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Administrative (Non-Clinical) Policy
As of April 1, 2016 this administrative policy applies to the operations and staff of legacy
UWHC. Effective July 1, 2015, the legacy operations and staff of UWHC and UWMF were integrated
into the University of Wisconsin Hospitals and Clinics Authority (UWHCA). All administrative policies
are being transitioned to apply UWHCA-wide, but until future revision to this policy # 9.04, it applies
only to the operations and staff of legacy UWHC.
Policy Title: Work Rules: UWHC Authority
Policy Number: 9.04
Effective Date: April 1, 2016
It shall be the policy of University of Wisconsin Hospital and Clinics (UWHC) Authority to establish the
highest standards of personal conduct to serve the best interests of UWHC and its patients, visitors, staff
and hospital employees. The rules and regulations are essential to the efficient and successful operation of
the organization. The rules listed in this policy are designed to provide guidance as to the expectations of
UWHC regarding employee conduct.
The rules set forth in this policy are not all-inclusive, but are intended to serve as a guide to the types of
conduct that may result in discipline. It is expected that all employees will consistently demonstrate
UWHC's performance standards: excellence, innovation, compassion, integrity, respect and
accountability. Those who, in the opinion of UWHC, fail to meet these standards will be subject to
disciplinary action up to and including discharge. Individual departments may develop their own work
standards based on departmental or unit operating needs. Department standards must be reviewed and
approved by the Director of Employee Relations and must be consistent with the organizational standards
and be communicated to all department members.
Whenever this policy refers to UWHC premises or property, it includes all buildings, parking lots and
non-work areas owned, leased or controlled by UWHC and its affiliates.
II. PERSONS AFFECTED
This policy applies to all regular, full-time and part-time UWHC employees, temporary staff, students and
volunteers employed or associated with UWHC. It is understood that "employees" below refers to all
categories of employees and staff listed above.
A. The following are examples of types of conduct that demonstrate disregard for UWHC's behavior
and performance standards and may lead to counseling or disciplinary action. Depending on
UWHC's assessment of the individual circumstances, this disciplinary action may be in the form
of counseling, a verbal warning, written warning, suspension without pay, or discharge,
depending upon a review of mitigating and extenuating circumstances.
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1. Negligence in the performance of assigned duties.
2. Interfering with another employee's efforts to meet UWHC work performance standards.
3. Failure to report promptly at the starting time of a shift or leaving before the scheduled
quitting time of a shift without the specific approval of the supervisor.
4. Unexcused or excessive absenteeism and/or tardiness and sick leave abuse.
5. Exceeding the authorized number or length of scheduled lunch, breaks, rest or wash-up
6. Failing to adhere to the work schedule as established by management, including working
unauthorized overtime, or refusal to work overtime or take call without a reasonable
7. Unauthorized solicitation for any purpose.
8. Inappropriate dress, grooming or personal hygiene.
9. Consuming food or beverages in patient care, diagnostic, and research areas except for
10. Smoking in prohibited areas.
11. Failure to properly display or wear the required identification badge.
12. Use of personal pagers, cell phones or other personal electronic devices (such as iPod's,
MP3 players, DVD players) is generally prohibited while working in all patient care
and/or public areas.
13. Unauthorized posting or removing of notices or signs from bulletin boards.
14. Failure to exercise good judgment or being discourteous in dealing with fellow
employees or the general public.
15. Solicit or accept anything of value with the express or implied understanding that his or
her conduct of hospital business will be influenced by the gift and not to use his or her
UWHC position to gain anything of substantial value for private benefit. (Refer to
UWHC's Authority Code of Ethics regarding “Conflicts of Interest” and, "Guidelines
16. Disorderly conduct, including but not limited to, horseplay; gambling; use of abusive,
intimidating, threatening, or profane language or offensive materials towards others.
B. The following types of conduct are more serious, demonstrating intentional disregard for
UWHC's work performance standards. They may lead to immediate discharge even on the first
offense after consideration of all mitigating and aggravating circumstances.
1. Insubordination, including disobedience, failure or refusal to carry out written or verbal
assignments, instructions or policies.
2. Loafing, loitering, sleeping, inattentiveness or engaging in unauthorized personal
business during scheduled work hours.
3. Unauthorized access to or disclosure of confidential information or records.
4. Falsifying records or providing false information to others.
5. Failure to cooperate and provide accurate and complete information when required by an
6. Failure to comply with health, safety and sanitation requirements, rules, and regulations.
7. Misappropriation of UWHC assets, funds, property or time compensated by UWHC.
8. Misusing UWHC funds, accepting UWHC funds under false pretenses, including but not
limited to, sick pay, disability and workers' compensation payments and/or failing to
notify and make prompt payment to UWHC of overpayments or missed payments.
9. Gross negligence or reckless behavior in the performance of assigned duties, and/or
intentional mistreatment or neglect of a patient.
10. Failure to notify the supervisor promptly of an unanticipated absence or tardiness (i.e.,
no-call, no-show) and fraudulent use of sick leave.
11. Unauthorized use, defacement, destruction or neglect of UWHC's owned or leased
property or equipment including, but not limited to: vehicles, medical equipment,
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information systems resources, telephones, uniforms, identification cards, badges,
permits, keys, supplies, materials, facsimiles or mail service. Destruction or defacement
of the property of an employee, patient or others.
12. Unauthorized possession, theft or removal of any UWHC owned or leased property, or
another person's private property without authorization (including damaged goods, scrap
material and packages) from UWHC premises or concealing such material on UWHC
premises. Failure to submit to and/or cooperate with a security officer or member of
UWHC administration in an inspection of materials, equipment (including such things as
lockers, desks and file cabinets), packages, vehicles, or personal affects brought onto,
stored on, or removed from UWHC premises.
13. Unauthorized entry to UWHC property, including unauthorized entry outside of assigned
work hours or entry to restricted areas, and/or allowing an unauthorized person on
14. Abusing, harassing, threatening, attempting bodily harm to others or acts of violence
(also refer to Hospital Administrative policy 9.58, Workplace Violence Reporting,
Investigation and Discipline).
15. Unauthorized possession of weapons while on UWHC premises.
16. Making false or malicious statements.
17. Reporting to work or while at work manifesting any evidence of having consumed
alcoholic beverages or illegal drugs or having possession of such items while on duty.
18. Requesting, retaining, or failing to report an offer of a bribe or gratuity.
19. Any form of prohibited retaliation against another person who makes a formal complaint
or provides information in a workplace investigation.
20. Failure to perform obligations under UWHC's Code of Ethics regarding “Conflicts of
Interest” and “Code of Conduct”.
21. Refusing to be tested or to undergo testing procedures if a manager or person in charge
determines there is reason to believe that an employee is under the influence of
intoxicants or nonprescription narcotics or drugs, or using or possessing intoxicants or
nonprescription narcotics or drugs while on UWHC property or on work time.
22. Testing positive on any tests administered under UWHC's Fitness for Duty: Impaired
Employee policy (Hospital Administrative Policy 9.34) or refusing to cooperate in the
fitness for duty process.
23. Failing to report to the employee's immediate manager the arrest and/or conviction for a
criminal charge or a plea of "no lo contender" to any criminal charge (excluding minor
traffic violations unless the employee drives hospital vehicles).
24. Failure by an employee to report to his/her supervisor/manager that the employee's
professional license has been placed on probation, come under suspension, has been
revoked, or has otherwise been subject to disciplinary action.
25. Failure to report to the employee's immediate manager any sanction or exclusion from a
federal health care reimbursement program, including but not limited to Medicare,
Medicaid, Tricare and the Veteran's Administration; or any investigation by any
governmental agency in connection with a federal health care reimbursement program.
26. Failure to comply with applicable state and/or federal laws or intentionally failing to
report suspected or potential violations of state and/or federal laws to the employee's
immediate supervisor, the Compliance Hotline (821-4130), or the Compliance and
Privacy Officer. If an employee makes a report intentionally in bad faith or with malice,
that employee may be subject to disciplinary action.
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This Policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made
for the purpose of inducing any person to become or remain an employee of UWHC, and should not be
considered "promises" or as granting "property" rights. UWHC may add to, subtract from and/or modify
this Policy at any time. Nothing contained in this Policy impairs the right of an employee or UWHC to
terminate the employment relationship at-will.
Sr. Management Sponsor: Vice President, Human Resources Operations
Author: Director, Employee Relations
Approval Committee: UW Health Administrative Policy & Procedure Committee
President, University of Wisconsin Hospitals
Chief of Clinical Operations
Previous revision: 122012
Next revision: 042019