36A77620Q0079-017.pdf

JAMES A. HALEY VETERANS’ HOSPITAL HOSPITAL POLICY

TAMPA, FLORIDA 33612 MEMORANDUM NO 00-02

MAY 2019

CODE OF CONDUCT FOR PATIENTS, FAMILY MEMBERS,

VISITORS, AND VOLUNTEERS

1. PURPOSE: To establish a policy for personal and professional standards of conduct for patients, family members, visitors, and all others while engaged in business, or services within the James A. Haley Veterans' Hospital and Clinics (JAHVH), or places of business under the auspices of JAHVH. To limit behaviors that might impinge upon the delivery of appropriate healthcare, which might foster medical errors, or negatively impact on the quality of patient care. The purpose is also to promote clear and collaborative communication between staff and others to foster safe and quality health care.

2. POLICY: It is the policy of the JAHVH to provide the best health care possible. This includes maintaining a safe environment and collaborative relationships between staff and others that fosters quality care and communication. Furthermore, the JAHVH is committed to reducing and preventing behaviors or other defined acts that might interfere with or undermine the quality of patient care. This includes disruptive or intimidating behavior. All individuals entering the hospital are expected to refrain from engaging in behaviors that might interfere with the safe and appropriate delivery of healthcare.

3. DELEGATION OF AUTHORITY AND RESPONSIBILITY:

a. The Director sets expectations for the conduct of others and defines acceptable, disruptive, and inappropriate behaviors and communicates these expectations to all who enter the JAHVH.

b. Service Chiefs and supervisors are responsible for fostering appropriate behavior by communicating standards of conduct, investigating incidents of inappropriate or disruptive behavior within their area of operations, and when found to be valid, acting upon reports of disruptive or inappropriate behavior. They are also responsible for reinforcing appropriate code of conduct.

c. All employees and trainees are responsible for abiding by VA regulations and policies so that the highest possible standards of conduct, honesty, integrity, impartiality, and ethical behaviors are maintained in the JAHVH at all times. Employees are also responsible for reporting disruptive or inappropriate behavior that undermines patient safety.

4. DEFINITIONS:

HPM NO. 00-02 MAY 2019

a. Appropriate Behaviors: Are considered actions that result in a safe and collaborative healthcare environment. The following is a listing, although not inclusive, of behaviors that are considered appropriate:

(1) Demonstrating sensitivity to diverse backgrounds, including gender, race, age, sexual orientation, nationality, or religion.

(2) Communicating in a respectful and open manner that facilitates positive relationships.

(3) Adherence to community standards of ethics and appropriateness of behavior.

(4) Offering cooperation and support of actions of the healthcare team.

b. Intimidating and disruptive behaviors include, but are not limited to:

(1) Behavior that is intimidating, threatening, or dangerous and may pose a threat to the health or safety of patients, VA employees, or visitors to the facility.

(2) Behavior that interferes with the delivery of safe medical care to patients at the medical facility.

(3) Behavior that impedes the operations of the facility.

c. Consistent with national recommendations, it is suggested that definitions of “disruptive behavior” are enhanced by the use of examples, thus the following are offered as best-practice guidance:

(1) Disruptive behavior in VHA may include, but is not limited to: verbal abuse (e.g., name-calling, racial or ethnic epithets, sexual harassment, loud or profane language);

direct, indirect, or implied threats; physical abuse (e.g., bumping, shoving, slapping, striking, or inappropriate touching); unwanted approaches toward or unwanted contact with others; possession or brandishing of weapons; persistent or intense outbursts; or disruptive behavior that requires resource usage to such a degree that that it interferes with the ability of other patients to access care (e.g., excessive calls to the 24-hour call center without a clear medical need, leaving repeated voicemail messages on a provider’s voice mail in such numbers that no other patients are able to leave messages, inappropriate and excessive use of Secure Messaging system, and excessive telephone calls to providers, clinics or administrative offices).

(2) Disruptive behavior may be exhibited in a personal encounter or deployed in any media, including telephone calls or messages, email, website postings, social media, video, or any other electronic, written or printed form.

(3) Disruptive behavior is defined by whether its occurrence would create fear in a reasonable person or would be perceived by a reasonable person as interfering with the delivery of health care or the performance of employee duties.

(4) Disruptive behavior is not defined by the disruptive patient’s expressed intentionality or justification for his/her behavior. Nor is disruptive behavior defined by the presence or absence of psychological or physical impairment, by the presence or absence of a patient’s decision-making capacity; or by whether the patient later expresses remorse or an apology.

5. PROCEDURES:

a. Employees who witness behavioral outbursts or activities that violate the code of conduct may take several forms of action, depending on the nature, location, and circumstances surrounding the event. Responses or consequences to such behavior may be progressive in nature and should be appropriate to the circumstances, with the goal of maintaining a safe and healthful workplace. These actions may include intervening verbally to limit the behavior, contacting additional or supervisory personnel, or in certain instances, calling the clinical response team (Code Orange Team) or contacting VA police. Persons who violate this policy may have restrictions placed on their visitation or may jeopardize their access to the facility.

b. Such behavior should be documented when possible and appropriate. Appropriate mechanisms for reporting may include a report to VA Police, Special Incident Involving a Beneficiary Report (VAF 10-2633), a report of contact form (VAF-119), completion of an electronic Disruptive Behavior Report System (DBRS) report, or other appropriate mechanisms including documentation within CPRS if the behavior is patient generated.

Documentation should include:

(1) The date and time of the questionable behavior;

(2) If the behavior was in the presence of a patient and/or affected or involved a patient in any way, and if so, the name of the patient;

(3) The circumstances that precipitated the situation;

(4) A description of the behavior limited to factual and objective language as much as possible;

(5) The consequences, if any, of the disruptive behavior as it relates to patient care or hospital operations;

(6) The name of witnesses, if any.

(7) Any actions taken and names of those intervening.

5. REFERENCES:

a. The Joint Commission Comprehensive Accreditation Manual for Hospitals

b. Title 38 CFR §17.107, VA Response to Disruptive Behavior of Patients (2010)

c. The Joint Commission Sentinel Event Alert, Issue 40, Behaviors that Undermine a Culture of Safety, http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea 40.htm

d. HPM 00-86, Employee/Patient Relationship Standards of Ethical Conduct

e. HPM 00-46, Code of Conduct for Employees and Trainees

f. HPM 00-47, Violence Prevention in the Workplace

g. VHA Directive 2012-026, Sexual Assaults and Other Defined Public Safety Incidents in Veterans Health Administration (VHA) Facilities.

6. FOLLOW-UP RESPONSIBILITY: Chairperson, Disruptive Behavior Committee, under the Mental Health and Behavioral Sciences Service (116A) is responsible for updating this hospital policy memorandum.

7. RESCISSION: Hospital Policy Memorandum number 00-02, dated, February 2014.

//s// Joe D. Battle Director

DISTRIBUTION: Electronic Distribution to All Employees http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea%2040.htm http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea%2040.htm