System and Professional Integrity

“Ideally, codes of conduct are not solely top-down mandates, but bottom-up initiatives engaging front-line physicians and other direct care providers to establish clinical and behavioral expectations to benefit patients and practitioners alike.”

The need to develop a code of conduct in healthcare organizations is growing as cost, quality, and access pressures increase. As sweeping changes in the healthcare system confront leaders, well-run healthcare organizations can no longer afford to allow physicians and other direct care providers to do whatever they desire clinically, opera- tionally, and behaviorally. Clinical protocols and behavioral norms must be established and followed. Codes of conduct are a strong mechanism to codify these expectations.

Organization development practitio- ners can consult with healthcare organiza- tions, particularly medical groups, to help them develop codes of conduct that elevate the culture and safety of the organization. An illustrative case study will be presented to show the development of a code of con- duct using an organization development (OD) approach. Sample statements are drawn from actual codes of conduct as an example in Table 1.

It is evident that these declarative statements address issues related to profes- sionalism, patient care, and quality of care. Prior to establishing a code of conduct, the advantages must outweigh the disadvan- tages. Each organization should identify its own but for the sake of illustration Table 2 (see next page) presents some of the more common advantages and disadvantages.

A code of conduct is broader than a code of ethics. It includes behaviors and expectations drawn from the standards of law and such accreditation bodies as The Joint Commission. The purpose of The Joint Commission is to ensure that health- care organizations meet specific standards

of quality, safety, performance and leader- ship. Health insurance companies often require that healthcare organizations are accredited by The Joint Commission before they will pay healthcare organizations for services rendered. Codes of conduct often go beyond a compliance focus to include alignment with the vision, mission, and values of the organization.

By William Martin

Beyond the Hippocratic Oath Developing Codes of Conduct in Healthcare Organizations

Table 1: Example of a Code of Conduct

» All Medical Staff members practicing in the Hospital must treat others with respect, courtesy, and dignity, and conduct themselves in a professional and cooperative manner.

» Members of the Medical Staff agree to refrain from engaging in any behavior that may impair the ability of the healthcare team to provide quality care and/or otherwise create a hostile or intimidating work environment.

» Members of the Medical Staff acknowledge and agree that the protection and safety of patients, employees, physicians, and others in the Hospital and the orderly operation of the Hospital are paramount.

» Practitioners base medical and business decisions upon the best possible care for patients, not personal financial interest.

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Caution must be taken to ensure that codes of conduct are not solely “Thou Shall Not” lists but also include some “Thou Shall.” There is a deep tradition of codes of conduct in medical societies, starting with the Hippocratic Oath. The difference is that these codes focus upon the profession rather than the organization. The other difference is that codes such as the Hippo- cratic Oath focus on the patient in contrast to codes that emphasize relationships with not only patients but other caregivers.

The Path to a Code of Conduct

Ideally, codes of conduct are not solely top- down mandates, but bottom-up initiatives engaging front-line physicians and other

direct care providers to establish clinical and behavioral expectations to benefit patients and practitioners alike.

There are numerous reasons for devel- oping a code of conduct, including risk management, organizational citizenship, and stewardship. A code of conduct should either state or refer to the reasons for its establishment.

Risk Management: The risk of failing to address unprofessional behavior range from adverse clinical outcomes to low staff morale. Many of these risks are prevent- able. As such, a code of conduct is one tool to improve patient safety and quality.

Organizational Citizenship: The previously mentioned “Thou Shall” expectations fall under the category of organizational citizen ship. As such, codes of conduct should include a focus on desirable behaviors and outcomes.

Stewardship: Stewardship addresses how people care for resources under their control or influence. As it relates to appropriate and inappropriate behavior at work, organizational leaders must take on their role as stewards of organizational resources, including the health and well- being of their workforce.

Risk management, organizational citi- zenship, and stewardship are not only the more common reasons for develop- ing a code of conduct but a way to better serve the organization and its members as a leader. The development of a code of conduct should yield anticipated benefits such as clarifying expectations surrounding appropriate and inappropri- ate behavior. Hickson et al. (2007) high- light six associated benefits: (1) improved human resources outcomes, such as staff

satisfaction and retention; (2) improved reputation; (3) improved organizational culture; (4) improved patient safety; (5) decreased liability exposure; and (6) a “more productive, civil, and desirable work environment” (p. 1047). After the code has been created, organizational leaders must implement and administer it. This work needs to be woven into the fabric and culture of the organization in order to have impact.

Choosing the Right Approach to Overcome Health Care Challenges

First, the way a code of conduct is created is the key to its acceptability and effective- ness. Huntoon (2008) describes the typical (and unhealthy) process of how codes of conduct are created:

Adoption of the physician code of conduct is thus often accomplished without the knowledge, review, or vote of the medical staff membership. Indeed, the hospital administration may not want the medical staff mem- bership to know about the physician code of conduct before it is adopted, and they may not want the medical staff membership to review and vote on it. (p.2)

This process is the antithesis of an OD approach. The OD approach first acknowl- edges that how change is implemented is a critical success factor. Any successful change process includes participation among key stakeholders, customer input, and alignment with the goals of the organization.

Another noteworthy challenge in creating a code is to define what type of behavior is regarded to be professional and unprofessional (Hickson et al., 2007). The answer to this quandary is more than a semantic debate. It is also a dialogue about personal, professional, and organizational values. It is a dialogue about what it means to be a healthcare professional. It ideally takes place when developing a code of con- duct, as shown in the illustrative case study that appears later in this article.

A third challenge arises when the code

Table 2: Advantages and Disadvantages of Codes of Conduct

Advantages Disadvantages

» Makes implicit explicit

» Reinforces the professions

» Weaves together commitment to the profession, the organization, and the patient

» Perceived as paternalistic

» Used solely as a tool to punish

» Lack of adoption at the level of behavior

New Leadership Standard

The Joint Commission, the major accred- iting body in healthcare, established a relatively new Leadership Standard, LD.03.01.01. A code of conduct is as an element of performance (EP 4) for meeting this accreditation standard, so long as the code defines acceptable, disruptive, and inappropriate behaviors (The Joint Commis- sion, 2008).

The former president of The Joint Commis- sion, Dr. Mark Chassin, has said: “Most heath care workers do their jobs with care, compassion and professionalism…But sometimes professionalism breaks down and caregivers engage in behaviors that threaten patient safety. It is important for organizations to take a stand by clearly identifying such behaviors and refusing to tolerate them” (Michigan Nurse, p. 13).

27Beyond the Hippocratic Oath: Developing Codes of Conduct in Healthcare Organizations

of conduct is not created and communi- cated from the perspective of quality of care and safety. This challenge can be overcome by focusing upon the positive culture of the organization, rather than catching “bad apples.” The American Medical Associa- tion in their Model Medical Staff Code of Conduct recommends: “To encourage a culture of safety and quality, organized medical staffs are encouraged to adopt a Code of Conduct as part of their medical staff bylaws” (2008, p. 1). After identifying the challenges, then the design of a process to develop a code of conduct should begin.

Establishing a code of conduct often encounters several common sources of resistance. Some stakeholders may feel that the organization is violating the privacy of individuals to conduct themselves as they see fit. Others may feel that organizations should not be in the business of telling adults what they can and cannot do. Or they may feel that adults should know what specific behaviors are acceptable or unac- ceptable and hence a code of conduct repre- sents a waste of organizational resources.

Another resistance comes from those who believe a written code cannot change behavior. They view codes of conduct as “not worth the paper they are printed on.” Basically, these critics believe that adults will do whatever they wish and an organization cannot alter that state of affairs. If the code of conduct is not rigor- ously implemented, their attacks could have some merit. Furthermore, a code of conduct absent positive consequences and negative consequences is quite simply a piece of paper. Yet, a code of conduct that is aligned with rewards for engaging in pre- ferred behavior and negative consequences for exhibiting inappropriate behavior has “organizational teeth.”

A Process for Developing a Code of Conduct

Schwarz (2004) proposed a model to serve as the guiding framework for developing a code of conduct. In Schwarz’s model (2004), there are four major elements: code content, code creation, code imple- mentation, and code administration. The effectiveness of the code, in this model, is

dependent upon perceptions of the code by stakeholders. Those perceptions are influenced by two factors: (1) code content and (2) code creation or process (Schwarz, 2004). A clear rationale for creating a code of conduct and the anticipated benefits must be identified because of their relationship to the code content and code creation or process. In essence, the organizational case must be articulated and communicated.

The Process for Implementing and Administering a Code of Conduct

Assume that the healthcare organization has designed an inclusive, participative pro- cess to identify appropriate and inappropri- ate conduct and results that are aligned with the mission, values, and goals of the organization. This information has been codified into a written code of conduct and voted upon by the relevant stakeholders or formally adopted by the relevant stakehold- ers. Then the process of implementation and administration begin.

The implementation of a formally adopted code of conduct should be based upon sound administrative principles to communicate the code of conduct, pro- vide training for managers to enforce the code of conduct consistently, and provide education and training for staff with regard to being able to demonstrate the desired

behaviors more frequently and decrease the presence of the undesirable behavior.

The following illustrative case study demonstrates an actual intervention for developing a code of conduct in a health- care organization using an OD approach and demonstrating many of the points addressed above. This OD approach was largely informed by following Schwarz (2004) who identified a set of factors associated with code effectiveness. Ten key factors that guided this OD intervention are listed in Table 3.

Illustrative Case Study

A relatively successful medical group with two locations in two major cities in the same state had grown significantly over the past 10 years. Its leaders expect continuing growth and complexity with the addition of a new site and services. Its board decided to develop a code of conduct after writing a strategic plan, including a mission state- ment and values statement. Their next step was to use Schwartz’s 2004 model because of its focus on code content and creation.

Before the Retreat

Selecting the Right Facilitator At the beginning of this engagement, the board of the medical group decided that a trained facilitator with experience working

Table 3: Key Factors Associated With Code Effectiveness: A Checklist

 The code contains a clear justification.

 The code contains examples of desired behaviors/outcomes.

 The tone of the code is positive and supportive.

 The code is not too long to be viewed as confusing and legalistic.

 The code was developed by involving key stakeholders in its development.

 The code was distributed in draft prior to being finalized.

 The code is supported by the board and/or senior leadership.

 Education and training is provided to reinforce the key elements within the code.

 The code is accompanied by a reporting system.

 The code is enforced regardless of position or status in the organization.

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with healthcare organizations, physicians, and human resources management would have the knowledge and skills required to help the group.

Planning the Event The board’s invitations to participants to attend this special retreat to develop a code of conduct reflected a multiple stakeholder

approach (Gilley et al., 2010). All physi- cians, whether partners or associates, as well as key administrative leaders were invited. This group consisted of both formal and informal leaders.

Prior to the actual event, the mission statement, vision statement, and strate- gic plan, as well as samples of codes of conduct, were distributed to each retreat participant by the physician chief execu- tive officer (CEO). Both the board of the medical group and the selected facilitator decided to provide all relevant informa- tion in advance, in keeping with Bujack’s (2003) approach to decreasing suspicion and mistrust, while at the same time promoting engagement.

It was decided that the physician CEO would kick off and end the retreat and the facilitator would take primary responsibility for the work of getting the medical group to develop their own code of conduct. It was also decided, in advance, that in case any question arose during the retreat that was organization specific that either the CEO and COO would be prepared to present more detailed qualitative and quantitative data.

During the Retreat

Guiding the Event The retreat process started early and lasted all day, with meals included to create a casual, relaxed atmosphere. The retreat was held off-site on the weekend to accommo- date the schedules of the physicians and to decrease any objections of missing the

opportunity to earn income. There were round tables with no assigned seating. Each table had a flip chart with markers to signal that this would be a working session where engagement was expected.

One of the initial steps of the process was to have the medical group revisit the reasons why they decided to become a medical group and revisit their mission and values. A benefit for revisiting these matters is to create a larger context that is grounded in individual, professional, and organizational purpose.

The retreat consisted of a series of short presentations lasting no more than 10–15 minutes, followed by a planned activ- ity to begin the process of actually creating the code. A sample of the topics presented included the following: » Mission/Vision/Values Review: The

goal of this presentation was to review the existing mission, vision, and values of the group practice as a way of estab- lishing common ground.

» Review of Patient Safety and Disrup- tive Behavior Literature: The goal of this presentation was to make the case drawing upon peer review literature that disruptive physician behavior has

a negative impact on patient safety and quality.

» Codes of Conduct Benchmarking: The goals of this presentation were to demonstrate that these types of codes of conduct are increasing throughout all types of healthcare organizations and to offer some illustrative examples.

The facilitator emphasized that the goal of the retreat itself was to agree upon the basic principles and tenets, not the precise words and phrases. It was also emphasized that in order to create a climate of owner- ship that it would be OK if the medical group, regardless of the reasons, did not or could not even agree upon basic principles and tenets. The fact that the vision, mis- sion, values, and strategic plan, as well as one relatively recent negative incident, were “on the table” made it more likely that the medical group would agree on the basic principles and tenets of their code of conduct. This proved true.

At the end of the retreat, the leftover issues were delegated to the appropriate parties for deliberation and action. The group created a running list of action items to finalize the code of conduct, authorize the code, enact it, and weave it into the culture of the organization.

After the Retreat

Upon conclusion of the retreat, partici- pants identified ways to move the code of conduct from a draft on paper to a living, breathing document. One of the next steps was to have the code of conduct reviewed by legal counsel, which fits with what others suggest (Gilley et al., 2010). Based upon Schwarz’s model (2004), these action items fall under the catego- ries of code implementation and code administration. One year later, the code of conduct is being woven into the fabric of this multi-city medical group. Fortunately, there have been opportunities to assess the effectiveness of the code of conduct. The message being communicated is that “We take our code of conduct seriously and so should you.”

The implementation of a formally adopted code of conduct should be based upon sound administrative principles to communicate the code of conduct, provide training for managers to enforce the code of conduct consistently, and provide education and training for staff with regard to being able to demonstrate the desired behaviors more frequently and decrease the presence of the undesirable behavior.

29Beyond the Hippocratic Oath: Developing Codes of Conduct in Healthcare Organizations

Lessons Learned and Recommendations for Consulting in Healthcare Organizations

Drawing upon this experience and 20 years of experience practicing OD in health- care organizations, three salient lessons emerged from this engagement. First, take Weisbord’s (1976) assessment of the fail- ure of OD in healthcare organizations as a word of caution for designing and deliver- ing OD interventions:

Science-based professional work differs markedly from product-based work. Healthcare professionals learn rigorous scientific discipline as “con- tent” of their training. The “process” inculcates a value for autonomous decision-making, personal achieve- ment, and the importance of their own performance, rather than that of any organization. (p. 17)

Furthermore, given the empirical finding that physicians do not view themselves as followers (Kornacki & Silverstein, 2000), it is critical that OD practitioners be especially attentive to power dynamics when working with physicians.

Recognize the challenge in work- ing with healthcare professionals is the tendency for these individuals to exhibit “deficit thinking,” as described by Stoller (2009), in contrast to “appreciative think- ing.” In this illustrative case, one of the focal points was to brainstorm professional behaviors. The medical group was chal- lenged to brainstorm desirable behaviors that were aligned with their mission and values.

Recognize the importance of maintain- ing a dual focus of developing both the organization and individuals. This dual focus is rooted in the definition of OD. In the illustrative case study, select members of the medical group leadership team were also being developed to design similar OD interventions. These leaders participated in leadership coaching for physicians (Henochowiciz & Hetherington, 2006).

Conclusion

As the Patient Care Protection and Afford- able Care Act of 2010 continues to be implemented through 2019 by hundreds of health systems, thousands of hospitals, tens of thousands of medical groups, and other healthcare organizations, the need for OD practitioners will only increase. An OD approach to developing a code of conduct, as shown in this illustrative case, demonstrate the work that can be done by OD practitioners to guide healthcare organizations to adjust to the turbulent tides of health reform. Organizations that seek to elevate their standards with a code of conduct, implemented with careful deliberations and an OD approach, can improve outcomes, safety, and satisfaction for patients, practitioners and the organiza- tion as a whole.

References

American Medical Association. (2008). Model medical staff code of conduct. Retrieved from www.ama-assn.org/ ama1/pub/upload/mm/21/medicalstaff- codeofconduct.pdf.

Gilley, K.M., Robertson, C.J., & Mazur, T.C. (2010). The bottom-line benefits of ethics code commitment. Business Horizons, 53 (1), 31–37.

Hickson, G.B., Pichert, J.W., Webb, L.E., & Gabbe, S.G. (2007). A complementary approach to promoting professional- ism: Identifying, measuring, and addressing unprofessional behaviors. Academic Medicine, 82 (11), 1040–1048.

Huntoon, L.R. (2008). The insulting physi- cian “code of conduct.” Journal of Ameri- can Physicians and Surgeons, 13 (1), 1–4.

Kornacki, J.B., & Silverstein, M. J. (2000). Leading physicians through change: How to achieve and sustain results. Tampa, FL: American College of Physician Executives.

Michigan Nurse Association. (2010, September - October). Bad behavior no longer acceptable. Michigan Nurse,

13–14. Retrieved from www.minurses. org/files/files/Nursing%20Practice/ badbehavior.pdf.

Schwarz, M.S. (2004). Effective corporate codes of ethics: Perceptions of code users. Journal of Business Ethics, 55 (4), 323–343.

Stohl, C., Stohl, M., & Popova, L. (2009). A new generation of corporate codes of ethics. Journal of Business Ethics, 90 (4), 607–622.

Stoller, J. K. (2009). Developing physician- leaders: A call to action. Journal of Gen- eral Internal Medicine, 24 (7), 875–877.

The Joint Commission. (2008, July 9). Behaviors that undermine a culture of safety. Sentinel Event Alert, 40. Retrieved from www.jointcommission. org/assets/1/18/SEA_40.PDF.

Weisbord, M.R. (1976). Why organization development hasn’t worked (so far) in medical centers. Health Care Manage- ment Review, 1(2), 17–28.

William Martin, PsyD, a doctoral trained psychologist, currently serves as Associate Professor at DePaul University in Chicago. He also serves on the Board of a large health system. Past positions include AVP of HR & HRIS, Director of Diversity, and Manager, Training & Development. He has over 20 years of experience in the field. He can be reached at martym@ depaul.edu.

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