

The completed form is given to an employee’s direct manager or, in the case of a medical staff member, the medical director. From there, the medical director examines the validity of the complaint by interviewing those involved and decides on a course of action.

Be assertive, not aggressive. Burroughs says a zero-tolerance policy can be counterproductive, as such a policy may alienate or anger staff. Instead, set expectations and hold staff accountable for their behavior without sending the message that they can never make another mistake.

Address core competencies. Sacred Heart Medical Center in Spokane, WA, updated its policy including elements of the six core competencies developed by the Accreditation Council for Graduate Medical Education (ACGME) and recently adopted by The Joint Commission.

The policy includes behavioral expectations under each of the following categories (the ACGME/Joint Commission six core competencies are identified in the parentheses):

  • Quality of care and technical skills (patient care)
  • Quality of service (medical knowledge)
  • Patient safety/patient rights (practice-based learning and improvement)
  • Resource utilization (interpersonal and communication skills)
  • Peer and coworker relationships (professionalism)
  • Citizenship (systems-based practice)

Using this model, Sacred Heart created behavioral expectations under the peer and coworker relationships category. They include:

  • Always acting in a professional, respectful manner to enhance a spirit of cooperation, mutual respect, and trust among the patient care team
  • Refraining from inappropriate behavior, including but not limited to impulsive, disruptive, sexually harassing, or disrespectful behavior or derogatory or inflammatory medical record entries not directly related to patient clinical status or the plan of care
  • Addressing disagreements in a constructive, respectful manner privately and out of earshot of patients or other noninvolved caregivers

Sacred Heart is currently revising its code of conduct policy to include a statement regarding the organization’s commitment to physicians.

This commitment includes:

  • Offering avenues by which providers can share their concerns with hospital administration
  • Training clinical staff members in communication skills
  • “It needs to be a two-way street,” Osborne says.

Offer guidance. Providing clinical staff members with conflict management training can make a dramatic difference in the way individuals in your organization react to disruptive behavior.

When Lakeview implemented its code of conduct policy in 2004, every employee attended conflict management training facilitated by an outside employee assistance program. During that training, employees learned to use behavioral assertive responses to help them better manage unpleasant situations. “It is about using ‘I’ statements instead of ‘you’ statements,” says O’Donnell. These behavioral assertive responses are now included in the organization’s code of conduct policy.

The following are two scenarios covered during the training, paired with examples of appropriate responses:

  1. If a physician speaks rudely to a nurse, the nurse could respond with, “Dr. X, I don’t deserve to be spoken to like this since I am only trying to understand the situation. I would appreciate being treated professionally and civilly.”
  2. If a physician witnesses inappropriate behavior from a colleague, he or she could respond with, “I have observed certain behaviors and heard comments that lead me to feel concerned for you.”

Hold everyone to the same standard. “A code of conduct policy should not only apply to physicians, but to all employees of the hospital, as well as all patients, visitors, and guests,” says Burroughs.

Editor's note: This article was adapted from "Tips for writing an effective code of conduct policy," featured in the HCPro Inc., publication Medical Staff Briefing