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St. Joseph’s Hospital – Phoenix
MEDICAL STAFF
Professional Behavior Policy
Policy
The St. Joseph’s Hospital and Medical Center (SJH) Medical Staff has determined that unprofessional conduct, as
defined in this policy, has the potential to adversely affect the quality of care delivered to patients within SJH.
Consequently, unprofessional conduct by members of the SJH Medical Staff is not acceptable. It is the policy of SJH
that all individuals within its facilities are treated courteously, respectfully, with dignity, and in accordance with the
organization’s core values of collaboration, excellence, justice, dignity, and stewardship. Matters addressed as a
result of this policy shall be confidential pursuant to Arizona revised statutes 36-2403 and 36-445.01 et. Seq.5
1. Expectations and Definition
All practitioners are expected to adhere to the SJH Medical Staff Bylaws and Rules & Regulations, including
but not limited to such reasonable expectations as:
1.1. Reasonable expectations:
Complying with practice standards,
Addressing concerns about clinical judgments with other practitioners, directly and
privately,
Addressing dissatisfaction with policies, equipment and personnel through appropriate
grievance channels,
Communicating with others clearly, directly, and with respect for their dignity, and
Being open to constructive criticism.
1.2 Unprofessional behavior is:
Malicious, threatening, disruptive or aggressive verbal communication or actions, which go beyond
the bounds of professional conduct and are directed toward members of the Medical Staff, hospital
personnel, or patients including their families and other associates.
Examples include but are not limited to
Demeaning, disrespectful, discourteous or abusive language or behavior toward others,
Sexual harassment (defined by Hospital Policy),
Impaired behavior resulting from observed and/or documented alcohol or other
substance abuse in a SJH facility.
2. Guidelines
2.1 Unprofessional behavior must be documented (Attachment A). Patterns of inappropriate
behavior should also be identified and documented. That documentation shall include, to the
extent available:
a. the location, date and time of the behavior(s) in question;
b. the medical records number of the patient (if the behavior affected or involved a
patient, or his/her care) or the name of the employee or other person(s) involved;
c. the circumstances surrounding the situation;
d. a legible concise, objective description of the questionable behavior;
e. description of any action taken to remedy the situation, including date, time, place,
action and name(s) of those intervening;
f. witness(es), if any, to the questionable behavior.
2.2 Any practitioner, employee, patient, or visitor may report potentially unprofessional behavior.
Reports will be kept confidential, except where disclosure is necessary to provide the practitioner
with an opportunity to respond to the report. Any form of retaliation against the reporting
individual is prohibited and may subject the retaliating practitioner to disciplinary action
according to the Corrective Action Article of the SJH Medical Staff Bylaws.
Orig: 10/28/98; MEC: 012802; 022502; Revised: 3/08/06; Reviewed: 5/3/06
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St. Joseph’s Hospital – Phoenix
MEDICAL STAFF
Professional Behavior Policy
2.3 Any practitioner who manifests behavior that compromises the quality of patient care, either
directly or by disrupting the ability of other professionals to provide quality care, may be
reported. If the behavior is deemed to present an immediate danger to patient, staff or
personal safety, the privileges of the practitioner will be suspended immediately in accordance
with SJH Medical Staff Bylaws.
2.4 Reports of events that are significantly disruptive of other professionals’ ability to provide quality
care on an ongoing basis may result in initiation of the corrective action process under the SJH
Medical Staff Bylaws. Other reports will be processed in accordance with Section 2.5 of this
policy.
2.5 Reports shall be submitted to the Department Chair and the Medical Director of Medical Staff
Administration (“MDMSA”) and Director of Medical Staff Services Department, acting as agents
of the Medical Staff. A review shall be completed as soon as possible after receipt of the report
consistent with the gravity of the situation. The Department Chair will investigate and, after
discussion with the MDMSA, may dismiss reports that are not deemed worthy of additional
review. The individual initiating the report and the practitioner will be informed that the report
has been received, reviewed and dismissed.
Those reports reviewed and considered worthy of additional investigation are to be addressed as
follows:
a. A letter will be sent to the practitioner with a copy of this policy. A discussion of the
content of the report will be included in the letter in addition to a request to respond in
writing to within 15 business days. Response time may be extended 15 days at the
discretion of the Department Chair or MDMSA, and the practitioner may request a
personal interview with the Department Chair, in addition to submission of a written
response. Upon review of the response and an interview with the practitioner, if
applicable, or if there is no response from the practitioner, the Department Chair may
conduct whatever additional investigation he or she feels is warranted before
determining whether to proceed under this policy or dismiss the report.
If the report is found not to be valid, the practitioner and the reporting party,
both will be informed in writing that the report has been dismissed.
If the report is found to be valid, the report will be trended to the practitioner.
In addition, depending on the nature and gravity of the event, and the existence
of any prior acts of unprofessional conduct by the practitioner, the Department
Chair may, at his or her discretion, take any one or more of the actions listed in
Section 2.5b below.
b. The Department Chair may, under the circumstances set forth in 2.5a, take any one or
more of the following actions:
Discuss the event with the involved practitioner, the Department Chair and
MDMSA and/or the Medical Staff Department peer review members appointed at
the discretion of the respective Department Chair.
Send the practitioner a letter informing him of his unacceptable behavior
offering an opportunity for written dispute or audience with the Department
Committee.
Refer the practitioner to the Professional Health Committee.
Require the practitioner to develop and comply with a written plan of correction.
Initiate corrective action per the SJH Medical Staff Bylaws.
Take any other action, not prohibited by the Medical Staff Bylaws, that the Chair
determines is reasonable.
Orig: 10/28/98; MEC: 012802; 022502; Revised: 3/08/06; Reviewed: 5/3/06
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