UPHS Policy on Professionalism and Standards of Conduct

 

POLICY

The University of Pennsylvania Health System ("UPHS") is committed to treating all individuals, including patients, students, employees and staff with courtesy, respect and dignity. Consistent with that commitment, all UPHS employees, medical staff, auxiliary health care providers, volunteers, and independent contractors must conduct themselves in a professional and collegial manner at all times. This policy defines inappropriate behavior and establishes a standard of conduct expected from all personnel.

PURPOSE

The purpose of this policy is to promote a safe, collegial, and respectful environment, which is critical to optimal patient care. This policy also is intended to prevent and resolve conduct that may affect patient care by disrupting operations, by affecting the ability of health care providers and employees to do their jobs effectively, by creating a hostile or intimidating environment, or by adversely affecting the confidence in the organization's ability to provide optimal patient care.

SCOPE

This policy applies to all personnel (including employees, medical staff, auxiliary healthcare providers, students, volunteers, contracted personnel, other personnel who provide contracted clinical services  to patients) of the Hospital of the University of Pennsylvania (HUP), those parts of Clinical Practices of the University of Pennsylvania  (CPUP) which practice at or in conjunction with HUP operating under its license, and UPHS Corporate Services departments.  This policy also applies to those practices and sites that are off campus facilities or departments of HUP and operating under its license, including e.g. HUP's inpatient rehabilitation facility. For purposes of this policy, the above facilities, practices and sites are collectively referred to as "entity."

IMPLEMENTATION

Implementation of and compliance with this policy are the responsibility Senior Leadership, Department Directors/Business Administrators, Managers and Supervisors.

PRINCIPLES OF RESPONSIBLE CONDUCT

All UPHS personnel, including, e.g. UPHS employees and medical staff members, are expected to adhere to the following Principles of Responsible Conduct:

  • Ethical and Responsible Conduct - Personnel should conduct themselves ethically, with the highest integrity, in compliance with all applicable laws, regulations, and UPHS and University of Pennsylvania ("Penn" or "University") policies, in all aspects of their work. They should be fair and principled in University and Health System business transactions and other related professional activities, acting in good faith when dealing with both internal constituents and external entities. Their conduct should always reflect their position of trust and loyalty with respect to University, the Health System, and members of these communities.
  • Respect for Others in the Workplace - Penn and UPHS recognize that people are the most important resource for achieving eminence in the areas of teaching, research, community service and patient care. Penn and UPHS value academic freedom, diversity and respect for one another. Penn and UPHS are committed to the principle of non-discrimination and do not tolerate conduct that constitutes unlawful harassment, including sexual, racial, ethnic, religious, or gender harassment.
  • Avoidance of Conflict of Interest -As more fully stated in Penn and UPHS' conflict of interest policies. Penn and UPHS' personnel should avoid conflicts of interest in their work.

As a non-profit institution, it is imperative, for both legal and ethical reasons that University and Health System personnel do not improperly benefit from their positions of trust at Penn and UPHS. Financial conflicts must be appropriately disclosed in accordance with conflict of interest and conflict of commitment policies, so they can be reviewed, and as appropriate, managed or eliminated. UPHS personnel are responsible for identifying potential conflicts and seeking appropriate guidance.

  • Responsible Conduct in Research - As members of a complex research university, Penn and UPHS personnel have significant responsibility to ensure research is conducted with the highest integrity, and in compliance with federal, state, and local laws and regulations, as well as University and Health System policy.
  • Responsible Stewardship and Use of Penn Property, Funds, and Technology - Penn and UPHS personnel are expected to ensure that Penn and UPHS property, funds, and technology are used appropriately to benefit the institution, consistent with all legal requirements as well as University and Health System policies.
  • Environment Health and Safety - Penn and UPHS are committed to protecting the health and safety of the University and Health System communities and creating a safe working environment. To accomplish this end, Penn and UPHS provide training in health and safety regulation and policy. Penn and UPHS personnel are expected to comply with sound practices and legal requirements.
  • Respect for Privacy and Confidentiality- In their various roles and positions at Penn and UPHS, personnel may become aware of confidential information of many different types. Such information may relate to students, faculty, administration, staff, employees, alumni, donors, research sponsors, licensing partners, patients, and others. Penn and UPHS personnel are expected to inform themselves about applicable legal, contractual, and policy obligations to maintain the confidentiality of such information, to protect it from improper disclosure and to protect the privacy interests of our community.
  • Appropriate Conduct with Respect to Gifts, Travel, and Entertainment - Penn and UPHS personnel are expected to conduct themselves so as to ensure that their positions are not misused for private gain, with respect to acceptance of gifts and the undertaking of university­ related travel and entertainment.
  • Appropriate Use of University Name and Logos - Penn and UPHS regulate the use of their names, shield, and related trademarks and logos in order to protect the University's and Health System's reputation, and to ensure that their use is related to the University's and Health System's educational, research, community service, and patient care missions. Penn and UPHS personnel are expected to protect the University's and Health System's name and logos from improper use
  • Responsible Reporting of Suspected Violations and Institutional Response - Penn and UPHS personnel are expected to report suspected material violations of University and Health System policies, as well as violations of application laws and regulation, to appropriate offices, as set forth in various policies. Penn and UPHS personnel may be subject to discipline in accordance with the various policies.

INAPPROPRIATE AND DISRUPTIVE BEHAVIOR IN THE WORKPLACE

UPHS does not tolerate behavior that leads to the disruption of patient care and/or creates a hostile work environment. In accordance with performance improvement policies, any violators of this policy may be subject to corrective action up to and including termination of employment. School of Medicine faculty members and non-employed auxiliary health care providers granted privileges or scope of practice at UPHS hospitals and/or in Clinical Practices of the University of Pennsylvania ("CPUP") practices (hereinafter, "Medical Staff') are covered by the Disruptive Medical Staff policies of the various hospitals.

PROCESS

Any employee may bring a complaint alleging inappropriate behavior against another employee, faculty, house officer or medical staff member. Inappropriate behavior may include:

  • Physical violence, or actual threat thereof;
  • Behavior that violates pertinent policies pertaining to prohibited discrimination and harassment;
  • Unprofessional verbal or physical language or conduct that may or may not potentially jeopardize patient safety or disrupt patient care;
  • Verbal abuse or physical harassment of non-constructive criticism is intended to intimidate, undermine confidence, belittle, or imply stupidity or incompetence; and
  • Refusal to perform duties or assignments reasonably expected.

An individual may bring a complaint in any of the following ways:

  • Complaints may be brought to the individual's supervisor or manager.
  • Complaints may also be brought to the individual's entity Human Resources Department.
  • Complaints involving a house officer may be brought to the program director or the Office of Graduate Medical Education. If brought to Human Resources, they will be referred to the program director.
  • Complaints involving a medical staff member (faculty or non-employed auxiliary health care provider) should be brought to the department chair, medical director, or the hospital's Professionalism Committee for handling in accordance with the hospital's Disruptive Medical Staff Policy. If brought to Human Resources, such complaints will be referred to the department chair, medical director, or the hospital's Professionalism/Ethics Committee for handling in accordance with the Disruptive Medical Staff Polic
  • Safety Net, Penn Medicine's web-based incident reporting system, is also available online and complaints can be entered into Penn Medicine Safety Net. However, not all Safety Net complaints can or will be investigated unless sufficient detail is evident or provided in the complaint itself. Employees are strongly encouraged to use one of the alternative reporting opportunities listed above when raising an alleged violation of this policy

CONDITIONS FOR IMMEDIATE TERMINATION OF EMPLOYMENT

Employees violating standards and/or work rules that jeopardize the safety of patients or staff; create  a hostile or intimidating work environment; and/or adversely affect confidence in the organization's ability to provide optimal care may be subject to immediate termination. As per the performance improvement policies, examples of violations that would result in immediate termination in the event of a single occurrence include:

  • Unreported absence from work for three consecutive work shifts Gob abandonment);
  • Failure to report to work after expiration of authorized leave of absence;
  • Smoking inside hospital buildings;
  • Intentional misrepresentation or falsification of clinical or other information or UPHS record; falsification of timekeeping records or permitting time records to be falsified;
  • Fighting or disorderly conduct; threat of intention to injure, fighting or assault;
  • Possession of a weapon, firearm or explosive on UPHS property (including parking lot or other exterior UPHS property);
  • Theft or unauthorized possession of property belonging to Penn Medicine, or another employee, patient or visitor;
  • Sleeping or giving the appearance of sleeping on the job;
  • Unprofessional verbal or physical conduct potentially jeopardizing patient safety or disrupting patient care;
  • Verbal and/or physical abusive behavior that violates pertinent policies pertaining to prohibited acts of discrimination, harassment and/or retaliation;\
  • Any act including providing false information intended to deceive an employee, patient or visitor;
  • Inappropriate access, release and/or disclosure of patient Protected Health Information (PHI) that represents a serious disregard for patient privacy rights.
  • Intentional conduct/activity that violates privacy/information security policies, typically done with malicious intent or for personal and/or financial gai
  • Unauthorized use or possession of a drug or alcohol on UPHS property;
  • Failure to perform job duties as a result of drug or alcohol consumption*;
  • Action or inaction that may create a life-threatening situation or that threatens the safety or well being of a patient, employee or visitor; fighting or threatening violence in the workplace.

*The Chief Human Resource Officer at the entity level may attempt to resolve the "fit for duty" violation by way of accommodation (if appropriate, in the case of disability) or refer case for Independent Review as per the guidelines of this policy.

The above list of examples is intended for illustrative purposes only and is not exhaustive.

INVESTIGATION OF COMPLAINT

Investigation of a complaint concerning employees not covered by the hospitals' Disruptive Medical Staff Policy will be conducted by the Office of Human Resources at the entity level. Any corrective action will be administered under the performance improvement policies.

CONDITIONS FOR INDEPENDENT REVIEW

The Executive Director at the entity level may seek an independent review of an investigation when the situation potentially jeopardizes the safety of patients/employees and/or adversely affects public confidence in the organization's ability to provide optimal care. An independent review is required if a terminable action has occurred and mitigating circumstances exist that support a disciplinary sanction other than termination. The independent review is coordinated through the Office of the Vice President, Human Resources at the corporate level in collaboration with other resources including Corporate Compliance and the Office of General Counsel.

ACTION STEPS REQUIRED IN SITUATIONS THAT WARRANT IMMEDIATE TERMINATION

In the event of an employee termination, Human Resources, in collaboration with Security, will ensure the following actions are taken to further safeguard the organization and the patients and staff it serves.

  • Terminated employees immediately surrender keys and identification badge;
  • Security immediately disables identification badge and building access
  • IT Security stops terminated employee's access to all information system applications and VPN access;
  • HR processes involuntary termination with a "Do Not Rehire" designation; and
  • Notification and/or cooperation with law enforcement agencies when a violation also includes an unlawful act.