Organizational Overview

Source of Evidence - OO15

The policies and procedures that address the identification and management of

problems related to incompetent, unsafe, or unprofessional practice and conduct.

OO15: The following policies and procedures are examples of policies and procedures

that address identification and management of problems related to incompetent,

unsafe, or unprofessional practice and conduct.

Policy and Procedure HR 6.5: Rules of Conduct (Attachment 1).

Policy and Procedure HR 6.7: Progressive Discipline (Attachment 2).

Reasonable Suspicion of Substance Checklist, Consent form, and Agreement for

Rehabilitation and Conditions for Continued Employment (Attachment 3).

Organizational Overview

Exhibits for SOE - OO15

CAPITAL HEALTH

CAPITAL HEALTH MEDICAL CENTER - HOPEWELL

HUMAN RESOURCES POLICY AND PROCEDURE

TITLE: RULES OF CONDUCT NO: HR:6.5 CHMCH

ORIGINATING SOURCE: Human Resources

EFFECTIVE DATE:

November 1, 2014 EXECUTIVE APPROVALS:

Al Maghazehe, Ph.D., FACHE

President & Chief Executive Officer

J. Scott Clemmensen

Vice President, Human Resources

Richard N. Werner

Director, Human Resources Operations

PERSONNEL:

All employees

SUPERSEDES:

November 6, 2011

DISTRIBUTION:

CHMCH Human Resources Policy Manual

CapitaLink Policies Library

Page 1 of 4

COMMITTEE APPROVALS:

N/A

EXPEDITED APPROVALS:

N/A

OO15: Attachment 1

Rules of Conduct

HR:6.5 CHMCH

Page 2 of 4

I. PURPOSE:

To establish behavioral standards for all employees which promote quality patient care, productivity, efficiency, safety, orderly conduct, cooperation among co-workers and positive relations between supervisors and subordinates.

II. FORMS/ATTACHMENTS:

None

III. EQUIPMENT/SUPPLIES:

None

IV. POLICY:

It is the policy of Capital Health (CH) that all employees are expected to comply with the established rules of conduct. These rules are designed to: A. Protect the interests and rights of all employees, patients, visitors and others on the premises. B. Promote positive behavior at all levels of the organization by assuring that disruptive behaviors

that could contribute to poor patient satisfaction, adverse patient outcomes, or that undermine the CH culture of safety are not tolerated.

Employees who fail to comply with these standards of behavior may be subject to disciplinary action, up to and including discharge (refer to Progressive Discipline Policy HR:6.7 CHMCH).

Although it is not possible to identify every situation which will result in disciplinary action, the following are some, but not all, examples of impermissible conduct and performance which will not be tolerated by Capital Health regardless of position or title: Insubordination, failure to follow instructions, policies or procedures Compromising patient care, abuse of a patient, or other rude, discourteous behavior Refusal or failure to perform assigned tasks, failure to accept work schedule, lack of cooperation Repeated failure to complete job assignments Unprofessional behavior Improper conduct towards supervisor or improper or unprofessional behavior of a supervisor towards

an employee Fighting, threatening or intimidating other employees, patients or visitors Creating an unsafe or unsanitary condition or contributing to such conditions by acts of omission Use of profane, abusive, offensive or improper language on CH property or acting in a disrespectful

manner Threatening, intimidating or coercing any individual Verbal outbursts Violation of safety regulations Unsatisfactory work performance

Rules of Conduct

HR:6.5 CHMCH

Page 3 of 4

Neglect of duty, including leaving work area without permission during scheduled work time Violation or abuse of meal and/or break policy Smoking and the use of tobacco products on CH owned or leased property Sleeping or loafing while on duty Unauthorized personal phone calls or doing other personal business during on-duty hours Unauthorized use of electronic media (e-mail, internet) for personal reasons Failure to follow procedures for reporting absence/lateness Excessive unauthorized non-productive time, including absences, tardiness and leaving early Failure to maintain current licensure/certification Violation of CH parking policy Unsafe motor vehicle operation on CH property or other unsafe CH motor vehicle operation Violation of dress code Failure to complete health screening requirements Failure to attend mandatory inservice Improper patient identification

Disrupting the work of others

Breach of confidentiality or unauthorized possession, use, copying, or reading of confidential material or disclosure of confidential information to unauthorized persons

Solicitation or acceptance of unauthorized gifts or gratuities from patients, visitors, or vendors Theft, misappropriation or unauthorized possession or use of property belonging to CH, patients,

visitors or other employees Careless waste of materials or mishandling of supplies or equipment Damaging, destroying or defacing, through negligence or deliberate acts, property of CH, patients,

visitors or other employees Violation of CH’s non-solicitation policy Possession, consumption, distribution, transfer, sale, purchase, or manufacture of drugs, alcohol, or

other chemical substances on CH property, or reporting to work under the influence of drugs and/or alcohol

Possession, consumption distribution, transfer, sale, purchase or manufacture of controlled substances on non-working time to the extent such use impairs an employee’s ability to perform his/her job or where such activities affect the reputation of CH with the general public or threatens its integrity

Failure to inform CH within five days of a conviction, guilty plea, or no contest plea for controlled substances-related violations under state or federal law

Indecent, immoral or illegal conduct of any nature Sexual harassment or creation of a hostile work environment Gambling or soliciting gambling while on CH property Carrying or possessing a weapon of any kind while on CH property Disorderly conduct such as fighting, horseplay, or creating a disturbance while on CH property Misrepresentation or falsification of employment, time, benefit, medical, or other hospital records Failure to fully and truthfully disclose all facts related to workers’ compensation, insurance claims

and leave requests Littering Violation of any rule, regulation, policy or practice of CH or a department of CH

Any other behavior that undermines the CH culture of safety

In addition to violations of these standards, should an employee’s performance, work habits, conduct or behavior become unsatisfactory in the judgment of CH, the employee will be subject to disciplinary

Rules of Conduct

HR:6.5 CHMCH

Page 4 of 4

action up to and including discharge. Although CH will attempt to help the employee to correct unsatisfactory performance, work habits, attitude, conduct and behavior prior to discharge, CH reserves the right to discharge employees without cause or notice. Employees have the same right to terminate their employment without cause or notice.

Employees who witness violations in the above standards must report the facts of their observations to their immediate supervisor. If for any reason employees are not comfortable addressing their concerns with their immediate supervisor, they should go to the next level on their chain of command or contact the Director of Human Resources Operations or his designee.

Employees may report and cooperate in the investigation of these events without fear of retribution or retaliation and may request anonymity with regard to their reports and involvement.

V. REFERENCES:

Progressive Discipline Policy HR:6.7 CHMCH The Joint Commission Standards

CAPITAL HEALTH

CAPITAL HEALTH MEDICAL CENTER - HOPEWELL

HUMAN RESOURCES POLICY AND PROCEDURE

TITLE: PROGRESSIVE DISCIPLINE NO: HR:6.7 CHMCH

ORIGINATING SOURCE: Human Resources

EFFECTIVE DATE:

November 1, 2014

EXECUTIVE APPROVALS:

Al Maghazehe, Ph.D., FACHE

President & Chief Executive Officer

J. Scott Clemmensen

Vice President, Human Resources

Richard N. Werner

Director, Human Resources Operations

PERSONNEL:

All employees

SUPERSEDES:

November 6, 2011

DISTRIBUTION:

CHMCH Human Resources Policy Manual

CapitaLink Policies Library

Page 1 of 4

COMMITTEE APPROVALS:

N/A

EXPEDITED APPROVALS:

N/A

OO15: Attachment 2

Progressive Discipline

HR:6.7 CHMCH

Page 2 of 4

I. PURPOSE:

To establish a fair and consistent standard disciplinary policy and procedure that identifies and remedies unacceptable behavior or performance, as identified in the Rules of Conduct Policy HR: 6.5 CHMCH.

II. FORMS/ATTACHMENTS:

Disciplinary Action Notice Performance Action Plan

III. EQUIPMENT/SUPPLIES:

None

IV. POLICY:

It is the policy of Capital Health (CH) that all employees are expected to comply with the System’s standards of behavior and performance, as well as the System’s policies and procedures. Disciplinary action will be taken whenever an employee’s behavior or performance is unacceptable and/or interferes with the efficiency, quality, productivity, or safe conditions of CH. Intimidating and disruptive behaviors can contribute to medical errors, poor patient satisfaction, adverse outcomes, increased hospital costs, and increased turnover of qualified employees. To promote quality and the culture of safety, CH will address behaviors that threaten performance within the healthcare team regardless of position, title, years of service, or discipline. In most instances, progressive discipline will be used so that employees have an opportunity to correct deficiencies in job performance, behavior, conduct, and attendance. The progressive steps involved in this disciplinary system are written warning, suspension and discharge. However, in order to protect the best interests and rights of those in the CH environment, Capital Health retains the authority to accelerate the disciplinary process or immediately discharge an employee if the severity of the offense warrants such action. Also, CH may accelerate the disciplinary process or immediately discharge temporary employees or employees during the introductory period if they fail to comply with CH’s standards of behavior and performance. CH also retains the authority to demote or terminate employees who fail to meet the requirements of the Performance Action Plan as outlined in the Annual Performance Evaluation (HR:2.20 CHMCH).

V. INFORMAL PROCEDURE:

Verbal Warning – Anecdotal notes will be completed by the supervisor summarizing discussion of the employee’s performance issues and expectations for improvement. This step will not be placed in the employee’s Human Resources record unless it is necessary to proceed to the Formal Procedure of this policy.

Progressive Discipline

HR:6.7 CHMCH

Page 3 of 4

V. FORMAL PROCEDURE: Following is a description of the progressive steps typically

followed in this discipline system:

1) First Written Warning - A Disciplinary Action Notice will be completed by the supervisor indicating the reason for the disciplinary action as well as expectations for improvement. The employee is encouraged to sign the form and to accept a copy. If he/she refuses, another supervisor should sign to attest to the fact that the employee was given the disciplinary action and refused to sign and/or take a copy. The original form will be placed in the employee’s Human Resources record.

2) Final Written Warning - A Disciplinary Action Notice will be completed by the supervisor

indicating the reason for the disciplinary action as well as expectations for improvement. The employee is encouraged to sign the form and to accept a copy. If he/she refuses, another supervisor should sign to attest to the fact that the employee was given the disciplinary action and refused to sign and/or take a copy. The original form will be placed in the employee’s Human Resources record.

3) Suspension - An employee will be suspended from work without pay for a period of one to three

days for serious or continuous violation of Capital Health rules. A Disciplinary Action Notice will be completed by the supervisor indicating the reason for the disciplinary action as well as expectations for improvement. The employee is encouraged to sign the form and to accept a copy. If he/she refuses, another supervisor should sign to attest to the fact that the employee was given the disciplinary action and refused to sign and/or take a copy. The original form will be placed in the employee’s Human Resources record. In certain instances, suspension may also be used to allow time to investigate the facts surrounding an incident.

4) Discharge - Typically, an employee will be discharged if disciplinary action over a period of

time has failed to remediate the problem, or if the offense is serious enough to warrant immediate dismissal. Employees who are discharged will be eligible to collect all accrued paid time off except in cases of theft, misappropriation, or damage. In these instances, any financial loss incurred by Capital Health will be deducted from the employee’s eligible accrued time.

Infractions that should be considered as terminable offenses include:

Neglect of duty, including leaving work without permission during scheduled work time Sleeping or loafing while on duty Unsafe motor vehicle operation on Capital Health property or unsafe operation of a

Capital Health vehicle Fighting, threatening or intimidating other employees, patients or visitors Breach of confidentiality or unauthorized possession, use, copying or reading of

confidential material or disclosure of confidential information by unauthorized persons Theft, misappropriation or unauthorized possession or use of property belonging to

Capital Health, patients, visitors or other employees Possession, consumption, distribution, transfer, sale, purchase or manufacture of drugs,

alcohol, or other chemical substances on Capital Health property, or reporting to work under the influence of drugs and/or alcohol

Progressive Discipline

HR:6.7 CHMCH

Page 4 of 4

Possession, consumption, distribution, transfer, sale, purchase or manufacture of controlled substances on non-working time to the extent such impairs an employee’s ability to perform his/her job or where such activities affect the reputation of Capital Health with the general public or threatens integrity

Indecent, immoral or illegal conduct of any nature Disorderly conduct such as fighting, horseplay or creating a disturbance while on Capital

Health property Misrepresentation or falsification of application for employment, time, benefit, medical

or other hospital records Failure to fully and truthfully disclose all facts related to workers’ compensation,

insurance claims and leave requests Violation of safety regulations

Supervisors must discuss all discharges with the Director of Human Resources Operations or his/her designee before any action is taken.

Eligible employees who feel they have been unfairly disciplined may use the Problem Solving Procedure HR:6.8 CHMCH.

OO15: Attachment 3