On July 9th, the Joint Commission issued a Sentinel Event Alert in which it reminded hospitals that effective January 1, 2009, a hospital must have a Code of Conduct that defines acceptable and disruptive and inappropriate behaviors.  Hospitals are also required to have their leaders create and implement a process for managing disruptive and inappropriate behaviors.

The Joint Commission also suggested several other actions that hospitals should take with respect to disruptive behavior. 

These include: 

1) educating all team members, both physician and non-physician, on appropriate professional behavior defined by the organization’s Code of Conduct (“Code”);

2) holding all team members accountable for modeling desirable behaviors and enforcing the Code consistent and equitably among all staff, regardless of clinical discipline; 

3) developing and implementing policies and procedures appropriate for the specific organization that address:

 a. zero tolerance for intimidating and/or disruptive behaviors, especially in the most egregious instances;
 b. Medical Staff policies regarding intimidating and/or disruptive behaviors of physicians within a healthcare organization; 
 c. reducing fear, intimidation or retribution, and protecting those who report or cooperate in the investigation of intimidating, disruptive and unprofessional behavior; 
 d. responding to patients and/or families who are involved in, or witness intimidating and/or disruptive behavior; and
 e. how and when to begin disciplinary actions;

4) developing an organizational process for addressing intimidating and disruptive behaviors;

5) developing and implementing a reporting surveillance system for detecting unprofessional behavior;

6) supporting of surveillance with tiered non-confrontational intervention strategies, starting with informal conversations directly addressing the problem, and moving toward detailed action plans and progressive discipline;

7) conducting all interventions within the context of organizational commitment to the health and wellbeing of all staff;

8) documenting all attempts to address intimidating and disruptive behavior.

Hospitals are encouraged to review their disruptive behavior policies and any Medical Staff Rules and Regulations or Policies and Procedures dealing with this subject to ensure that they comply with the July 9th Sentinel Event Alert.  Those institutions that do not have disruptive behavior policies should develop and implement them prior to January 1, 2009. 

For further information, please contact Roy Bossen or your regular Hinshaw attorney.

This alert has been prepared by Hinshaw & Culbertson LLP to provide information on recent legal developments of interest to our readers. It is not intended to provide legal advice for a specific situation or to create an attorney-client relationship.