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Model Medical Staff Code of Conduct

Model Medical Staff Code of Conduct

Effective Jan. 1, 2009 the new Joint Commission Leadership Standard (LD.03.01.01), Elements of Performance 4 and 5 require that hospitals have a code of conduct that defines acceptable, inappropriate and disruptive behavior; and, that Leaders create and implement a process for managing disruptive and inappropriate behaviors. The Joint Commission identified those disruptive behaviors which it believes undermine a culture of safety in a July 9, 2008 Sentinel Event Alert. In response to these actions by The Joint Commission, the American Medical Association adopted policy H-225.956, “Behaviors That Undermine Safety,” which calls for medical staffs to develop and implement their own code of conduct in the medical staff bylaws, and that hospitals also have a code of conduct applicable to members of the board, management and all employees.

To assist medical staffs with implementation of a code of conduct in accordance with AMA Policy, and consistent with The Joint Commission Leadership Standard, the AMA Office of the General Counsel with the assistance of Elizabeth Snelson, Esq., in conjunction with the AMA-OMSS, drafted a model code of conduct for insertion in medical staff bylaws. This comprehensive document is available to medical staff.  Also, available at no cost to AMA members is the “Physicians’ Guide to Medical Staff Organization Bylaws,” an excellent resource for medical staffs and their Bylaws Committees.