ELLIOT HEALTH SYSTEM
WORK ENVIRONMENT & WORK RULES
SECTION V
SUBJECT

Work Rules

Hours of Work

Attendance

Attire and Grooming

Scent and Fragrance Free

Statement of Responsibility/Confidentiality

Confidential Information

Conflict of Interest

Computer Usage, E-mail, Internet & other Communication Services

Telephones

Personal Cell phones

Social Media & Social Networking Policy

Disruptive Behavior

Harassment/Sexual Harassment

Workplace Violence

Solicitation, Distribution, Access & Raffles

Tobacco and Smoke Free Workplace

Parking

Substance Abuse

Fire safety

Inclement Weather/Storm Policy

Critical Incident Stress Debriefing

Cultural/Religious/Ethical Treatment Conflicts
ELLIOT HEALTH SYSTEM
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Work Rules
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
APPLIES TO: All Elliot Health System (EHS) employees, Contractors, Consultants and Vendors
POLICY STATEMENT: A number of work rules exist at EHS which provide for the protection and well-being of patients,
employees, visitors and volunteers at EHS. The enforcement of these rules is essential to the continued safe and efficient
operation EHS employees. Violation of these rules may be grounds for disciplinary action up to and including termination
PURPOSE:
BULLETIN BOARDS
Bulletin boards located throughout EHS are for items of departmental interest. These boards are under the exclusive control
of the Manager in whose area they are located. Employees who wish to utilize the bulletin board must submit any notice to be
posted to the Manager. Notices posted by employees other than the Manager or their designee are prohibited and shall be
removed from the bulletin board.
Personal notices or items from organizations other than EHS must be submitted to the Vice President, Human Resources for
posting in accordance with EHS policy. Notices from EHS Medical Staff may not be posted without permission from the
Medical Staff Executive Committee.
Bulletin boards located in public areas are for the exclusive use of EHS to display items of broad interest, notices of coming
events and notices which must be posted according to law. These boards are maintained by the Human Resources Department.
In addition, the Human Resources Department maintains specific bulletin boards for information pertaining to employment
opportunities, activities and mandatory postings.
ELEVATORS
Elevators should be left free, to the extent possible, for the use of visitors, and the transporting of patients and patient supplies.
Elevators which are malfunctioning should be reported to the Facilities Department. On weekends, the Security officer on
duty should be notified.
CONDUCT/APPEARANCE
Employees' conduct and appearance vital parts of the impression, formed by patients and visitors of EHS Employees are
expected to be well-groomed and to conduct themselves in an orderly and professional manner at all times. Any action that is
injurious, insulting or detrimental to a patient will result in disciplinary action, up to and including termination.
It is not the intent of this policy to restrict individualism, but rather to provide employees with direction in their appropriate
dress in the workplace. Dress code standards will be established by Human Resources and will be enforced by the Manager.
Employees arriving at work inappropriately dressed may be sent home without pay to change and return to work
immediately. Please refer to the EHS Attire policy.
IDENTIFICATION BADGES
As part of EHS orientation, employees are issued an identification badge which must be worn and visible at all times while on
duty. The badges identify and reassure patients that they are assisted and cared for by EHS-staff members. Badges are
ELLIOT HEALTH SYSTEM
required to be worn and access EHS may be prohibited without badges. Lost badges to the employee through the Security
Department.
USE OF LOCKERS AND DESKS
Lockers and desks are owned and maintained and are considered to be EHS property. EHS lockers and desks are intended to
be used to store personal items that an employee may need either before, during or after the workday. For example, employees
may choose to keep their lunch, jacket, or umbrella in their locker. For everyone's security EHS reserves the right to access its
lockers and desks to inspect their contents when EHS believes it is appropriate to do so. In the event an employee uses a lock
other than one provided by EHS to secure the contents of the locker or desk and the employee is not present to open his/her
personal lock, then EHS may have to gain access to the locker or desk by whatever means is required.
PERSONAL MAIL, CALLS AND VISITORS
Employees should not receive personal telephone calls, visitors or mail at EHS. The making of personal phone calls should be
limited to break time and should not be done on EHS phones. The mail and phone lines must be left available for patients and
bona fide EHS business.
Personal visitors during working hours interrupt the course of EHS business and are not permitted. Personal telephone calls
will not be forwarded to employees either by the switchboard or the Human Resources Department except in cases of bona
fide emergency.
TERMINABLE OFFENSES
Violations of the work rules listed below are examples of grounds for termination of employment. This list is for illustration
purposes and is not intended to be all inclusive.
a.
Patient abuse, neglect, mistreatment or abandonment or failure to adhere to any patient care standard and
which results in or could result in an adverse patient outcome.
b.
Possessing or using weapons on the Employer's property.
c.
Gross insubordination; including willful failure to carry out instructions or assignments
d.
Stealing or receiving stolen properly on EHS premises
e.
Omission; misrepresentation; falsification or unauthorized use of any records, time cards, I.D. badges,
reports or other documents.
f.
Theft or destruction or damaging of property, EHS patients, employee, visitors, volunteer or physicians.
g.
Physical violence or threatened violence against EHS employees, physicians or patients.
h.
Conviction and or felony of a crime, the nature of which is deemed inappropriate for continued employment
at EHS.
i.
Sleeping during work time, unless sleeping on premise due to on-call responsibilities.
j.
Loss of or failure to produce original evidence of any required certification or licensure for the employee’s
position.
k.
Misappropriation or misuse of any of EHS medications, equipment, documents or other property.
l.
Disclosing to unauthorized persons, information regarding EHS business plans or financial condition, other
than report required to be made public. Employees may not divulge financial information regarding EHS to
persons outside EHS unless such information has been previously reported publicly.
m. Operating or participating in illegal activities on EHS property.
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n.
Accepting from a customer, or other person or company doing business or seeking to do business with EHS a
business opportunity not available to other persons, or that is made available because such employee’s
position with EHS.
o.
Deliberate and/or gross violation of safety rule and practices.
p.
Failing to report to work for three (3) consecutively scheduled shifts without proper notice.
q.
Leaving job or assigned work area before the end of the work day without supervisor’s or his/her designee’s
prior permission.
r. Knowing violation of EHS Code of Conduct.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Hours of Work
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
APPLIES TO: All Hospital Employees
POLICY STATEMENT:
PURPOSE:
SCHEDULING
Each Department Manager is authorized to arrange the schedule of working days, working hours, shift rotation, meal periods
and work breaks in the department in conformance with wage and hour regulations.
BREAK TIME
An employee who works a shift of more than 5 hours must be permitted a minimum of one half hour of unpaid time off during
the shift for a meal or other personal business regardless of the shift they work. Meal and other breaks which have not been
taken during the course of the day may not be combined to accommodate an early departure or late arrival for work. Based
on department staffing, certain shifts of employees on meal breaks may NOT be permitted to leave Elliot Health System (EHS)
grounds. Please note: the break policy will apply to those employees needing to use break time for smoking.
Employees are expected to remain in their working area at all times except when released by the immediate Supervisor.
Unauthorized departure from EHS during working hours is considered a voluntary resignation and may result in termination
of the employee’s employment.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
ELLIOT HEALTH SYSTEM
MANUAL:
TITLE:
STATUS:
APPROVED BY:
HR Manual
Attendance Policy
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
July 1, 2011
REVISED DATE:
July 1, 2011
REVIEWED:
July 1, 2011
REPLACES:
Previous EHS Attendance Policy
APPLIES TO:
Attendance and Tardiness
POLICY STATEMENT: Elliot Health System’s (EHS) primary objective is delivery of quality patient care, and as such
expects all employees to be at work as scheduled or assigned. EHS requires punctuality and dependable attendance of all
employees. Both of these factors are significant components in the over-all performance appraisal process. An assessment of
an employee's attendance and punctuality records constitutes an evaluation of that employee's ability to meet the commitment
to work the scheduled hours. Excessive absenteeism or tardiness will be subject to a progressive discipline process, up to and
including termination of employment. A record of excessive absenteeism or tardiness could also limit an employee's ability to
transfer within the health system. Guidelines have been established to ensure fair and consistent treatment for all employees
whose absenteeism is not acceptable
PURPOSE: To provide clear, consistent guidelines to be used throughout the health system to ensure quality patient care and
smooth hospital operations by providing appropriate patterns of staffing.
EXCEPTIONS: Certain absences, such as an approved leave of absence, Family Medical Leave (FMLA), worker’s
compensation, bereavement, military, personal leave and jury duty may not be counted toward unscheduled absences.
Absences due to illnesses or injuries which qualify under the Family and Medical Leave Act (FMLA) will not be counted
against an employee’s attendance record. Medical documentation within the guidelines of the FMLA may be required in these
instances.
ABSENCES AND TARDINESS Any consecutive absence due to the same illness, injury or other incident will be viewed as
follows: 1-2 consecutive days equal 1 occurrence; 1-3 consecutive days’ equal 2 occurrences, 1-5 consecutive days’ equal 3
occurrences. An occurrence will not be counted if more than 50% of the shift is worked. The start of an employee’s shift is the
definite start time. Tardiness is defined as any time late after the definite start time of the shift.


Occurrences are counted in a rolling six-month period.
Pattern of Absences = Absences occurring in patterns (same day of week, same time of year, tardiness, repeated early
departures, adjacent to a weekend, holiday, vacation, or other leave, etc.) may be indicative of an attendance problem
and may be subject to disciplinary action.
NOTE: In the case of illness or injury, a Return to Work release from Employee Health would be required, only, after a staff
member is out for three days consecutively.
CORRECTING EXCESSIVE ABSENTEEISM Employees who have used an excessive amount unplanned time as defined
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above should be counseled in a timely fashion in order to correct the problem. Managers should keep current and accurate
time and attendance records to verify the existence and extent of an employee’s attendance problem.
The progressive disciplinary process, as described in the Disciplinary Process Policy, may be utilized to help correct the
attendance problem. In addition, Managers and Supervisors may refer employees experiencing attendance problems to the
Employee Assistance Program. In addition to the Disciplinary Process, employees with attendance problems may also be
required to make up missed shifts, or in some cases, be denied accrued leave time if the nature of the absence cannot be
verified.
Coaching Two occurrences in any six-month rolling window of time will be the basis for a coaching discussion between the
employee and direct supervisor. The purpose of the coaching session is to make the employee aware that he/she has been
absent or tardy frequently enough to draw attention and to be certain that the employee understands this policy and the
consequences of violation. The supervisor should retain records sufficient to enable recall of occurrences of the coaching
discussion, but no formal documentation is placed in the employee's personnel file.
Verbal Warning The 3rd additional occurrence in a six-month rolling window of time is cause for the 1st verbal warning with
documentation to the employee’s file. The verbal warning, delivered by the employee’s direct supervisor, serves to notify the
employee that he/she is in violation of the EHS policy and that additional occurrences will result in further disciplinary action
up to and including termination.
Written Warning The 4th additional occurrence in a six-month rolling window of time is cause for a written warning with
documentation to the employee’s file. The written warning, delivered by the employee’s direct supervisor, serves to notify the
employee that he/she is in violation of this company policy and that additional occurrences will result in further disciplinary
action up to and including termination.
Final Written Warning The 5th occurrence in a six-month rolling window of time is cause for a final written warning. This is
considered the final step in the disciplinary process regarding attendance. An additional absenteeism occurrence in a sixmonth rolling window of time may be cause for termination of employment.
NO CALL/NO SHOW
Not reporting to work and not calling to report an absence is considered no call/no show and is a serious matter. The first
instance of a no call/no show will result in a final written warning. The second separate offense may result in termination of
employment with no additional disciplinary steps. Any no call/no show lasting three days is considered job abandonment and
will be considered voluntary resignation.
PROCEDURES
No disciplinary actions will be taken without the direct involvement of the Human Resources Department as counsel to
management. All verbal, written and final warnings will be delivered by the direct supervisor or manager. Human Resources
will be available to assist when appropriate and will be present if termination of employment is necessary.
Human Resources management reserves the right to use its discretion in applying this policy under special or unique
circumstances.
DISCIPLINE – UNSCHEDULED ABSENCES IN A ROLLING SIX MONTH PERIOD
ELLIOT HEALTH SYSTEM
2 OCCURENCE TOTAL
COACHING SESSION
3 OCCURENCE
VERBAL WARNING TO FILE
4 OCCURENCE
WRITTEN WARNING TO FILE
5 OCCURENCE
FINAL WRITTEN WARNING TO FILE
6 or more OCCURENCE
TERMINATION OF EMPLOYMENT
NUMBER OF DAYS TARDY
1-4 Days
DOCUMENTED COACHING SESSION
5 Days
VERBAL WARNING
6 Days
WRITTEN WARNING
7 Days
FINAL WRITTEN WARNING
8 Days
TERMINATION OF EMPLOYMENT
Employees must meet the eligibility requirement of EHS time off benefits before they can use their earned time for absences
from work. Once eligible, employees are required to use their accrued benefit time for any vacation time or absence due to
illness, a need for personal time off and/or holidays.
An employee’s supervisor or manager must approve in advance all requests for scheduled absences. While supervisors and
managers will attempt to accommodate the request for scheduled absences EHS business needs are the first priority.
An employee needs to be absent/tardy free for a six (6) month period following their last disciplinary action to qualify to begin
a new six (6) month cycle. Finally, supervisors/mangers should review their staff’s attendance records regularly to ensure that
employees are fulfilling their commitment to work. If an employee fails to meet the attendance standards, the
supervisor/manager will take the appropriate disciplinary action (please refer to Progressive Disciplinary Action Policy).
PREPARED BY: Human Resources
REVIEWED BY: VP, Human Resources
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS: Attendance and Tardiness
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
TITLE:
STATUS:
APPROVED BY:
EFFECTIVE DATE:
REVISED DATE:
REVIEWED:
REPLACES:
ELLIOT HEALTH SYSTEM
HR Manual
Attire and Grooming Policy
______________________________________
Sabrina Granville, VP Human Resources
April 2012
Previous EHS Policy on Attire and Grooming
POLICY STATEMENT: Elliot Health System (EHS) strives to provide a safe, healthy and professional work environment.
Due to our high visibility to the public and to one another, EHS promotes a professional atmosphere and appearance.
PURPOSE: A well-groomed professional appearance and attire is required of each employee. All EHS employees are
required to exercise good judgment in choosing the appropriate professional attire for their position within the policy
guidelines below.
PROCEDURE:
Employees should consult their supervisor if they have questions as to what constitutes appropriate appearance and dress.
Employees who need accommodation with respect to the requirements of this policy should consult with their supervisor and
human resources. Certain employees may be required to meet special dress, grooming and hygiene standards, such as wearing
uniforms or protective clothing, depending on the nature of their job. If applicable, employees should refer to their job
descriptions for additional guidelines.
Standards
Employees are expected to practice good personal hygiene habits at all times. Perfume, cologne, after shave, body lotions,
powders, tobacco smell should not be of a strong scent due to patients and employees with allergic sensitivities or respiratory
illnesses and problems.
Visible body piercing is not permitted, other than two traditional earrings per ear lobe piercing. Body piercing other than two
earrings per ear lobe piercing will need to be removed while in the workplace.
All tattoos must be covered at all times. If you are you are providing direct patient care or food preparation you can cover
tattoos by wearing a lab coat or long sleeves etc. In the event you have visible tattoos we do not expect you to cover them with
a bandage/dressing. From an Infection Prevention standpoint your are expected to wash with soap and water from elbows to
hands then don your lab coat.
In clinical and food preparation areas hair longer than shoulder length should be tied back. Fingernails and facial hair should
be groomed and of a length so as not to cause sanitation concerns or injury to self, patient, visitors, or co-worker. Any staff
member with direct patient care and food preparation is prohibited from wearing artificial nails or shellac nails. The Elliot
maintains from an Infection prevention practice, that shellac nails are considered artificial nails and employees in patient care
areas and food preparation are prohibited from that practice. Please refer to the EHS Infection Control manual.
Employees should avoid excessive make-up and jewelry. If you are working in a patient care setting, hanging earrings should
not pose a safety issue to patients or to the employee and excessive rings should be avoided to prevent infection and/or injury
to patients. Short necklaces may be worn but must be of a length that does not hang into the patient care field while care is
ELLIOT HEALTH SYSTEM
being provided. No bracelets are to be worn with the exception of medical alert bracelets.
Direct patient care employees who are in direct risk for blood/body fluid exposure, sharp injuries, chemical spills or other
possible injuries to the legs/feet (moving wheelchairs, beds, stretchers) must wear footwear that would protect them from
these risks. OSHA guidelines state that shoes are a part of standard precautions in the prevention of exposure to blood and
body fluids in the work environment and those shoes should be appropriate to the job performed. Closed toed skid free shoes
are considered part of proper personal protective equipment when they prevent blood or other potential infectious material
from reaching the healthcare worker skin or clothing. Hosiery must be worn and legs covered at all times.
All EHS employees are prohibited from wearing hip-hugger scrubs or rolled down waists, “denim style” or “camouflage
style” scrubs or material, hospital issued scrubs in non-designated departments, sweatshirts, sweatpants, T-Shirts, shorts,
spandex, gym clothes, hooded shirts or jackets, tank tops, tight fitting clothing, or any like article of clothing. Bare or partly
exposed midriffs, exposed cleavage, exposed backside when bending over, low cut tops, see-through clothing, miniskirts, or
any kind of clothing that is revealing in any way are prohibited. Employees are expected to wear appropriate
undergarments and they must not be exposed or seen through clothing. Jeans, shorts or jean jackets may be worn for special
occasions or special circumstances to be determined at the manager’s discretion and should have no holes, rips, bleached or
worn spots and must be hemmed and in good condition. Shoes should convey a professional image and be sensible for safety
reasons: no flip-flop footwear (rubber/beach or otherwise), unlaced shoes, or gym/athletic shoes.
1. Attire for RNs, LPNs, LNAs, MA’s, Technicians and Department Aides and all clinical positions will consist of any
combination of recognized scrub or healthcare provider uniform apparel in prints or solids. Only EHS scrubs are
allowed, no scrubs with other hospital or affiliations are allowed. Cartoon prints may only be worn in departments
routinely caring for pediatric patients. Knitted shirts such as solid colored t-shirts or turtlenecks, free of logos and/or
text, may be worn. Sleeveless apparel may be worn if covered at all times by a scrub jacket or other appropriate item
with sleeves. Fleece vests with the EH logo may be worn. Hospital issued scrubs may only be worn by staff in designated
departments. Attire must be clean and non-wrinkled, and pants must be hemmed so that they do not come in contact
with the floor. Footwear must be reasonably clean and either white/primarily white, black or of a solid color in a style
that is designated for healthcare facilities. Exception: Sneakers are permitted if reserved for work use. They must be all
white/all black or primarily white or black in color. No flip-flop footwear (rubber/beach or otherwise), unlaced shoes, or
gym/athletic shoes permitted. Perforated shoes not approved for use in a health care facility are not to be worn by direct
care staff.
Uniforms EHS employees who are required to wear a uniform are responsible for keeping it clean and in good condition at all
times to reduce the chances of cross-infection as well as maintain the standards of our organization. Torn, noticeably stained
or wrinkled uniforms should not be worn.
ID badges are to be displayed prominently on the upper torso to be visible. Color coded badge tags specifying role are to be
worn by all nursing services personnel in patient care areas. Badges are to be affixed using a badge pin, clip or retractable
badge holder. No stickers are allowed on badges. Lanyards are not permitted due to potential safety and infection control
concerns in clinical areas.
Reasonable Accommodation of Religious Beliefs. EHS recognizes the importance of individually-held religious beliefs to
persons within its workforce. EHS will reasonably accommodate an employee’s religious beliefs in terms of workplace attire
unless the accommodation creates an undue hardship. Employees requesting a workplace attire accommodation based on
religious beliefs should be referred to the Human Resources department.
Additional Information Any employee not in compliance with the attire/dress code, good personal hygiene guidelines and
grooming standards may be subject to disciplinary action and will be sent home without pay to change and report back to
work within a reasonable time period. The only exceptions to this policy are campus-wide holiday or other theme-day
ELLIOT HEALTH SYSTEM
initiatives involving a temporary, pre-announced change in dress code (costumes, sports gear, etc.).
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
TITLE:
HR Manual
Scent and Fragrance Free Workplace
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
REVIEWED:
REPLACES:
APPLIES TO: All EHS Employees
POLICY STATEMENT: Elliot Health System (EHS) strives to provide a safe and healthy work environment.
PURPOSE:
Recognizing that employees, patients, and visitors to our workplace may have sensitivity and/or allergic reactions to various
fragrant products and body odor, Elliot Health System (EHS) strives to be a scent and fragrance-free workplace. Personal
fragrant products (fragrances, colognes, lotions, powders, and other similar products) that are perceptible to others should not
to be worn by employees. The scent of smoke, tobacco, body odors related to poor hygiene are not permitted in the workplace.
Other scent and fragrant products such as scented candles and/or potpourri and other similar items are also not permitted in
the workplace.
Any employee not in compliance with this policy, good personal hygiene guidelines and grooming standards (please refer to
the Attire and Grooming policy) may be subject to disciplinary action and will be sent home without pay to change and report
back to work within a reasonable time period. Any employee with a concern about scents or odors is to contact his or her
Manager and/or the Human Resource Department.
PROCEDURE:
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER:
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Statement of Responsibility/Confidentiality
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
APPLIES TO: All Elliot Health System (EHS) Employees
POLICY STATEMENT:
PURPOSE:
A. CONFIDENTIALITY OF RECORDS
1.
PATIENT INFORMATION
As employees, we must be constantly aware of this role as providers of business services or patient care and must
never divulge confidential information to other staff, family, or members of the general public electronically, by
phone or answering machine messaging systems and alike who do not have a strict business need to know the
information. EHS and you as an individual, may be held legally liable for any unauthorized disclosure of patient
information
All relationships between EHS and its patients are confidential. EHS records both paper and electronic,
containing personal information on EHS patients are confidential. As such, they are to be carefully safeguarded
and kept current and accurate. They should be disclosed or shared only to authorized staff having a "need to
know," or in accordance with legal requirements. Such information should not be disclosed to third parties
except as expressly permitted in EHS procedures or if EHS becomes legally obligated to do so. If you have any
questions about disclosure, consult with your Supervisor before releasing any information. We must be aware of
the presence of visitors throughout EHS and should not discuss the care/admission of patients and/or
confidential EHS business in public areas of the facility.
2.
COMPUTER ACCESS AND INFORMATION
Every EHS employee, volunteer and contract employee with a designated need is assigned a password in order to
access the EHS Information System. Your Manager will determine the appropriate level of access for you to
perform your job duties. Once your password is assigned, you may not share that password or secure access to
the system on behalf of anyone else. Any employee who believes someone else may have knowledge of their
password must notify the Information Technology (IT) department immediately in order to change that
password.
All EHS computers, software and computer systems including E-mail and personal computers (provided by)
EHS and all affiliates and physicians offices which are part of EHS and are intended for patients care and
business purposes only. Under absolutely no circumstances is any computer or computer system owned or leased
by EHS or its affiliates, to be utilized to harass or otherwise offend anyone, to access unauthorized, confidential
ELLIOT HEALTH SYSTEM
patient medical or employee information, or for any unlawful purpose. EHS and its affiliates, including EHS
reserve the right to monitor any information stored or transmitted on this equipment or its systems.
Use of EHS Information System is only for the furtherance of patient care and administrative activities.
Employees may only access that information which is necessary for the job to which they are assigned. You must
not access the system for the purpose of curiosity or to obtain info on behalf of another. Inappropriate use of the
EHS Information System is inconsistent with our obligation to protect the confidentiality of our patients, and will
therefore subject the offending employee to disciplinary action, up to and including termination. EHS staff
should be aware that periodic audits are conducted to review who accesses which modules of this, the duration of
access and the detail which is accessed. This audit is done electronically and will therefore reveal, indisputably,
when someone has viewed information inappropriately. From time to time employees may have access to other
data bases throughout EHS which contain confidential patient information. Such information is to be treated in
the same manner as that which is available from EHS Information System.
3.
EHS INFORMATION
Information about EHS and its plans, financial condition, and business, other than reports required to be made
public, is confidential and may not be disclosed to unauthorized persons. EHS staff should use care not to discuss
EHS business in any place or manner that would in any way impair EHS patient confidentiality and or
competitive position. Financial information about EHS is not to be given to persons outside EHS unless it has
been previously reported publically. Questions about disclosure of financial information should be referred to the
Vice President/CFO and Vice President of Human Resources.
4.
NEWS MEDIA INTERACTIONS
EHS and its affiliates strive to maintain open, appropriate and forthcoming relationships with the media, and
cooperates with the media provide the public with information that, is appropriate and necessary. The Vice
President Marketing and the Director of Community & Public Affairs have primary responsibility for
coordination and responding to inquiries from the media. It is EHS policy that all inquiries from the media be
referred to the Director of Community & Public Affairs
Any person employed by EHS who wishes to speak out privately on matters of public interest that are unrelated
to EHS and its affiliates is free to do so. The views or opinions expressed must be as personal views, however, and
not those of EHS unless approved by Marketing and Public Affairs
Under no circumstances may employees knowingly present to the media slanderous or detrimental
misinformation or untruths, whether written or oral concerning EHS and its affiliates
Employees should notify Marketing and Public Affairs promptly about any calls from or contact with the media.
This includes reporters, photographers, freelance writers or video production organizations from any newspaper,
magazine, television, radio, or World Wide Web-based media outlet. Please speak with Marketing and Public
Affairs. After normal business hours, a public affairs representative may be reached through the page operator
at EHS.
Failure to adhere to the requirements of this policy may be grounds for disciplinary action, up to and including
termination
5.
USE OF FACSIMILE MACHINES
Employees should be wary of the use of fax machines for the transmission of patient and other confidential
information. While the use of these devices has hastened our delivery of certain patient care services, it is not
without risk. Before transmitting confidential information, every EHS employee has the responsibility to
ascertain the location of the receiver, and whether or not others may have unnecessary access to the fax.
INTEGRITY OF EHS RECORDS AND SYSTEMS
1.
The business records of EHS are of critical importance to meeting all relevant financial, legal and management
ELLIOT HEALTH SYSTEM
obligations. All reports, vouchers, bills, payroll and service records, and other essential data must always be
completed and input accurately, reliably and with care and honesty. In completing such records, care must be
taken to ensure compliance with and adherence to all guidelines and regulations governing federally funded
health care programs.
2.
There is no excuse for a deliberately false or misleading report or record. Certain business record offenses,
including, without limitation, falsification of time cards to obtain payment for time not worked, unauthorized
destruction, alteration of records or memoranda, or failure to comply with established guidelines and regulations
are cause for immediate termination.
3.
REPORTING VIOLATIONS
All EHS members are responsible for following EHS procedures and policies for conducting business transactions
and conducting those transactions with honesty and integrity. If in the course of performing his or her duties, an
employee identifies any circumstances which appear to violate the norms of sound and prudent business or the
substance of this Statement of Responsibility, it is that employee’s responsibility to promptly notify the EHS
General Council. Such reports of suspicious or unusual activities or transactions may be submitted orally or in
writing, and anonymously as well to EHS Compliance Hotline at (603) 663-2970.
The EHS will make reasonable efforts to treat such matters confidentially if the reporting employee so requests,
although EHS cannot assure complete confidentiality in light of responsibilities to government agencies and the
interest in investigating such matters. Employees will not be subject to reprisals or other adverse action for
truthfully and confidentially reporting violations of this code of conduct.
No matter how the matter is raised EHS will act on every complaint of violations of which its Management is
informed.
4.
RESPONSIBILITY OF SUPERVISORS, DEPARTMENT MANAGER, AND OTHER MEMBERS OF
MANAGEMENT
Any Supervisor, Department Manager or other member of Management who is made aware of a complaint or
possible code of conduct violation must immediately report the complaint to the Vice President of Human
Resources.
Supervisors, Department Managers and other members of Management to whom complaints of code of conduct
violations are addressed are responsible for thoroughly investigating those complaints in cooperation with the
Vice President of Human Resources. Confirmed cases of wrongdoing will be corrected and eliminated
immediately and appropriate discipline up to and including termination and corrective action directed at
offending parties.
5.
PREVENTION OF VIOLATIONS
Department Managers shall formally notify all employees, including newly hired employees and Supervisors, of
the existence of this policy, and review it with all staff at least annually.
All Supervisors, Department Managers and other members of Management shall work to create an atmosphere
in which integrity in all business interactions is supported.
B. GUIDELINES FOR ACCEPTANCE OF GIFTS, FAVORS OR GRATUITIES
1.
INTRODUCTION
Gifts to EHS staff members from patients and vendors are generally intended as sincere expressions of
appreciation and friendship based on the relationships that often develop in the normal course of providing
patient care. Nevertheless, substantial gifts of any kind, whether in the form of food, merchandise, unusual
discounts, entertainment, or the use of customer or supplier facilities may create an appearance of impropriety,
may cause conflict of interest to EHS or its employees. Accordingly, any staff member who receives or is offered
anything of value should consult and adhere carefully to the guidelines below.
2.
POLICIES AND PROCEDURES
ELLIOT HEALTH SYSTEM
a.
b.
GENERAL RULE
No EHS staff member may: solicit, demand or accept anything of value from any EHS
patient, supplier or any other person or company in return for or in consideration of any
business service, consideration, or confidential information of EHS.
EXCEPTIONS
The prohibitions in paragraph (a) above shall not apply to: (I) acceptance of meals,
refreshments, entertainment, accommodations or travel arrangements, all of reasonable
value, in the course of a meeting or other occasion, the purpose of which is to hold bona fide
business discussions, to further the fund raising efforts of EHS or to foster better business
relations provided that the expense would be paid for by EHS as a reasonable business
expense if not paid for by another party; (ii) acceptance of advertising or promotional
material of reasonable value, such as pens, pencils, note pads, key chains, calendars, and
similar items; (iii) acceptance of civic, charitable, educational, or religious organization
awards for recognition of service and accomplishment
D. CONFLICTS OF INTEREST
1.
CONFLICTS OF INTEREST PROHIBITED
a. EHS employees shall not conduct their personal or business affairs in a manner that places
their professional, business or financial interests in conflict with those of EHS. Nor shall
EHS employees accept from a customer or other persons or company doing or seeking to do
business with the EHS, a business opportunity not available to other persons, or that is made
available because of such employee's position with the EHS.
b.
There should be sensitivity to possible criticism of the EHS or its employees on the grounds
of self-dealing for personal advantage. For this reason, no EHS employee may purchase any
property directly or indirectly (other than obsolete office equipment and similar items on
terms and subject to conditions approved in advance by the designated EHS official) from
the EHS.
c. Any EHS employee who engages in or intends to engage in outside employment activity has
the responsibility to consult with his or her Supervisor, in advance, as to whether such
employment or activity will result in or create an appearance of a conflict of interest with the
employee's duties and responsibilities.
2. REPORTING REQUIREMENTS
EHS employees shall promptly advise their designated EHS Manager of all potential conflicts of interest,
including those in which they are inadvertently placed due to either personal or business relationships with
patients, suppliers, business associates, or competitors of EHS. The information shall include all relevant facts
and the specific steps taken by the person to avoid an actual conflict of interest with EHS. The designated EHS
official shall retain the information.
E. CONFIDENTIALITY
In accord with New Hampshire law and the declaration of patients' rights by the EHS,
patients are
guaranteed certain rights regarding their treatment at our facilities. One of these is the right, "to confidentiality of all
records and communications, to privacy during medical treatment or other rendering of care."
EHS INFORMATION
The EHS Patient/Management Information System provides a very useful tool to enhance our abilities to serve our customers
well. However, the use of the EHS Information System must be restricted to the scope of an individual's position and their
specific daily tasks. It must never be used to access information which is unrelated to an employee's assignment. The use of the
system for casual curiosity is strictly forbidden and is grounds for immediate termination
INQUIRIES
Information requests regarding patient medical records should be referred to the Director of Health Information. The Health
Information Department operates under strict guidelines regarding release of information concerning patient treatment and
ELLIOT HEALTH SYSTEM
diagnosis.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Confidential Information
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO:
POLICY STATEMENT:
CONFIDENTIAL INFORMATION
Elliot Health System (EHS) trusts employees with a wide spectrum of information.
Therefore, we all share responsibility of keeping this information confidential.
Upon accepting employment with EHS, employees are asked to sign an employee's
agreement, which states that you will not disclose or use any confidential
information, either during or after your employment. If you have not signed an
employee's agreement, you are still required to maintain confidential information
Examples of confidential information, but not limited to, are listed below:

Any patient’s information such as any personal information as well as
care provided at EHS.

Employee information such as rate of pay and personal information may
ELLIOT HEALTH SYSTEM
not be shared without employee's permission.

EHS research plans, projects, data and reports.

Computer materials, such as programs and systems.
In addition EHS has policies and procedures in place to ensure that we are in
compliance with the
Health Insurance Portability and Accountability Act (HIPAA). The scope of this
Act includes maintaining the confidentiality and privacy of health-care
information that is in paper form or electronically collected, maintained, stored
and transmitted. All employees are required to comply with these regulations, as
well as the policies and procedures put in place by EHS.
Any violations of this law may result in disciplinary action, up to and including
termination.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Conflict of Interest
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
TBD
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO:
POLICY STATEMENT:
CONFLICT OF INTEREST
EHS takes ethical behavior very seriously, and expects all employees to display integrity and honesty in their business dealings
as part of their employment, as well as in outside business dealings. We ask that each employee be mindful of the potential for
conflicts of interest, and avoid even the appearance of such a conflict
ELLIOT HEALTH SYSTEM
It is the responsibility of all EHS employees to recognize potential conflict of interest situations and to avoid such conflicts of
interest in their contact with individuals and organizations outside of EHS. Careful compliance by employees with the
Conflict of Interest policy is essential for employees' protection, as well as the protection of EHS and its suppliers' and
customers.
EHS respects the right of its employees to engage in activities outside of their employment with EHS, which are of a private
nature, such as social, community, political or religious activities. However, in some circumstances, if employees participation
in outside activities, or become obligated to individuals or organizations outside of EHS they may find that such interests
might influence, or appear to influence, their ability to make objective decisions in the course of their job responsibilities, or
may be prejudicial to the legitimate interests of EHS. A conflict of interest can be considered to exist in any circumstance
where the actions or activities of an employee involve obtaining an improper gain or have an adverse effect on the legitimate
interests of EHS
Prior to engaging, directly or indirectly, in any activities or relationships, or holding any financial or other interests with
outside individuals or organizations which have a potential of conflict with the interests of EHS or which may in any way
impair employees' objectivity regarding their responsibilities to EHS, or their ability to properly carry out such
responsibilities, employees must disclose these activities to the Vice President of Human Resources, in writing, and seek his/her
permission to participate in such activities.
Examples of conflicts of interest are:
 Acting as an employee, consultant, director, officer or otherwise of an organization which is or is about to become a
supplier, customer or competitor of EHS.




Holding any investment or interest in an organization, which is or is about to become a supplier, customer or
competitor of EHS other than an investment or interest represented by securities listed on a national securities
exchange or publicly traded in the over-the-counter market and not significantly large in relation to the outstanding
securities of the issuer.
Entering into any business relationship other than the usual banking, insurance and other consumer business
relationships with an organization, which is or is about to become a supplier, customer or competitor of EHS.
Accepting any favor, gift, honoraria or other form of gratuity, money, services or any other thing of value, which is
more than a token or reasonable holiday gift significance from an organization which is or is about to become a
supplier, customer or competitor of EHS without the approval of the Vice President of Human Resources.
Participating in SuSu or the like activity: Participating in SuSu activity, gambling or similar types of solicitation
and/or collections of monies, distribution of money, giving or receiving SuSu like loans in the workplace on any EHS
property is strictly prohibited.
As a general rule, conflicts of interest are not permitted. However, there may be exceptions to the general rule if the conflict
is promptly disclosed to Vice President of Human Resources or his/her designee approves it.
Violations of this policy may be grounds for disciplinary action up to and including termination of employment.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES:
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Computer Usage, Email, Internet & Other Communications Services
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
TBD
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO:
POLICY STATEMENT: Elliot Health System (EHS) maintains a state-of-the-art information system and information
network for the benefit of the people we serve. These systems are to be used only by authorized employees to enable them to
perform their jobs effectively and to aid in making good decisions. Authorization to access electronic resources depends upon
an employee’s particular job function and need. Use of the EHS electronic communication media is considered to be a nonprivate, business-related use of EHS resources. Employees should have no expectation that their use of e-mail, the internet
voice-mail, wireless devise or any other electronic communication media made available by EHS are private. Authorized
representatives of the organization from time to time may monitor the use of such equipment and resources. The information
contained on EHS systems must be kept confidential. All employees who are granted access must review and understand the
Information Technology (IT) policies and procedures of computer and systems use at EHS and will be held
accountable/responsible for all activities associated with their username and password or disclose this information to other
employees. All Information Technology policies are available online via IKE or can be obtained from, the Information
Technology Help Desk.
PROCEDURE:
1. Employees are granted authorization for computer usage by completing an authorization form. The form must be
signed and approved by the employee’s manager. Authorization forms can be obtained from the Information
Technology Help Desk or e-mail help desk or online via IKE.
2. Computer access (including e-mail and Internet access) is to be used primarily for work-related purposes only. The
use of the system for personal use during breaks or after hours is permissible as long as the employee does not abuse
the resources and does not violate any existing EHS policies and procedures.
3. Information technology reserves the right to deny or block access to certain websites per IT System Security policies.
4. Employees must conduct themselves honestly, professionally and appropriately on the computer network at all times.
ELLIOT HEALTH SYSTEM
5. Employees must respect the copyrights, software licensing rules, property rights, privacy and prerogatives of others.
6. All existing EHS policies apply to conduct when using the computer network, e-mail, Internet and intranet or any
other communication services provided by EHS.
7. Employees must maintain confidentiality, HIPAA privacy, and data security.
8. Employees must abide by all existing EHS policies and procedures when using the computer network services.
9. Inappropriate usage (i.e., downloading/accessing sites of a sexual nature, use of profanity, threatening or harassing
behaviors, unlawful usage, etc.) is prohibited and could lead to termination of employment or criminal prosecution.
10. Excessive, unnecessary or unauthorized usage causes network and server congestion and can take away from work
time. Therefore, such usage will not be tolerated.
11. All employees whose positions require that they have access to computing, e-mail and/or the Internet must sign an
EHS computer user agreement.
12. All EHS computers on the EHS network and the information they contain are the property of EHS.
13. Violation of this policy may be grounds for disciplinary action up to and including termination of employment
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Telephones
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
ELLIOT HEALTH SYSTEM
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO:
POLICY STATEMENT:
Elliot Health System (EHS) recognizes that there are times when an employee has to receive or make personal phone calls
during work hours: however, these calls should be kept to a minimum. If making and receiving personal phone calls becomes
excessive and interruptive to an employee's responsibility, the employee's manager will address the issue by way of the
Progressive Discipline policy. Employees should not leave their units/departments during their shift to make or receive a
personal phone call unless it is an emergency situation. Employees are not allowed to make personal long distance calls unless
the situation is an emergency.
EHS reserves the right to monitor phone logs of all phone calls made from its building. In some cases (not including an
emergency situation) where long distance personal phone calls are made the employee will be asked to reimburse EHS for the
amount of the call and disciplinary action may be taken.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Personal Cell Phones
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
ELLIOT HEALTH SYSTEM
POLICY STATEMENT: As a major health care provider the professional image of the staff with the Elliot Health System
(EHS) is important to the overall delivery and effectiveness of the services provide. Professional and appropriate conduct is
important in our interactions with our patients, family members, visitors and colleagues. This policy applies to all nonmanagement employees within EHS, including each of its corporate subsidiaries and affiliates, regardless of department or
location, with a nonclinical job function or position involving interaction with patients and /or visitors. It is the responsibility
of the directors, managers and supervisors of each area to monitor and enforce these guidelines. Failure to adhere to the
Personal Cell Phone Guidelines will result in disciplinary action, up to and including termination of employment.
PURPOSE: This guideline was established to ensure that personal cell phones are not permitted in patient areas/work place.
This guideline represents minimum standards for personal cell phone use.
GUIDELINES











Personal cell phone use is not part of the non-management employee’s job responsibilities
Personal cell phones are not permitted in public view of patients
Personal cell phones must remain in your purse, locker or with your personal belongings at all times
Personal cell phones must be turned off at all time when in the work place
Staff should not subject patients to personal cell phone conversations or texting
Personal cell phone are not permitted to be answered/viewed in patient/public areas of the office
Calls/texting can be returned in the Break room when on an official break time or in your personal vehicle
Personal emergencies calls should be instructed to cal the department’s main line or backline telephone numbers. See
your Director, Manager, and Supervisor for this number
Exception – President, Vice president, Directors, and Managers that must use their personal cell phones for Elliot
Health System business. For President, Vice president, Directors, and Managers their cell phone is one of their tools
that they need to do their job.
Business use cell phones should be on vibrate at all times
Exception can be made during times of emergencies
PREPARED BY: Ann Gilbert, Corporate Director Patient and Physician Access
REVIEWED BY: Richard Elwell, Senior VP, CFO, Sabrina Granville, VP Human Resources, Ann Gilbert, Corporate
Director Patient and Physician Access
CUSTODIAL MANAGER: Corporate Director Patient and Physician Access
KEYWORDS:
REFERENCES:
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
Human Resource Dept.
ELLIOT HEALTH SYSTEM
TITLE:
Social Media Policy
STATUS:
Final
APPROVED BY:
______________________________________
______________________________________
______________________________________
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
None
POLICY STATEMENT:
The parameters for personal use of social networking sites, professional networking sites and
weblogs are below. Please note that information publically published on the Internet can be viewed by Elliot Health System
(EHS) administration at any time, and is subject to alignment with the EHS Code of Conduct.
DEFINTIONS:
A weblog, more commonly referred to as a blog, is an online journal often tied to a web site or published independently on
sites such as Blogger or WordPress.
Social Networking refers to sites such as Facebook, Twitter, MySpace and MeetUp.
Professional Networking refers to sites such as Linked In, Spoke and Xing.
1.
Professional networking sites, personal blogs or social media accounts that mention or link the originator to EHS
should have clear disclaimers that the views expressed by the author in the blog is the author’s alone and do not
represent the views of the organization. Be clear and write in first person. Make your writing clear that you are
speaking for yourself and not on behalf of the organization.
Sample disclaimer: “THIS IS A PERSONAL WEBLOG. THE VIEWS AND OPINIONS EXPRESSED HEREIN
ARE MY OWN AND MINE ALONE. THE CONTENT DOES NOT NECESSARILY REFLECT THE OFFICIAL
POSITIONS OR POLICIES OF ELLIOT HEATH SYSTEM.”
2.
3.
4.
5.
6.
7.
8.
Information published on your blog(s), social media accounts or professional networking sites should comply with the
organization’s confidentiality and disclosure of proprietary data policies. This also applies to comments posted on
other blogs, forums, and social networking sites.
Be respectful to the organization, other employees, customers, partners, and competitors.
Social media activities should not interfere with work commitments. Refer to the Electronic Communications Policy.
Your online presence reflects the company. Be aware that your actions captured via images, posts, or comments can
reflect that of our company.
Respect copyright laws, and reference or cite sources appropriately. Plagiarism applies online as well.
Company logos and trademarks may not be used without written consent.
Patient information of any kind must never be published online. Violations of this policy will result in application of
the Progressive Discipline Policy up to and including immediate termination and may subject the releasing individual
to sanctions and/or liability under state and /or federal laws.
ELLIOT HEALTH SYSTEM
The parameters for social networking use on behalf of EHS are below:
1.
Utilization of social networking tools on behalf of EHS must be approved by the VP of Marketing and the VP of
Human Resources.
2. Any branding must be consistent with the Marketing Departments brand guidelines.
3. The intent of the online posting or usage must be consistent with the mission and values of Elliot Health System.
4. Confidential organization and/or patient information must never be referenced in any way without a release.
5. Content will be routinely monitored by EHS Administration.
6. Potentially malicious and/or harmful content on social networking sites may be filtered when accessed from EHS
locations as needed to protect EHS assets.
7. Content should not be downloaded from social media sites or untrusted Internet sites to EHS computing devices.
Social media represents a significant risk to information security as these sites are a heavily targeted resource for
malware/hacking software.
8. Social Media accounts should follow best practices for using controls to sensibly restrict access to sensitive
information. Strong passwords should be selected that are not the same as any credentials used within the
enterprise.
9. Information must be presented in a professional, honest, clear and concise way. Proper spelling and grammar must
be utilized.
PURPOSE:
Elliot Health System encourages the responsible utilization of technology and the Internet, including the utilization of weblogs,
social networking sites, professional networking sites and other mediums. When used appropriately, the Internet can be a
valuable tool for research, networking, marketing and connection. Inappropriate usage and content, however, is irresponsible
and can be damaging. The purpose of this policy is to enable the EHS workforce to embrace social networking and to provide
parameters to work within.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER:
KEYWORDS: Social Media, Social Networking
REFERENCES: Electronic Communications Policy
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
TITLE:
STATUS:
APPROVED BY:
EFFECTIVE DATE:
REVISED DATE:
REVIEWED:
REPLACES:
HR Manual
Disruptive Behavior
______________________________________
Sabrina Granville, VP Human Resources
N/A
N/A
POLICY PURPOSE: The goal of Elliot Health System (EHS) is to foster a work environment of mutual
ELLIOT HEALTH SYSTEM
respect and service excellence. To that end, all individuals are required to conduct themselves in a
professional manner within EHS and at EHS related events.
POLICY STATEMENT:
Disruptive conduct is behavior in the professional setting that is judged inappropriate and is
unacceptable to colleagues, staff, patients or their family members. Examples may include, but are not
limited to, the following:
1. Any verbal or physical intimidation or attack including but not limited to shouting, swearing,
berating or hanging up the telephone that is aimed at anyone at the EHS. EHS has zero tolerance
for any kind of workplace bullying.
2. Any sabotage, destructive behavior, and/or disparaging comments that injure the reputation or
business of EHS. Any inappropriate electronic, written or verbal comment or communication
(including illustrations) that disparages the quality of care at the EHS or the quality of a
particular EHS regardless of whether made publicly or privately.
3. Any non-constructive criticism that is addressed to recipients in such a way as to intimidate,
undermine confidence, belittle, and imply stupidity or incompetence. Any behavior that is
considered discriminatory, harassment or sexual harassment under the Humans Resource Policy:
Sexual Harassment.
4. Any behavior that is considered violence in the workplace under the Humans Resource Policy:
Violence in the Workplace.
EHS will not tolerate harassment or discrimination against a provider, employee, volunteer, trainee,
patient, or any other person based on age, race, color, ethnicity, ancestry, national origin, citizenship,
language, religion, creed, culture, sex, gender identity or expression, sexual orientation, marital status,
military service, veteran status, educational background, socioeconomic status, source of payment for
care, physical, developmental, or intellectual disability, genetics, or any other classes protected by law.
As appropriate in EHS’s discretion, corrective action will be undertaken for confirmed violations of this
policy when substantiated by a thorough and fair investigation in accordance with the appropriate EHS
policies and procedures.
GUIDELINES Resolution disruptive behavior:
1. Informal Resolution: If an EHS employee feels that he/she has been subjected to disruptive
behavior, it is recommended that the staff member either discuss the behavior with the EHS
employee involved or bring it to their supervisor/manager or Human Resources (HR) attention.
Those involved are encouraged to resolve the issue immediately.
2. Formal Resolution: At any point in the process an employee may contact the Human Resources’
ELLIOT HEALTH SYSTEM
Director of Talent Management or HR designee regarding concern that there has been a violation
of this policy.
3. The Human Resources’ Director of Talent Management will coordinate an investigation.
As
appropriate, the Human Resources’ Director of Talent Management will involve others in the
investigation such as the appropriate Vice President, Supervisors, Manager, Director and involved
individuals.
4. A complaint of disruptive behavior will be initiated by the responsible department employee,
supervisor, manager or director or by the person who received the complaint. Appropriate
corrective or disciplinary action up to including termination, if necessary will be taken following a
thorough Human Resource investigation.
Nothing in this policy will be interpreted to contradict or supersede existing EHS policies. For example,
please refer to the EHS Medical Staff policy on “Disruptive Practitioner Behavior.”
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Harassment
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
ELLIOT HEALTH SYSTEM
APPLIES TO:
POLICY STATEMENT:
This policy states the Elliot Health System (EHS) position against unlawful harassment in compliance with Title VII of the
Civil Rights Act of 1964 as amended and indicates a course of action to be taken by employees who feel they have been
unlawfully harassed.
Elliot Health System intends to provide a working environment free from all forms of harassment or intimidation.
Harassment of any person by supervisory personnel, leadership, management, co-workers, employees, non-employees,
physicians, students, volunteers, patients, vendors or other persons will not be tolerated and is strictly prohibited. EHS will
make every effort to prevent and eliminate sexual harassment.
PROCEDURE:
Sexual harassment is defined as:
Any unwelcome verbal or written comments of a sexual nature (e.g., jokes, innuendoes, or slurs), physical conduct (e.g., touching
or gesturing), sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature will be considered
sexual harassment and will subject the offender to disciplinary action when:
1.
Submission to such conduct is made either explicitly or implicitly a condition of an individual’s employment, education or
care;
2.
Submission to or rejection of such conduct by an individual is used as a factor in any decision affecting the individual’s
employment, education, status, or care, including but not limited to any decision related to admission, advancement,
performance assessment, compensation, assignments, schedules, discipline, and termination; or
3.
Such conduct unreasonably interferes with an individual’s employment or performance or creates an intimidating, hostile,
or offensive environment.
NON-DISCRIMINATION and HARRASSMENT
EHS is committed to promoting a workplace that does not discriminate against any person because of his or her race, color,
religion, national origin, gender, sexual orientation, age, disability, marital status or veteran status.
All employees are expected to treat their fellow co-workers with dignity, decency and respect. Any conduct that creates a
workplace environment that is hostile, offensive, intimidating or humiliating will not be tolerated. EHS prohibits
discriminatory practices, including harassment.
Harassment is physical or verbal conduct that denigrates or shows hostility or aversion toward an individual because of
his/her race, color, religion, national origin, gender, sexual orientation, age, disability, marital status or veteran status, or any
characteristic protected by law. Harassment includes, but is not limited to epithets, slurs or negative stereotyping,
threatening, intimidating or hostile acts, and/or denigrating jokes. Written or graphic material that denigrates or shows
hostility or aversion toward an individual or group is also not permissible. Such material should not be circulated. If an
employee is found to have engaged in discriminatory activities and/or practices, the employee will be subject to disciplinary
action up to and including termination.
SAFETY and SECURITY
ELLIOT HEALTH SYSTEM
EHS is committed to the safety and security of all its employees. Violence in the workplace will not be tolerated. We ask
employees to help protect one another from physical harm, theft, and vandalism. Therefore, employees should be on alert at
all times. Suspicious individuals or behaviors should b e immediately reported to a member of the Security Department, your
manager, or a member of the Human Resource Department. EHS provides 24-hour security services to residents, staff,
volunteers and visitors. Security guards are available to escort staff to their cars and can be reached by calling the telephone
operator.
OTHER FORMS OF HARASSMENT
Any unwelcome verbal or written comments or physical conduct of a hostile or offensive nature, which is based on a person’s
race, color, religion, sexual orientation, national origin, ancestry, age, marital or parental status, or disability, will also be
considered harassment and will subject the offender to disciplinary action.
Procedure for Raising Complaints:
All complaints of sexual harassment maybe formally raised with Management through the Employees Appeals procedure.
The following is a list of individuals to whom complaints may be addressed. This is a suggested list, and is not intended to be
all inclusive:
Vice President of Human Resources
Compliance Officer
No matter how the matter is raised, EHS will act on every complaint of sexual harassment of which its management is
informed. EHS will not tolerate the taking of any reprisal by a Department Manager, Supervisor, Management official, or
employee against any complaining employee, or employees who cooperates with the investigation of a sexual harassment
complaint. Such retaliation is unlawful and therefore prohibited and may subject an employee to disciplinary action, up to
and including termination.
RESPONSIBILITY
SUPERVISORS, DEAPRTMENT MANAGERS, AND OTHER MEMBERS OF MANAGEMENT
Supervisors, Department Mangers, or other members of Management who is made aware of a complaint of possible sexual
harassment must immediately report the complaint to the Vice President of Human Resources or Compliance Officer.
Supervisors, Department Mangers, and other members of Management to whom complaints of sexual harassment are
addressed are responsible for thoroughly investigating and impartially resolving those complaints in cooperation with the Vice
president of Human Resources. Al complaints should be reported immediately to the Vice president of Human Resources or
Compliance officer.
Confirmed cases of sexual harassment will be corrected and eliminated immediately and appropriate discipline up to and
including termination and corrective action directed at offending parties (See Disciplinary Process Policy).
Allegations of sexual harassment may have serious consequences for the employees involved and EHS. For this reason,
information about the sexual harassment claim, its participants and its investigation and resolution, should be limited to those
with a legitimate need to know.
OUTSIDE AGENCIES
In the event that internal means of resolving a complaint of sexual harassment are unsuccessful, an employee may contact the
following agencies for assistance in investigating his/her complaint:
ELLIOT HEALTH SYSTEM
New Hampshire Commission Against Discrimination
Equal Employment Opportunity Commission
SEXUAL HARASSMENT INVESTIGATION
When we receive the complaint, we will promptly investigate the allegation in a fair and expeditious manner. The investigation
will be conducted in such a way as to maintain confidentiality to the extent practicable under the circumstances. Our
investigation will include a private interview with the person filing the complaint, the alleged harasser, and with any necessary
witnesses. All employees are expected to cooperate in investigations under this policy and will be expected to preserve the
confidentiality of the investigations. When we have completed our investigation, we will, to the extent appropriate, inform the
person filing the complaint and the person alleged to have committed the conduct of the results of the investigation. If it is
determined the inappropriate conduct has occurred, we will act promptly to eliminate the offending conduct, and where it is
appropriate we will also impose disciplinary action.
DISCIPLINARY ACTION
If it is determined that inappropriate conduct has been committed by one of our employees, we will take such action as is
appropriate under the circumstances. Such action may range from counseling, to termination of employment and may include
such other forms of disciplinary action as we deem appropriate under the circumstances.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Workplace Violence
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
ELLIOT HEALTH SYSTEM
REPLACES:
N/A
APPLIES TO:
POLICY STATEMENT: Elliot Health System (EHS) is committed to proving safe, healthful workplace that is free from
violence or threats of violence. EHS does not tolerate behavior, whether direct or indirect through the use of our facilities,
property or resources that is violent; threatens violence; harasses or intimidates others; interferes with individual legal rights
of movement or expression; or, disrupts the workplace the academic/research environment or EHS’ ability to provide service
to the public. EHS will not tolerate discrimination or retaliation against any employee who makes a good faith report of
workplace violence. EHS also will not tolerate discrimination or retaliation against any employee who participates or
cooperates in EHS investigations of complaints of workplace violence. This policy applies to all persons involved in EHS
operations, including but not limited to: EHS employees, contract and temporary workers, volunteers, interns and anyone else
on EHS property.
EHS has zero tolerance for violence in the workplace. Workplace violence is any conduct that is severe, offensive or
intimidating enough to make an individual reasonably fear for his/her personal safety, or the safety of family, friends or
property. Examples of workplace violence include, but are not limited to implied or expressed threats or acts of violence or
behavior that causes a reasonable fear or intimidation response that occurs:

On EHS premises, no matter what the relationship is between EHS and the perpetrator or victim of the behavior

Off EHS premises, where the perpetrator is someone who is acting as an employee or representative of EHS at the
time, where the victim is an employee who is exposed to the conduct because of work for EHS, or where there is a
reasonable basis for believing that violence may occur against the targeted employee or others in the workplace.
Examples of conduct that may be considered threats or acts of violence under this policy include, but are not limited to the
following:

Threatening physical or aggressive contact directed toward another individual or engaging in behavior that causes a
reasonable fear of such contact

Threatening an individual or his/her family, friends, associates or property with physical harm or behavior that
causes a reasonable fear of such harm

Intentional destruction or threat of destruction of EHS or another’s property

Harassing or threatening physical, verbal, written or electronic communication, including a verbal statement, phone
call, email, letter, fax, website material, diagram or drawing, gesture and any other form of communication that
causes a reasonable fear or intimidation response in others.

Stalking. Stalking is defined as a pattern of conduct over a period of time, however short, which evidences a
continuity of purpose includes physical presence, telephone calls, emails and any other type of correspondence sent by
any means.
Stalking or engaging in stalking behavior. Stalking or engaging in stalking behavior are defined willfully, maliciously,
and repeatedly following or harassing another EHS employee, patient, or visitor here the victim reasonable perceives
the behavior as being threatening. This prohibition applies whether the stalking or stalking behavior occurs on or off
EHS property.

Physical contact of a aggressive or violent nature (i.e., shoving and hitting)
ELLIOT HEALTH SYSTEM

Veiled threats of physical harm or like intimidation or statements, in any form, that lead to a reasonable fear of harm
or an intimidation response.

Communicating an endorsement of the inappropriate use of firearms or weapons of any kind.

Illegal possession or use of explosives, or other dangerous substances.

Possessing a weapon of any type, whether licensed or not. The only exception is local state, and federal law
enforcement officers acting in the line of duty.

Actions that create a hostile or threatening climate.
Workplace violence refers to behavior that is personally offensive, threatening or intimidating. Individuals who engage in
violent behavior may be removed from the premises, and may be subject to arrest and /or criminal prosecution. Any
employee who commits workplace violence will be subject to disciplinary action up to and including termination of
employment and may also be subject to legal action, as appropriate.
All Managers and supervisors should periodically review their work sites to ascertain potential exposure to unsafe occurrence.
Manager and Supervisors may request assistance in this review from any member of the Workplace Violence Task Force.
All Managers who believe it may be necessary to terminate or discipline the employment of a staff member must notify
Human Resources prior to taking action. In an effort to defuse potentially violent situation, a Human Resource representative
will attempt to meet with every terminated employee whether that termination is voluntary or not, the Human Resource
representative may, at his or her discretion, refer a particular situation to the Workplace Violence Task Force for evaluation
and follow up.
In addition, Managers and Supervisors must identify encounters with staff or visitors that may have a potential violent nature.
Such potential situations should also be referred to the Task Force for assistance. If the potentially violent encounter involves
a patient, notify the patient’s care physician and nursing management.
Restraining Order. Employees are encouraged to notify their Manager, Security, the Human Resource (HR) representative
and the Employee Assistance program if they have taken out a restraining order against an individual, even if that individual
is not an employee. The person receiving such a report should notify Security and the Vice president of Human Resources
immediately. This notification will not reflect negativity on the employee and will aid in safety planning for all involved.
Criminal Charges. In the event that EHS learns that an employee has been arrested or that criminal charges have been filed
against him or her, EHS reserves the right to examine the circumstances of the arrest or criminal charges and take any
corrective action necessary to ensure the safety of its employees, patients and visitors. Each case will be reviewed on an
individual basis and ay action taken will be in conformance with applicable law.
It is the responsibility of every EHS employee to immediately report al threats or potential threats of violence either from
internal persons or from individuals not connected with EHS.
Any Leaders or Directors or Managers, and Supervisors, Clinical leaders to whom a report is made, is responsible to take
personal action by reporting the matter to the Vice President of Human Resources or the Director of Talent Management.
The Vice President of HR shall make an initial review of the circumstance of the complaint and determine whether the matter
should be referred to the Security department for review, or whether the matter will be dealt with solely by the Human
Resource department. Once the matter is referred to the Security Department, the, Human Resources and Security shall
investigate the matter thoroughly, take appropriate steps to ascertain the level of risk involved, and develop a suitable strategy
for responding to the situation.
ELLIOT HEALTH SYSTEM
Whenever an incident is brought to the attention of EHS, which calls into question the safety of the employees in the work
environment, EHS reserves the right to take such personal action that EHS as a prudent employer, deems necessary for the
general safety of its employees, patients and visitors. Victims of workplace violence will be referred to the Employee
Assistance Program.
IMPLICATIONS
All EHS employees should be aware that the threat of violence will be taken very seriously. Consequently, disciplinary action
will result from any threat by an employee to another employee, patient, family member or visitor, etc. Disciplinary action
may range from a warning to immediate termination, depending on the nature of the specific circumstances. EHS reserves the
right to take whatever corrective action may be necessary to reassure and protect a threatened employee. Such corrective
action could include changing work schedule or job locations of the involved employees. In addition, employees who have
been found to have engaged in or threatened violence in connection with their worksite, and who retain their position, will be
referred to the Employee Assistance Program.
EHS has an obligation to take appropriate measure to protect the safety of those present in any of our facilities. Therefore,
EHS reserves the right to search and inspect the staff lockers, containers and all personal belongings being carried into or out
of the buildings. Such searched may be conducted by Mangers with the Security department.
FOLLOW-UP
1. In each case of threatened or actual violence in the workplace, one or more members of the Human Resources and
Security departments will conduct a post-incident assessment to determine what action might be necessary to avoid
future incidents.
2. In some cases, Human Resources may initiate the Critical Incident Stress Debriefing protocol as described in the
Critical Incident policy.
3. Workplace violence referral incident/trends are reviewed quarterly at Safety Committee to identify opportunities for
prevention/control and program improvement.
4. In general, EHS will send a letter to the employee who has made complaint indicating that EHS’ investigation is
complete and notifying them of any corrective action, as appropriate.
DISCRIMINATION AND RETALIATION ARE PROHIBITED
EHS will not tolerate discrimination or retaliation against any employee who makes a food faith report of workplace violence.
EHS also will not tolerate discrimination or retaliation against any employee who participates or cooperates in the EHS
investigation of complaints of workplace violence.
EDUCATION
EHS will periodically conduct training on the Workplace Violence Program (WVPP) for staff and Managers. New employees
are made aware of the Workplace Violence program upon hire at new employee orientation.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Solicitation, Distribution Access & Raffles
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO: All Elliot Health system (EHS) Employees, Volunteers, Visitors, Students and Interns
POLICY STATEMENT: No employee may neglect his or her work or interfere with the work of other employees for the
purpose of solicitation or the distribution of literature. Therefore, solicitation of one employee by another employee is
prohibited while either the employee soliciting or the employee being solicited is on this or her work time. Further, the
distribution of literature by one employee to another employee is prohibited at all times in patient care or treatment area or
work areas.
The EHS Information System (ITS) may not be used for solicitation. Literature may not be left on motor vehicles in the
parking lot. No employee may solicit or distribute literature in a manner that endangers the employee or others.
Except for work-related activates that assist EHS to further its health care functions and responsibilities, persons not
employed by the EHS may not solicit or distribute literature on EHS property for any purpose at any time. (Outside sales
representatives should be referred to Materials Management).
The EHS may conduct fund-raising and benefit promotions and other activities to further the mission of the health system or
its affiliated agencies.
Off-duty employees are prohibited from patient care or treatment areas or work areas of buildings. Certified employee
representatives will be permitted access to these areas with the permission of the Vice President of Human Resources.
This rule applies equally to volunteers and visitors.
Questions regarding the interpretation of this policy should be referred to the Vice President of Human Resources.
DEFINTIONS
SOLICITATION: is an attempt to obtain contributions, signatures or support for a particular purpose.
DISTRIBUTION of LITERATURE: is the dissemination of printed material.
ELLIOT HEALTH SYSTEM
WORKING TIME: is those periods during an employee’s shift when an employee is expected to be working. It does not
include time before or after work, or break or meal periods.
PATIENT CARE or TREATMENT AREAS: including operating rooms, emergency room outpatient rooms, therapy rooms,
radiology rooms, recovery rooms, patient rooms, sitting rooms, family rooms, and lounges frequented by patients and all other
areas in the EHS used for the care and treatment of patients.
WORKING AREA: are places where employee performs their assigned duties (excluding patient care and treatment areas)
such as labs, kitchen and serving areas of the cafeteria, and business offices. They do not include parking lots or break areas,
except for employees who regularly work there and while those employees are on their work time.
HOSPITAL PROPERY: includes the buildings and grounds to the property lines and EHS owned motor vehicles.
RAFFLES
A raffle is permitted only if it benefits EHS, a department of EHS or an affiliated agency of EHS. Solicitation for the raffle
must be conducted in accordance with this policy.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: EHS Fundraising Policy
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM POLICY
MANUAL:
Human Resources Policy Manual
TITLE:
Tobacco and Smoke Free Campus
STATUS: Final
APPROVED BY: ____________________________________________
Rick Phelps, MD, Executive Vice President, Chief Operations Officer
_____________________________________________
Sabrina M. Granville, Vice President, Human Resources
EFFECTIVE DATE:
REVISED DATE:
REVIEWED:
REPLACES:
April 18, 2012
N/A
N/A
None
POLICY STATEMENT: Elliot Health System (EHS) provides a tobacco-free and smoke-free workplace and
environment, prohibiting tobacco use in its facilities and on its campuses and adjacent grounds, by employees, patients,
visitors, medical staff members, vendors, students and volunteers. Tobacco use is prohibited within and at all Elliot
locations, outside entrances to those buildings, in any walkways leading to entrances, ramps, sidewalks, parking lots,
ELLIOT HEALTH SYSTEM
parking garages, and in any parked cars at any Elliot location, and in Elliot owned vehicles regardless of location.
Off-campus tobacco product use is not permitted in areas/neighborhoods adjacent to any Elliot locations. Tobacco use is
also prohibited in any manner that results in the emission of tobacco smoke or smell onto private property adjacent to
Elliot locations, or that impedes the ingress or egress of pedestrians or traffic on public property or right of way, or
trespasses onto private property. Employees who elect to use tobacco products off campus must ensure that they properly
dispose of cigarette butts and other refuse.
The potential health consequences related with employee, patient and sensitivity to smoke and other tobacco product
odors necessitate that all employees who use tobacco products ensure that they do not carry the scent or odor of tobacco
products while in the workplace.
For purposes of this policy, tobacco use is defined as the burning or combustion of any type of tobacco product including,
but not limited to, cigarettes, cigars, pipes, and any product that gives the appearance of smoking, (such as an “Ecigarette”), and the use or consumption of any other tobacco product including but not limited to chewing tobacco.
Any employees violating the policy will be subject to the disciplinary process with action up to and including termination
of employment.
PURPOSE: Elliot’s primary mission is to protect the health of those in our community while promoting
and supporting a community culture of healthier living. Tobacco use poses serious risks to the tobacco user and to
nonsmokers exposed to “second hand” smoke. Elliot Health System has therefore set the
above policy regarding tobacco use.
PROCEDURE:
1. Signs are posted at each facility’s entrance and throughout parking areas, and outdoor sitting
areas, thanking employees and others for not smoking in accordance with this policy.
2. The EHS leadership team will orient current employees to the EHS tobacco and smoke-free campus policy.
3. Employee Health and Human Resources will communicate the tobacco and smoke -free campus policy to new hires
prior to their start date.
4. Assistance will be provided to those wishing to participate in a tobacco and smoke free use/smoking cessation program.
5. All EHS employees are required to comply with this policy. Any employee who smells of smoke and/or tobacco will be
sent home without pay to change their clothes and make appropriate hygiene and report back to work within a reasonable
time period.
6. Leaders will be responsible for ensuring compliance with this policy.
7. Staff members will be asked to courteously remind any individuals observed violating the
Tobacco and smoke -free policy and to suggest that smoking materials be extinguished. The Security
Department may be contacted for additional support.
8. In the event that a tobacco or smoke use violation involves a potential threat to health or safety (smoking where
combustible supplies, flammable liquids, gases or oxygen are used/stored), the Security
Department may be contacted for additional support.
9. Security cameras will be used to monitor compliance with this policy.
Any employees violating the policy will be subject to the disciplinary process with action up to and including
termination of employment.
PREPARED BY: Director, Talent Management
REVIEWED BY: Rick Phelps, MD, Executive Vice President, Chief Operations Officer, Sabrina M.
Granville, Vice President, Human Resources, Policy Committee 2010
CUSTODIAL MANAGER: Vice President, Human Resource Dept.
ELLIOT HEALTH SYSTEM
KEYWORDS: Smoking, cigarettes, tobacco and smoke free, campus
REFERENCES: Joint Commission Standard/ Environment of Care (CAMH / Hospitals) Nov. 2008,
Frequently Asked Questions.
ATTACHMENTS: Smoking
ELLIOT HOSPITAL
Manchester, NH
MANUAL:
TITLE: Parking Policy
STATUS: Final
APPROVED BY: __________________________
Sam Auciello, Director Security
EFFECTIVE DATE: August 1996
REVISED DATE: May 2011, April 2010, February 2008
REVIEWED: January 2008, January 2007, February 2006, February 2003
REPLACES: None
POLICY STATEMENT: It is the policy of Elliot Health System to control and coordinate parking on the Elliot Hospital
campus.
PURPOSE: The Security Department is responsible for enforcing all parking policies.
PROCEDURE: Special instructions and/or procedures (if indicated):
1. All employees must register their vehicle(s) by obtaining an authorized „Parking Permit” from the Security Department.
Forms to obtain the permits can be found on “IKE” and submitted electronically. Permits will be sent to employees via interoffice mail.
2. Employee parking permits shall be place on their vehicle (driver‟s side, bottom left inside of windshield). Doctor‟s permits,
shall be placed on the rear view mirror. Parking permits must be displayed on the vehicles at all times while parked on the
Elliot Health System campus.
3. The Security Department issues permits Monday through Friday.
4. Employees are restricted from parking in “specially designated” areas, i.e. Lab
Lab Couriers, Handicapped, Special Permit, Fire Lanes, Etc.
5. Service and Contractor vehicles are required to park in lot 15 (Massabesic St.)
Page 2 of 2 This document is only accurate and timely when viewed on IKE. Last printed 05/27/2011 6:50 AM
Compliance and Enforcement:
1. Any employees, visitors, or contractors in violation of the parking policy will be issued a “Parking Enforcement Notice.” A
copy of the notice will be sent to the employees Director.
2. Department Directors are required to return the “Notice” to the Director of Security with a written explanation regarding
the violation and any request for exceptions to the parking policy. The Director of Security will review all requests.
3. Three parking violations within two months, will be “Just Cause” to suspend the staff member‟s parking privilege for 30
days. If the vehicle is parked on Elliot Hospital Property during the thirty (30) day suspension, he/she will lose parking
privileges for ninety (90) days and the vehicle will be towed at his/her expense.
PREPARED BY: Director of Security
REVIEWED BY: Director of Security, Policy Committee 2010
ELLIOT HEALTH SYSTEM
CUSTODIAL MANAGER: Director of Security
KEYWORDS: Parking
REFERENCES: N/A
ATTACHMENTS: N/A
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Substance Abuse
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO: All Elliot Health System (EHS) Employees & Volunteers
POLICY STATEMENT: Employees are the Elliot Health System’s most valuable resources and for that reason, their health
and safety are of paramount concern.
EHS is committed to maintaining a safe, healthful, and efficient environment which enhances the welfare of our employees,
patients, and visitors. It is the policy of the EHS to maintain an environment which is free of impairment related to substance
abuse by any of its employees. The intent of this policy is to provide employees with a rehabilitative, rather than punitive
approach to drug and alcohol abuse prevention to ensure a safe and healthy workplace. For this reason, employees are
strongly encouraged to cooperate fully with the procedures outlines below.
Our patients and EHS expect employees to arrive for work in a condition free of the influence of alcohol and drugs. EHS also
expects employees to remain free of the influence of alcohol and drugs while at they are on the job and to refrain, except as
noted below, from their use or their unlawful manufacture, distribution, sale, dispending, or possession while on EHS
property or any site under its control.
DEFINITIONS
“Under the Influence” means for the purposes of this Policy that the employee is affected by a drug or alcohol or the
ELLIOT HEALTH SYSTEM
combination of the drug and alcohol in any detectable manner wherein such use or influence may affect the safety of the
employee, co-worker, patients, or members of the public, the employee’s job performance or the safe or efficient operation of
EHS. The symptoms of influence are changes in behavior, including impairment of physical and/or mental ability.
“Legal Drug” includes prescribed drugs and over-the-counter drugs which have been legally obtained and are being used for
the purpose for which they are prescribed or manufactured.
“Controlled Substance” includes: any drug (a) which is not legally obtainable; (b) which is legally obtainable but has not been
legally obtained; (c) which has been legally obtained, but is not being used for prescribed purposes.
PROCEDURE:
A.
ON THE JOB USE, POSSESSION, THEFT OR SALE OF DRUGS OR ALCOHOL:
Alcohol and Controlled Substances: Being under the influence or in the possession of alcohol and/or controlled substances by
any employee while performing EHS business or while in the EHS facility or vehicles is prohibited. Under o circumstances
should an employee who delivers patient care or provides essential services consume alcohol cu beverages and/or controlled
substances prior to going to work. Consistent with existing State and Federal laws, the presence in any detectable amount of
any illegal drug in an employee or the unlawful manufacture, distribution, sale, dispensing, possession, or use by an employee,
while performing EHS business or while on EHS property is prohibited.
1. Legal Drugs: Employees are permitted to take legally prescribed and/or over the counter medications consistent with
B.
appropriate medical treatment plans while performing EHS business. However, when such prescribed or over the
counter drug therapies affect the employee’s job performance, safety or the efficient operation of EHS, The Vice
President of Human Resources/designee should be consulted to determine if the employee is capable of continuing to
perform his/her job or if action, including discipline or leave of absence, may be required.
DISCIPLINARY ACTION: Violation of this Policy can result in disciplinary action up to and
including termination, even for the first offense.
C.
DRUG AND ALCOHOL SCREENING: When there is reason to suspect an employee maybe
working or on EHS property under the influence of alcohol and/or drugs, he/she maybe required to
submit to a medical assessment, blood test, urinalysis, or other drug/alcohol screening. This
screening will be conducted in the following manner:
1. EHS must have reasonable suspicion based on specific, objective facts to believe that the employee’s faculties are
impaired on the job (see D below) because of the consumption of alcohol or drugs, concerning which the employer has
received no reasonable explanation;
2. The employee is to be given an opportunity to rebut or explain the test results.
D.
PROCEDURES TO BE FOLLOWED BEFORE REQUEST OF DRUG AND ALCOHOL SCREENING
1. The Supervisor/Charge person who observes or to whom it has been reported that an employee whose behavior
suggests may be under the influence of a drug and/or alcohol, must confirm the observations or report by establishing
that there is reasonable suspicion for action which is manifested in the employee’s behavior and job performance.
2. Prior to initiating Questioning relative to use or possession, the Supervisor/Charge person is to first consult with the
ELLIOT HEALTH SYSTEM
Director of Talent Management or the Vice president of Human Resources. The Supervisor/Charge person is to have
another Supervisor/Charge person present and limit questioning to that which will determine the employee’s general
condition. (It is advisable that this second Supervisor/Charge person be a Human Resource Representative.
3. The Supervisor/Charge person is to follow the procedures outlines in Attachment A, including the request for the
employee to sign a consent form for testing, and notifying him/her that refusal may lead to disciplinary action up to
and including termination.
4. Following the completion of the appropriate attachments, the employee should then be informed that she/she is being
suspended pending the return of test results and /or a review of the situation by the Vice President of HR or designee.
The employee should be informed that following this review the appropriate disciplinary action will be taken, up to
and including possible mandatory rehabilitation and/or termination.
5. At the point that the employee has been suspended to await the results of the tests or because the employee has
refused testing, the Vice President of HR or designee, will assume responsibility for further direction of the incident.
6. All employees involved in the process are to restrict conversations concerning possible violations of this policy to those
persons who are participating in any questioning, evaluation, investigation or disciplinary action and who have a
“need to know” about the details of the drug/alcohol investigation. This restriction includes not mention the name of
the employee or employees suspected of violating this Policy. All employees involved in the process and investigators
are to instruct other employees, except as stated above, not to talk about such violations. Under most circumstances,
test results and related information will only be released to” management personnel on a “need to know” basis,
treatment program personnel, a court or administrative agency as required and to others only with the employer’s
consent.
E.
CONFIRMATION OF TEST RESULTS: All employees have the right to request a confirmatory
retest of the original sample at the individual’s own expense. Employees must pay the costs of the
second test unless the results are negative.
1. Opportunity to Justify a Positive Test Result: All confirmed positive test results will be reviewed by a Medical
Review Officer to determine whether there is any legitimate explanation for the positive test result. Individuals
testing positive will be given the opportunity to discuss with the Medical Review Officer any legitimate reasons for
testing positive. A legitimate explanation may include, for example, a valid prescription medication or food which
may trigger a positive test result. If the Medical Review Officer determines there is a legitimate medical
explanation for the confirmed positive test result, the officer will report the test result to management as negative.
2.
Consequences of a Verified Positive Test Result: If the individual is unable to establish that the substance was
legally obtained or cannot obtain a physician’s certificate, and if the Medical Review Officer determines that
there are no legitimate medical explanations for the confirmed positive test result, the Medical Review Officer will
report these confirmed results to Management as a verified positive test result. Employees will be subject to
immediate termination and/or mandatory rehabilitation.
3. Quality Control and Privacy Concerns: Procedures have been developed in an attempt to ensure the integrity,
confidentiality and reliability of controlled substance tests and minimize the impact upon the privacy and dignity
of persons undergoing such tests to every extent feasible. Test results shall reveal only whether an individual has
tested positive or negative for controlled substances. EHS has established a chain of custody procedure for both
sample collection and testing that will verify the identity of each sample and test result. All testing and collection
ELLIOT HEALTH SYSTEM
procedures will be in compliance with applicable General and State Law requirement.
4. Testing Expenses: All costs of controlled substance testing required by EHS shall be paid for by EHS. Any test
not required by EHS shall be paid for by the individual being tested.
F.
EMPLOYEE ASSISTANCE PROGRAM: The EHS maintains an Employee Assistance Program
(“EAP”) which provides completely confidential help to employees who suffer from alcohol or drug abuse and other
personal/emotional problems. Employees are encouraged to seek assistance from this program in confidence. However, it
is the responsibility of each employee to see assistance from the Employee Assistance program at 877-259-3785 before
alcohol and drug problems lead to disciplinary action which can include termination for the first offense. Once a
violation of this Policy occurs, subsequently using the EAP on a voluntary basis will not necessarily lessen disciplinary
action and may, in fact, have no bearing on the determination of appropriate disciplinary action. Should an employee
choose to make it known, he/she has sought prior assistance from the Employee Assistance Program this information will
not be used as the basis for an investigation for drug and/or alcohol use, and will not be used against the employee in any
disciplinary proceeding. On the other had, using the EAP will not be a defense to the imposition of disciplinary action
where facts proving a violation of this Policy are obtained outside of the EAP.
G.
REHABILITATION: At the discretion of EHS, any employee who violates EHS’ Substance
Abuse policy may be required, in connection with or in lieu of disciplinary actions; to successfully participate in and
complete EHS approved controlled substance or alcoholic assistance or rehabilitative program. Employees who are
under treatment at approved rehabilitative programs may protect their employment status at EHS as follows:
1.
EHS has a Leave of Absence policy whereby, an employee, by their own volition, may request a Personal Leave of
Absence to confidentially correct a drug/alcohol abuse problem before job performance is affected and noticed by
management.
Employees may keep their substance abuse problem and treatment confidential from EHS, if they wish to pursue this
option. Because of the confidential nature of the EAP, the EAP may still be used by the employee. The employee may
also take a Family and Medical Leave in conjunction with the provisions of the Leave of Absence, provided the
requirements for such a leave are met.
2.
Employees who have been determined by EHS to Have a substance abuse problem and who agree to go through a
drug and/or alcohol rehabilitation program for the first time will be conditionally reinstated to a job provided
they; (a.) take a leave of absence no longer than three calendar months. (see Leave of Absence policy for effect of
LOA on benefits); (b) successfully complete an approved substance abuse rehabilitation program. Employees will
be required to supply ongoing documentation which indicates they are remaining substance free for a two year
period.
3.
Employees returning from these rehabilitation leaves will be required to sign a Conditional Reinstatement
Agreement (Attachment E) or other appropriate documents/agreements as determined by the Vice President of
Human Resources on a case by case basis. They will also be required to submit continuing documentation on a
periodic basis and be subject to random testing, if indicated in conditional Reinstatement. The EHS reserves the
right to return the employee to a position other than their existing position, unless otherwise required by law.
Employees whose performance on the job is impaired over the subsequent two (2) years due to drug or alcohol
abuse may be subject to immediate termination.
4.
An employee whose impaired status was discovered under conditions threatening their own, patients’ or other
ELLIOT HEALTH SYSTEM
employees’ safety, as well as employees who are involved with theft or other major malfeasance will not be
permitted to use options G. 1, 2 and 3 above.
H.
INVOLVEMENT OF LAW ENFORCEMENT AGENCIES/LICENSING AGENCIES: The
Use, sale, purchase, transfer, theft or possession of an illegal drug is a violation of the law. EHS will refer such illegal
drug activities to law enforcement, licensing and credentialing agencies when appropriate. All such referrals will be done
only after Senior Management, appropriate Vice President/designee and the Vice president of Human Resources/designee
is informed.
I.
EMPLOYMENT SCREENING
1.
2.
3.
It is not the policy of EHS to conduct routine or random employment urine and/or blood screens for the presence
of controlled substances.
If the Employee Health Services finds objective evidence of substance abuse during employment screening or
episodic visit, the employee may be denied clearance to work until the employee is evaluated by the EHS
physician or designee.
It is the policy of EHS to conduct testing only when reasonable suspicion exists or under the guidelines
established in a Conditional Reinstatement.
SPECIAL CIRCUMSTANCES
DEPARTMENT OF TRANSPORTATION REQUIREMENTS
Certain job categories are required to have pre-employment and random substance abuse testing in accordance with the
Department of Transportation requirements. These employees/applicants will be informed if they fall into one of these
categories upon hire or reasonable time from, if already employed.
RESPONSIBILITY
The administration of this policy is the responsibility of each Department Director/designee and Supervisor/Charge person
working in conjunction with the Vice President of Human Resources/designee.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS:
ATTACHMENT A
(Procedure to be followed)
ATTACHMENT B
(Questions)
ATTACHMENT C
(Agreement to Submit)
ATTACHMENT D
(Refusal to Submit form)
ELLIOT HEALTH SYSTEM
ATTACHMENT A
PROCEDURES TO BE FOLLOWED BY SUPERVISOR/Charge PERSON WHO SUSPECTS AN EMPLOYEE IS UNDEER
THE INFLUENCE OF ALCOHOL AND/OR DRUGS
Checklist for handling an intoxicated or impaired (by drugs, legal or illegal) employee. Procedure to be followed in situations
where there is an employee who appears to be under the influence of alcohol, drugs, including controlled substances, or both.
In an effort to establish if a violation of EHS rules and regulations occurred, all supervisors with Human Resources should
implement the following procedure:
1.
2.
3.
4.
Determine, in person, if an employee “appears” to be under the influence of alcohol, drugs, including controlled
substances and prescriptions, or both. Request a second Supervisor/Charge person to observe and confirm your
suspicion prior to initiating additional investigation.
During the investigation with the employee, representative (if requested), and second Supervisor/Charge person
still present, complete the Attachment B (all sections) sign and request witnesses signatures.
If you conclude that the employee does not appear to be under the influence of alcohol or drugs, including
controlled substances and prescription drugs and is able to perform work duties, and then have the employee
return to work station.
If you have reasonable suspicion to believe that the employee is under the influence of alcohol, drugs, or both,
then request the employee to submit to having testing for alcohol and /or drugs. The employee should sign the
Agreement to Submit to Testing (Attachment C). Call the Elliot Occupational Health office or page the on-call
employee health staff member. Then arrange for the employee to be taken to Occupational Health Services
secure specimen collection area where the appropriate specimen for drug and alcohol screen will be collected
from the employee. A member of security at EHS will escort the employee and the employees Supervisor.
If a situation arises when Elliot Occupational Health Services is not available, EHS will use the assistance of an
outside certified compliance company to provide the testing. Failure to comply with such testing shall result in
termination of employment. Submission of an adulterated or masked sample or receipt of an inconclusive result
shall be considered failure to comply with the test and subject to immediate termination of employment.
Employees who are asked to submit to a drug/alcohol test will not be permitted to drive to the test facility. They
will be taken to the test facility by security or another member of management. The Supervisor /Charge person
must remain available to Occupational Health Services during the specimen collection. Following the completion
of the Occupational Health Services visit the Supervisor/Charge person and Vice president, Employee and
HR/Designee will be notified.
5.
If the employee refuses to be tested, the employee should be requested to sign the Refusal to Submit form
(Attachment D)
6.
The employee should then be informed that they are being suspended without pay pending return of test results
and/or a review of the situation by the Vice President of Human Resources or HR designee. Employees should be
informed that following this review the appropriate disciplinary action will be taken, up to and including possible
mandatory rehabilitation and/or termination.
ATTACHMENT B
Questions for Suspected Substance Abuse
ELLIOT HEALTH SYSTEM
Section I
With another Supervisor present, please ask the employee who is suspected of substance abuse the following questions in the
order listed. This form needs to be filled out completely and signatures obtained.
IF THE EMPLOYEE ADMITS, AT ANY TIME DRURING THE QUESTIONING, TO BEING UNDER THE INFLUENCE
OF A DRUG(S) OR ALCOHOL, THEN ARRANGE FOR THE EMPLOYEE TO BE ESCORTED TO OCCUPATIONAL
HEALTH SERVICES FOR MEDICAL EVALUATION AND TESTING. THEN SUSPEND THE EMPLOYEE PENDING
FINAL DETERMINATION AND ADVISE OF EHS RULES(S) THAT WERE VIOLATED. INDICATE THAT
APPROPRIATE ACTION, UP TO AND INCLDUING TERMINATION, MAY BE TAKEN.
1. Your work performance has appeared to have deteriorated today, can you explain why?
______________________________________________________________________________
______________________________________________________________________________
2. Are you feeling ill? ____Yes ____No ___No response
If yes, what are your symptoms?
_______________________________________________________________________________
_______________________________________________________________________________
3. Are you under a doctor’s care that could explain your deteriorated work performance?
____Yes ____No ____No response
________________________________________________________________________________
What is your doctor’s name and address?
_________________________________________________________________________________
When did you last visit the doctor?
Section II
Directions: Check pertinent items bases on your visual observation of the employee.
1.Walking/Standing
____Normal
____Stumbling
____Staggering
____Falling
____Swaying
____Unsteady
____Holding On
____Unable to
2. Speech
____shouting
____Silent
ELLIOT HEALTH SYSTEM
____Whispering
____Normal
3. Demeanor
____Normal
4. Actions
____Normal
____Slow
____Rambling/incoherent
_____Slurred
____slobbering
____Sleepy
____Crying
____Silent
____Talkative
_____Excited
____Fighting
____Resisting Communications
____Drowsy
____Fighting
____Threatening
____Hyperactive
____Hostile
_____Profanity
5. Eyes
____Erratic
____Bloodshot
____Watery
____Glassy
____Droopy
____Flushed
____Pale
____Sweaty
7. Appearance/clothing
____Unruly
____Messy
____Dirty
____Normal
____Partially dressed
____Normal
6. Face
____Closed
____Normal
____Stains on
Clothing
8. Breath
____Alcoholic Odor
____Faint alcoholic odor
____Normal
____No alcoholic odor
9. Movements
____Fumbling
____Jerky
____Normal
____Nervous
____Hyperactive
ELLIOT HEALTH SYSTEM
____Slow
10. Eating /chewing
___Gum
____Normal
11. Presence of Drug
Paraphernalia
12.
____Candy
____Other
____Mints
Identify other if
possible________
____Pipes
____Roach clip
____Cigarette Paper
____Pieces of foil
Other Observations:______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Section III
OPINION BASED ON OBSERVATIONS AND QUESTIONING BY Supervisor/Charge Person
A.
Reasonable suspicion to suspect the employee may be under the influence of alcohol and/or drugs
____Yes ____No
B.
____Uncertain
Unfit for work
____Yes ____No
____Uncertain
If both A & B are “yes” or “uncertain”, ask the employee the following questions:
Would you submit to a drug and/or alcohol screening?
____Yes ____No
____No response
Then,
1. Have the employee sign Agreement to Submit to Drug and /or Alcohol Screen (Attachment C).
2. Check with Occupational Health Services for satisfactory arrangements.
C. If the employee refuses to sign the Statement of Testing, the employee should be told that by refusing
he/she may be subject to further disciplinary action up to and including termination.
ELLIOT HEALTH SYSTEM
Remarks: ___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
___________________
___________
Name of Employee
Time
_____________________
Signature of Employee
_____________________
Signature of Supervisor
_____________________
Signature of Human Resources
____A.M. ____P.M.
_______________________________
Date
_______________________________
Date
_______________________________
Date
ATTACHMENT C
AGREEMENT TO SUBMIT TO DRUG AND/OR ALCOHOL SCREEN BY BLOOD AND URINE TESTS AND
AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION BY THE, EMERGENCY DEPARTMENT OR
EMPLOYEE HEALTH SERVICES
I have been informed that EHS, based on my behavior and appearance, is concerned that I may be under the influence of
drugs or alcohol, or may otherwise have violated EHS rules against drug and alcohol use, and that my ability to perform my
job duties, is therefore in question and as a result, I have been requested to submit to a drug and/or alcohol screen which is to
be administered by the Occupational Health Service.
I have been informed and I understand that my agreement to submit to the requested alcohol and/or drug screens is
completely voluntary on my part and that I have the right to refuse to submit to the test. I am aware and have been told, that
my refusal to submit to the drug and/or alcohol screen may be grounds for disciplinary action up to and including
termination.
I have also been informed and am aware and hereby authorize that the results of this drug and/or alcohol screen may be
released to the Vice President of Human Resources and such other EHS officials and employees as the Vice President of
Human Resources and his/her designee may determine to disclose such information. I understand that the information so
released to EHS will be use to determine whether I was fit to perform my job duties and /or whether I had violated EHS work
rules concerning drug and alcohol use and that the results of such test may form the basis for disciplinary action against me,
up to and including termination.
ELLIOT HEALTH SYSTEM
I understand I will have the opportunity to explain test results prior to issuance of my possible final disciplinary action. I
understand that I have the right to request a confirmatory test (if positive) at my own expense.
With full knowledge of the above information, I have decided to voluntarily submit to the requested drug and/or alcohol
screen by Occupational Health Services if applicable, and in recognition of this agreement, do sign this consent form.
_______________________
________________________________
Date
Employee Signature
(Note: a Human Resource witness other than the Supervisor who has requested that the employee submit to a drug and/or
alcohol screen should also sign the consent form)
_______________________
________________________________
Date
Human Resource Witness
_______________________
________________________________
Date
Supervisor
ATTACHMENT D
REFUSAL TO SUBMIT TO DRUG AND/OR ALCOHOL SCREEN
I hereby refuse to authorize testing for alcohol and/or drugs. I understand that my refusal means that I cannot complete a
medical exam and such refusal will require a review of the facts by management which may necessitate discipline, up to and
including termination of employment.
_______________________
________________________________
Signature
Human Resource Witness
_______________________
________________________________
Date
Date
ELLIOT HEALTH SYSTEM
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Fire Safety
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO:
POLICY STATEMENT:
In case of a fire, the following steps should be taken:
Rescue- Remove from immediate area anyone in imminent danger from fire, heart smoke and/or vapor
Alarm– Yell CODE RED to alert co-workers to the presence of a fire emergency. Activate the nearest pull station or dial 911
from any EHS phone and report your exact location and nature of emergency.
Contain – Contain and, if appropriate, remove residents/staff to the next safest area.
Extinguish/Evacuate – Evacuate to a safe area as instructed by Supervisor/Security/Maintenance
Alarm Announcement: You will know a fire alarm is going off when the red fire alarm boxes throughout EHS begin to flash,
followed by the two-part announcement: “Alarm in Progress – (LOCATION).” Once the situation has been addressed and
resolved, you will hear the announcement: “Alarm in progress – ALL CLEAR,” which indicates the fire alarm situation is
over.
You should familiarize yourself with the alarm announcement for your area, EHS Emergency plan (available on IKE),
response expectations specific to your work area, and the locations of pull stations, emergency exists, and fire extinguishers in
your work area.
ELLIOT HEALTH SYSTEM
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: Code Red Fire Response Plan
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Inclement Weather/Storm Policy
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO:
POLICY STATEMENT: Services must be provided every day regardless of any complications or unfortunate
experiences we may have, such as handling inclement weather. Therefore, all staff, regardless of their regular job
responsibilities, is expected to come to work during bad weather.
PURPOSE:
In the event of severe weather, or other calamity, the following shall serve as a general guide:
1.
Elliot Health System (EHS) management will determine and communicate exactly what hours the Storm
Policy is in effect.
2.
You are expected to report for duty at your regular reporting time.
3.
Should you be delayed past your regular reporting time, you must contact your supervisor on duty to give
an estimated time of arrival.
4.
Staff on duty will not be released until all direct patient care areas are adequately staffed.
5.
If you were scheduled to work and did not report to work, you must use your benefit time to
be paid. In general, time will be approved only when the circumstances are clearly justified.
ELLIOT HEALTH SYSTEM
6.
If you were released early after it has been determined that all direct patient care areas are
adequately staffed, you must use your benefit time.
7.
When the storm policy is in effect, all hours worked in excess of eight (8) per day, or hours in
excess of previously scheduled hours, whichever is greater, will be paid at the rate of time and
one-half to all staff who are entitled to overtime.
8.
Additional requirements may apply in the case of specific State-declared emergencies.
9. Any kind of payment outside the above parameters will need to be approved by Human Resources
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES:
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Critical Incident Stress Debriefing (CISD)
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO: All Eliot Health System (EHS) Employees
POLICY STATEMENT: To provide a support mechanism for personnel who have been involved in a traumatic
event or critical incident.
PURPOSE:
1.
A critical incident can be defined as any incident that causes personnel to experience unusually strong
emotional reactions which have the potential to interfere with their ability to function either at the event or later.
The following situations should be considered critical incidents
a. the death of a child
b. the death of a co-worker
c. multiple patient deaths
d. gruesome incidents
e. events that attract heavy media attention
f. the death of a loved one
Debriefing sessions should be initiated following the above situations, usually within 24 to 72 hours after the
incident.
ELLIOT HEALTH SYSTEM
The critical incident debriefing is coordinated by the Employee Assistance Program. To access Employee
Assistance Program call 877-259-3785.
2.
This service is considered an employee benefit and, therefore, attendance at debriefing sessions is considered
paid time.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM
MANUAL:
HR Manual
TITLE:
Cultural/Religious/Ethical Treatment Conflicts
STATUS:
APPROVED BY:
______________________________________
Sabrina Granville, VP Human Resources
EFFECTIVE DATE:
REVISED DATE:
N/A
REVIEWED:
N/A
REPLACES:
N/A
APPLIES TO:
POLICY STATEMENT: From time to time an employee’s personal cultural values, ethics and/or religious
beliefs may necessitate that the employee refrain from participation in or delivery of an aspect of patient care
including treatment. In those instances where a staff member perceives that specific aspects of care or treatment
conflict with the staff member’s cultural values or religious beliefs, he/she may request not to participate. Each
request shall be reviewed and evaluated, in such a manner as to assure that the patient's care will not be negatively
affected
PROCEDURE:
Upon Hire
1.
Each applicant who is hired for employment and who may be asked to participate in procedures or
treatments that may conflict with that applicant's cultural values or religious beliefs will be informed
about such potential conflicts during the interview process.
2.
Treatments that might give rise to such conflicts include: abortion, blood transfusion and treatments at the
end of life.
3.
If the applicant indicates that there is potential conflict that applicant will be considered for employment
opportunities that may be available in other areas of Elliot Health System (EHS) or if reasonable
accommodations can be made with the position applied
During Employment
ELLIOT HEALTH SYSTEM
1.
During the course of employment if specific aspects of patient care present a conflict with the employee's
cultural values or religious beliefs, that employee should inform his/her Supervisor immediately. The
employee must identify the specific aspect of care or treatment which he/she is asking to be exempted
from, as well as a brief description of the nature of the religious or cultural conflict. Treatments that might
give rise to such conflicts include: abortion, blood transfusion and treatments at the end of life.
2.
The Supervisor, in conjunction with the Vice President of Human Resources shall make a determination
whether the request shall be granted. Such determination shall be based upon:
a. whether the request and the nature of the conflict coincide, and
b. whether there is generally accepted agreement as to the nature of the conflict, and
c. whether patient care would be compromised as a result of granting the request
Every effort will be made to grant all reasonable requests.
3.
All granted requests will be reviewed on an annual basis or as needed in accordance with the needs of the
patient and EHS. In granting any such requests, the Department Manager and Division Vice President shall
be responsible for ensuring that adequate staff resources exist to replace the excused employee.
4
In the event a request is not granted, the employee may utilize the Employee Appeals Procedure to appeal
the decision. Such appeal will be heard as the final step since both the
5
The employee may be required to provide written documentation from a religious/cultural leader, or other
documentation deemed necessary by EHS to support the request for exclusion. EHS reserves the right to
reassign the employee to another shift or unit either on a permanent or a temporary basis to accommodate
an approved exclusion. The employee must promptly notify the Vice President of HR if the employee’s
religious/cultural beliefs change, thereby making this exclusion unnecessary.
PREPARED BY:
REVIEWED BY:
CUSTODIAL MANAGER: Director of Talent Management
KEYWORDS:
REFERENCES: N/A
ATTACHMENTS: None
ELLIOT HEALTH SYSTEM