UW MEDICAL FOUNDATION POLICIES AND PROCEDURES
Employee Performance Expectations Policy
As of 10/26/2015, this administrative policy applies to the operations and staff of legacy UWMF.
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 # 108.026, it
applies only to the operations and staff of legacy UWMF.
Effective Date: 10/26/2015
Supersedes Policy Date: 07/23/2015
The purpose of this policy is to define the guidelines to be taken by a supervisor to
assist an employee in meeting acceptable standards of performance. These guidelines
also will ensure compliance with the policies and procedures set forth by the University
of Wisconsin Medical Foundation (UWMF). This policy does not grant substantive
contractual rights to an employee but only is intended to set forth guidelines for action
dependent on the circumstances.
UWMF, as a matter of policy, reserves the right to discipline, suspend and/or terminate
an employee. However, no one will be disciplined or terminated without appropriate
investigation. An employee may be suspended (with pay), if necessary, until the
investigation is completed. If the termination is the result of a major act of misconduct
by the employee, the supervisor should suspend the employee and then consult with
Human Resources. This will lend maximum protection to employees of UWMF against
An employee disciplined or discharged may file a grievance. A filed grievance will be
viewed as formal and thus the formal grievance procedure will be followed. In the event
of a discharge, the grievance shall be heard at the third step. Please see the
“Employee Grievance Policy” for more details.
The UWMF follows a progressive improvement process in most situations. The
progressive improvement process involves four (4) disciplinary steps: Verbal Warning,
Initial Written Warning, Final Written Warning, and Termination. However, due to the
severity or nature of the issue, steps within the process may be skipped to more
appropriately address the issue. Disciplinary action will be documented with an
Employee Improvement Report in accordance with the following procedure:
The Employee Improvement Process
1. The supervisor conducts an initial investigation of issues affecting an employee’s
performance or possible policy violation. If the employee is not meeting
performance expectations or has violated a policy, the supervisor, at his/her
discretion, shall begin the progressive improvement process and issue an
Employee Improvement Report to the employee.
2. Once the supervisor completes the investigation of issues affecting performance
or behavior, the supervisor will meet with the employee and discuss these issues
and prepare a plan of action. The meeting may be considered a coaching
discussion or the supervisor may present the employee with a formal
Employment Improvement Report depending on the severity or nature of the
issue. The employee is expected to improve performance/behavior within an
established time period.
3. If the employee's performance or behavior continues to be substandard, the
supervisor will issue another Employee Improvement Report at the next
progressive level of disciplinary action. The supervisor will again meet with the
employee to review the substandard performance issues.
The supervisor will then establish corrective, attainable performance goals with
realistic time frames within which to achieve these goals. If they are not attained,
further disciplinary action and/or termination will occur.
Depending on the nature of the substandard performance, it may be necessary
to skip steps. The supervisor will work with Human Resources to discuss the
4. The final step in the progressive improvement process prior to termination is a
final written warning. The supervisor will again meet with the employee; outlining
specific issues (see Steps 2 and 3). The employee will be notified that any
further failure to meet performance standards will result in termination.
5. Termination of an employee shall be on the recommendation of the supervisor
and their department manager and director. In the event of termination the
department manager or supervisor/manager shall not deliver the termination to
the employee without consulting with a Human Resources representative. At the
time of the delivery of the termination, the employee should be notified by the
department manager and the supervisor/manager that his or her employment is
terminated effective immediately.
For all warnings, the supervisor will provide the employee with a copy of the
Employee Improvement Report. All attempts should be made to provide a
copy of documentation immediately. If this is not possible, the employee must
be provided with a copy within three (3) working days. The notice must be
signed by the supervisor and the employee, signifying the notice has been given.
If the employee refuses to sign the notice, the supervisor should seek out a
witness, preferably another supervisor, and document that notice has been
Formal disciplinary action is considered “active” for a twelve-month period. If an
employee is on formal disciplinary action, he/she is not eligible to apply for other
positions within UWMF until a six-month timeframe has lapsed without any
further disciplinary action.
If an employee does not receive a notice for substandard performance/behavior
for a twelve (12) month period, all notices for substandard performance/behavior
prior to said twelve (12) month period shall not be considered as one of the three
(3) progressive notices toward discharge or in matters relating to performance
reviews. Notices involving acts of gross misconduct shall not be covered
by the twelve (12) month limitation period.
Disciplinary decisions relating to intentional breaches of patient privacy will be
considered a permanent part of employee’s disciplinary record. Additional
disciplinary actions relating to intentional breaches of patient privacy will
compound for the duration of the employee’s employment with UWMF.
If an employee resigns their position with UWMF and is on an active discipline,
the employee will not be eligible for rehire. A discipline is active for twelve (12)
months from the date of the Employee Improvement Report.
Exceptions to “Progressive Improvement Process”
One exception to the foregoing relates directly to the employee who neither calls nor
reports to work for three consecutive work days. The UWMF will accept the employee’s
voluntary resignation under the “no call, no show” provision in the Attendance and Time
The second exception is a situation warranting immediate discharge where no warning
or progressive discipline is appropriate, e.g., breach of confidentiality, falsification of the
employee’s time-record or other acts of gross misconduct.
Common sense, good judgment and regard for the rights and interests of the
organization and one's co-workers will ensure the well-being of the patients entrusted to
our care. In health care, particularly, we expect adherence to high standards of
personal conduct at all time. The importance of this matter necessitates that the
UWMF take disciplinary action which may include discharge against any employee for
any act of misconduct, including, but not limited to, the following:
1. Falsification of employment records or other UWMF records, including reports,
time-records, etc. This includes clocking in or out for another employee;
falsification of work time (i.e.: clocking in and subsequently parking your vehicle
or conducting work while not clocked in or being paid); repeated failure to clock
in and out for beginning/end of shift or for any non-work related business other
than for authorized breaks.
2. Unauthorized absence from the workplace during regularly scheduled work hours
and/or leaving company property during paid hours.
3. Loitering or sleeping on duty.
4. Failure or refusal to follow the instructions of a duly assigned supervisor,
including refusal to accept job assignments for which the employee is qualified to
5. Use of vile, intemperate or abusive language or acting in a disrespectful manner
to any employee, supervisor, patient, or visitor.
6. Use, distribution or unauthorized possession of intoxicating beverages, illegal
narcotics or controlled substances on UWMF premises or violation of the
Substance Abuse Policy.
7. Threatening, intimidating or coercing another employee or patient by word or
8. Fighting, horseplay or other disorderly conduct on UWMF premises.
9. Creating or contributing to unsafe or unsanitary conditions by act or omission.
10. Unauthorized passing or removal of notices in any UWMF locations.
11. Unauthorized possession, use, copying, photography, distribution or destruction
of company records, employee records, computer records or patient records or
disclosure of information contained in such records to unauthorized persons.
12. Theft, fraud or unauthorized possession or use of property belonging to UWMF,
employees, patients, or visitors.
13. Excessive and/or unexcused absence or tardiness, except those absences
protected by law.
14. Soliciting or accepting tips or gratuities. See Gratuity Policy for more details.
15. Disregard of one's appearance, dress, or personal hygiene. Please see Dress
Code Policy for more details.
16. Immoral or illegal conduct on UWMF premises.
17. Inducing another employee to commit any breach of the foregoing regulations.
18. Harassment, including but not limited to sexual harassment. Please see
Harassment Policy for more details.
19. Misuse of or breach of confidentiality of employee, patient information, UWMF,
etc. Please see Confidentiality Policy for more details.
20. Substandard performance of job duties and assignments.
21. On or off duty conduct that adversely affects the integrity of UWMF or has a
negative impact on UWMF.
22. Failure to comply with the immunization, CPR, TB and influenza vaccine
requirements set forth by the UWMF/UW Health.
23. Excessive personal phone calls and/or cellular phone use. This includes
incoming and outgoing calls, text-messaging, and photography. Personal cell
phones may not be worn or utilized while working.
24. Misuse of company computer systems, software, email, and internet. See UW
Health Access to Electronic Information Systems Policy for more details.
25. Excessive personal emails and internet use. See UW Health Access to
Electronic Information Systems Policy for more details.
26. Retaliation against an employee for making a good faith report of potential legal
or policy violations.
27. Possession or use of weapons or other harmful, threatening, or hazardous
objects on UWMF property, including objects used in a harmful or threatening
manner. (On-duty law enforcement officers are excluded from this provision.)
28. Failure to cooperate and/or not being truthful during an investigation.
29. Bullying or hostile behavior toward another employee or patient. Not limited to
intimidation, assault; extortion; oral or written threats; teasing; putdowns; name-
calling; threatening looks; gestures, or actions; rumors; false accusations; social
isolation, and cyber-bullying.
30. Failure to obtain or maintain current license/registration/certification. This
includes a valid driver’s license for required positions.
31. Smoking and/or use of tobacco products (cigarettes, e-cigarettes, cigars,
chewing tobacco, snuff, pipes, etc.) in any indoor or outdoor areas of all UWMF
clinics, buildings, company vehicles, and premises.
32. Filing a false workers compensation claim or failure to comply with
33. Not being available, refusal or failure to report for duty when scheduled to be on
34. Repeated requests not to work above scheduled FTE.
35. Unauthorized use/misuse of Company vehicle, not following driver safety
regulations and failure to report a motor vehicle accident involving Company
vehicle or private vehicle driven during official UWMF business. See Risk
Management Motor Vehicle Policy for more details.
36. Failure to successfully complete the annual Compliance and Ethics training and
37. Failure or refusal to sign forms necessary for background check purposes. See
Background Check Policy for more details.