Research Bench Lab

Corporate Policies and Procedures | Administrative and Organizational (AD)

Professional Conduct Policy

Category: Conduct and Conflicts (CC)
Policy#: AD.CC.060
Applies To: MCW Employees, MCW Students and Third Parties Individuals


Fostering a climate of respect, civility and citizenship is critical for the Medical College of Wisconsin (MCW) to remain a leader in the areas of patient care, education, research and community engagement. As representatives of MCW, all employees are uniformly expected to exemplify professional conduct. This policy provides guidance and a framework for professional conduct expectations for faculty and staff. All employees are expected to be familiar with this Policy and ensure their conduct is in alignment with the expectations and standards outlined here.

Not Applicable

Guiding Values
MCW’s Professional Conduct Policy is guided by the following standards all employees are expected to exemplify. These standards are meant to provide a guide for professional behavior and are not meant to be exhaustive.

Treat others with dignity and respect. Exhibit confidentiality, honesty, and actions that build trust and strengthen relationships. Listen to others and effectively communicate in a clear and concise manner through written and verbal communication. Demonstrate respect and commitment to the values of diversity and equity; seek out and incorporate diverse perspectives into decision making.

Excellence & Creativity
Exhibit initiative and ingenuity by taking ownership of tasks to proactively improve services, avoid problems, or develop opportunities. Generate novel and valuable ideas to impact institutional missions. Identify and implement new methods to increase efficiency and quality.

Education & Development
Display an ongoing commitment to continuous learning and self-improvement in one’s area of responsibility. Actively seek out mentorship and learning opportunities that can be applied to current and future work activities. Develop and maintain professional affiliations. Participate in design, development and/or evaluation of instructional materials, methods, courses or programs.

Agility & Judgment
Remain flexible and versatile in a rapidly changing environment and adapt quickly to changing circumstances. Adapt your behavioral style or method of approach as appropriate to the situation. Make timely and sound decisions based on analysis of information, experience and logic. Show reliability and accountability in the successful completion of all work.

Stewardship & Institutional Citizenship
Support transformational change to achieve institutional vision and strategies. Be an active and thoughtful participant in institutional initiatives, meetings and committee work. Conserve and use resources in an efficient and cost effective manner across all institutional missions. Look for ways to improve and promote quality within area of influence.

More specifically, faculty and staff must refrain from:

  • Engaging in any behavior that is, or could be perceived to be, harassing in nature.
  • Engaging in any unprofessional conduct that causes or could be perceived to cause a hostile work environment or the discomfort of any employee, staff, student, resident, patient, family member or visitor to MCW.
  • Engaging in any unwelcome sexual or physical conduct of any kind with others.
  • Violating the MCW Nepotism Policy.
  • Treating others in a disrespectful fashion that negatively impacts the working, learning or clinical environment including (but not limited to): shouting, insulting, using foul language, bullying, threatening, or abusive, unsafe, disruptive, belittling, or throwing objects in the workplace.
  • Unwillingness to cooperate, assist and work in harmony with others and discourtesy or conduct creating disharmony, irritation or friction among co- workers, patients or visitors.
  • Engaging in any conduct that is retaliatory in nature.
  • Participating in activities that are academically dishonest in nature including false reporting of information, facts, data or research.
  • Disclosing, outside of a peer review or other confidential setting and process, adverse personal opinions, criticisms, concerns and other information regarding the performance of other practitioners, including documenting such adverse information in a medical record, email, text, letter or other correspondence with other practitioners or institutions, except as described in #4 of the Procedure section of this document. This does not preclude required reporting under Wisconsin’s Duty to Report Statute (see references).
  • Providing to a current or prospective patient or their family information that is derogatory or inflammatory regarding the competence of, or care provided by, other practitioners. Instead focus on communication with the patient or their family on recommending appropriate care for their identified clinical needs.
  • Expressing a personal or political position or opinion in a manner that might imply that the position or opinion is necessarily reflective of MCW without prior approval from the Office of the President, Office of the Executive Vice President, or the Office of Government and Community Relations.

All faculty and staff of MCW have a responsibility not only to engage in professional conduct at all times, but to help ensure a positive and collegial environment through reporting unprofessional or threatening behavior.

If an employee observes conduct that is unprofessional in nature, the following steps can be used as a guide for managing the behavior.

  1. Addressing professionalism concerns
    • If comfortable, MCW employees are encouraged to address unprofessional behavior in a direct and non-threatening manner. In many cases, a person may be unaware of their unprofessional behavior and open to feedback if it is brought to their attention in a constructive manner. Employees should start by describing the behavior, the impact of the behavior, and the desired outcome.
    • If the unprofessional behavior continues or the employee does not feel comfortable engaging the other person directly, it may be helpful to seek counsel from another internal source. Employees are encouraged to reach out to their supervisor, Department Leadership, the Office of Human Resources, the Office of Faculty Affairs, the Ombuds Office, or the Office of Compliance as appropriate to discuss concerns and identify potential options for resolution.

  2. Seeking guidance and problem resolution support
    • When an employee raises a professionalism concern, a supervisor and/or Department Leadership, Human Resources, Faculty Affairs, and/or Compliance may meet with the individual(s) to provide problem resolution guidance.
    • The appropriate parties will provide support in as discrete a fashion as possible to protect the privacy of individuals involved. Confidentiality and anonymity may not be guaranteed based on the circumstances and type of information provided.
    • The Ombuds Office is available for confidential or anonymous consultation and problem resolution support regarding professional conduct concerns in accordance with the MCW Ombuds Policy.

  3. Interventions to provide developmental support
    • If it is determined an employee has engaged in unprofessional conduct, further developmental support may be warranted. In this event, feedback about the concern will be discussed with the employee by their direct leader. It is the responsibility of the leader to engage in a developmental support conversation to discuss the concern and reinforce the expectations outlined in this Policy.
    • If warranted, MCW may seek to supplement the individual developmental needs by providing additional support such as: continued performance monitoring, additional training, performance coaches, performance review feedback, compensation adjustments and/or corrective action where necessary.
    • If concerns with an individual are severe, or continue to persist, MCW will inform the employee that the behavior needs to change immediately. Additional corrective steps may be pursued in accordance with the applicable institutional policies and Handbook which may include removal from the patient care or teaching environment, suspensions and/or restriction of clinical credentialing, salary reduction, and suspension and/or termination of employment or appointment.

  4. Reporting and escalating concerns regarding patient care or practitioner competence
    • If a faculty or staff member has concerns about the quality or safety of patient care or the competence or conduct of another practitioner, they will communicate such concerns in a manner that is consistent with this policy. The employee shall escalate any concerns regarding the quality or safety of patient care or the competence or conduct of another practitioner through the chain of command to their supervisor, the respective Division Chief, Department Chair, Chief Medical Officer of the respective affiliate hospital, and/or the Dean of the School of Medicine as appropriate. In addition, the employee shall report such concerns as appropriate in the respective affiliate hospital’s incident reporting system.

  5. Employee actions and response regarding concerns raised
    If an employee is informed that they have been observed behaving in an unprofessional manner, or are provided coaching regarding their behavior, the following steps are recommended.
    1. Listen to the feedback being provided in a respectful manner.
    2. Thank the individual for sharing their concerns.
    3. If you were unaware that you were being perceived in this manner, let them know you were not aware that you were being perceived as unprofessional.
    4. Consider sharing what you were intending to communicate. Consider apologizing to the individual.
    5. If you are being provided a corrective action from your supervisor and you find that you have a different perspective, ask if you can share your thoughts. Otherwise, consider writing a letter to your supervisor explaining your thoughts about the situation.
    6. Employees are encouraged to review the Professionalism toolbox, reach out to their supervisor, Department Leadership, the Office of Human Resources, the Office of Faculty Affairs, the Ombuds Office, the Employee Assistance Program, or the Office of Compliance as appropriate to seek guidance, discuss concerns, and identify potential options for resolution.

Notwithstanding the above procedures, if a situation is so severe, safety is compromised, conduct interferes with patient care or operations, an individual is making the work environment hostile, or other circumstances as warranted, MCW may determine at any time, that corrective action available under applicable policy/handbook is necessary and/or the employment relationship may be terminated at any step or in lieu of the steps listed above.


Professionalism Toolbox*

*This link requires a unique MCW user ID and password to access.

Policy Revisions

Effective Date: 1/21/2011
Revision History: 10/15/2016, 1/23/2019
Supersedes Policy: Professional Behavior Policy - MCP
Review Date: N/A
Approved By: /S/ John R. Raymond, Sr., MD, President and CEO Medical College of Wisconsin