Behavioral Code of Conduct

Washington University School of Medicine             
DEPARTMENT OF SURGERY
June 25, 2007   

The Washington University Department of Surgery is committed to a culture of mutual respect and safety. This Code amplifies the University’s Code of Conduct and the School of Medicine’s Policy Against Abusive Conduct, and reflects the Department’s dedication to a positive working and learning environment in which every member of the Department, as well as those with whom we work in hospitals and other settings, are treated with professionalism and respect.

The Department is also committed to providing patient care of the highest quality, which requires that surgical teams operate cohesively in an atmosphere of cooperation and respect. Inappropriate behavior can disrupt the proper functioning of the surgical team and can create an environment in which members of the team are afraid to ask questions or make comments concerning appropriate patient care, to the detriment of the patient.

Inappropriate behavior by a Department member is also potentially destructive to his/her career. The University has reporting obligations to the National Practitioner Data Bank and must respond truthfully to credentialing questionnaires.

For all of these reasons, the Department has established this Code to address and prevent instances of inappropriate behavior.

I. Purposes

• To optimize the effectiveness and reliability of the healthcare and departmental teams.
• To enhance communication and interpersonal relations among all individuals involved in patient care, research and education.
• To improve the quality of patient care and safety.
• To reinforce an atmosphere of mutual respect for all who interact with or are associated with the Department.
• To prevent conduct which:
  • Interferes with an individual’s ability to practice or work safely.
  • Creates a hostile or intimidating work environment.
  • Disrupts the delivery of patient care, research or educational activities.

II. Scope

This Behavioral Code of Conduct applies to all Washington University Department of Surgery employees, regardless of where they work (i.e., Barnes-Jewish Hospital, St. Louis Children’s Hospital, Barnes-Jewish West County Hospital, Shriner’s Hospital, Veteran’s Administration Hospital or other off-site locations). This Code complements the codes of conduct and other related policies at Washington University and its School of Medicine and affiliate hospitals and off-site locations.

III. Standards of Behavior

A. Leadership Expectations:

Department of Surgery faculty and administrative leaders will be expected to set an example of professional conduct and to model the behaviors expected of all faculty and staff members in the Department.

B. Expected Behaviors:

• Communication will take place in a timely fashion, involving the appropriate person(s), in an appropriate setting.
• Communications, including spoken remarks, written documents, and e-mails, will be honest and direct and conducted in a professional, constructive, respectful and efficient manner.
• Telephone communications will be respectful and professional.
• Cooperation and availability are expected of faculty, fellows, residents and staff whenever serving in a professional capacity. When individuals are paged, they will respond promptly and appropriately.
• Recognition that a variety of experience levels exists, and that tolerance for those who are learning is expected.

C. Examples of Unacceptable Behaviors:

• Shouting, screaming or yelling
• Threatening or violent behavior
• Profane or disrespectful language
• Criticism of performance and/or competency delivered in an inappropriate location (i.e., not in private) and/or not aimed at performance improvement
• Inappropriate arguments with patients, family, staff, and other physicians
• Sexual comments or innuendo
• Inappropriate touching, sexual or otherwise
• Racial, ethnic or discriminatory jokes/slurs
• Slamming or throwing objects in anger or disgust
• Hostile, condemning, or demeaning communications
• Other behavior demonstrating disrespect, dishonesty, intimidation, or disruption to the work environment
• Repeated failure to respond to call or pages
• Retaliation against any person who reports or addresses unacceptable behavior

D. Expected Action if Unacceptable Behavior Occurs:

In situations where unacceptable behaviors occur, the Department expects the faculty member, staff member or resident/fellow to recognize their unacceptable behavior and apologize to all parties involved. In addition, the faculty member, staff member or resident/fellow is expected to take remedial measures, on his/her own initiative, as necessary to prevent the recurrence of such unacceptable behavior. 

 IV. Procedure
 
Given the close working relationship among employees of the Department, Barnes-Jewish Hospital and St. Louis Children’s Hospital, unprofessional behavior by a member of the Department may affect employees of one or more of those entities. Hospital employees may choose to report complaints or concerns regarding unprofessional behavior by a member of the Department to hospital administration, in which case the hospital will report the matter to the Department. In such circumstances, the matter will initially be addressed under the policies of the hospital. If the hospital cannot resolve the matter through informal means, the appropriate Department of Surgery Division/Section Chief will then determine the best approach for addressing the issue.
 
Complaints or concerns by a Department employee (or by a hospital employee who would prefer the matter to be addressed by the Department in the first instance) regarding unprofessional behavior by a Department member may be directed to a variety of resources:  a supervisor or manager, WUSM Human Resources, the Executive Director, the Residency Program Director, the Faculty Ombudsperson, the relevant Division/Section Chief, the Department Chair, or the Department of Surgery Hotline (phone #) housed in WUSM Human Resources.  The recipient of such a complaint or concern must promptly report it to the appropriate Division or Section Chief, who will then determine how to address the situation based on the particular circumstances involved. If the complaint is regarding a Division Chief it will be reported to the Department Chairman.
 
In recognition of the fact that situations involving improper conduct within the Department can involve a variety of circumstances, the Division/Section Chief must retain flexibility in determining how best to address the problem in each particular situation. For example, the Chief may determine that the assistance of WUSM Human Resources or the Department’s Faculty Ombudsperson would be helpful in reviewing and addressing the matter. In most instances, efforts should be made to encourage discussion between the individuals involved, with the assistance of a facilitator if appropriate. If that approach is not feasible or is unsuccessful, the Division/Section Chief or the Chairman will determine what other means are necessary to review and address the matter. If necessary to prevent harm to patients, students, staff or faculty, the Department may determine that an administrative suspension is warranted pending review of the matter, consistent with the Washington University Administrative Suspension Policy for faculty members.
 
 V. Remedial and Disciplinary Action
 
In addressing concerns of unprofessional conduct by Department members, the primary objective is to restore a collegial and safe environment for working, learning and patient care. Remedial measures may include, for example, sincere apologies and/or therapy/counseling. Disciplinary measures may also be warranted, including for example oral or written warnings or reprimands, reduction of compensation, reduction or loss of privileges or benefits (e.g., research/travel funding, endowed professorship), suspension, denial or delay of promotion, demotion, non-renewal of appointment or termination.
 
At the conclusion of the matter, the Department Chair or designate (e.g., Division/Section Chief, Executive Director) will prepare a written report summarizing the complaint or concern, the Department’s review, and the outcome of the matter. All reports will be collected in the Department’s Behavioral Code of Conduct database.
 
 VI. Prohibition on Retaliation
 
Retaliation against any individual who reports or addresses concerns under this Code is prohibited and will not be tolerated. Allegations of retaliation will be promptly reviewed by the Division/Section Chief and the Department Chair.
 
 VII. Faculty Ombudsperson
 
The Department Chair will appoint a faculty member to serve as the Department’s Faculty Ombudsperson. The Faculty Ombudsperson will perform the functions identified in this Code, such as fact finding, facilitating resolution and chairing the Behavioral Code of Conduct Council, and will serve as a model of professional behavior.
 
 VIII. Behavioral Code of Conduct Council
The Department’s Behavioral Code of Conduct Council is charged with monitoring the integrity and efficacy of this Code on a periodic basis. The Council is chaired by the Department’s Faculty Ombudsperson. Additional membership includes the Department Chair, Executive Director, Residency Program Director, and two Division/Section Chiefs appointed to a three-year term by the Faculty Ombudsperson.
 
Semi-annually, the Council will review reports contained in the Department’s Behavioral Code of Conduct database to identify any trends or patterns of behavior and to make appropriate recommendations or take appropriate action. The Council will maintain close working relationships with key hospitals leaders in order to further understand and monitor these trends and patterns. The Council will also ensure that Department faculty, staff and residents and fellows annually review the Behavioral Code of Conduct as a part of the annual performance review process.
 
The Council will identify learning needs and develop other strategies to support faculty, staff and fellows/residents in meeting the expectations of this Code.