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Policies,Administrative,UWHC,Department Specific,Pharmacy,Administration

Administrative Standards (1.7)

Administrative Standards (1.7) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.7

POLICY & PROCEDURE





Effective Date:

July 2004
Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter

Policy #: 1.7


Revision 7/16

Page 1
of 8

Title: Administrative Standards


I. PURPOSE: This policy outlines standards for University of Wisconsin Hospital and Clinics
(UWHC) Department of Pharmacy employees that supplement standards outlined in UWHC
Administrative policies.
II. POLICY:
A. Patient/Family/Visitor, Customer and Public Relations
1. Refer to UWHC Administrative Policies
a. Patient Rights and Responsibilities 4.34
b. Responding to patient/family concerns, complaints and grievances 4.46
2. Department of Pharmacy employees are expected to hold themselves accountable to the
following standards when interacting with patients, families, visitors, internal/external
customers, other employees, and the general public:
a. Communication should be courteous, respectful, honest, positive, open,
collaborative, and professional
b. Patients/Families/Visitors should be addressed by their formal name (e.g. Mr.,
Mrs. or Ms.) unless otherwise specified.
c. Always assist in answering a question or help find someone who can find an
answer to a question.
d. Smile, make eye contact, introduce yourself and your role
B. Confidentiality of Patient Information.
1. Refer to the following UWHC Administrative Policies
a. Using and disclosing (or releasing) protected health information 4.13
b. Release of mental health information 4.14
c. Release of patient information to news media 4.16
d. Release of alcohol and other drug abuse patient information 4.38
e. Electronic medical record audit policy 4.39
f. Corrective Action for Non-Compliance with Confidentiality of Protected Health
Information 9.11
2. Department of Pharmacy employees shall avoid discussion about or with patients in
public areas (e.g. cafeteria, hallways, elevators, lobbies, etc.) or outside the institution.
3. Only use the minimum-necessary patient information to perform your duties
4. Snooping (accessing patient information that is not the minimum-necessary to perform
your duties) is never allowed. Verbal authorization does not allow you to access the
record of anyone without a work-related reason.
5. Never leave paper or electronic patient information unattended where others can see it.
6. Never gossip about a patient with anyone.

POLICY & PROCEDURE





Effective Date:

July 2004
Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter

Policy #: 1.7


Revision 7/16

Page 2
of 8

Title: Administrative Standards


7. Remove patient documents from fax machines and copiers promptly.
8. Discard all documents containing patient information in confidential bins for shredding.
9. Do not forward a UW Health email to another email address (e.g. “yahoo” or “google”).
10. Report accidental disclosures of patient information to a supervisor or to the compliance
helpline 608-265-7400
11. Never share passwords, employees are responsible for every click that occurs using their
user name or password
C. Dress and Appearance.
1. Refer to the following UWHC Administrative Policies
a. Photo Identification Badge and Security Access Systems 1.30
b. UW Health Dress Code and Appearance 9.16
c. Scrub Suit Attire 9.29
2. Additional Department of Pharmacy specific expectations include the following:
a. Scrubs may be worn whenever assigned responsibilities include sterile products
and/or operating room support or overnights or emergency department shifts
b. All male pharmacists must wear a collared dress shirt and necktie when not in
scrubs
c. All inpatient, ambulatory, and clinic pharmacists, technicians, interns, and
students will wear a clean white lab coat in all public patient care areas (e.g.
hallways, patient rooms) and for patient/caregiver/family interactions while on
duty. Exceptions to this expectation are employees working in AFCH or inpatient
psychiatry and patient-specific infection control restrictions
3. Pharmacy employees, residents, students, should use perfumes, cologne, or aftershave
sparingly. Sites which house individuals with medically-proven allergies to various
fragrances may prohibit use of these substances.
D. Hand Hygiene
1. Refer to the following UWHC Administrative Policy Hand Hygiene 13.08
2. Refer to Department of Pharmacy Policy Sterile Product Preparation – Personal Hygiene
6.1
E. Personal Activities on the Job - Food, Beverage, Smoking, and Misc.
1. Refer to the following UWHC Administrative Policies
a. Restrictions on Food and Beverage Consumption 13.01
b. Alcoholic Beverage Possession and Consumption at UWHC 1.23
c. UWHC Smoke Free/Tobacco Free Workplace 1.41
d. Telephone and Cellular Phone Use 9.01

POLICY & PROCEDURE





Effective Date:

July 2004
Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter

Policy #: 1.7


Revision 7/16

Page 3
of 8

Title: Administrative Standards


2. Unless permitted by a manager, eating or drinking is only allowed in public areas (e.g.
cafeteria, conference rooms, lounges) and non-patient care areas (e.g. employee break
rooms, private offices)
3. Radios, computer speakers, headphones may be used at the discretion of the supervisor or
manager. Volumes must be curtailed to avoid being heard outside the actual work area,
and must not negatively affect patients or other employees. Unless permitted by the
manager, personal sound systems and headphones (e.g. portable CD, tape players, i-pods,
mp3 players) are not permitted in work or patient care areas. Use of this equipment
should be limited to break & lunch periods and used outside of the work or patient care
areas.
4. In general, use of the telephones or cellular phones for personal use (texting, internet
browsing, calling) is not permitted during work time.
a. Local personal calls during break period should be kept to a minimum and at the
discretion of an employee's immediate supervisor.
b. Long distance calls for personal use are not permitted without the approval of a
supervisor/manager for emergencies.
c. Calls made to an employee, during the work shift, should be limited in number
and duration and should in no way interfere with an employee's performance.
Calls between employees unless work related will be considered personal.
d. At no time are personal cell phones allowed in central pharmacy. Phones should
be stored for use on non-work time (break rooms, lockers, etc.)
5. Personal activities should be performed only during break or lunch (e.g.; reading
newspaper, homework, personal phone calls or emails) outside of pharmacy work areas.
F. Drug-Free Workplace.
1. Refer to the following UWHC Administrative Policies
a. Drug Free Workplace 9.05
b. Employee Assistance Program 9.15
c. Fitness for Duty 9.22
2. The unlawful manufacture, distribution, sale, purchase, dispensation, possession, or use
of drugs and controlled substances, or unauthorized use, or being under the influence of
alcohol or drugs, on UWHC premises or while conducting UWHC business off premises
are strictly prohibited. Violation of this policy will result in disciplinary action, up to and
including discharge, and may have legal consequences. Note: This policy in no way
interferes with the normal; job related daily handling of controlled substances by
pharmacy personnel.

POLICY & PROCEDURE





Effective Date:

July 2004
Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter

Policy #: 1.7


Revision 7/16

Page 4
of 8

Title: Administrative Standards


3. Employees must report to an Employee and Labor Relations Consultant in the Human
Resources department and the Director of Pharmacy any arrest or conviction under a
criminal drug statute. A report of a conviction must be made within five (5) days after the
conviction.
G. Permanent employee resignation.
1. Pharmacy Managers and Supervisors shall provide a minimum of two months written
notice
2. Pharmacists shall provide a minimum of four-weeks written notice
3. All other staff shall provide a minimum of two-weeks written notice
H. Attendance and Punctuality
1. Refer to the following UWHC Administrative Policies
a. Work Rules: UWHC Authority 9.04
b. Attendance and Punctuality 9.13
c. Leaves of Absence, Excluding Sick, Family and Medical Leaves 9.40
d. Sick, Family and Medical Leaves of Absence 9.72
e. Inclement Weather 9.45
f. Snow/Sever Weather Advisory 12.50
2. All Department of Pharmacy employees provide clinical and/or operational support of
patient care. Regular attendance and punctuality of all employees is necessary to provide
safe, timely, effective, efficient, equitable, and patient-centered care.
3. Employees are expected to report for work as scheduled and to notify the designated
departmental representative in a timely manner whenever unable to do so.
4. Definitions
a. Ready to work - An employee at their scheduled start time: is physically present
in assigned work location; is monitoring appropriate pager(s)/phone(s); is logged
into appropriate software applications; is monitoring work queues, meets dress
code and appearance expectations, is wearing photo identification badge
b. Tardiness – Failing to report promptly, ready to work, at the scheduled starting
time or taking unauthorized extended rest or meal periods.
c. Early departure – Leaving prior to the scheduled ending time
5. Hourly employees who work in areas in which hospital issued scrub attire are required
and must be donned before entering the work area are allowed ten minutes to change and
report to their scheduled shift. Employees in these scheduled shifts are also allowed ten
minutes to change back into personal clothes prior to the end of their shift. Hospital

POLICY & PROCEDURE





Effective Date:

July 2004
Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter

Policy #: 1.7


Revision 7/16

Page 5
of 8

Title: Administrative Standards


issued scrub attire are not to be worn off the UW Health campus and must be cleaned by
the hospital.
a. Refer to UWHC Administrative Policy 9.29 Scrub Suite Attire
6. Notification of an unscheduled absence, tardiness, early departure
a. Pagers or cell phones can be contacted directly or via the paging operator
b. Employees must contact the designated department representative (see table)
within a reasonable time prior to the start of their work shift to report an
unscheduled absence, tardiness or early departure. For represented employees,
any requests to leave early or arrive late must also be authorized via completion
of the Overtime and Clocking Issues form and signed by the appropriate
Pharmacist, Supervisor, or Manager.
UWHC Paging Operator 608-262-2122 Direct Paging Number 608-265-7000
Inpatient Pharmacists
Weekdays
Monday at 0800 until Friday at
1700

Manager or Supervisor
(Personal pager/cell phone)
Holidays and Weekends
Friday at 1700 until Monday at 0800

Inpatient Pharmacy Manager On-
Call (pager 8771)
Drug Policy Program
Medication Management
Pharmacists and Analysts
Digestive Health Center
Pharmacists
Infusion Center
Pharmacists
Pharmacy Office Staff
Unity Pharmacy Program

Inpatient Pharmacy,
Digestive Health Center,
Operating Room, and
Clinic Technicians, Interns
and Students
Technician Sick Call Pager (pager 7951)
Call between 0500-2200 7-days/week. Calls made between the hours of
2200 and 0500 should be limited to: night shift ‘no call/no show’; night
staff need to leave early due to sickness; automation/technology
downtime requiring extra staff to be called in

Pharmaceutical Research
Center Pharmacists and
Technicians
Pharmaceutical Research Center Pharmacist On-Call
(pager 2717)

Ambulatory Pharmacists

POLICY & PROCEDURE





Effective Date:

July 2004
Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter

Policy #: 1.7


Revision 7/16

Page 6
of 8

Title: Administrative Standards


Ambulatory Pharmacy Manager On-Call
(pager 1298)

Ambulatory Technicians,
Interns, and Students
Weekdays
Technical Supervisor or Resident
On-Call
(Pager 7579)
Holidays and Weekends
Technical Supervisor or Resident
On-Call
(Pager 7579)


7. Trading shifts. Employees must complete necessary schedule-change paperwork or
Schedule One Source procedures at least 48 hours before the scheduled shift so that the
appropriate scheduling changes can be made accordingly. If this is not possible then the
employee must notify their manager/supervisor directly. Represented and hourly
employees are not allowed to switch shifts if it causes overtime, unless preauthorized by
a manager.
8. Monitoring of attendance and punctuality.
a. Refer to the following UWHC Administrative Policies
i. Attendance and Punctuality 9.13
b. It will be the responsibility of the designated departmental representative or the
supervisor/manager to monitor the attendance record of each employee and to
determine through a review process whether excessive absenteeism, excessive
tardiness or sick leave abuse exists. A review of an employee's attendance or
punctuality may be initiated periodically, as a result of the employee's discipline
or potential for discipline for non-attendance issues, or if any of the following
circumstances exist:
c. Given the limited hours students are employed by the pharmacy department,
unscheduled absences by students may be grounds for immediate dismissal.
9. Discipline for non-represented employees.
a. Refer to the following UWHC Administrative Policies
i. Workplace Violence Reporting 9.58
ii. Disciplinary Action for Non-Represented Employees 9.55
iii. Corrective Action for Non-Compliance with Confidentiality of Protected
Health Information 9.11
iv. Work Rules 9.04
10. Discipline for represented employees

POLICY & PROCEDURE





Effective Date:

July 2004
Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter

Policy #: 1.7


Revision 7/16

Page 7
of 8

Title: Administrative Standards


a. Refer to the following UWHC Administrative Policies
i. Attendance and Punctuality 9.13
I. Meeting Attendance.
1. Pharmacy department staff and team meetings are conducted on a regular basis and are an
important way to deliver critical information and allow for two-way communication
between managers and staff. All pharmacists, interns, pharmacy technicians and residents
are expected to attend staff and team meetings if scheduled to work that day. Information
conveyed during the meeting will be made available through minutes and will be posted
electronically. All employees, regardless of ability to attend (because of scheduling or
patient care needs) will be responsible for reviewing staff and team meeting minutes and
will be held accountable for any expectations conveyed.
2. Pharmacist Staff Meeting
a. All Inpatient, Drug Policy Program, Pharmaceutical Research Center, and
Medication Management team pharmacists working an AM shift the day of the
meeting are required to attend unless excused by their manager
b. The manager is responsible for notifying the pharmacy office to mark the
pharmacist as excused on the attendance roster
c. Pharmacist schedules and the attendance roster will be reconciled to identify
pharmacists with unexcused absences
3. Regular attendance and active participation for pharmacists and technicians sitting on
department or hospital committees is expected. Individual committees set guidelines on
these expectations.

J. Time Reporting for Hourly and Non-Hourly Employees.
1. Refer to the following UWHC Administrative Policies:
a. Recording Paid Time 9.14
b. Vacation and Legal Holidays 9.50
c. Clinical Overload Staffing 9.74
i. See also: Payments to Pharmacists for Extra Shifts and Night Shifts
Pharmacy Policy 1.39
2. Refer also to the following UWHC Pharmacy Policies and Procedures
a. Pharmacy Staffing and Scheduling 1.11
3. Pharmacy hourly employees will use an automated time and attendance system consisting
of identification badges, badge readers, electronic time cards, and automated time card
calculation. Pharmacy hourly employees must input their paid productive time by using a

POLICY & PROCEDURE





Effective Date:

July 2004
Pharmacy Policy Manual
Chapter: Administrative
Operations Procedure Manual
Chapter

Policy #: 1.7


Revision 7/16

Page 8
of 8

Title: Administrative Standards


badge reader or MyTime. Pharmacy employees are required to input their paid non-
productive time (vacation, legal holiday, sick leave and personal holiday). Pharmacy
employees may use any badge reader located within their work site (Clinical Science
Center, University Station, East Clinic, and West Clinic). Employees working at non-
hospital sites (i.e., Northeast Clinic, Center for Drug Policy, 1 S Park, East Towne, and
West Towne) will be exempt from using the badge reader, but must use MyTime at the
location they are scheduled to staff that day.
4. Overtime Approval
a. Hourly employees must have prior approval from supervisor or pharmacist to
sign in early, work through lunch or work after shift has ended. Failure to
comply will result in counseling. An Overtime Approval and Clocking Issues
Sheet (located in the pharmacy break room) must be filled out by the employee
and signed by supervisor or pharmacist and handed into the office mailbox


Approved By:_______________________________
Director of Pharmacy

Date:__________