A. Policy Statement:

It is the policy of Franciscan Alliance (Franciscan Health) and each of its affiliated hospitals that all persons be treated with courtesy, respect, and dignity. Accordingly, the Board of Directors of each Franciscan Alliance affiliated hospital (“Board”), including the Board of this hospital (“Hospital”), requires that all physicians and other professional health care providers who maintain Medical Staff Membership and/or Clinical Privileges at the Hospital (collectively referred to as “Practitioners”) conduct themselves in a professional, cooperative, and non-disruptive manner while in the Hospital and all locations subject to the Hospital’s license including Practitioners rendering care remotely through telemedicine technology.

1. For purposes of this policy, examples of “Inappropriate Conduct” include, but are not limited to, the following:

1. Impulsive, disruptive, sexually harassing, or disrespectful behavior with fellow members of the medical staff, the Hospital staff, patients, or their families.
2. Degrading or demeaning comments (written or verbal) regarding one or more Individuals or the Hospital;
3. Threatening, degrading, demeaning, intimidating, or abusive language in any form and through any media, including social media, directed at, or in the presence of, patients, visitors, volunteers, students, Hospital personnel, nurses, physicians, health care providers, or others (collectively referred to as “Individuals”);
4. Profanity or similarly offensive language (written or verbal) directed at, or in the presence of, one or more Individuals;
5. Inappropriate physical conduct, intimidating behavior, or threats of physical conduct or harm directed at an Individual;
6. Public derogatory comments (written or verbal), including but not limited to social media posts, regarding the quality of care being provided by the Hospital, Practitioners, or other health care providers at the Hospital;
7. Documentation in the medical record that does not directly relate to the clinical status of the patient and plan of care or that is derogatory or inflammatory concerning the care provided to the patient. Maintain medical records consistent with the medical staff bylaws and rules and regulations including, but not limited to, timely completion of History and Physical examination reports, Operative Reports, Progress Notes and Discharge summaries.
8. Imposing onerous or unreasonable requirements on the nursing staff or other Hospital employees;
9. Failure to Sign, date and time telephone and verbal orders in a timely manner consistent with local rules and regulations, established hospital or medical staff policies, or bylaws.
10. Failure of Hospital-based physicians to communicate with community-based referring physicians regarding patient care in a timely manner consistent with local rules and regulations, established hospital or medical staff policies, or bylaws. Community-based physicians should likewise communicate with hospital-based physicians when one of their patients is sent to the hospital.
11. Failure to reasonably cooperate with Individual(s) in the performance of professional health care services in such a manner that adversely impacts, or could adversely impact, patient safety, or the quality of patient care;
12. Failure to reasonably cooperate with Individual(s) in such a manner that creates, or could create, a hostile work environment, or that otherwise unreasonably interferes with an Individual’s performance of duties or reasonable satisfaction in performing such duties;
13. Failure to comply with training or educational requirements related to the electronic medical record or other aspects related to Medical Staff Membership or Clinical Privileges;
14. Failure to meaningfully appear for and participate in peer review, quality review, or risk management related meetings, activities, or processes when requested or required;
15. Failure to accept or perform Medical Staff assignments, participate in committee or departmental meetings and affairs, or otherwise comply with those duties that may be requested, or that are required, by the Hospital or Medical Staff pursuant to the Hospital or Medical Staff Bylaws, Rules and Regulations, or Policies;
16. Active or passive behavior that unreasonably interferes with the safe, efficient, and/or effective operation of the Hospital;
17. Sexual Harassment”, which is defined as any communication and/or physical conduct of a sexual nature that is unwelcome and offensive to those Individuals who are subjected to it or who witness it, including, but not limited to, sexual advances, requests for sexual favors, requesting sexual favors as an explicit or implicit condition of employment or future employment, and any other verbal or physical harassment of a sexual nature including offensive remarks about a person’s sex. (e.g., innuendoes, epithets, derogatory slurs, off-color jokes, propositions, graphic commentaries, suggestive or insulting sounds, obscene gestures, derogatory posters, suggestive objects, cartoons, drawings, or pictures).
18. Retaliation in any fashion by a Practitioner who is subject of Inappropriate Conduct report against those individual(s) who were involved in making the report, or who were otherwise involved in the review or investigation of the report.

All Franciscan Alliance (Franciscan Health) hospitals