Code of Conduct Policy

March 24, 2022

Posted on by Courtney Patterson

QUESTION:
I am the chief of the division of family medicine at my hospital.  I recently learned that a nurse’s aide complained to her supervisor about my tone when speaking with the mother of a patient in our clinic.  The complaint made its way into the peer review system, and I was sent a “letter of guidance” referencing the organization’s Code of Conduct and encouraging me, for lack of a better explanation, to be on my best behavior and be mindful of my reputation and that of the health system.

To be honest, although I am involved in leadership and understand the underlying motivation for the Code of Conduct, I found this to be a really patronizing experience.  The aide who made the complaint knows nothing about my history with this patient and his mother, nor the practical or clinical reasons why I might take a serious tone with her.  My treatment of this patient and his mother was appropriate, given the circumstances and I feel pretty strongly that the aide should have stayed out of it or at least raised her concerns with me before reporting me to her supervisor.

I would like to take this opportunity to discuss this situation with the aide and her supervisor.  It’s important for the aide to understand that some patients of the clinic are well known by clinic staff to require more intense interactions regarding appropriate treatment options and the importance of compliance with the treatment plan.  I am not expecting an apology from the aide as a result of this conversation but, instead, see this conversation as an opportunity to improve how the clinic team operates and, hopefully, prevent frivolous reports in the future.

Last week, I approached the supervisor regarding this, to schedule a time for all three of us to sit down to talk (me, the supervisor, and the aide).  The supervisor told me that my plan was not appropriate and could be viewed as intimidation.  She refused to schedule the session and said I’d better run my plan past the Chief of Staff first.  I did and she said it’s better to “leave it alone.”

Has the whole world gone crazy?  Can’t professionals talk to each other anymore?  How is this supposed to improve the patient care environment?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
It’s easy to see why you might be frustrated, given the scenario you have described.  A key component of any peer review process should be transparency.  This means all practitioners who are subject to the process should understand that it exists and how it works.  Information should, ideally, be periodically pushed out to members of the Medical Staff to help them understand the many moving parts to the peer review process.  When the process is better understood, practitioners are less likely to feel targeted when their own practices come under scrutiny.

Transparency requires more than knowledge of the process, however.  It also requires practitioner involvement in their own peer review.  In your case, it appears as though the peer review of the concern involving your conduct was concluded without anyone ever asking for your input and getting your side of the story.  How can practitioners be expected to buy-in to a process that does not include their input?  As you describe it, that input may have been vital in deciding the appropriate outcome.  Maybe if you had been given a chance to discuss the facts with those conducting the review, they would have concluded that rather than sending you a letter of education, they should provide additional information and training to clinic personnel regarding tough, non-compliant patient management.

At this point, what’s done is done.  Your best bet may be to respond to the letter of education explaining your side of the story and requesting that consideration be given to obtaining your input should any future, similar concerns be reported.  Further, you might consider recommending that clinic personnel receive additional training to help them understand and manage situations like this.  Don’t worry that your response will be seen as controversial or adversarial.  A professionally-worded response, sent through appropriate channels, is part of the review process and is completely appropriate.  After all, the aim of the peer review process should not only be to work with privileged practitioners to address concerns that are under their control, but also to bring to light related, systemic concerns that should be addressed to improve patient care overall.

With that said, we agree with the aide’s supervisor that it is not a good idea for you to sit down with the aide to discuss this matter.  While doing so might be the fastest, most efficient way to get from point A to point B, the supervisor is right – your actions could intimidate the aide.  And, in the long run, that could lead to aides (and other personnel) being reluctant to report meaningful concerns about practitioners due to fear of retaliation.

This advice may be frustrating, because your intentions may be good.  Instead of focusing on your intentions, though, try to think about process.  Can an effective peer review process rely on the good intentions of every physician whose conduct is reported?  If practitioners are given free rein to “confront” those who report concerns about that, would that have a chilling effect on future reports?  Would that promote advancements in quality?

You can see where we are going with this.

Ideally, this issue would have been addressed with you earlier (when your input was first sought by the leadership reviewing this matter) and, at that time, the organizational definition of retaliation could have been provided, along with a caution about engaging in any conduct that could be viewed as retaliatory.  Our recommendation is that a professionalism policy include any contact with the individual who filed a report, in an attempt to discuss the matter, as retaliatory – no matter the intention.  Letting practitioners know this early in the process avoids any embarrassment or confusion later.  Further, bringing it up early in the process avoids an implication that the practitioner is pursuing retaliatory conduct and allows it to serve as a generalized, non-confrontational FYI.  In most organizations, it works well and keeps disputes (and retaliation) to a minimum.

Peer review is tough and imperfect. Organizations are constantly tweaking their processes to correct deficiencies and improve the experience for the practitioners who are subject to review.  We hope you can take the flaws you perceived in this review of your conduct and work through available channels at your organization to suggest appropriate changes (e.g., earlier, methodical request for the practitioner’s input and guidance to practitioners of who they can contact to discuss the matter).

February 15, 2018

Posted on by hortyspringer

QUESTION:        Our hospital is employing a lot more physicians than in the past.  When we receive a complaint about the behavior of one of these employed Medical Staff members, we’re not sure if we should review it through the Medical Staff process or through the employment process (i.e., HR policies or the employment agreement).  Or should we use both?

ANSWER:            We recommend that the Medical Staff Professionalism Policy (or Code of Conduct Policy) have a “triage” process.  If a behavioral concern is raised about a Hospital-employed physician, a Medical Staff leader (such as the Chief of Staff) will discuss the concern with a representative of the employer.  The Medical Staff leader and the employer representative then decide which process will be used to review the complaint.

If a decision is made to use the employment process, the Medical Staff process would be held in abeyance.  Critically, though, the employer would keep Medical Staff leaders continually informed of the status and outcome of the review.  If the Medical Staff leaders are unhappy with how the review is being conducted, they can commence their own review under the Professionalism Policy at any time.  On the other hand, if the Medical Staff leaders are satisfied with what the employer is doing, the Medical Staff leaders would essentially adopt that action as their own.  Thus, the Medical Staff is not “punting” or abdicating its responsibilities.  It’s evaluating the actions of the employer, then deciding to either adopt that action as its own or conduct a separate review.

There are several goals to this process.  The first is to avoid a duplication of effort by both the physician under review and those conducting the review.  The second is to use the most effective process to address the concern.  In some cases, the employer will have better tools for dealing with the issue, while in other cases the Medical Staff process will be more effective.  Finally, a triage process can help to avoid inconsistent results that send mixed messages to physicians and create legal risk.

For a more detailed discussion of peer review of hospital-employed physicians, join us in sunny Austin, Texas for The Peer Review Clinic on March 1-3, 2018.