New code of conduct improves employee outlook, patient satisfaction

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New code of conduct improves employee outlook, patient satisfaction

After reading this article, you will be able to:

  • Differentiate between the old and new code of conduct at Fredonia Regional Hospital
  • Discuss ways Fredonia improved staff and patient satisfaction

When it comes to certain policies, it’s all about the details. 

In 2006, Pam Harmon, RN, legal nurse consultant and CNO at Fredonia (KS) Regional Hospital (FRH), took a closer look into her facility’s employee code of conduct.

The Commitment to Coworkers policy, as the code of conduct was then known, only pertained to the nursing staff. This went against FRH’s new goal for the facility policy. The code of conduct’s new purpose was to include everyone—not just the nursing staff—and to change the attitude of every staff member in FRH.

In order to include all staff members at FRH, Harmon took matters into her own hands, and with the help of an in-service committee, went about changing the information of FRH’s employee code of conduct.


Harmon searched the Web to find examples from other facilities across the nation to get a broader perspective on her facility’s options. Using key words such as “standards of performance” and “code of conduct,” Harmon gathered a few examples that she brought to an in-service committee meeting.

Harmon was careful not to try to layer another facility’s policy onto FRH but rather to add selected items that were applicable to her facility. “We took a lot of information from other facilities’ examples, only taking what we felt necessary for Fredonia,” says Harmon. From these examples, Harmon and the in-service committee blended information to fit the needs of FRH and came up with the standards of performance to include all the staff members.

“Throughout the development of the standards of performance, the in-service team and I decided which information would be important enough to feature in the document,” says Harmon.

Improving the attitudes and the quality of patient care, along with the attitudes of the staff members, was on Harmon and the committee’s mind when reviewing all the information.

Old versus new

Eventually Harmon and the committee determined the areas the new standards of performance would focus on. Some of these areas include:

  • Attitude
  • Personal appearance
  • Communication
  • Culture of safety
  • Commitment to patients
  • Commitment to coworkers
  • Safety awareness
  • Sense of ownership

The previous code of conduct was a one-page document that only addressed patient care staff, and there was no requirement to sign any documentation, saying they had read and understood the code. Now the standards of performance is a two-page document that everyone in the facility—from the CEO all the way down to new hires—has to sign.

“We have been talking about focusing on positive thinking, and we as a committee feel if we could get something everyone could read, sign, and commit to, then we would have a better outcome and performance from all staff members,” says Harmon.

The new standards of performance document is not only signed by everyone in the facility, but is also reissued annually, so staff members are reminded of the commitment they have to themselves, the patients, and other staff members at FRH.

The policy is also an important part of the hiring process. During the interview process, the expectations derived from the standards of performance are discussed in great length.

“We ask the potential candidate questions regarding the policy and handling particular situations so they are thinking about these things before they sign in to be a part of our facility,” says Harmon.

No tolerance for negativism 

With any new policy, there are staff members who do not take things seriously, and with FRH’s new standards of performance, there were a few necessary teaching moments.

“Over the three years, there have only been a few instances where employees did not abide by the standards of performance policy,” says Harmon.

For a first offense, employees receive a verbal warning if they are not living up to the areas stated in the new policy. A second offense earns a written warning, and if the behavior continues, the staff member might even be put on suspension and eventually terminated from FRH.

“We developed a policy that has no tolerance for negativism and a goal of improving customer service by improving the attitude of all our staff,” says Harmon.

Keeping patients and staff members satisfied

To help encourage staff members to keep a positive attitude, Harmon and her committee developed a “Kudos board.”

At FRH, patients receive a satisfaction survey that allows them to comment on their stay and rate their overall experience. The survey asks patients to comment on the nurses and whether anyone went above and beyond the call of duty or fell short of the patient’s expectations.

If a patient comments on one nurse and how the nurse exceeded the patient’s expectations, staff members at FRH can see the nurse’s name on the Kudos board.

In addition to having his or her name displayed on the Kudos board, the nurse also receives a thank-you gift card, good for a snack in the cafeteria.

“As the results from our satisfaction survey improve, it is important to continue to build up staff morale and praise good behavior,” says Harmon.

To help with patient satisfaction, FRH now calls patients two to three days after discharge. Nursing supervisors at FRH call the patients to see how they are doing. The nursing supervisors also answer any questions the patients may have and make sure the patients have made follow-up appointments with their doctors.

Helpful piece of advice

Overall, Harmon is satisfied with the new standards of performance policy and does not think it is necessary to make any changes. (See p. 5 for the new policy.)

“A few weeks ago, I saw one of the unit clerks placing a handwritten thank-you card into one of their colleague’s locker,” says Harmon. “It’s nice to know that the staff members are carrying out this behavior amongst themselves.”

To other facilities looking to improve upon their code of conduct, Harmon emphasizes to them the importance of making it relevant to all areas of the facility.

“It has to pertain to everyone,” says Harmon. “Everyone has to be viewed as the customer because there can be doctors who are coming from an outside source. Everyone is the customer, and not just the patient.”


Adapted from Briefings on the Joint Commission, February 2010.


Fredonia Regional Hospital employee standards of performance


My job is to serve all our customers by providing quality service with care and courtesy. I know that my customers are the patients, their family members, the medical staff, volunteers, the public/services we have daily contact with, and my peers. I will always thank our customers for choosing Fredonia Regional Hospital and try to exceed all our customers’ expectations.

Personal appearance

I will present myself in a professional manner, always welcoming and greeting patients, visitors, and employees. I will follow the department’s dress code policy, wear my employee badge at all times, and keep it secure when not being worn.


I will communicate with others in a positive manner, striving to find a way to compliment and uplift all persons. I will be responsive in all workplace interactions, listening to my customers whether they are patients, family members, or other members of the workforce. I will smile and be aware of my body language and nonverbal communication. I will provide an interpreter for a second-language patient or family member.

I will identify myself when talking on the telephone and provide the correct number and get the caller’s permission before transferring his or her call. I will answer all calls as quickly as possible. I will take the initiative to express concerns and suggestions to benefit the team as a whole.

Safety culture

I understand the commitment of the organization to a culture of safety and fearless communication. I will be responsible for reporting any issue to the proper person and will do so with the understanding that the organization has a policy of nonpunitive reporting. If there is ever an occasion where I feel I have been made to feel uncomfortable for reporting, I will bring this to the attention of my director or the HR director.

Commitment to patients

I will acknowledge patients’ questions and concerns immediately. I will always address patients with respect and dignity while making their needs first priority. I will provide a pleasant environment to promote healing, keeping a holistic perspective. I will provide continuity of care by reporting to coworkers before change of shift.

Nursing: I will acknowledge patient call lights in a timely manner and anticipate the patients’ needs before leaving the room to decrease their need to use the call light.

Commitment to coworkers

I will welcome all newcomers to make their adjustment as a team player to the hospital and department as pleasant as possible, remembering that I was once in their shoes. I will demonstrate a strong work ethic by showing that I care about myself, my job, and my coworkers by being on time and lending a helping hand whenever possible. I will treat my coworkers as professionals deserving courtesy, honesty, respect, and cooperation in the same manner as I would expect to be treated. I will respond to pages, requests, e-mails, and phone calls in a timely and professional manner.

In addition, I will acknowledge other departments’ policies and procedures that relate to me and follow their rules and regulations. All attempts will be made to work out any problems between coworkers on a personal basis in a timely manner before involving supervisors with the attempts being documented.

Customer waiting

I will acknowledge the patients/families that are waiting by checking in on them periodically according to department policies. I will offer an apology if the wait is longer than anticipated, always thanking the customer for waiting. I will try to make their wait comfortable, offering chairs if possible.

Hallway etiquette

Courtesy and professionalism will be extended to patients, visitors, and each other in the hallways and will be a top priority of the employees of Fredonia Regional Hospital. I will make eye contact, smile, and say hello to visitors, patients, and coworkers. I will never be too busy to help someone or ask whether help is needed. Talking to coworkers in the hallways will be kept to a minimum, and I will never be so involved in a conversation that I overlook a visitor needing help. If someone is lost, I will walk him or her to where they need to be. I will open doors cautiously and use the safety mirrors provided. I will continually strive to exceed the expectations of others as I pass through the halls.


I am committed to the protection of my fellow employees as well as the patient’s rights to personal and informational privacy. I fully understand that I have the responsibility to ensure that all communication and records inclusive of demographic, clinical, and financial information is treated and maintained as confidential. I will do this in the hospital as well as in the community. I am committed to the value of providing care and communication in an environment that respects privacy. I will be considerate in all interactions and in the provision of care at all times and under all circumstances with the highest regard for a person’s personal privacy and dignity. I expect, of other employees and myself, behavior that represents the expressed value in honoring and protecting everyone’s right for privacy and personal safety.

Safety awareness

I will complete all yearly mandatory training as required by Fredonia Regional Hospital. I have a personal responsibility to be familiar with and follow the safety policies and procedures. If I observe any unsafe condition or safety hazard, I will correct it if possible or report it immediately. I understand the importance of reporting all accidents and/or incidents promptly.

Sense of ownership

I will accept all the rights and responsibilities of being part of the hospital’s team by living the hospital’s mission, vision, and values. I am an example to others and I will be a leader in providing excellent customer service both in the hospital and community. I will hold the people and property of the hospital in high regard. I will be responsible for my own work area. If I see or make a mess, litter, or spill, I will clean it up or get appropriate help when necessary.

I have read Fredonia Regional Hospital’s employee standards of performance and will perform them to the best of my ability.

Signature:                      Date:

Print name:                    Department:

Source: Fredonia (KS) Regional Hospital. Reprinted with permission