Appendix AA – SLUH SOM Code of Professional Conduct for Residents & Fellows

a. the date and time of the behavior;
b. whether the behavior affected or involved a patient and, if so, the name of the patient;
c. the circumstances associated with the incident, including an objective description of
the behavior, including potential triggers;
d. the consequences for patient care and/or Hospital operations resulting from the
behavior, if any;
e.
description of any contemporaneous action taken to remedy the situation and the
name(s) of those intervening;
f. a list of all known witnesses to the events).
G. All complaints regarding violations of this policy will be investigated and appropriate corrective
action will be taken. Any investigation that involves a Hospital employee, a Human Resources
representative shall be present during interviews with the employee.
H. Confidentiality:

1. During the complaint process, the confidentiality of the information received will be
   maintained to the extent possible. Information will be disclosed strictly on a need to know
   basis and in accordance with applicable law.
2. The expressed wish of the complaining person will be considered in the context of SSM’s
   obligation to action on the inquire or complaint.
3. When necessary to protect the integrity of the investigation, those who participate in an
   investigation will be expected to maintain confidentiality.
   I. SUMMARY SUSPENSION/REQUEST FOR FORMAL CORRECTIVE ACTION
4. Nothing in this policy shall be interpreted to prevent or require (i) the imposition of a
   Summary Suspension of a practitioner or independent provider’s clinical privileges; or (ii) the
   immediate request for formal corrective action in lieu of the procedure outlined in this policy,
   or pursuant to the PIP Policy, at any time in accordance with the Hospitals’ respective
   Medical Staff Bylaws whenever action must be taken immediately to prevent imminent
   danger to the health of any individual or for the continued effective operation or reputation of
   the Hospital or its Professional Staff.
   VI. FILE MAINTENANCE INFORMATION:
   Effective Date: 1/13/2011
   Last Review Date: 03/12/2024, 03/08/2024
   Revision Date(s): 01/29/2018
   Author(s): SSMSTL Hospital Vice Presidents of Medical Affairs
   Approval Teams): SSMSTL Medical Executive Committees; SSMSTL Bylaws and Policy
   Advisory Committee
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Practitioner’s and Provider’s Aid Committee or corrective action pursuant to the Medical
Staff Bylaws, as appropriate for the circumstances.
B. A cause for concern for professional staffs is the practitioner or independent provider whose
practice patterns or behaviors may compromise the quality of care provided to patients. These
practitioners or independent providers may not have bona-fide substance abuse or psychiatric
disorders. Historically, professional staffs have tolerated a wide range of behaviors, appropriately
so, as no single set of personality attributes is perfect for all patients or clinical circumstances.
Nonetheless, at the extreme, some patterns of conduct may interfere with effective clinical
performance. As a consequence, patient safety may be placed at risk. Such behavior will not be
tolerated by SSM Health St. Louis and cannot be allowed to continue.
C. The Professional Staff must be prepared to assist practitioners and independent providers to work
cooperatively and effectively with other health care professionals to meet the goal of quality care
When it can, the Professional Staff should serve as the advocate for an individual practitioner or
independent provider’s efforts to achieve this goal. At times, however, it may be necessary in the
interest of the Hospital and/or patient safety for the Professional Staff to intervene and discipline
a practitioner or independent provider as result of certain behavior.
D. A hospital setting can present an especially stressful working environment. This environment
makes enforcement of a “disruptive conduct” policy particularly difficult. Nonetheless, when a
practitioner or independent provider’s conduct disrupts the effective operation of a Hospital or its
Professional Staff, affects the ability of others to perform their duties, creates a “hostile work
environment” for Hospital employees or other practitioners and independent providers on the
Professional Staff, or begins to interfere with the practitioner or independent provider’s own
ability to practice competently, action by the Professional Staff may be necessary.
E. To facilitate a healthy working and patient care environment, SSM-STL has outlined expected
behaviors through various policies and procedures, including the Achieving Exceptional Patient
Care (AEPC) standards, Expectations of Physicians and other policies educating practitioners or
independent providers regarding prohibited conduct. SSM-STL is committed to the provision of
ongoing training programs to promote awareness as to this policy and convey SSM-STL’s lack of
tolerance for Disruptive Behavior.
F. REPORTING AND DOCUMENTATION

1. The practitioner, independent provider, Hospital employee, patient or visitor that is the
   recipient of or observes sexual harassment, prohibited or unwelcome conduct by member of
   the Medical Staff/Allied Health Staff should submit a complaint to the appropriate
   Department Chairperson or to the Chief Medical Officer (“CMO”).
   a. In the absence of the Department Chairperson or CMO, the Hospital President should
   be notified.
   b. The procedures set forth in this policy shall also apply to any member of the Medical
   Staff/Allied Health Staff who is accused of harassment, regardless of the source of
   complaint.
2. Timely and consistent reporting of and documentation of Disruptive Behavior is critical
   because it may not be one incident that justified disciplinary action but rather a pattern of
   conduct. The practitioner, independent provider, Hospital employee, patient or visitor that is
   the recipient of or observes the Disruptive Behavior (“Complainant”) shall report the conduct
   to the Department Chairperson or the Hospital’s Chief Medical Officer (“CMO”). In the
   absence of the Department Chairperson or CMO, the Hospital President should be notified.
   The Complainant will be asked to document the incident in writing and sign the written
   summary.
3. Documentation should include:
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C. Prohibited Conduct: Any unwelcome conduct - whether verbal, physical or visual - that
may be inflicted as a result of the person’s sex, race, color, religion, national origin,
gender, sexual orientation, gender identity, pregnancy, age, physical or mental disability,
veteran status or any other protected characteristic. Such unwelcome conduct includes
epithets, slurs, insults, intimidating acts or posting of written or graphic materials that
show hostility toward a person based on a protected characteristic. SSM prohibits such
conduct even if it is not sufficiently severe or pervasive to constitute unlawful
harassment.
D. Sexual Harassment:

1. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical
   conduct of a sexual nature constitute sexual harassment when: (1) an employment
   decision affecting the person is made because the person submitted to or rejected the
   unwelcome conduct; or (2) the unwelcome conduct unreasonably interferes with an
   individual’s work performance or creates an intimidating, hostile, or abusive work
   environment.
2. Unwelcome sexual conduct such as the following is inappropriate and, depending on
   the circumstances, may meet the definition of sexual harassment or contribute to a
   hostile work environment:
   a. (1) sexual teasing, jokes, or pranks;
   b. (2) repeated sexual flirtations or advances;
   c. (3) verbal abuse of a sexual nature;
   d. (4) visual conduct, including leering or making sexual gestures;
   e. (5) display of sexually suggestive objects, pictures, or cartoons;
   f. (6) letters, notes or gifts that are sexually suggestive;
   g. (7) touching or grabbing of a sexual nature or repeatedly standing too close to
   or brushing up against a person.
   E. Unwelcome Conduct: conduct that is uninvited and offensive to the person is considered
   unwelcome conduct. Conduct that is acceptable to one person may be offensive and
   unwelcome to another.
   V. PROCESS:
   A. Leaders of SSM Health St. Louis are responsible to assure that all individuals within its facilities
   be treated courteously, respectfully, and with dignity. SSM Health St. Louis requires all
   individuals, including employees, physicians, volunteers and students to conduct themselves in a
   cooperative and professional manner.
3. SSM Health St. Louis forbids all forms of harassment, and all Practitioners and Independent
   Providers shall refrain from engaging in any of the activities described herein. With regard to
   sexual harassment, no Practitioner or Independent Provider shall threaten or insinuate, either
   directly or indirectly, that the refusal of an employee, job applicant, patient, Practitioner or
   Independent Provider to submit to sexual advances will adversely affect that person’s care,
   employment, work status, evaluation, wages, advancement, assigned duties, work shifts, or
   any other condition of employment, Medical Staff/Allied Health Staff membership, career
   development or clinical care. Similarly, no individual shall promise, imply, or grant any
   preferential treatment to a patient, employee, job applicant or Practitioner or Independent
   Provider in exchange for engaging in sexual conduct or submitting to sexual advances.
4. A practitioner or independent provider whose conduct threatens the health of any individual
   or impedes the effective operation of the Hospital shall be subject to the Hospital’s Medical
   Staff Professional Staff Member Interaction Policy (PIP policy) and possibly referral to the
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SSM Health - St. Louis Region
Administrative Policy
• SSMHealth
I. TITLE: Medical Staff Code of Conduct and Disruptive Behavior
Il. OUTCOME STATEMENT: To support the culture of safety and to ensure a professional health care
environment by defining a process for dealing with disruptive behaviors by members of SSM Health
St. Louis (SSMSTL) Hospitals’ Medical and Independent AHP staffs (“Professional Staff”), as
defined in each SSMSTL hospital’s (“Hospitals”) Medical Staff Bylaws. To encourage individuals to
report disruptive behavior and to ensure such disruptive behavior is appropriately addressed.
III. SCOPE:
This Policy is applicable to all SSM Health St. Louis employees, agents, volunteers and medical
staff and, unless otherwise specified, is implemented at the following entities: SSM Health St.
Clare Hospital - Fenton (“SC-SL”), SSM Health DePaul Hospital- St. Louis (“DP-SL”), SSM
Health St. Joseph Hospital- Lake St. Louis (“SJ-LSL”), SSM Health St. Joseph Hospital- St.
Charles-SSM Health St. Joseph Hospital- Wentzville (“SJ-SC/SJ-WZ”), SSM Health St. Mary’s
Hospital - St. Louis-SSM Health Cardinal Glennon Children’s Hospital (“SM-SL/CG-SL”), SSM
Health Saint Louis University Hospital (SLUH-SL”) effective 12/3/2020.
IV. DEFINITIONS:
A. A disruptive practitioner or independent provider is a practitioner or independent provider whose
conduct significantly impedes the operations of the Hospital.
B. Disruptive behaviors are defined as interactions between physicians, Hospital staff, patients,
family member, visitors or others that interfere with patient care (“Disruptive Behaviors’).
Disruptive Behaviors can cause distress among other staff members and affect overall morale
within the work environment, undermining productivity and possibly leading to high staff
turnover or even to ineffective or substandard care. Disruptive Behavior can take many forms,
including tirades in the operating room, abusive treatment of patients, visitors or employees,
sexual harassment, sexual comments/innuendo or disruption of meetings. Disruptive Behavior
may include, but is not limited to, such behavior as:

1. Attacks leveled at other members of the Professional Staff, Hospital employees, patients or
   visitors which are personal, irrelevant, or go beyond the bounds of fair professional comment;
2. Use of foul language or profanity, persistent outbursts of anger, and any other inappropriate
   comments or responses to members of the Professional Staff, employees, patients or visitors;
3. Inappropriate comments written (or illustrations drawn) in patient medical records, or other
   clinical documents, impugning the quality of care in the Hospital, or attacking particular
   practitioners or providers, Hospital employees, or Hospital policy;
4. Non-constructive criticism, addressed to its recipient in such a way as to intimidate,
   undermine confidence, or belittle, including inappropriately raising one’s voice, unnecessary
   sarcasm, name calling, blaming insults and any other personal attacks;
5. Criticism about members of the professional staff, Hospital employees and patients in front of
   other patients and visitors as well as public derogatory comments about the quality of care
   provided by others;
6. Refusal to accept appropriately assigned Professional Staff assignments or tasks, or to
   participate cooperatively, in committee or departmental affairs, including being disruptive in
   meetings;
7. Imposing requirements on the nursing or other Hospital staff other than for the purpose of
   serving patient care or the interests of the Hospital;
8. Repeated violations of Hospital or Professional Staff policies and procedures; and
9. Behaviors that impair a practitioner or independent provider’s ability to work with a team to
   provide care in a hospital setting.
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   Printed copies are for reference only. Please refer to the electronic copy for the latest version.