9.55 Disciplinary Action: Non-Represented UWHC Authority Regular Employees
UWHC Administrative Policy Print
July 1, 2014
Personnel (Hospital Administrative)
Disciplinary action is a corrective process to assure satisfactory job performance and adherence to the University of
Wisconsin Hospital and Clinics Authority’s (UWHC) policies and/or work rules. It is a means to assist and encourage
employees to correct misconduct and to achieve satisfactory work performance by complying with the UWHC's
work rules. Disciplinary action should be directed towards improving employee performance and/or behavior. It
ensures that the interests of UWHC, its patients, visitors and employees are considered in the application of
II. PERSONS AFFECTED
This policy applies to all non-represented regular employees of UWHC, and excludes probationary employees,
temporary employees, Graduate Medical Education trainees and supervisors and above. Employees who are part of
a recognized collective bargaining unit are covered under the provisions outlined in their agreement and not this
1. Prior to issuing discipline to any employee for violation of policies and/or work rules, managers
must first hold an investigatory meeting and conduct a timely investigation to determine the
validity of suspected violations.
2. During the investigatory meeting, the manager must provide the employee an opportunity to
respond to issues and concerns that may lead to discipline.
3. Whenever possible, another manager should be present at an investigatory meeting, and the
employee may select a peer to attend (see below).
4. Investigations should be prompt, appropriately documented, and may need to be coordinated
with Employee and Labor Relations (ELR). Managers may also need to consult with Patient
Relations, Security, and Compliance, depending upon whether potential risks of harm to other
employees, patients, and/or the public exist.
5. Employees have a duty to cooperate with the investigatory process and must participate in good
faith. Employees who fail to do so may be subject to disciplinary action up to and including
termination from employment.
6. Managers should generally remind employees that they have access to the Employee Assistance
Program (EAP) during investigations.
7. Employees may request a UWHC employee act as peer support (peer) in an investigatory
meeting that may result in discipline.
a. Non-employees, including attorneys, students and temporary employees, may not serve
as a peer. Additionally, relatives of the employee or supervisor/manager, or any other
person creating a potential conflict of interest, shall not serve as a peer.
b. Peers who have been released to attend an investigatory meeting are encouraged to
review the “Role of Peer Support Person” document, available on U-Connect prior to
attending the meeting. Managers should provide the peer a copy of the “Role of Peer
Support Person” document prior to conducting investigatory meetings.
c. The peer will be in a paid status to attend investigatory meetings and for thirty (30)
8. An employee’s selection of a peer may not unreasonably delay the scheduling of an investigation,
particularly those that relate to caregiver misconduct investigations or any other investigation
related to patient or employee safety.
a. An employee who requests a peer should inform his/her manager of the designated
peer, and the peer must obtain permission from his/her manager to ensure that he/she
can be released from staffing to attend.
b. Primary responsibility for obtaining prompt peer release rests with the employee
requesting peer support. Employees are encouraged to consider several peer options in
case their first preference peer cannot be released from staffing for operational reasons.
Managers may choose to assist with the peer release process to promote efficiency.
9. For operational reasons managers may need to deny requests for peer support and proceed with
an investigation without a peer.
a. Prior to denying the release of a peer to attend an investigation, the manager denying
the request should confirm this decision with her/his director, and if possible, check with
the manager of the employee being investigated to see if rescheduling the investigation
b. For operational reasons, and in consultation with their directors, managers may impose
reasonable general limitations on the release time of employees serving as peers. (hours
per week per peer)
10. Employees and their peer will be granted thirty (30) minutes in advance of an investigatory
meeting to prepare.
11. Peers at investigatory meetings will not be retaliated against for participating in investigatory
meetings. Peers should immediately report any concerns about retaliation to the Director, Human
B. Administrative Leave During Investigations
1. Managers may place employees on administrative leave during an investigation if there is reason
for the manager to be concerned about the employee’s presence in the work place during the
investigation. Additionally, others involved in an investigation may be placed on an administrative
leave pending investigation to preserve the need for workplace efficiency and confidentiality
during the investigation.
2. Managers will coordinate the placement of employees on administrative leave with ELR or
Security (if ELR is not available outside of normal business hours) prior to placing employees on
administrative leave. Compliance and Patient Relations will be consulted as appropriate during
caregiver misconduct investigations.
3. Managers may verbally communicate to employees that they have been placed on an
administrative leave, and will follow up with a written notice to the employee detailing the rights
and responsibilities while on leave.
4. Administrative leave during an investigation is not punishment, and administrative leaves will be
with pay unless ELR determines that in special circumstances that it will be without pay.
C. Disciplinary Decisions
1. At the conclusion of an investigation, managers should consider whether counseling should be
utilized in lieu of discipline. In certain cases, counseling will be sufficient to correct problems with
performance and/or behavior.
2. If after a thorough and prompt investigation, a manager concludes that disciplinary action is
necessary, the manager will consult with his/her supervisor as well as an Employee and Labor
Relations Consultant/Human Resources Consultant (ELRC/HRC) before proceeding or issuing any
3. Disciplinary procedures will be administered consistently, and in a manner that is intended to be
corrective rather than punitive.
4. Discipline generally should be progressive. However, certain misconduct may be so serious as to
warrant suspension or termination for a single or first offense.
5. Although misconduct may not appear to be serious, the employee must be made formally aware
that it is inappropriate and that it cannot continue. Counselings, documented verbal reprimands
and letters of reprimands put the employee involved on notice, and if properly documented,
provide an important record that such notice has been given.
6. Demotion or transfer of an employee is not to be used as a substitute for disciplinary action, but
rather should be considered when an employee has demonstrated the lack of skills or knowledge
to do the assigned work.
7. In determining the severity of discipline to be applied for misconduct, the manager should
investigate and consider the following criteria:
a. Nature and seriousness of the misconduct, including actual or potential impact upon
UWHC's operations and patient care.
b. If multiple offenses are involved in the same occurrence, for example, sleeping on the
job due to reporting to work under the influence of alcohol, these separate facts should
be considered and reflected in the level of discipline.
c. Overall work records, including reference to performance evaluations.
d. Length of employment at UWHC.
e. Disciplinary history.
f. Effective communication of behavioral and performance standards and whether the
employee knew or should have known what was expected.
g. Consistency and uniformity in the enforcement of standards.
h. Extenuating or mitigating circumstances.
i. Reliance on circumstantial, hearsay or unsubstantiated evidence.
j. Efforts made by the employee to correct unacceptable behavior.
8. The manager should determine based on the facts of the particular circumstance in conjunction
with Hospital Administrative policy 9.04-Work Rules: UWHC Authority and Section I of this policy,
whether progressive discipline is appropriate. If so, discipline generally will be applied in the
a. Documented Verbal Reprimand - Usually the first step in the formal disciplinary action
b. Letter of Reprimand - Usually the second step in the disciplinary process. It may follow a
documented verbal reprimand issued for a repeated offense or a pattern of misconduct.
However, a documented verbal reprimand need not precede it. Ordinarily there should
be no sequence of letter of reprimands for the same or similar offenses. The supervisor
or manager, in coordination with his or her immediate supervisor will prepare the
disciplinary letter, and will consult with an ELRC/HRC before the discipline is issued.
c. Suspension - When lesser forms of discipline have not corrected an employee's behavior,
or when an occurrence is severe enough to warrant it, a suspension without pay (or a
“Letter of Reprimand in Lieu of Suspension”) may be issued, depending on the
circumstances. Ordinarily there should be no sequence of suspensions for the same or
similar offenses. The manager is responsible for ensuring any needed payroll
adjustments are initiated, and will consult with an ELRC/HRC before the discipline is
d. Discharge - When lesser forms of discipline have not corrected an employee's conduct,
or when an occurrence is serious enough to so warrant, the employee may be
discharged. Prior to discharging an employee, an ELRC/ HRC should review the decision
and the director should approve. The manager is responsible for ensuring that the
termination process is completed, and for obtaining any UWHC property (e.g., ID Badge,
keys, laptops, cell phones, etc.) held by the employee, and will also ensure that the
employee’s end appointment form, including the rehire recommendation, is consistent
with the disciplinary decision. The manager will also ensure that the employee’s access
to Information systems (e.g computer access and e-mail) is terminated.
9. The following decision matrix outlines responsibilities regarding disciplinary action:
Disciplinary Action Recommends Evaluates Approves
Documented Verbal Reprimand Supervisor HR – ELRC or HRC Manager
Letter of Reprimand Supervisor HR – ELRC or HRC Manager
Suspension/Demotion/Discharge Manager HR – ELRC or HRC Director
10. Once the decision to proceed with discipline is finalized, the supervisor shall provide the
employee with the disciplinary letter that includes:
a. The employee's inappropriate performance or misconduct,
b. The level and terms of discipline,
c. Availability of the Employee Assistance Program (EAP) (Hospital Administrative policy
9.15-Employee Assistance Program),
d. Consequences of continued policy violation/misconduct, and
e. The employee's appeal rights under Hospital Administrative policy 9.54-Formal Appeal
11. The original copy of the disciplinary letter is given to the employee. A copy (preferably a signed
electronic copy [PDF]) should be forwarded to HR and the UWHC File Room
(UWHCHRFileRoom@uwhealth.org) to be included in the employee's personnel file.
12. Documented formal discipline will remain in an employee’s personnel file indefinitely. However, it
will be considered active for purposes of progressive discipline for a period of two years from the
date of issuance.
13. Once a disciplinary action has been determined and issued to the employee, it should not be
modified unless the manager obtains knowledge of additional facts showing that the original
offense was different than originally believed.
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 a non-represented employee or UWHC to terminate the
employment relationship at-will.
A. Contact Security as needed if they should be present and/or in the immediate area during an investigatory
meeting or when discipline is issued.
B. In the event an employee is placed on paid administrative leave during the investigation and/or receives a
suspension, the employee's manager/supervisor should immediately ensure that the employee's
employment status is changed to "Administrative Leave" and/or "Suspension", for payroll purposes, by
contacting their ELRC/HRC.
C. In the event an employee is terminated, the manager/supervisor should immediately complete and submit
to HR an "End Appointment" form (refer to Hospital Administrative policy 9.36- End Appointment and
Appointment Change) and/or contact Security and IS to have building and systems access deactivated.
Hospital Administrative Policy 9.04-Work Rules: UWHC Authority
Hospital Administrative Policy 9.15-Employee Assistance Program
Hospital Administrative Policy 9.26-Probationary and Annual Performance Appraisals
Hospital Administrative Policy 9.36-End Appointment and Appointment Change
Hospital Administrative Policy 9.54-Formal Appeal Process
Senior Management Sponsor: Senior Vice President, Human Resources
Author: Director, Human Resources
Approval Committee: Administrative Policy and Procedure Committee
President & CEO