777 E. Park Drive, Harrisburg, PA 17105 • Phone: (800) 228-7823,

1• M o d u l e 1 •

Values, TrusT, ConduCT

module 1

module 1: Values, Trust, Conduct

Introduction page 3

Assessing Your Issues page 4

Gap Analysis page 6

Professional Code of Conduct page 10

Professional Compact Examples page 11

Professional Compact Selection Tool page 13

Performance Improvement and Quality Improvement Resources page 17

module 2: Assessment of Current Medical Staff Structure and Restructuring for the Future

module 3: Engaging Physicians and Enhancing Professional Satisfaction

module 4: Communication

module 5: Credentialing and Privileging

V a l u e s , T r u s T , C o n d u C T

go to www.pamedsoc.org to obtain modules

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• Considerdevelopingaprofessionalcompactwiththemedicalstaff,hospitaladministrationandgoverningbodythatclearlyoutlinestheroles,responsibilities,andexpectationsofeach.

• DevelopaProfessionalCodeofConductformedicalstaffmembersoutliningexpectationsforcreatingaprofessionalenvironmentamongstallmedicalstaffmembers.

• Consistentcommunicationisimperative;fromhospitaladministrationtomedicalstaff,andfrommedicalstafftohospitaladministration,regardingthecurrentmissions/prioritiesofeach,andhowtheothercanorshouldbeinvolvedincollaborativeeffortsandprovidejointcommitment,supportedbythegoverningbody.

• Encouragehospitaladministrationtoregularlydeliver“reportcards”tomedicalstafffromadministrationontheongoingactivitieswithinthehospital,particularlythosedirectlyimpactingpatientsand/orphysicians,asameansofprovidingopenandfrankinformationsharing.

• Developanddemonstrategoodcitizenship.

Professional CompactCreatingacompactbetweenthehealthsystemadministrationandtheorganizedMedicalStaffmayassistinimprovinganexistingcultureproblemandhelpeveryoneachieveidentifiedgoals.Theactofhavingindividualsfrombothareassittogetherandattempttodefinevaluesandrolesisanexcellentstartingpoint.Thiscompactshouldclearlystatethecommitmentofeachpartytomutualgoalsofqualitypatientcare,safetyandvalue,andanyotherareasthatareofmutualimportance.Aligningthegoalsandbehaviorsofallpartiescanhelpensuresuccessgoingforward.

In Module 1 – Physician/Health System Compact –

Building a Compact that Works you will find some examples of professional compacts between medical staff and health system leaders/governing bodies. In addition, you will find a tool that will help you and your administration/governing body customize a compact to meet your needs by selecting those elements most important to all parties.

Professional Code of ConductA culture of professionalism is vitally important in a health care setting. While the expectation exists that this is inherent by virtue of the fact that physicians are professionals, the two are not always mutually inclusive. Professionalism can go a long way in building trust and encouraging cooperation within the health care team. • Surveyhospitalstafftofindexamplesof

unprofessional conduct that they have witnessed.• Analyzeresultstoidentifytrendsorrecurring

themes. Use these to develop facility-specific code.• Createadocumentthatwillbedistributedtoall

hospital staff, displayed in prominent locations, and distributed to all medical staff members.

The code should include such items as:• Treatothersasyouexpecttobetreated.• Showrespecttoall,nomatterwhatjobtheydo.• Chooseappropriatetimesandplacestodiscuss

problems.• Communicateclearlyanddirectlywithteam

members.• Don’texpectperfection.Acceptthatsometimes

things are beyond our control. A culture of blame is a direct threat to the safety of patients.

• Choosewordscarefully,especiallywhenangry.• Apologiesareacceptedwhenwarranted.

IntroductionIn this module, we will explore how to align the values of the medical staff (both employed physicians vs. independent physicians), the hospital administration, and governing body. In addition, we will look at how to determine if there are trust issues among these groups, and if so, how to help build trust, while enhancing collaboration among all members of the health care team.

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Assessing Your Issues

• Arethereproblemswithinyourhealthsystem?• Arethings“notquiteright”?• Dothedoctorsjustnotcareaboutthehospital?• IstheCEOatyrant?• Doyoufeelyouthatyouarebeingtoldthetruth?• Arephysicianstakingadvantageofadministration’s

goodintentions?• Areyouworkingtoohardfortoolittlepay?• IstheretheperceptionthattheCMOmighthide

outinherofficeanddonothing?• Arephysicianstheonly“goodguys”?• Doesitseemthattheadministrationpurposely

feedsthemedicalstafflimitedinformation?• Aresomephysicianswastingresources?• IstheCEOyourbiggestchampion?• Whocanyoutrust?Someoftheseproblemsandconsiderationsmayexistin your health system, and some may not. Very little is thesameateverysinglehealthsystem.Eachsystemhasits own environment and its own culture.

Severalthingsarealmostalwaystrue:

• Physiciansandhospitaladministratorscarefirstand foremost about patients.

• Sometimesyousimplycan’ttelleveryoneeverything that is going on right now because it couldputsomethingatrisk,etc.Theminutetheycan tell you, they usually will.

• Fewpeopleinanybusinesseverfeeltheyarebeingpaid enough.

Oneofthemostdifficultthingsforagrouptodoistoidentifyexactlywhatisbroken,andhowtogoaboutfixing it. There are conflicting values, feelings can get hurt,andsomepeopleeitherdon’tthinkthereisaproblem,orjustdon’tcare.

Forthosewhocare,themostimportantthingthatyoucandoistofindlike-mindedindividualswhoarewilling to spend the time to figure out what needs to be done to improve the culture of the health system.

Areyourissuesphysiciantophysician?Aretherephysiciansonthemedicalstaffwhoaremakingeveryonemiserable?Isitpersonality,mentalillness,substanceuseorclinicalincompetence?Arephysicianleadersawareoftheproblem?Hasthephysicianinquestionbeenspokentoandprovidedsupport?Doyourbylawsaddressphysicianprofessionalconduct?Ifnot,theyshould.Everythingthatimpactsthemedicalstaff must be addressed in the medical staff bylaws, and rules and regulations. When was the last time your medicalstaffbylawscommitteereviewedthem?Makesure they are current, relevant and appropriate.

Arephysiciansnotwillingtotakeonleadershiproles,ortoserveonmedicalstaffcommittees?Arethesamepeopledoingeverythingallofthetime?Whatdoyoudo to entice physicians to participate in the activities of theorganizedmedicalstaffanditsgovernance?

Isthereoverallapathywithinthemedicalstaff?Howcanyougetphysiciansengaged?Whyaretheynotinterested in the future of the medical staff within your hospital?Lookbackandtrytofigureoutwhenorwhyitbegan.Wasthereachangeinleadership?Didalargenumberofphysiciansleavetheareaatonetime?Wasthereasingleeventthattriggeredtheapathy?Howlonghasitbeengoingon?Reachouttophysicianswho have been on staff for a long time to get their historical perspective.

Are the problems you face between physicians and hospitaladministration?Doyouknowwhatisimportanttothehospitaladministrators?Tothegoverningbodymembers?Dotheyknowwhatisimportanttothemedicalstaff?Ifyouhonestlydon’tknow,thenyouneedtostartthere.Askwhatkeepsa hospital administrator up at night. What worries himorherthemost?Canthemedicalstaffhelp?Sometimesjustknowingtheburdensomeoneelseiscarrying is enough to get us to open our minds and be more receptive.

ThejobofahospitalCEOisoneofthetoughestjobsthereis.Ifhe/shedoesabadjob,itcandirectlyimpactthehealthofthecommunity.CEOsneedtohave a crystal ball to see the future, so that they can

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appropriatelyplanforit.Theyneedtokeepamedicalstaff, administrative staff, nursing staff, and everyone elsewithinthesystemhappy.So,whoismakingsuretheCEOishappy?Exactly!

Thejobofaphysicianintoday’shealthcareenvironmentisalsotough.Physicianshavetotakecareof clinical needs of their patients, deal with mountains ofadministrativepaperwork,complywithcomplexrules and regulations if they want to get paid for their services, decide if they want to try to survive private practiceorgetajobwithalargegrouporhealthsystem, and still find the time to have a life.

SometimestherejustarenotenoughhoursinadayfortheCEOorthephysicians.Oneofthemostbeneficialgoalsthatcanbemetisforbothtoworktogether.Aspartofateamworkingforthesameoutcomes,CEOsand physicians can help and support each other.

TheCEOdoesn’tnecessarilyunderstandwhatarobotdoesintheOR,andthesurgeondoesn’tnecessarilyunderstand where the money comes from to buy the robot, but both must be involved in the decision to purchaseornottopurchase.Thisisjustoneexampleofhowadministratorsandphysiciansneedtoworktogether for the benefit of the patients they serve.

Takingthetimetohaveopenandhonestconversationswhiletryingtounderstandthe“otherside”iscriticalin coming together for a common goal. As a physician, givesomethoughttothethingsthataCEOofahealthsystemneedstoworryabout.Doyouthinkabouthow much disposable gloves cost, and how much moneythehospitalspendseachyearbuyingthem?Probablynot.Everythingthatispurchasedforandbyahospitaladdstotheoverallcostofhealthcare.Staffexpenses, recruiting physicians and other health care workers,insurancecoverage,propertymanagement,governmental regulations, reimbursement rates, and the list goes on and on.

Ontheflipsideofthatcoin,physiciansspendtheirtime worrying about the patient that they may not have enough time to spend with, or the diagnosis that might have eluded them, or the patient who is going to die alone because she has no family. They are worried that their patient with congestive heart failure is going to need to be readmitted shortly and so the insurance companyprobablywon’tpayforthatadmission.Theyaren’tsuretheyaredocumentingcorrectlyintheirpatients’chartstogetproperreimbursement,and“howintheworlddoIgettothenextpageofthiselectronic medical record so that I can examine my patient who is waiting on the exam table now for more than5minutes?”

The first step to finding a solution to a problem is to understand where the other person (group, etc.)iscomingfrom,andhowtheyarelookingatthe situation. What is important to them and how doesthismeshwithwhatisimportanttoyou?Findcommon ground.

Findingsolutionsthatworkisthenextbigstep.Caneveryoneagreeonwhatwillwork?Isthereacostinvolved?Howcanyoutestit?Doyouhavetheresourcesyouneedtoassumethetask?Hospitalphysician leaders and hospital administration leaders can,andshouldwantto,worktogethertobuilda dynamic, patient-centric environment that is poised for the rapidly changing world of health care. RegulationsandstatelawprovidethattheorganizedMedicalStaffisresponsiblefortheclinicaldecisionsmadewithinahospitalorhealthsystem.Makingsurethat this structure is strong and in place is one of the mostimportantthingsthatyoucanworkontogetherto enhance the safety and value of the care delivered to your most important asset – your community.

Hopefullythetoolsthatweareprovidinginthesemodules will help to stimulate discussion and help guide all parties to build an optimal medical staff governancesystem,withqualityatthecore.

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Professional Codes of Conduct

A professional code of conduct can be beneficial as partoftheMedicalStaffBylaws.ThesecodesprovideclearstandardsofacceptablebehaviorofMedicalStaffmembers.

Bothappropriateandinappropriatebehaviorshouldbedefinedclearlyandconcisely.Examplesofappropriatebehavior can include:• Treatingotherswithrespect• Communicationthroughproperchannels• Cooperationwhenresolvingissues• Clearandhonestcommunicationwithcoworkers• Constructivecriticismofferedandreceived

professionally• Promptresponsetoconsults,pages,oranyother

patient care eventExamplesofinappropriatebehaviorcaninclude:• Threateningorintimidatingothers• Bullyingbehaviorofanykind• Treatingotherswithdisrespect• Harassmentofanytype(verbal,physical,sexual)• Useofprofanity• Refusaltoperformconsults,oranyotherpatient

care event, in a timely manner

• Failuretorespondtopagesorreturnphonecalls• Personalinsultstostaff,patientsorfamily

members/visitors• Physicalcontactorbehaviorthatisinanyway

inappropriate• Verbalthreatsofanynature,includingretaliation,

joblossorharassmentinanyform• ThreatofviolenceoractualphysicalviolenceThe policy should also outline actions that will betakenwhenphysiciansengageininappropriatebehavior, who may investigate, and who may determinewhat,ifany,correctiveactionwillbetaken.

EachmemberoftheMedicalStaffshouldsigntheCodeofConduct,andshouldberegularlyprovidededucational programs that discuss professional behavior issues and resources available in instances of issues with physicians.

As with all policies and procedures included in the MedicalStaffBylaws,pleaseconsultyourattorneyforassistance in developing this code.

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Professional Compact Examples

Physician/HealthSystemcompactsarebeingusedtoday by many systems across the country. They help to focus both hospital administration and physicians on the most important aspect of healthcare —thequalityandvalueofthecaredeliveredtopatients. They provide an opportunity for open and frankconversationsbetweenphysicianleadersandadministrative leaders within the health system, allowing each group to understand the priorities and concerns of the other while identifying and supporting shared values and goals.

Boththemedicalstaff/physician’sandtheorganizationadministration’sresponsibilities,goals,and commitments to each other, as well as to the community, need to be identified and refined to find those value-based behaviors that each group feels are the most significant and therefore belong in the compact.

When developing a compact, it is important to consider who should be invited to participate from eachgroup.Communicationaboutwhatvalueseachgroup holds important, what values align, and which values might conflict is critical.

The first thing that the group will determine is what is thepurposeofthecompact?Isitbeingbuilttodevelopa partnership or relationship that does not currently exist,ortoenhanceanalreadyexistingpartnership?Whatvaluesorphilosophiesaresharedalready?What do the groups involved feel that the other groupsaremissing?Itisvitalthatallofthesethingsbe put in writing before selecting the components of the compact, and that they be referred to regularly when deciding what should be included in the final document.

The following categories are often used in physician compacts:

Leadership;customerservice;partnership;superiorclinicalquality;patient-centeredness;patientsafety;service;financialsuccess;growth;communication;alignment;professionaldevelopmentandgrowth;integrity;excellence;respect;stewardship;

compassionatecare;honesty;transparency;support;value;bestpractices;ownership.

Thereare,ofcourse,manymore.Thesearejustafewexamples that are seen in professional compacts.

ExamplesofResponsibilities/Commitments/Goals

PatientQualityCareValues:• Bothsideswillactivelysupportandagreeto

providesuperiorqualitycare• Bestclinicalpracticeswillbeidentified,

implemented and supported• Strivefor,andsupportclinicalexcellence• Compassionatecarewillbeprovidedatalltimes• Practicestateoftheartmedicine• Ensureaccessforpatients• Helpdevelopanduseclinicalguidelines• Helpsupportapatient-centricenvironment• Supporthealthcareteams,aswellasindividuals

Leadership:• ActivelyparticipateinorganizedMedicalStaff

activities• Provideleadershipwithintegrity• Embracenecessarychangesandhelpintegrate

thesechangesamongMedicalStaffmembers• Activelylisten,collaborate,andshareideas.• Takeadvantageofleadershiptraining

opportunities• MentorotherMedicalStaffmembers

CommunicationandTransparency:• ShareinformationamongMedicalStaffmembers,

as well as hospital administrators when appropriate• Ensurethatcommunicationisclear• Provideandacceptregularfeedbackanddialogue• Physicianswillcommunicateeffectivelywithother

members of the health care delivery team• Listenwithrespectforothervaluesandopinions

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Ethics:• Providefaircompensation• Demonstratehighestprofessionalconduct• Worktogethertofindethicalandeffective

solutions• Leadorganizationwithintegrityand

accountability

CustomerService:• Developandmaintainpatient-centricculture• Analyzepatientsatisfactiondatatoidentifyareas

of improvements, share data with medical staff• Encouragepatientinvolvementinhealthcareand

treatments• Consistentlyactinawaythatisbestforthe

patient

FinancialSuccess:• Eachpartywillactivelyworktoprovidevaluein

health care• Eachpartywillactivelyworktodemonstrate

accountability for rising costs of health care• Eachpartywillactivelyworktofostersuccessinan

environment of limited resources• Eachpartywillactivelyworktogetherandshare

information regarding business decisions effecting health care

CompassionateCare:• Providecarewithoutdiscrimination• Supportphysiciansintheireffortstoprovide

compassionate care

• Respectthepatient-physicianrelationship• Communicateclearlywithpatientsandtheir

families• Educatepatientsandguidethemintheircare

Respect:• Agreetotreatothersasyouexpecttobetreated• Showrespecttoall,regardlessoftheirposition• Chooseappropriatetimesandplacestodiscuss

issues/concerns• Acceptthatsometimesthingsarebeyondour

control• Clearlycommunicatethereasonsfordecisions

made so that the rationale is understood by all• Apologizewhenwarranted

ProfessionalDevelopmentandGrowth:• Provideorganizationaltrainingactivities• Activelyparticipateinorganizationaltraining

activities• Providetoolstoachievestateoftheart,high

qualitymedicine• Takeadvantageofleadershiptrainingcourses• Usequalitydatatoidentifyareasofimprovement

in patient care and value• Providesupportandresourcesforadditional

training and research• Embraceinnovationandcontinuousquality

improvement

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AMAConvenedPhysicianConsortiumforPerformance Improvement: www.ama-assn.org/resources/doc/cqi/ pcpi-overview-flyer.pdf

PCPIApprovedQualityMeasuresRoyaltyFree: www.ama-assn.org/apps/listserv/x-check/ qmeasure.cgi?submit=PCPI

PCPIWebinarstoadvancequalityof care and patient safety: www.ama-assn.org/ama/pub/physician-resources/physician-consortium-performance-improvement/knowledge-center/webinars.page?

PatientSafetyOrganizationLeadershipChecklist:www.ama-assn.org/resources/doc/ethics/ patient-safety-checklist.pdf

NAHQCalltoAction—Safeguardingthe IntegrityofHealthcareQualityandSafety Systems,October2012: www.nahq.org/uploads/NAHQ_call_to_action_FINAL.pdf

AgencyforHealthcareResearchandQuality(AHRQ)PatientSafetyNetwork—PatientSafetyPrimers:http://psnet.ahrq.gov/primerHome.aspx

AHRQCareCoordinationAccountability MeasureforPrimaryCarePractice: www.ahrq.gov/qual/pcpaccountability

AHRQSurveysonPatientSafetyCulture: www.ahrq.gov/qual/patientsafetyculture

References/Resources/Readings

CommonwealthFund—ProvidenceSt.VincentMedicalCenter—ImprovingEfficiencybyStandardizingCareandEnsuringAccess: www.commonwealthfund.org/Innovations/ Case-Studies/2011/Jul/Providence-St-Vincent-Medical-Center.aspx

CommonwealthFund—ReducingHospitalReadmissions:LessonsfromTop-PerformingHospitals:www.commonwealthfund.org/Topics /Health-Care-Quality.aspx

CommonwealthFund—QualityMattersNewsletters:www.commonwealthfund.org/Publications/Newsletters/Quality-Matters.aspx

HealthAffairs—TheDesignandApplicationof SharedSavingsPrograms:LessonsfromEarlyAdopters: http://content.healthaffairs.org/content/31/9/1959.abstract

InstituteforHealthcareImprovement—IHIGlobalTriggerToolforMeasuringAdverseEvents:www.ihi.org/knowledge/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx

PennsylvaniaMedicalSociety— ManagingRiskNewsletters: www.pamedsoc.org/MainMenuCategories/Publications/Managing-Risk

The Foundation of the Pennsylvania Medical Society and the Pennsylvania Medical Society extend their sincerest appreciation to the Physicians’ Foundation for its investment to develop and refine these learn-ing modules focused on creating an optimal governance structure.