April 4, 2024

We have a podiatrist who practiced at our hospital.  There were a number of serious complaints about her behavior and her ability to work well with others which we tried to address through our Professionalism Policy.  Ultimately, we developed a rigorous Performance Improvement Plan for Behavior, which she signed.  She resigned almost immediately thereafter.  Now, she wants to come back.  What do we do?

Many medical staffs have stringent threshold requirements that applicants must meet in order to be eligible for appointment.  While those criteria might render a physician ineligible if they resigned while under investigation, the criteria probably don’t include a resignation while under a Performance Improvement Plan.  You should check your threshold criteria just in case.

Remember, the burden is always on the applicant.  Even if your criteria do not render the podiatrist ineligible for appointment, that does not mean that, as part of your credentialing process, you should appoint her to your medical staff (of course, denial of appointment is always a last option).  You can require her to demonstrate that she meets your standards, including your standard to work harmoniously with others.  You can require her to address and resolve the questions that had been raised about her conduct before she resigned.

Furthermore, you could inquire about whether she completed the relevant elements of the Performance Improvement Plan.  For instance, if the Performance Improvement Plan included anger management, CME, and/or coaching elements, you could ask for confirmation (and evidence) that she satisfied those elements.  Additionally, you could ask about her practice history since she resigned, including whether she has ever been subject to any collegial efforts or progressive steps at any other facility since she resigned.

Just like with any problem applicant, you should tell her that no further action will be taken until she fully resolves the questions and concerns about her behavior.  It is usually a good idea to give an individual like this a set time frame to respond, as reflected in your bylaws documents and notice that “If you do not fully and completely respond to our questions in the next 60 days, we will deem your request to be withdrawn and no further action will be taken.”

If you have a quick question about this, e-mail Susan Lapenta at slapenta@hortyspringer.com.

June 8, 2023

An independent member of our Medical Staff has a long history of unprofessional conduct.  Our Leadership Council addressed various complaints using progressive steps under the Professionalism Policy, such as educational letters and collegial meetings.  We even tried sending the physician to an on-site educational course on behavior with no success.  Before we refer him to the Medical Executive Committee for its review under the Bylaws, are there any other options we could try?

Yes.  A “personal code of conduct” might be successful where other efforts have failed.  A personal code of conduct outlines specific expectations for behavior and, more importantly, specific consequences for failing to meet those expectations.

With respect to expectations, a personal code of conduct may simply require compliance with the standards for behavior set forth in the Professionalism Policy.  (To assist with enforcement of the personal code of conduct, it’s very helpful if the Professionalism Policy includes specific examples of inappropriate behavior.)  Additional expectations might include periodic mentoring meetings with Medical Staff leaders, 360 reviews, or additional training.

The personal code of conduct could then describe the process that will be followed to review the facts if an additional concern is raised about the physician’s behavior.  This fact-finding process may include steps in addition to those set forth in the Professionalism Policy.

The personal code of conduct could then outline the consequences if the Leadership Council determines that there has been a “formal violation.”  The Leadership Council has the flexibility to define these consequences in any reasonable manner.  For example, the first confirmed violation could result in a final letter of warning, the second could result in the physician not exercising his or her clinical privileges for five or 10 days, and the third could result in a referral to the Medical Executive Committee for a formal investigation under the Medical Staff Bylaws.  The personal code of conduct could be indefinite or have a fixed term, and the number of formal violations could be re-set to zero if the physician goes “x” months/years without a violation.

It’s important to include other language in the personal code of conduct, such as a statement that truly egregious behavior can be referred immediately to the Medical Executive Committee.

In our experience, two formal violations are not common and three formal violations are very rare.  As long as the Leadership Council is willing to enforce personal codes of conduct, they can be an effective tool for physician leaders who are attempting to deal with long-term inappropriate behavior.

If you have a quick question about this, e-mail Phil Zarone at PZarone@hortyspringer.com.

July 21, 2022

Our hospital recently employed a small group of orthopedic surgeons. There have been rumblings that hospital administration was unhappy with the performance of the private orthopods and there is clear tension between administration and the private group. There was an incident last week in the cafeteria where one of the private orthopods allegedly yelled and got in the face of one of our hospital administrators. The administrator wants to deescalate the situation and hasn’t filed a complaint, but how should we as a medical staff handle the matter?

This is an excellent question and the administrator’s response is completely understandable, but the best practice in this situation is to follow your Medical Staff Professionalism Policy.  If medical staff leaders become aware that a practitioner’s behavior in the hospital may be inconsistent with the expectations for medical staff members, the leadership can and should review that behavior under the Professionalism Policy.  The review by the medical staff leadership does not depend on the administrator filing a complaint.

The Professionalism Policy should require that appropriate fact-finding take place and that the private orthopod have an opportunity to provide input.  This fact-finding and input will allow the medical staff leaders to understand the context in which the dispute occurred.

As I said, the administrator’s hesitance in filing a complaint is natural.  From that individual’s perspective, filing a complaint will not only increase the tension that seems to be occurring between hospital administration and the private orthopods, but it will also open a door for the private orthopods to claim they are being targeted by administration.  However, the risk of not acting is that potentially inappropriate behavior is not addressed.  This is bad for the culture at the hospital and the credibility of the medical staff leadership.  Also, allegations that administration is targeting the private orthopods can be addressed by good fact-finding and documentation (e.g., by talking with others who witnessed the event).  Allegations of bias, while scary, would be easily dispelled in this situation.

Additionally, the downsides of not filing a complaint are potentially much greater.  For example, what if the surgeon’s behavior continues to cause disruption in the hospital and the medical staff needs to impose some form of discipline?  Without addressing this particular incident, your medical staff will be missing a key part of the record to use if and when the time comes to deal with the surgeon’s behavioral issues.

March 28, 2019

QUESTION:        We are finally reviewing our conduct policy after a number of years, and in the policy we define unprofessional conduct with a few broad categories, such as abusive or threatening language, throwing an object, or inappropriate physical contact.  Is this what you recommend?

ANSWER:            First, it is fine to have broad categories, but we recommend that those categories include specific examples.  For instance, “abusive or threatening language” is fine, but it should be further reinforced with examples, such as “abusive or threatening language, e.g., belittling, berating, and/or non-constructive criticism that intimidates, undermines confidence, or implies stupidity or incompetence.”  It could also be language that is “degrading, demeaning, or condescending.”  This makes it clear that “abusive or threatening language” is more than just yelling/screaming, etc.

For example, unprofessional behavior also means:

  • refusal or failure to answer questions regarding patients, return phone calls, or respond when on call for the Emergency Department in a timely manner;
  • intentional misrepresentation to Hospital administration, Medical Staff leaders, or others in an attempt to avoid responsibility for an action taken;
  • retaliating against any individual who may have reported a quality and/or behavior concern regarding a practitioner;
  • repeatedly failing to renew legally-required credentials prior to expiration;
  • inappropriate medical record entries impugning the quality of care being provided by the Hospital, another practitioner, or any other individual;
  • inappropriate access, use, disclosure, or release of confidential patient information.

The point is to make the list as specific and exhaustive as possible (but even so, still include language stating “including but not limited to” before the list).  This will help Medical Staff leaders tremendously because those leaders can point to a specific category/example without having to resort to interpretation of the language and trying to convince others that this category does really include that behavior.

Finally, we recommend that these polices be called “professionalism” policies, not “conduct” policies to reinforce that all practitioners conduct themselves in a professional and cooperative manner.

For more on this topic, please sign up for the upcoming
Grand Rounds audio conference
“Professionalism Policy — Key Elements”
on April 2, 2019 from 
1:00 pm to 2:00 pm (Eastern time)
presented by: Lauren Massucci and Phil Zarone

June 22, 2017

QUESTION:        I am a new physician CEO at a physician group affiliated with a hospital system.  I get calls and e-mails from physicians directly when they have concerns about the communication/behavior/responsiveness of other physicians, before any medical staff involvement.  There is an agreement to share information between medical staff committees and the employer group.  How should I respond?

ANSWER:            It would be a good idea to develop a policy for the group as to how issues are triaged and addressed. If the issues primarily involve conduct in the hospital setting, as opposed to employment, you could still choose to handle them initially within the group process (and consider subsequent reporting if the issue is not resolved) or you could report the concerns to the appropriate individual in the hospital. That may be the CMO, a medical staff officer, or Leadership Council as described in a Medical Staff Professionalism Policy.

While it may be suitable for you to handle some issues in an informal way by your personal immediate involvement, too much of that style of intervention may not be a good use of your time.  Many issues are best directed through appropriate channels within either the group or the hospital/medical staff.  (That doesn’t necessarily mean too much bureaucracy!)  There may be more to a story than what is reported by one person; often, more fact-gathering is needed.

For issues that implicate medical staff performance, in some systems, a group’s CMO may be appointed to a hospital medical staff peer review committee or may be invited to the Leadership Council or similar group. A Leadership Council is commonly composed of the officers, hospital CMO and key support staff, and can convene regularly or when an issue involving the hospital practice or behavior of an employed physician is to be triaged.