ASANTE WIDE Policy Title: CODE OF CONDUCT Entity: Asante Department: Human Resources Category: Employment Document Control Number: 400-HR-090 Date of Origin: 12/2008 Department of Origin: Compliance Policy Effective Date: 02/2011 Policy Owner: Fred Bockstahler Policy Review Due Date: 02/2013 Last Actual Review/Revision Date: 02/2011 Key Words: Conduct, harassment, violence, disruptive behavior, assault, retribution, threats, bullying AUTHORIZATION: Signature: /s/gregg K. Edwards Title: Chief People Officer Date: 02/15/2011 POLICY SUMMARY: The purpose of this policy is to clarify Asante s expectations of conduct for all staff. These expectations are shaped by and reflect Asante s guiding values. This policy details the processes Asante has in place to report situations where there are violations of our behavioral standards, and it describes how such behaviors can be managed. The ultimate goal is to create a workplace where all employees feel safe from threatening behavior, all kinds of physical and verbal abuse, bullying, intimidation, coercion, and harassment, and where employees feel comfortable constructively discussing with each other issues that hinder our ability to ensure an environment where employee and patient safety are paramount. The obligation to maintain a safe work environment includes protecting employees from the acts of others (patients, visitors, customers and fellow employees) as well as protecting others from the acts of employees. Employee conduct of this nature may be subject to immediate and appropriate corrective action up to and including termination of employment. (For non-employed physicians, refer to policies 100-HR-028 and 110-MS-PR1.) DEFINITIONS: 1. Staff Staff is defined as all people who provide care, treatment, and services, including those receiving pay (e.g., permanent, temporary, and part-time/on-call personnel), as well as contract employees, volunteers, and health profession students. This definition does not include licensed independent practitioners who are not paid staff or who are not contract employees. 2. Threatening Behavior Threatening behavior consists of any expressed intention, directly or indirectly, that would: harm another individual or oneself, endanger a group of employees or others on the premises, or destroy personal or organizational property. Policy Name: Code of Conduct Policy #: 400-HR-090 Page 1 of 6
3. Bullying Bullying is an act of repeated aggressive behavior in order to intentionally hurt another person, physically or mentally. Bullying is characterized by an individual behaving in a certain way to gain power over another person. Behaviors may include name calling, verbal or written abuse, exclusion from activities, exclusion from social situations, physical abuse, or coercion. 4. Coercion Coercion is the practice of compelling a person or manipulating them to behave in an involuntary way (whether through action or inaction) by use of threats, intimidation, or some other form of pressure or force. Coercion may involve the actual infliction of physical or psychological harm in order to enhance the credibility of a threat. The threat of further harm may then lead to the cooperation or obedience of the person being coerced. 5. Harassment Harassment is behavior that is intended to create an unpleasant or hostile situation, especially by uninvited and unwelcome verbal or physical conduct. Harassment is unlawful when it targets an individual s sex, race, age, disability, religion, sexual orientation, national origin, veteran s status or any other status protected by law. 6. Sexual Harassment Sexual harassment is a specific form of unlawful harassment which includes any unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature which (1) is made either explicitly or implicitly a term or condition of an individual s employment or treatment; (2) is used as the basis for employment decisions such as promotion and benefits affecting such individual; (3) substantially interferes with an individual s work performance or creates an intimidating, offensive, or hostile working environment; or (4) interferes with a patient s or visitor s right to be free from such prohibited conduct. POLICY DETAILS: 1. Threatening Behavior/Bullying/Coercion No employee may commit an act of violence or engage in threatening, bullying, or coercive behavior while on Asante s premises, while performing any work for Asante (whether the work is performed on Asante premises or elsewhere), while using Asante s vehicles, or during working hours (including breaks and even meal time when the threatening act is related to the workplace). Threats made as a joke, prank, in jest or in connection with horseplay are considered real threats under this policy and will not be permitted. A. Patient Care Asante is committed to protecting its caregivers during the course of their interactions with patients, visitors, and family members. In situations where the potential of threatening behavior exists, staff may request a change of assignment or request that they provide care only with assistance, if caring for the patient creates unreasonable anxiety or stress. Policy Name: Code of Conduct Policy #: 400-HR-090 Page 2 of 6
When a potential threat is identified, security officers will be summoned to the area immediately. Situations may occur in which physical force is necessary to reduce the possibility of injury to employees, patients, and other visitors. In most instances, the use of physical force is limited to staff who are trained in methods to physically restrain a combative patient. In emergency situations, when there isn t time to summon a security officer or, if needed, while waiting for security to arrive an employee who uses self-defense when assaulted will not be subject to corrective action only if he/she: acted in self-defense in response to the use or imminent use of physical force, used an amount of physical force that was reasonably necessary to protect the employee or a third person from assault, and used the least restrictive procedures necessary under the circumstances. B. Weapons Weapons are prohibited in all Asante buildings. Weapons include firearms as well as other objects such as knives (other than small pocket knives and tools required by employees to perform their jobs), electronic stun weapons, and other instruments that someone could use to harm another person. Even individuals licensed by the state to carry firearms are subject to the prohibition against weapons in Asante buildings. Law enforcement officers who are on the premises carrying out their law enforcement duties are the exception to this prohibition. Adequate signs at entrances and in selected public areas throughout each entity shall be posted advising of the prohibition of weapons. Individuals known or suspected to be carrying weapons will be asked to remove the weapons from all Asante buildings or to turn over the weapon to Security so that they can lock it up until the individual is ready to leave the property. Individuals who refuse to cooperate or act inappropriately will be escorted off the premises by security or police. C. Searches When reasonable grounds exist to believe that the safety of the work area may be threatened, Asante reserves the right, at all times and without prior notice, to inspect and search any and all Asante property, work areas and personal belongings brought onto Asante premises. Failure to cooperate in such a search will be considered insubordination and result in corrective action up to and including termination. Managers should contact Security and Human Resources whenever there is reasonable cause to conduct a search. D. Reporting Procedure All employees are responsible for helping to maintain a safe workplace. To this end, it is incumbent upon each employee to immediately report any violent act or threat of violence directed against himself/herself, any co-worker, manager, customer, visitor, other individual on Asante s premises, or while conducting business on behalf of Asante, even where the violent or threatening act occurs away from the workplace or during non-working hours, when the threatening act is related to the workplace (e.g., a manager who has issued a corrective Policy Name: Code of Conduct Policy #: 400-HR-090 Page 3 of 6
action document at work is threatened away from work by the employee who received the corrective action). Asante will investigate all such reports thoroughly and promptly and take whatever action deemed appropriate to protect Asante s employees, customers, visitors and property. Employees are expected to cooperate in any investigation in Asante s efforts to maintain a safe workplace. Employees who believe they are subjected to, or are aware of, threats, harassment, intimidation, physical abuse, verbal abuse or coercion from employees, patients, customers, visitors or others or who are aware of the presence of weapons will report all specific occurrences and circumstances to their supervisor or Human Resources. If a threat is imminent and direct in nature, 911 Emergency or the local law enforcement authority should be immediately contacted followed by on-site security, if available. Behavior that constitutes an imminent and direct threat includes any behavior a reasonable person would interpret as: - A potential physical assault or use of a weapon; - Actions or statements that have the immediate potential for violence against persons or property (e.g. breaking or throwing objects, gesturing with a fist, etc). If there is a threat of harm or of a disturbance between employees, between employees and supervisors, between an employee and a patient, or between a member of the outside public and an Asante employee, on-site security (if available) should be immediately notified. Behavior which could constitute potential warning signs includes: - Loud and/or argumentative behavior; - Throwing things/inflicting intentional damage due to anger; - Threats, explosions of anger, tantrums In some instances, where the desire is to have many people respond immediately to control a situation or physically restrain a patient or other person, 777 Code Green should be called immediately (per Code Green policy #400-EC-612). However, keep in mind that in some potentially violent situations (such as threat of a weapon), the goal is to avoid bringing many people together and, rather, only to have law enforcement and/or security personnel respond. E. Assault Assessment and Prevention Program Asante periodically assesses the environment to identify existing or potential hazards and eliminate or minimize the hazard. Based on these assessments, Asante develops and implements an assault prevention program. Assault prevention and protection training is conducted within 90 days of an employee s initial hiring date. Policy Name: Code of Conduct Policy #: 400-HR-090 Page 4 of 6
2. Harassment Asante does not tolerate any forms of harassment or sexual harassment. Epithets, slurs, negative stereotyping, threats, intimidation, hostile acts or offensive humor that relates to race, color, religion, gender, sexual orientation, national origin, age, veteran s status, or disability, or any other protected status, are strictly prohibited. This includes behavior or written or graphic material that belittles or shows hostility or aversion toward an individual or group because of their protected status. The prohibition against such conduct extends to computer screens, email, walls, bulletin boards or other places, and materials circulated in the workplace. Asante policy also prohibits harassment of this type based on characteristics of an individual s relatives, friends or associates. Harassment by vendors, suppliers, visitors, volunteers, patients or family members, or by other non-employees of Asante with whom Asante s employees or invitees interact during the workday is just as unacceptable as from other employees. An employee experiencing such harassment should utilize the same harassment complaint procedure as exists for complaints against fellow employees. A. Reporting Procedure If an Asante employee finds certain behavior or conduct unwelcome, he or she is encouraged, but not required, to inform the other person that the behavior or conduct is not welcome. However, every employee at Asante has a duty to promptly report harassment to their manager or to an HR generalist. No reprisals will be taken against any employee who makes such a report. Complaints will be kept confidential to the extent possible while allowing the investigation to proceed. An investigation of all complaints will commence in a timely fashion. Any individual employee who is found by Asante, after appropriate investigation, to have harassed or committed offensive conduct against another employee will be subject to appropriate sanctions, depending on the circumstances, up to and including termination of employment. Patients who feel they have been treated inappropriately are encouraged to report such behavior utilizing the procedures outlined in the Patient Handbook. B. Non-Retaliation/Confidential Reporting It is strictly prohibited to harass, discipline, or retaliate in any way against an individual who in good faith reports a matter he or she believes requires investigation. Violation of this nonretribution policy is a basis for disciplinary action up to and including termination. If you believe that someone has retaliated against you for reporting a Code of Conduct issue, contact your supervisor, another member of management, or the Asante Compliance Officer at 15668. To provide a vehicle to report incidents confidentially, Asante has established a compliance hotline (1-800-296-7173). Asante established the compliance hotline to ensure that staff has a convenient, safe way to report compliance related concerns. Calls to our hotline are received by an outside organization and forwarded to the Asante Compliance Officer for follow up. An operator answers calls made during regular business hours; after-hour calls go to a confidential voice mail Policy Name: Code of Conduct Policy #: 400-HR-090 Page 5 of 6
system. Even if you wish to remain anonymous you may call the hotline to get an update on the concern you reported. If you leave your name or a number where you can be reached when you make a call to Asante s hotline, you will receive an initial response within 48 hours. C. False Reports Any employee who is found to purposefully report a false allegation will be subject to discipline, including termination of employment. Policy Submitted By: Policy Reviewed By: Fred Bockstahler, Corporate Compliance/Privacy Officer 02/2011 HR Policy Review Committee 02/2011 Title Date Title Date Policy Name: Code of Conduct Policy #: 400-HR-090 Page 6 of 6