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Medical College of Wisconsin Corporate Policies and Procedures | Administrative and Organizational (AD)

Professional Conduct Policy

Category: Conduct and Conflicts (CC)
Policy#: AD.CC.060
Applies To: MCW Employees


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. All employees are expected to be familiar with this policy and ensure their conduct is in alignment with its expectations and standards.

Bullying Behavior: repeated mistreatment of an individual (or a group) that targets another individual (or a group), and includes abusive conduct that is intimidating, degrading, threatening, humiliating and/or undermines the targeted individual(s).

Professional Conduct: conducting yourself responsibly, respectfully, diligently, courteously, and with civility, citizenship, skill, and maturity.

All members of the MCW community are responsible for sustaining the high ethical standards of this institution, and of the broader community in which we function. The Professional Conduct policy is a shared statement of our commitment to uphold the ethical, professional, and legal standards we use as a basis for our decisions and actions. We are each individually accountable for our own actions and, as members of the MCW community, are collectively accountable for upholding these standards of behavior. Specifically, all employees must refrain from:

  • Engaging in any behavior that is or could be perceived to be Bullying Behavior and/or harassing in nature.
  • Engaging in Bullying Behavior that is offensive, severe, or pervasive that it interferes with an individual’s participation in working and learning activities. Bullying Behavior can occur face to face, in a group, through social media, or other electronic communication tools that result in disruption to the work environment. Bullying Behavior may involve verbal or non-verbal communication and/ or a real or perceived power imbalance. In rare circumstances, Bullying Behavior may not consciously intend harm, but would be judged to be intimidating, degrading, humiliating, or undermining by a reasonable person.
  • Engaging in a pattern of unprofessional conduct that causes or could be perceived to be Bullying Behavior and/or 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.
  • 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.
  • 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. The expectation is that communication with the patient or their family is focused 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 MCW employees 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, bullying or threatening behavior.

If an employee observes conduct that is Bullying Behavior and/or 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 and/or Bullying Behavior in a direct and non-threatening manner. In many cases, a person may be unaware of their bullying or 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 and/or Bullying Behavior continues, becomes severe or pervasive 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 the person they feel most comfortable with, such as, their supervisor, Department Leadership, the Office of Human Resources, the Office of Faculty Affairs, the Ombuds Office, or EthicsPoint, the MCW Compliance Reporting Hotline, by calling (844) 703-8171 as appropriate to discuss concerns and identify potential options for resolution. An investigation may or may not be needed depending on the report provided.
  • Employees can seek support by contacting the MCW the Employee Assistance Program for support in coping with the stress of the situation.
  1. Seeking guidance and problem resolution support
  • When an employee raises a concern about unprofessionalism and/or Bullying Behavior, a supervisor and/or Department Leader, Human Resources, Faculty Affairs, Ombuds, and/or others may meet with the individual(s) to provide problem resolution guidance.
  • If an employee does not find that a matter is resolved after seeking guidance and making a report, or they are not comfortable approaching their leader, Human Resources or Faculty Affairs, they can contact EthicsPoint, MCW’s Compliance Reporting Hotline by calling (844) 703-8171.
  • The appropriate parties will provide support in as discreet 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 (MCW network access required).
  1. Interventions to provide developmental support
  • If it is determined an employee has engaged in unprofessional conduct and/or Bullying Behavior, further developmental support or corrective action may be warranted. In this event, feedback about the concern will be discussed with the employee by their 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, work assignment restrictions and/or corrective action where necessary.
  • If concerns with an individual are severe, or continue to persist despite prior interventions, 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.
  1. Reporting and escalating concerns regarding patient care or practitioner competence
    If an employee 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 leader, 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.
  1. 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 and/or displaying Bullying Behavior.
  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 direct leader, Department Leadership, the Office of Human Resources, the Office of Faculty Affairs, the Ombuds Office, the Employee Assistance Program, or the Office of Corporate 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.

MCW will report findings of violations of this policy to external agencies such as the National Institutes of Health (NIH) and the National Science Foundation (NSF), as required for researchers including key personnel, as well as, through the credentialing process for clinical providers. MCW may also report findings of violations of this policy to other institutions of higher education and in response to requests for reference information. By accepting employment with MCW, employees agree to be a part of our culture of professionalism and acknowledge that findings may be reported.


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, 10/19/2022
Supersedes Policy: Professional Behavior Policy - MCP
Review Date: N/A
Approved By: John R. Raymond, Sr., MD, President and CEO, Medical College of Wisconsin