POLICIES & PROCEDURES
Medical Staff: Disruptive Physician
Policy
SUBJECT:
POLICY:
PROCEDURE:
GUIDELINE:
NO.
EFFECTIVE
DATE:
ADMINISTRATIVE
APPROVAL:
COMMITTEE APPROVAL/REVIEW:
PAGE 1 OF 2
SUPERSEDES:
REVISION INITIATED
:
Medical Executive Committee; Board of Directors
DEVELOPMENT TEAM/AUTHOR(S)
BY:
AUDIT REVIEW:
DATE:
Policy
_________ Medical Center has adopted core beliefs as part of the mission and vision of the organization. The core beliefs
are respect, integrity and cooperation. "Treating everyone with acceptance, valuing individual and cultural difference, and
showing care and concern for others" demonstrate respect. Integrity means "we hold ourselves accountable to the highest
standards for honesty, truthfulness and public service." Cooperation includes "joining others across the organization to
advance the interest of the patient and family." The Board of Directors of _________ Medical Center requires that all
hospital individuals (employees, physicians, and other independent practitioners) follow the values of the organization and
conduct themselves in all interactions in a professional and cooperative manner.
Employees who fail to conduct themselves according to the values of the organization shall be addressed following
_________ human resources policies. If a physician or other independent practitioner fails to conduct himself/herself in an
appropriate manner the incidence shall be addressed through the following policy. Any infraction of the values of the
organization will be handled firmly, fairly, and equitably.
Disruptive Behavior and Other Infractions
The Physician Health Committee will address disruptive behavior by physicians and other independent practitioners.
There are some single incidents of behavior that may result in immediate termination of employment or medical staff
privileges. These incidents include physical or sexual harassment, assault, a felony conviction, theft, damaging hospital
property, a fraudulent act or physical behavior considered inappropriate by common standards. Issues of this nature may
be referred to Human Resources for investigation and action recommendation.
NOTE: Behavior that places a patient's safety in jeopardy will be handled immediately including precautionary suspension
as outlined in 12.2 section of the Medical Staff by-laws.
Policy Intent
The intent of this policy is to provide a health care environment that will enhance optimum patient outcomes and prevent,
decrease/eliminate actions that:
•
Negatively impact the operation(s) of the hospital, departments or units
•
Affect individuals in their ability to do their jobs
•
Create a "hostile work environment"
•
Interfere with other practitioners or professionals' ability to practice competently
•
Impact the community's confidence in the hospital's ability to provide collaborative and cooperative quality
patient care
Guidelines
Actions that are considered "disruptive" will be handled immediately upon disclosure. Complaints must be in writing. The
physician or other medical staff member will not be afforded a "fair hearing" procedure as defined in the Medical Staff by
laws. The Physician Health Committee may refer and/or collaborate with the Washington Physician Health Program
Disruptive behavior may include, but is not limited to:
1. Shouting, rude, foul or abusive language that is demeaning towards other medical staff, hospital staff, patients or
visitors;
2. Written comments or drawings made in patient medical records or other document that stray from factual
information to subjective opinion;
3. Pushing, shoving, throwing objects or other attempts at physical intimidation;
4. Communication that intimidates other members of the medical staff, hospital staff, patients or visitors;
5.
Describing or implying that others are stupid or incompetent;
6.
Refusing to follow or sidestepping hospital policy expectations of professional responsibilities. Does not follow
through on expected medical staff assignments or on a committee or departmental requirements except on own
terms.
All incidents of disruptive behavior must be documented to obtain an objective and clear description of the behavior. It is
important to determine if the behavior is a one-time occurrence or a pattern of inappropriate conduct. The documentation
must include:

The date and time of the behavior and an objective and factual description of the event;

A description of whether the behavior affected or involved a patient in any way, and, if so, the patient's name;

The situation that seemed to cause the behavior;

The results of this behavior on the individuals present, the situation or area. Included are consequences to patient
care or hospital operations;

Any intervention that was done to stop or de-escalate the situation, including the date, time, place, action, and
name(s) of those involved.
Reporting
Any person in the hospital, including visitors may report perceived disruptive physician behavior. The written report (on the
Patient Advocacy or Incident Report Form) shall be forwarded to the Chair of the Physician Health Committee. The report
should be made no later than five (5) working days of the occurrence.
Procedure
Action Step 1
The Chair of the Physicians Health Committee will select a "friendly colleague" representing the referral source to
conduct a one on one conversation with the Physician. Prior to the discussion the Physician will be told that
confidentiality will cease if the behavior persists. If the report is considered without merit it will be dismissed with no
retribution to the person who reported it. If there is no further occurrence of the reported behavior for the duration of
a two-year period, the incident report will be expunged.
Action Step 2
If a second incidence of the disruptive behavior occurs a second meeting will be held in a confidential formal
format with the entire Physician Health Committee and the "friendly colleague." An "expectation of cessation of
behavior" is stated and a warning of further consequences if behavior continues.
Additional Option
The Washington Physician Health Program (WPHP) may be contacted by the Physician Health Committee for
consultation. The Physician may also contact the WPHP for consultation. If the Physician agrees to see the
WPHP, and if appropriate, the WPHP will develop recommendations for dealing with the behavior. If the Physician
agrees to this action, WPHP will monitor the progress. If the Physician refuses the _________ Physician Health
Committee will resume monitoring of the Physician.
Action Step 3
If the behavior continues a third meeting will be convened of the Physician's Health Committee which will include
the "friendly colleague" plus administrative, medical staff and supervisory individuals as appropriate. The
documented behavior will be reviewed and the Physician will be asked to sign a behavior contract. If the
Physician does not want to sign a contract he/she may be referred to the disciplinary process as outlined in the
Medical Staff by laws. If the Physician signs the contract the Physician's Health Committee will provide monitoring
of the contract. The Physician will be informed that any violation of the contract may result in disciplinary action.
Action Step 4
Continuation of the behavior will result in a fourth meeting with a Disciplinary Group that gives the Physician two
choices: be referred to the WPHP with conditions, or face suspension. If the Physician agrees to work with WPHP
he/she must agree to:
a) sign a release for a two-way communication between WPHP and a designate of the Physician's
Health Committee
b) Call WPHP (206 583-0127) within 3 working days of the referral
c) Complete any recommended evaluation
Evaluation
IF an evaluation does not identify any treatable medical illness causing or contributing to the behavior, the
Physician will continue along the disciplinary tract for monitoring. If the behavior persists, suspension will result.
If a diagnosis is determined, the Physician will implement a contract with WPHP which will included therapeutic
recommendations plus behavioral expectation agreed upon by all parties. The contract must be executed within
10 (ten) working days of its completion. Both WPHP and the Physician Health Committee will monitor the
Physician. The Physician will be told in clear terms that any violation of the contract will result in an immediate
review by the disciplinary group followed by a probable suspension. If the behavior is corrected, the case will be
closed.
Documentation
In addition to written reports to the Physician' Health Committee on disruptive behavior, minutes to the following
meetings will be documented: the Physician Health Committee, the Administrative Committee, and the involved
disciplinary group. Monitoring and all behavioral contracts reports will be in writing. Violations of the contract will
be presented in written form. Copies of all written records will be submitted to WPHP prior to the Physician
referral. WPHP may be contacted for consultation calls for any situation, issue or procedure.
See attached flow chart