Professional Conduct and Misconduct Policy

Scope

This policy was developed for SIU Medicine. SIU Medicine collectively applies to the SIU School of Medicine (SIU SOM), including the Federally Qualified Health Center (FQHC), and SIU HealthCare (SIU HC). These entities are collectively referred to as SIU in this document.

This document applies to SIU staff, faculty, trainees, agents, officers, directors, interns, volunteers, contractors, and any other individual or entity engaged in providing teaching, research and health care items and services at SIU. These individuals are collectively referred to as SIU personnel in this document.

Definitions

Resident: The term “resident” is inclusive of all trainees at SIU SOM, whether training in a residency or fellowship program. 

Program:  The term “program” is inclusive of all SIU residency or fellowship programs, whether accredited or non-accredited.

Disruptive behavior:  Behavior that is disruptive to team work and the delivery of good care.  Behavior that is unusual, unorthodox or different is not alone sufficient to classify as disruptive behavior. Examples of inappropriate conduct might include, but are not limited to abusive or profane language; comments that are degrading, demeaning or aggressive; yelling at patients, families and/or members of the health care team; inappropriate physical contact; and behaviors of omission such as chronic and recalcitrant failure to comply with stated program or hospital procedures or policies, not answering pages, or completing medical records in a timely manner, etc.

Misconduct:  Involves improper behavior. Examples of misconduct include, but are not limited to intentional wrong doing; dishonesty; plagiarism or academic dishonesty; engaging in discriminatory conduct, provision of false information or omission of information on any application materials (ERAS or other application, CV, credentialing or licensure forms, etc.); threats and/or physical assaults on anyone; and violation of a law, practice standard or program or hospital policy. 

Purpose

Good working relationships, team work and appropriate ethical conduct are necessary among all members of the health care team.  All members of the team must treat others with respect, courtesy and dignity and conduct themselves in a professional, honest and ethical manner.  Disruptive or unethical behavior is not acceptable.  This policy outlines how to address allegations of disruptive behavior or misconduct.

Procedure

Any individual who observes disruptive behavior or misconduct by a resident should report this to the program director or to the complainant’s supervisor who will then report it to the program director. Documentation of the behavior should include 1) the date, time and location of the questionable behavior; 2) a description of the behavior limited to direct factual observations; 3) circumstances that precipitated the situation; 4) actual or expected consequences, if any, to patient care; 5) record of any action taken to remedy the situation and; 6) the name of the individual who is making the report, as well as any other witnesses.

Upon receipt of a complaint regarding conduct of a resident, the program director should conduct an inquiry, as follows:

• Meet with the complainant or otherwise review the complaint.
• If the program director deems the complaint to have merit, meet with the resident to advise the trainee of the existence of the complaint, to give the trainee an opportunity to respond to the allegations and to identify any potential witnesses to the alleged disruptive behavior or misconduct.
• The program director may consult with others as appropriate based on the issues and the people involved (i.e. DIO/Chair of GMEC, legal counsel, administrator of appropriate hospital, human resources personnel, etc.).
• Behaviors or incidents occurring at a hospital site will be addressed by the program director in conjunction with the appropriate hospital personnel, according to the code of conduct policy of the appropriate hospital.  If the behavior or incident occurs at a site that is not the resident’s employing hospital, the CMO/CPE of the employing hospital will be notified.
• Incidents involving inappropriate sexual comments or behaviors will be addressed by the program director in conjunction with appropriate hospital and/or SIU School of Medicine Human Resources staff/SIU Title IX staff, according to the sexual harassment and Title IX policies.  Behaviors which indicate the presence of impairment in the resident will be addressed according to the impairment policy.  These may proceed simultaneously.
• Upon consensus of the program director, DIO and appropriate hospital administrator, the trainee may be removed from duty (with or without pay) pending the outcome of the inquiry.

Inquiries will be conducted with due regard for confidentiality to the extent allowed.  However, full confidentiality cannot be guaranteed.  Retaliation for reporting disruptive behavior or misconduct or participating in an investigation of reported inappropriate behavior is strictly prohibited. 

Outcome of Inquiry: If the inquiry results in a finding that no inappropriate behavior occurred, no action will be taken against the trainee.  If the trainee was suspended during the inquiry, they will be reinstated with full benefits and pay. 

If the inquiry results in a finding that disruptive behavior occurred that does not reach the level of misconduct, it may be addressed in accordance with the Academic Deficiency Policy as a deficit in the area of professionalism. As such, the program may take one or more responses including, but not limited to:

• A verbal or written warning
• Issuance of a Letter of Deficiency
• Education regarding appropriate behavior

Or, the program may take one or more Actions (as defined in the Academic Deficiency Policy):

• Non-promotion to next PGY level
• Denial of credit for previously completed rotations
• Repeat of a rotation(s) that extends the required period of training
• Suspension
• Non-renewal of contract
• Termination from the residency or fellowship program

If the inquiry results in a finding that a trainee participated in misconduct, the program director (in consultation as appropriate with the DIO, hospital administrator, human resources personnel, legal counsel or other individuals) shall determine what response is appropriate to remedy the situation.  Determination as to whether an inappropriate behavior constitutes misconduct, versus disruptive behavior, is at the discretion of the program director.  A program is under no obligation to offer any resident a second opportunity to engage in misconduct, especially in the patient care setting. The program may take one or more Actions including, but not limited to:

• Suspension
• Non-renewal of contract
• Termination from the residency or fellowship program

 

Actions: A decision not to promote a resident to the next PGY level, to suspend a resident, to extend a resident’s defined period of training, to not renew a resident’s contract and/or to terminate a resident’s participation in a training program may require disclosure to others upon request, including but not limited to privileging hospitals, licensure agencies or specialty boards. If a resident is subject to an Action as a result of disruptive behavior or misconduct, they must be notified of this in writing.  Such notification must be signed by the program director and the DIO/Chair of GMEC.  A non-renewal or termination of contract must be reported to the Illinois Department of Financial and Professional Regulation by the program.

Due Process and Request for Review: A resident who is subject to an Action as a result of disruptive behavior or misconduct may request a review of the decision as described in the Due Process and Resident Complaint Policy.  A copy of the Due Process and Resident Complaint Policy should be given to any resident who is subject to an Action.