Category: HR-EMPLOY
POLICY & PROCEDURE
Subject:
Disciplinary and Corrective Action
Classification:
Management Approved
Policy Owner:
Senior Vice President, Human Resources
Approved by:
WFH President and CEO
POLICY:
Effective: December 1, 2011
It is the policy of Wheaton Franciscan Healthcare (WFH) that standard systems of disciplinary
or corrective action are used when an associate engages in conduct that interferes with
operations; denotes continued poor performance; violates work rules or policies; discredits the
organization; or is offensive to fellow associates, patients, customers, or visitors.
WFH expressly reserves the right to terminate an associate’s employment “at will.” However,
disciplinary or corrective action may be suggested whenever his or her manager believes that
an associate’s performance or conduct is less than satisfactory and can be improved through
adequate counseling. Corrective or disciplinary action is completely at the discretion of an
associate’s manager. Even if corrective or disciplinary action is implemented, an associate’s
employment may be terminated at any step, at the discretion of his or her manager.
WFH, in its sole discretion, may warn, suspend, or discharge any associate at will, whichever
it chooses and at any time.
RATIONALE:
Our mission and values call us to excellence in service. Our Value of Development requires
us to provide for the professional and personal growth of others. Accordingly, managers are
expected to pay close attention to the growth and development of each associate in the
organization. When a performance and/or behavior issue exists, it is a manager’s
responsibility to work toward correction of the problem and to communicate to the associate
the consequences of uncorrected behavior.
Our Values also call us to be good stewards of resources, which include establishing and
maintaining a safe, healthy, and efficient work environment. This is accomplished by setting
clear expectations of behavior and performance, and holding associates accountable for poor
performance and/or behavior. This policy is designed to provide a consistent system to help
associates and managers discuss and resolve performance and behavior issues.
SCOPE:
This policy applies to all WFH associates in the owned and managed regions.
PROCEDURE:
All associates are expected to conduct themselves in a manner that supports our mission,
reflects our values, and is conducive to efficient operations. An associate who commits an
act that is offensive to the rules of common sense or decency or commits an act that
violates a published policy may face corrective or disciplinary action up to and including
immediate termination of employment. Examples of violations include, but are not limited
to:
1.
2.
Insubordination, including failure or refusal to follow the lawful directions of a supervisor
to perform assigned work, or otherwise intentionally failing to perform an expected
assignment or job responsibility in a timely and proper manner.
Violation(s) of the Drug Free Work Place: Alcohol, Drug and Controlled Substance
Abuse Program, HIPAA, criminal background and state caregiver laws, corporate
compliance standards, Office of Inspector General regulations, or the rules or
regulations of any other licensing or regulatory agency violations.
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3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Dishonesty, including but not limited to: falsification of any report, records or other
organization-related documentation and theft or misappropriation of WFH property or
that of an associate, visitor or patient.
A finding of unfitness for duty.
Deliberate misconduct that could or does result in damage to any person or property.
Harassing a patient/customer, co-worker, or visitor or other acts of harassment that are
a violation of the Anti-harassment and Non-discrimination policy.
Failure to follow established organizational or departmental policies and procedures.
Failure to complete mandatory education.
Failure to follow safety regulations. Failure to immediately report an accident or injury to
the supervisor.
Misuse of confidential information.
Giving false or misleading information, circulating false or malicious rumors.
Receiving or soliciting tips, favors, or gifts from patients/customers, visitors, suppliers, or
contractors of the organization.
Unwillingness to cooperate, assist and work in harmony with others and discourtesy or
conduct creating disharmony, irritation or friction among coworkers, patients or visitors.
Careless, negligent or inefficient performance of duties, including failure, inability or lack
of effort to maintain proper standards of performance; behavior that negatively
impacts the patient and/or customer experience.
Leaving the regularly assigned work location without notifying the immediate supervisor.
Leaving the workstation without relief. Sleeping or the appearance of sleeping while on
the job.
Eating or drinking in unauthorized areas.
Unsafe or unauthorized use of the organization’s machines, tools, or equipment or use
of materials, tools, or equipment for commercial use or personal gain. This includes
telephones and computers.
Misuse of e-mail, Internet, and intranet as outlined in the Use of Computer and
Communication Systems policy
Performing unauthorized personal work during scheduled working hours.
Behavior that is threatening or abusive, unsafe, disruptive or results in inefficiency;
disorderly conduct of any kind such as fighting, horseplay, harassment, intimidation, or
using abusive, obscene or threatening language or gestures towards patients,
coworkers, or visitors.
Establishing a pattern of excessive absenteeism or tardiness.
Stealing property from WFH, coworkers, patients or visitors.
Carrying or possessing weapons or firearms.
Misuse, falsification, or improper documentation of timekeeping or attendance records.
Unauthorized work time and/or overtime.
Gambling including sports pools, lottery tickets, and raffles other than those sponsored
by the WFH or its auxiliaries or foundations.
Violations of the Solicitation, Distribution of Literature and Facility Access policy.
Failure to adhere to the dress code or poor personal hygiene.
Violations of WFH “No Smoking” policy.
Disciplinary or Corrective Action Procedures.
WFH and its member organizations are committed to ensure that all disciplinary or corrective
actions are administered in a fair, impartial, thorough, and thoughtful manner. Discipline and
corrective action is a manager’s tool to modify inappropriate behavior or unacceptable
performance. A manager has an obligation and responsibility to investigate a behavior or
performance issue fully before proceeding to disciplinary or corrective action procedures. The
investigation should include all pertinent facts and should evaluate whether the associate
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knew, or should have known of the particular rule, policy or performance standard. The
associate should generally be provided an opportunity to explain what he/she knows about a
situation before any disciplinary or corrective action is taken. Levels of discipline or corrective
action include the following:
Level I (not a formal step in discipline process)
One-to-one counseling: The manager meets with the associate to discuss the facts
around the performance or behavior issue needing attention, the improvements that are
required to correct the issue, and the consequences of the associate’s failure to make
those improvements. Managers must document and retain a written note of the
counseling session for future reference and consideration.
Level II:
Written Warning: If the unacceptable behavior or poor performance continues, the next
step is a written warning. Ordinarily, no written warnings should be given to the
associate without prior review by human resources. The manager’s written warning
should include, but is not limited to:
a.
b.
c.
d.
The event(s) and/or reason(s) for the warning;
A record of past counseling sessions (when applicable);
The action(s) required to correct the situation;
Behavior(s) or performance that must be corrected, including an appropriate
timeframe for expected improvements;
e. Assistance to be provided by the manager (when applicable)
f. The action to be taken if the associate fails to correct the situation, behavior(s), or
performance;
g. Specified period of time to review expectations;
h. The signature of the associate acknowledging that he received the written warning
The associate should be asked to acknowledge receipt of the written warning by
signing the written warning. At the time the written warning is issued to the associate,
the reason(s) for the warning should be discussed with and explained to the
associate. If an associate wishes to provide additional written comments, it should be
submitted on a separate sheet of paper that can be attached to the original written
warning. If the associate refuses to sign the written warning, the refusal to sign
should be noted on the warning notice and witnessed by another manager or by
human resources. The associate will be given the written warning and one copy will
be retained for the associate’s personnel file.
Level III:
Final Written Warning: In most instances, the last step in the disciplinary or corrective
action process before termination is a final written warning. Though it is completed in the
same manner as the first written warning, it serves to notify the associate that further
behavior or performance issues will lead to termination of employment.
OR:Final Written Warning with a Day of Consideration: In conjunction with the final
written warning, the manager has the option of implementing a “day of consideration.”
The day of consideration is considered an unpaid suspension. The associate is asked to
leave his/her place of work for one day to consider the consequences of his/her
continuing to behave or perform in an unacceptable manner as stated in the final written
warning. The associate is to use this time to decide whether he/she is going to make the
improvements stated in the final written warning. If the associate decides to make the
improvements, the associate will be expected to return to his/her place of employment on
the first scheduled day of work immediately following the day of consideration. Prior to
beginning work, the associate is to meet with the manager and with human resources to
apprise them of his/her decision to make the improvements as stated in the final written
warning. If the associate decides that he/she will not be able to improve or that he/she no
longer wishes to be an associate of the organization, the associate is to provide his/her
manager or human resources with a letter of resignation. Even if the associate doesn’t
deliver a letter of resignation, he/she will still be considered to have voluntarily resigned.
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Level IV:
Termination: When, despite written warning(s), improvement has not been
demonstrated, or if a serious violation has occurred that cannot be tolerated, the
associate’s employment may be terminated. All potential discharges must be reviewed
with human resources. After review of the situation, the manager and/or human
resources will notify the associate of the termination. Written documentation of the
termination notification should be given to the associate and will become a part of the
associate’s personnel file.
Suspensions Pending Investigation.
For serious misconduct or offenses in which the organization has reason to believe that
associates, visitors, or patients may be at risk or harm or that the associate should not
continue his/her job duties, the suspected associate will be suspended pending a full
investigation of the facts. The associate will be informed that he/she is suspended without
pay pending the outcome of an investigation and subsequently will be asked to leave the
premises. If such investigation finds that the associate was not at fault, pay for any lost
time will be provided.
Appeal Process.
For appeal rights and processes, associates should consult the Fair Treatment policy
Corporate Compliance/HIPAA Violations
In cases of HIPAA violations, the regional privacy officer will be involved in the
investigatory and disciplinary process
License Verification/Certification
Refer to License Verification policy
BLS, ACLS, PALS, NRP
It is the associates responsibility to renew any certifications required for their job (per the job
description and/or department Scope of Service) prior to the recommended renewal date.
Associates who have Basic Life Support (BLS), Advanced Cardiopulmonary Life Support
(ACLS), Pediatric Advanced Life Support (PALS) and Neonatal Resuscitation Program (NRP)
certifications as a job requirement will be removed from the schedule and placed into a Level
II or next appropriate level of discipline if their certification has not been renewed by the
recommended renewal date. There is no grace period. Associates will only be allowed to
return to work after completing an approved course and providing their leader with proof of
completion.
A continued pattern of non-compliance with mandatory education will result in the initiation of
the formal disciplinary process.
Mandatory Education Discipline Process
Mandatory education is the information/education required for all associates in a specific
job code for a specific department or site to maintain standards of practice and compliance
including but not exclusive to : HIPAA, Safety, Skills Fairs, competencies and education to
meet The Joint Commission and other Regulatory standards.
Level I:
This step is initiated when the associate is noncompliant after one cycle/ or ample
opportunities to complete the education have been avoided
a. A counseling session where the department leader or designee talks with the
associate regarding the noncompliance, the improvements required to correct the
issue, and the consequences of the associates failure to correct the noncompliance.
The leader will document and retain a written note of the counseling session for future
reference and consideration. In the event the associate cannot be reached by phone
or in person within 72 hours, a certified letter will also be sent to the associate’s home
informing the associate that he/she has 15 business days or next available class to
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complete the required material from the date of the discussion.
b. Failure to complete within 15 business days or next available class will progress to
written warning.
c. Leader may delegate verbal discussion and/or development of action plan to
educator.
Example A: Mandatory requirement due by May 30th. Discussion with associate (and
documentation to associate) on May 31st. Mandatory education/competency needs to be
completed by June 20th.
Level II:
Written warning is next if noncompliance continues. This documentation should include:
the event or reason for the warning; a record of the past counseling sessions; the action
required to correct the situation; noncompliance that must be corrected, including the
appropriate time frame, and the action to be taken if the associate fails to correct the
situation; the specified time frame to review the noncompliance; the associates signature
acknowledging that the written warning was received.
Associate is given 15 business days or next available class to complete
requirement. Failure to complete requirements in 15 business days or next
available class will progress to final written warning.
Example A continued: June 21st---associate put in written warning and mandatory
education/competency due by July 11th.
Level III:
Final written warning in next step if noncompliance continues. The associate is removed
from the schedule without pay. The associate has 5 business days or next available
class to complete requirements. Failure to complete will result in termination.
NOTE: Consult with HR prior to placing associate in final written warning/
termination.
Example A continued: July 12th---associate given final written warning and
mandatory education/competency due by July 19th.
Level IV:
Termination is the final step. When, despite written warning(s), mandatory
education/competency requirements have not been completed, the associate’s
employment may be terminated. All potential discharges must be reviewed with human
resources. After review of the situation, the manager and/or human resources will notify
the associate of the termination. Written documentation of the termination notification
should be given to the associate and will become a part of the associate’s personnel file
Example A continued: July 20th, associate terminated.
LOA/FMLA/Seasonal Associate (i.e. nurse intern returning from college)
Associates returning from approved leaves of absence and seasonal associates are required
to complete mandatory education requirements within 15 business days or next available
class of return to work or with the next available course offering.
Introductory Period.
During the first 90 days of employment, associates are evaluated to determine their suitability
for the job. During this period, the supervisor reviews associate qualifications, behavior and
job performance to determine ability to meet job requirements on a continuing basis. Based
on the review, employment may be terminated or continued on at at-will basis. As a general
rule, any disciplinary or corrective action that is deemed necessary during the first 90 days of
employment is an indication of poor suitability for the job and therefore should be considered
grounds for termination. Based upon the factors noted above, an associate’s introductory
period may be extended beyond 90 days.
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Other Corrective Actions
Other corrective actions short of discharge can be used in recurring cases of deficiencies in
performance or reliability. These could include demotion or reduction in FTE, as examples.
Disciplinary Status and Records of Infractions
Disciplinary or corrective actions remain active for twelve (12) months from the date of the
infraction. Disciplinary or corrective documentation is retained in the associate file for
subsequent reference as appropriate.
Replaces:
All Saints: Corrective Action; Marianjoy: Disciplinary Action
Covenant-Mke: Expectations of Personal Conduct and Disciplinary Procedures;
Covenant-IA: Disciplinary Action
Cross reference:
Anti-harassment and Non-discrimination
Associate Documentation Form
Confidentiality, Privacy and Security of Health Information (ii)
Dress Code and Personal Appearance
Drug Free Workplace: Alcohol, Drug and Controlled Substance Abuse Program
Fair Treatment
Gifts, Gratuities and Business Courtesies (ii)
Information System Access (ii)
Internet Usage & Security (ii)
License Verification
Solicitation, Distribution of Literature and Facility Access
Use of Computer and Communications Systems (ii)
Work Attendance
Review Period:
One (1) year
Original Policy Date:
January 1, 2006
Dates Updated:
January 1, 2007; February 1, 2010; December 1, 2011
(ii) – You must be on the internal intranet in order to link to these documents.
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