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Development of a Professionalism Committee Approach to Address Unprofessional Medical Staff Behavior at an Academic Medical Center

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Background: The Joint Commission Leadership standard on the need to create and maintain a culture of safety and quality and to develop a code of conduct was based on the rationale that unprofessional behavior undermines a culture of safety and can thereby be harmful to patient care. Few reports have described effective and successful approaches to defining and managing unprofessional behavior. The Professionalism Committee (PC)–based approach at the University of Pennsylvania Health System (UPHS) may serve as a model for other hospitals and health systems.

Methods: Each of the three large teaching hospitals within UPHS has a PC that reports to its respective Medical Executive Committee. The PCs serve as a resource for department chairs and hospital administrators to address unprofessional behavior among faculty. Key features of the PC include the PC chair as the first point of contact and the integration of psychiatry into the model by virtue of the Professionalism Committee chair's training and expertise in psychiatry.

Results: In the 2009 calendar year, the PC chair received contacts concerning behavior of only 2 physicians, which increased to 42 physicians in 2011 and 39 in 2012. Contacts involved referrals, management consults, interview screening, and the need for general advice. Of 79 resolved cases, 30 involved interpersonal issues, and 2 were associated with poor clinical outcomes.

Conclusion: One key feature of the UPHS approach is early identification of the role of behavioral health issues in unprofessional behavior (as opposed to physical, cognitive, or systems issues) by virtue of the PC chair's professional training and expertise. Although aspects of the UPHS experience may not be generalizable, the PC structure and approach are replicable.

Document Type: Research Article

Publication date: April 1, 2014

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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