Policy on Professional Conduct

Questions, suggestions, and concerns regarding this policy are welcomed, and should be directed to the UW Medicine Continuous Professionalism Improvement Committee (blackley@uw.edu).

Download UW Medicine Policy on Professional Conduct (PDF)

Policy

UW Medicine values professionalism among our faculty, staff, residents, fellows, and students in carrying out our mission of improving the health of the public. Professionalism includes demonstrating excellence, respect, integrity, compassion, altruism, and accountability in all endeavors. Diversity of ideas, perspectives and experiences is integral to our mission. All individuals in our UW Medicine community are responsible for creating a welcoming and respectful environment where every person is valued and honored.

It is the policy and expectation of UW Medicine that all members of our community will conduct themselves in a professional manner in interactions with patients, colleagues in the University community, and the public. Leaders in our community are expected to model, promote, and advocate for a strong and visible culture of professionalism.

Definitions

Excellence represents dedication to continuous improvement of quality of care, research inquiry, and teaching effectiveness. Excellence also includes promoting and cultivating an institutional culture of inclusion, equity, and diversity in all its forms. Pursuit of excellence should be accompanied by respect, integrity, compassion, altruism, and accountability.

Respect includes actions that recognize the inherent dignity and value of all persons and that seek to understand the perspectives of others.

Integrity refers to honesty in all interactions and upholding high moral and ethical standards in all endeavors.

Compassion is recognition of suffering and taking action to help. Compassion must also extend to self, recognizing that self-care is a key element of personal wellness.

Altruism reflects a commitment to advocate for the needs and interests of others.

Accountability refers to accepting responsibility for one’s behavior and striving to uphold professional standards. This includes working to recognize and address one’s own biases (conscious and unconscious), and mitigating their impact on behavior as providers of care, teachers, scientists and learners. Accountability includes assisting UW Medicine in recognizing and addressing institutional racism and other forms of bias and taking action that demonstrates intolerance of discrimination, in contrast to condoning or perpetuating discrimination through inaction.

Professionalism in clinical practice settings includes adherence to the UW Medicine Service Culture Guidelines  and includes, but is not limited to safeguarding the privacy and confidentiality of patient information,  communicating effectively, observing established standards for patient safety and timely completion of medical records, participating in quality improvement initiatives, exercising cultural humility, reporting errors, and following rules for billing and compliance.

Professionalism in the conduct of research includes, but is not limited to practicing intellectual integrity, ensuring the welfare of human and animal research subjects, exercising diligent and unbiased acquisition, evaluation, and reporting of scientific information, adhering to university regulations for the conduct of research, and employing collegial, non-threatening and fair treatment of residents, fellows, students and staff. When appropriate, research should be undertaken and conducted in a manner that is inclusive of diverse populations.

Professionalism in education includes, but is not limited to respect for diverse experiences and perspectives, modeling community and civil discourse, a commitment to the highest standards of scholarship, innovation in teaching methods, and leadership through modeling of life-long learning.

Professionalism in administration includes, but is not limited to respect for the culture and values of the academy, commitment to creation of collegial partnerships with co-workers one is responsible for and responsible to, support of the work of collaborative teams, recognition of the needs of patients and our professional community, and dedication to the mission of the institution.

Ethical business practices means the wise and fair use of resources and practices that comply with laws, regulations, and policies governing conflicts of interest, sponsored research, and the delivery of and reimbursement for healthcare services.

Unprofessional behavior means behavior that violates laws or rules regarding discrimination and harassment, violates rules of professional ethics (including professionalism in clinical, educational, research or business practices), or is disrespectful, demeaning, retaliatory, or disruptive.

Rules of professional ethics means the adoption of ethical standards that have been established by external professional societies and associations (e.g., The Joint Commission, American Association of Medical Colleges, National Institutes of Health) or by UW Medicine entities for various professions (e.g., physicians, nurses).

Discrimination and harassment means discrimination or harassment as defined in University of Washington (UW) Executive Order 31.  As of the effective date of this policy, this includes discrimination or harassment on the basis of race, color, creed, religion, national origin, citizenship, sex, age, marital status, sexual orientation, gender identity or expression, disability, or military status. 

Disrespectful, retaliatory, or disruptive behavior includes, but is not limited to behavior that in the view of reasonable people impacts the integrity of the healthcare team, the care of patients, the education of trainees, or the conduct of research, such as:

  • Shouts, profane or offensive language;
  • Degrading or demeaning comments;
  • Discriminatory or harassing behavior or language (as defined above);
  • Physical assault or other uninvited or inappropriate physical contact;
  • Threats or similar intimidating behavior, as reasonably perceived by the recipient;
  • Unreasonable refusal to cooperate with others in carrying out assigned responsibilities; and
  • Obstruction of established operational goals, beyond what would be considered respectful dissent.

Values in Action / Procedures

Engagement of our community to advance professional values. All members of our community should seek opportunities to acknowledge, promote, and celebrate professionalism in our environment. Leaders in our community are especially accountable for creating a culture of professionalism in their own units by exhibiting professionalism, recognizing individuals and teams that exhibit best practices and demonstrate core principles, finding opportunities to convey the importance of professionalism in our shared work, and making time for collaborative, inclusive dialogue around challenging issues.

Incorporating the principles of professionalism into applicable documents. UW Medicine units should incorporate these principles as appropriate into their policies, procedures, and practices. Professionalism expectations should be included in offer letters, merit evaluations and promotion criteria. Expectations and any available measures of professional behavior should also be specifically highlighted in annual performance reviews.

Supervisor responsibility. Supervisors, including health care and research team leaders and teachers, are expected to exhibit professionalism, set clear expectations, and manage performance of their subordinates in accordance with these standards through regular communication and timely performance reviews. Supervisors are expected to respect diversity of opinions and will not retaliate against subordinates who offer their respectful, dissenting views. Finally, supervisors are expected to address professionalism concerns and deficiencies through routine performance evaluations, counseling, discipline, or other action as appropriate in accordance with policies and procedures within the UW, UW Medicine, affiliates and partner entities.

For individuals covered by collective bargaining agreements, UW Medicine managers and supervisors are expected to apply this policy in a manner consistent with the principles of just cause, as well as any other applicable requirements of the labor agreements.

For hospitals and clinics that are part of UW Medicine, this policy is intended to define “professionalism” at the UW Medicine level in accordance with The Joint Commission standards. Under this policy, “desirable behavior” means demonstrating professionalism as described above and “disruptive behavior” means engaging in conduct that is unprofessional as described above. The hospitals and clinics will have policies and practices implementing these principles and may further define expectations regarding appropriate conduct.

Mechanisms for addressing unprofessional behavior. UW Medicine does not condone or tolerate unprofessional behavior, and individuals who engage in such behavior may be subject to disciplinary action up to and including termination.  Supervisors are expected to address unprofessional behavior as described above.  Members of our community at all levels may also raise concerns and/or ask for support through a number of avenues depending on the particular circumstances, including but not limited to the following: (1) informal and collegial one-on-one resolution; (2) bringing the issue to their supervisor or the next highest individual of authority, if the concerns involve the supervisor; (3) following applicable grievance procedures under collective bargaining agreements; (4) contacting Human Resources or Academic Human Resources; (5) contacting the University Complaint Investigation and Resolution Office (UCIRO); (6) contacting the University Title IX office; and/or (7) contacting the University of Washington Ombud. The UW Safe Campus office is also available as a resource in situations involving non-urgent safety concerns.

For certain types of concerns, a particular avenue may be most appropriate, or even required by UW policy.  For example, Administrative Policy Statement 46.3 (Resolution of Complaints Against University Employees), contains information and processes for addressing complaints about employees, including violations of the University’s non-discrimination policy (http://www.washington.edu/admin/rules/policies/APS/46.03.html) and other concerns.    Detailed administrative or contractual processes also exist to address specific types of complaints including classified and professional staff complaints, whistleblower complaints, and patient complaints. There are also existing processes for addressing student conduct issues and for addressing faculty members’ rights to resolve or adjudicate issues under the Faculty Code. Individuals should contact their supervisor for help in determining whether a particular behavior is covered by an established procedure.

This Policy was revised in 2016 by the Continuous Professionalism Improvement (CPI) Committee, with engagement and feedback from UW School of Medicine elected Faculty Councils and Vice Deans, the Medical School Executive Committee (MSEC) and the UW Medicine Strategic Leadership Council. The CPI committee reviews the Policy annually, with formal renewal when changes are needed. Please send feedback regarding this policy to the Chair of the CPI Committee (Molly Blackley Jackson, MD - blackley@uw.edu).

Approved by,
Paul G. Ramsey, M.D.
CEO, UW Medicine
Executive Vice President for Medical Affairs and
Dean of the School of Medicine,
University of Washington
11/21/16