Glossary
EP - Exemplary Professional Practice

EP28: Diversity and Workplace Advocacy-Describe and demonstrate the organizational structure(s) and process(es) that are in place to identify and manage problems related to incompetent, unsafe, or unprofessional conduct.

All members of the Board of Trustees, the professional staff, the entire workforce, the Medical Staff and volunteers are required to conduct themselves with dignity and respect for patients, visitors and each other at Jersey CityMedicalCenter. The organization utilizes a Code of Conduct and Business Ethics (Reference 0020-B) that applies to all Medical Staff, employees, vendors, contractors, external advisors and consultants. Standards of Conduct include: Compliance with legal requirements and ethical standards, reporting conduct that is of concern, respect for patients and their privacy, the avoidance of conflict of interest, adherence to proper business standards and behavioral standards and occupational safety. Employees and the Medical Staff are provided with telephone numbers in order to report any non-compliance issues. An anonymous independent Hotline is provided to report complaints and a website is also provided. The Hotline is available twenty-four hours per day, seven days per week.

The Rules of Behavior Policy (Reference 0020-A) is a guideline for employees and management and identifies unacceptable behavior. These behaviors include, but are not limited to, insulting, intimidating or threatening behavior; obscene or abusive language; harassment of any kind; disorderly conduct and public derogatory remarks made in reference to the MedicalCenter, the employees or the medical staff. Failure to comply with these behavioral standards may result in disciplinary action up to and including termination.

Disciplinary/Corrective Action is a corrective process to assure satisfactory job performance and adherence to the Rules of Behavior (OO21-B). It assures that the interests of Jersey CityMedicalCenter, its patients, visitors and employees are considered paramount. Discipline is progressive including counseling, verbal warning, written warning, suspension without pay and termination. In most cases, employees will be afforded an opportunity to improve performance or correct behavior, preventing the need for further progressive disciplinary action. The manager is required to conduct a thorough investigation of the incident and obtain factual, objective statements from all witnesses and other persons involved. Factors taken into consideration prior to the disciplinary action include: seriousness of conduct, past employment record, similar infractions, level of impact that the action had on patients, visitors, co-workers and the hospital. Any issues that are of such a serious nature as to warrant immediate dismissal are discussed with the Chief Nursing Officer and The Vice President of Human Resources. Any incident that requires reporting to the State Board of Nursing in New Jersey, is handled by the Chief Nursing Officer.

Very frequently, incompetent or unsafe behavior may be identified and verbally reported to the Manager of the unit, or via incident reports entered into rL Solutions. Also, unsafe behavior may be brought to the fore front by investigation following an adverse event. Root Cause Analysis (RCA), as discussed in OO25, is another hospital-wide process that frequently addresses unsafe conduct or behavior. The Assistant Director of Nursing (ADN) report which is issued on a daily basis may address unplanned events that may have occurred during the evening and night shifts (Appendix EP28-A). These reports are provided to Karen Caldas MSN-BC, RN Nursing Risk Manager and Rita Smith DNP, RN, NEA-BC CNO.

In 2010, Jennifer Jones MSN, RN, CNL and Cris Amato BSN, RN, CEN developed a peer review process based on a review of the literature (Reference EP28-B). The Nursing Peer Review Committee is structured so that there is a nursing representative from each Division. Case referrals are made via RCA meetings, educational opportunities, near misses, unusual clinical presentation or at the request of the Department Head. The cases are presented to the Peer Review Advisory Committee (Appendix EP28-B), which is composed of CNLs and Nurse Educators from each Division. The case is reviewed by the Advisory Committee for appropriateness and approval. A representative of this committee will meet with the staff member and prepare the case. The Peer Review Advisory Committee formulates questions and prepares recommendations and an Action Plan to the staff member. All responses are sent back to the Advisory Committee. The Action Plan is reported to the manager of the unit and the appropriate councils/committees. Review the flow chart below:

Flow Chart