LIVING HOUSTON METHODIST VALUES A Handbook for Employees | 2016

houstonmethodist.org

HOUSTON METHODIST

MISSION To provide high-quality, cost-effective health care that delivers the best value to the people we serve in a spiritual environment of caring in association with internationally recognized teaching and research.

VALUES

INTEGRITY We are honest and ethical in all we say and do.

COMPASSION We embrace the whole person and respond to emotional, ethical and spiritual concerns as well as physical needs.

ACCOUNTABILITY We hold ourselves accountable for our actions.

RESPECT We treat every individual as a person of worth, dignity and value.

EXCELLENCE We strive to be the best at what we do and a model for others to emulate. DEAR HOUSTON METHODIST EMPLOYEE

Please keep this handbook handy for quick reference to answer any questions you may have about Houston Methodist. It contains important information that you may eventually need — such as employee benefits and business practices. While this book contains a lot of institutional information, it’s our employees who help create a culture and patient experience unique to Houston Marc L. Boom, MD Methodist. By embracing our I CARE values of President & Chief Executive Officer integrity, compassion, accountability, respect and excellence, you are helping create something special. These values are at the core of our culture and ensure that the patient is at the center of everything we do. The patient experience is an integral part of our external promise of leading medicine. Our goal is to set a new standard for leading academic medical centers through unparalleled safety, quality, service and innovation. We can’t do this without you. You play a vital part in our commitment to leading medicine — a commitment that has made Houston Methodist one of the premier hospital systems in the United States. While new patients come to us for our innovative treatments and clinical expertise, it’s their extraordinary patient experience at Houston Methodist — which depends on you — that will bring them back to us and earn their loyalty.

Thank you for everything you do for our patients. Marc L. Boom, MD President Chief Executive Officer Houston Methodist CONTENTS

7 ABOUT HOUSTON 21 BUSINESS PRACTICES: METHODIST ETHICS AND COMPLIANCE 7 About Houston Methodist 21 Business Practices Program Hospital 22 Employee Responsibilities 8 About Houston Methodist Complete Business Practices San Jacinto Hospital Program Training 9 About Houston Methodist Do the Right Thing! Report St. Catherine Questionable Practices 10 About Houston Methodist Information About Business St. John Hospital Practices EthicsLine and Follow-up 10 About Houston Methodist Sugar Land Hospital 24 Management Responsibilities 12 About Houston Methodist 24 Conflicts of Interest The Woodlands Hospital Business Contracts Business Courtesies and Gifts 12 About Houston Methodist West Hospital Accepting Gifts and Tips from Patients and Visitors 13 About Houston Methodist Outside Activities Willowbrook Hospital 27 Interactions with Physicians and 15 Houston Methodist Primary Other Health Care Providers Care Group 28 Research Integrity 15 Houston Methodist Specialty Physician Group 15 Houston Methodist Research 29 CAREER OPPORTUNITIES Institute 30 Professional Development 16 Houston Methodist Global 30 Promotions and Transfers Health Care Services

17 THE HOUSTON METHODIST EXPERIENCE 18 I CARE Values 19 Personalized Service 20 Culture of Safety

3 31 COMPENSATION AND 41 DISCIPLINARY ACTION PAYROLL PRACTICES 41 Penalties for Noncompliance 31 Appropriate Use of Unpaid 41 Managing Performance Persons 42 Workplace Violence 31 Exempt and Nonexempt Status 31 Pay Periods 43 EMPLOYEE BENEFITS 32 Payroll Deductions 43 Bereavement Leave 32 Payroll Direct Deposit 43 Educational Assistance Plans 32 Pay Administration Tuition Reimbursement 32 Pay Changes Due to Job College Scholarship for Changes Children of Employees 33 Performance Evaluations 44 Employee Assistance Program 33 Merit Increases 44 Family Medical Leave 33 Shift Differential 46 Holidays 33 On-Call Pay 46 Leave of Absence 34 Overtime 47 Paid Time Off (PTO) 34 Time Records 47 Retirement 34 Work Hours, Schedules and 47 Reward and Recognition Locations Programs 47 HealthyDirections 35 INFORMATION 48 Workers’ Compensation MANAGEMENT Insurance 35 Antitrust Laws 48 Termination of Benefits 36 Accuracy of Records, Charts Coverage and Other Documents 37 Retention and Disposal of Records, Charts and Other Documents 37 Information Security and Confidentiality 39 Computer Passwords 39 Medical and Billing Records 40 Personnel Records

4 57 Harassment 49 EMPLOYMENT PRACTICES 57 Hiring Former and Current AND WORKPLACE Government and Fiscal BEHAVIOR Intermediary Employees 49 Accommodations for 58 Jury Duty Disabilities 58 Lactation Accommodation 49 Alcohol and Drugs in the Workplace 58 Managing Staff Requests 59 Annual Influenza Compliance 58 Meal and Rest Periods 50 Attendance 59 Off-Duty Employees 50 Background and Credentials 60 Outside Employment Verification 60 Parking and Transportation 50 Contacts with the Media 60 Participation in Political 51 Contingent Workers Activities (Independent Contractors, 62 Personal Appearance Agency, and Temporary Employees) 62 Personal Mail 51 Copyright 62 Persons or Organizations Excluded from Medicare, 52 Dispute Resolution Medicaid and Other 53 Distribution and Solicitation Government-Funded Programs 53 Electronic Communications 63 Reporting to DNV-GL System Use 63 Smoking/Tobacco Use of Social Networking 64 Subpoenas and Service of 54 Employee Identification Legal Papers 54 Employee Orientation 64 Telecommuting 54 Employer’s Right to Access 64 Telephones and Employee Information in the Communication Equipment Workplace 65 Termination 55 Employment of Relatives 65 References and Employment 55 Equal Employment Opportunity Verifications 56 Exit Interview 65 Union-Free Workplace 56 Foreign Nationals 66 Weapons-Free Environment Export Control and Sanctions Compliance Sponsorship of Foreign Nationals Employees on Visas Not Sponsored by Houston Methodist

5 67 GOVERNMENT 75 CODING, BILLING AND INVESTIGATIONS CHARGING FOR SERVICES 75 Appropriate Charging of 69 MARKETING PRACTICES Medical Supplies and Services 69 Houston Methodist Brand 75 Clinical Decision-Making 69 Commitment to Truth in 75 Correction of Payment Errors Marketing 76 Cost Reports 76 Reimbursement Related to 71 PATIENT CARE AND Research PATIENT RIGHTS 77 Submission of Claims 71 Patient Care 71 Admission, Transfer and 79 SAFETY AND EMPLOYEE Discharge HEALTH 72 Emergency Medical Treatment 79 Employee Health Services 72 End-of-Life Decisions Ongoing Health Assessment 73 Informed Consent If You Become Ill While on the Job Your Return to Work 73 Reporting of Suspected/Alleged Abuse or Neglect 81 Accidents and Injury Reporting 73 Research 81 Environmental Management 73 Right to Protected Health 81 Fire Plan Information 82 Safety Training Access 82 Severe Weather and Accounting of Disclosures Emergencies Amendment Complaint 83 REFERENCES Confidential Communications Notice of Privacy Practices Restrictions

This handbook covers many situations that may arise during the course of your work. There may be times when the answers to your questions are not apparent. Please see your supervisor for guidance or explanation when needed. You may also speak with a representative of the Human Resources Department or the Business Practices Office. Changes to existing policies are made on a regular basis. The most current version of the Houston Methodist Policies and Procedures are found on the Houston Methodist intranet and take precedence if in conflict with the printed handbook. In the event that an employee does not have access to a computer, the policies and procedures may be obtained from the employee’s manager or the Human Resources Department at the appropriate entity.

6 ABOUT HOUSTON METHODIST Houston Methodist Hospital, the flagship hospital of Houston Methodist, is located Medical Center. in the Texas more than 95 years, For Houston Methodist Hospital has served the Houston community and the world with the highest-quality patient care in a cost-effective, spiritual environment. Affiliated 7 From its humble beginnings in downtown Houston, Houston Methodist From its humble beginnings in downtown Houston Methodist is primarily affiliated with Weill Cornell Medicine Cornell primarily affiliated with Weill Houston Methodist is HOUSTON METHODIST HOSPITAL METHODIST HOUSTON Houston Church, Conference of the United Methodist with the Texas Methodist continues its longstanding commitment to improving the health and well-being. community’s largest private nonprofit Hospital has evolved into one of the nation’s hospitals hospital with 828 operating beds. The has more than 10,000 employees, making it one of the largest employers in Houston. Houston Methodist has a proud tradition of leading medicine. It is comprised a proud tradition of leading medicine. It Houston Methodist has Center, Medical center in the world-renowned Texas of an academic medical six community hospitals, acute care hospital, a long-term a leading-edge institute, and freestandingresearch care and imaging centers emergency system will Houston area and beyond. In 2017, the that serve the Greater of a seventh community hospital,expand with the addition in when the facility is completed. Woodlands The centers leading Hospital, two of the nation’s and NewYork-Presbyterian A&M Methodist also has affiliations with Texas for clinical care. Houston Methodist and the University of Houston. Houston Health Science Center leverages these affiliations to take in medicine on the toughest challenges high-quality patient care and to pioneer better treatments and provide cutting-edge research. ABOUT HOUSTON METHODIST HOUSTON ABOUT ABOUT HOUSTON METHODIST Hospital outside of Houston to be honored with full accreditation byThe outside ofHoustontobehonoredwith fullaccreditation Hospital supplemented Humble’s giftwith$1.2million. health carefacility, localbusinesses,organizations andindividuals Confirming theneedforafirst-classcommunity inBaytown. of ahospital HOUSTON METHODIST SAN JACINTO HOSPITAL orthopedics (22),pulmonology(17),andurology(19). (26), gynecology(45),nephrology(28),neurology&neurosurgery(16), surgery(10),geriatrics & endocrinology(23),gastroenterologyandGI following areas:cancer(36),cardiology&heartsurgery(21),diabetes increaseditsrankings insevenspecialtiesandisrankedthe Hospital inTexas1 hospital andNo.1inthe Houston area.Methodist issue,andforthefourth yearinarowisnamedtheNo. “Best Hospitals” in11specialtiesbyU.S.News&World inits2015 hospitals Report motivation inthedevelopmentofsixmultidisciplinarycentersexcellence: commitment toimprovingpatientoutcomesrepresentasignificant In 1950, Houston Methodist San JacintowasthefirstHarrisCounty In 1950,HoustonMethodistSan isrankedamong thecountry’sHouston MethodistHospital top HoustonMethodistOrthopedics&SportsMedicine • HoustonMethodistNeurologicalInstitute • HoustonMethodistLynda K.andDavidM.UnderwoodCenterfor • HoustonMethodistJ.C.Walter Jr. Transplant Center • Heart&Vascular HoustonMethodistDeBakey Center • HoustonMethodistCancerCenter • The hospital’s forexcellenceinpatientcareandits reputation Digestive Disorders 8 $500,000 fortheconstruction Refining Companycontributed 1944 whenHumbleOiland hospital’s origingoesback to Montgomery since1948.The of Chambers,Libertyand the surroundingcounties east HarrisCountyand quality medicalcarefor hasprovided Jacinto Hospital Houston MethodistSan ABOUT HOUSTON METHODIST Houston Methodist St. Catherine Hospital, which opened in 2014, is a long- term acute care hospital that proudly serves the Greater Houston area, focusing on the needs of patients who require extended hospitalization. Located west of the Texas in Katy, Houston Medical Center, 9 As an extension of Houston Methodist West Hospital just two miles As an extension of Houston Methodist West Today, Houston Methodist San Houston Methodist for comprehensive care Jacinto provides Today, Methodist St. Catherine is committed to providing its patients with Methodist St. Catherine is committed to service and innovation that the community quality, unparalleled safety, and their families are at the depends on from Houston Methodist. Patients hospital’s Catherine does. The center of everything Houston Methodist St. care team combines a comprehensive, interprofessional unique approach health care providers that works of physicians, nurses, therapists and other planning the outcomes the patient needs. From family to achieve with each the care team works with patients and recovery, and treatment to discharge of care and to facilitateand their families to provide the highest-quality home. transition back patient’s each several outpatient services are offered at Houston Methodist St. away, Catherine, including imaging, rehabilitation and wound care. HOUSTON METHODIST ST. CATHERINE HOSPITAL CATHERINE ST. METHODIST HOUSTON Joint Commission on the AccreditationJoint Commission Since Care Organizations. of Health then, the hospital attributable number of milestones a has achieved to its available to the and expansion of services to the enhancement growth and Baytownresidents of surrounding areas. and patients at every stage hospital of life. The care to the people offers quality inpatient and extensive outpatient services.it serves through its acute treatment services include skilled nursing care, cancer Provided health care services, occupational health occupational therapy, programs, physical and and rehabilitation, and audiology services. adult psychiatry as speech as well hospitalThe services and a medicine residency also provides cardiovascular Sanprogram. Houston Methodist most Jacinto is committed to providing the to better serve its community. and technology current medical services ABOUT HOUSTON METHODIST HOUSTON METHODIST ST. JOHNHOSPITAL HOUSTON METHODIST SUGAR LANDHOSPITAL aquatic therapies. therapy, aconcussionandspinecenter, andphysical,occupational imaging, advancedlaparoscopicprocedures,women’s services,pediatric medical services,criticalcarededicatedoncologyunit,diagnostic emergency department,cardiologyandcardiovascularspecialties,inpatient artery disease,andstrokeheartfailure. Association’s modelsoftheGetWith theGuidelinesprogram:coronary in Texas for all threeoftheAmericanHeart tobeaparticipatinghospital College ofSurgeonsCommissiononCancer. Itisalsothefirsthospital designation,and isaccreditedwiththeAmerican a stroke-readyDNV Methodist St.Johnboastsanationallyaccreditedchest paincenterand CT scannerandanadvancedcatheterizationangiographylab.Houston 64-slice diagnostic imaging,which includesthenextgenerationGE Comprehensive medical services at the hospital include afull-service Comprehensive medicalservicesatthehospital 10 offers state-of-the-art offers state-of-the-art communities. The campus throughout thesurrounding sports medicineclinics and sevenorthopedic ambulatory surgerycenter, operating rooms,anon-site licensed beds,including8 with178 care hospital isageneralacute Hospital Houston MethodistSt.John diagnosis andtreatment. the highest-qualitymedical convenience, whileoffering maximize patientcomfortand isdesignedto The hospital home-like environment. medical careinaunique, edge technology andexcellent offersleading- Land Hospital Houston MethodistSugar ABOUT HOUSTON METHODIST

® 11 Houston Methodist Sugar Land has grown into a world-class facility withHouston Methodist Sugar Land has grown An integral part of the Fort Bend community since 1998, the hospital since 1998, the Bend community part of the Fort An integral is representing the full range of medical More than 900 physicians, neuroscience, oncology, in cardiology, centers of excellence With Sugar Land performed the In 2007, surgeons at Houston Methodist designation awarded by the American Nurses Credentialing Center and is Credentialing Center and is designation awarded by the American Nurses the only hospital Bend County that is nationally accredited by the in Fort on Cancer. American College of Surgeons-Commission it the largest health care provider243 beds and 20 operating rooms, making the needs of the community it continue meeting To Bend County. in Fort expand its physical footprintserves, Houston Methodist Sugar Land will tower that will add 104 beds,again in 2016 by building a six-story patient primarily for intensive care and medical/surgical patients. U.S. News & World Report hospital ranked the & World In 2015, U.S. News No. 9 in the at Houston area. Center, Medical Hospital of Houston Methodist an extension in the Texas with the same That standards to quality. and commitment of excellence center expertise and hometown convenience combination of medical Bend for Fort Sugar Land the first choice makes Houston Methodist patients. County physicians and specialties, are on staff Methodist Sugar Land — not to at Houston caring nursing staffmention an experienced, and support personnel patients. dedicated to serving Sugar services, Houston Methodist and women’s orthopedics, urology aquatic of services and facilities, including Land offers a wide range cardiology, cancer center, breast care center, birthing center, therapy, emergency department, catheterization lab, diagnostic imaging, inpatient services, infusion center, center, headache endoscopy, lab, neuroscience and spine center, intensive care, joint center, speech respiratory therapy, physical therapy, occupational therapy, support groups, surgical services (including robotic technology) therapy, and wound care. And since then, Houston Bend County. first open-heart surgery in Fort more “firsts” and has Methodist Sugar Land has performed many for excellence in patient received numerous recognitions and awards and community innovations, medical advancements care, technological pain center accreditation involvement, including chest and stroke hospital the Pathway to Excellence certification. The also achieved ABOUT HOUSTON METHODIST HOUSTON METHODIST THE WOODLANDS HOSPITAL the campus.By2017,asecond patientbedtowerwillopenandfurther service emergencydepartment, andtwomedicalofficebuildingsresideon a hybridroom.Aninfusioncenter, cancercenter, breastcarecenter, full- outpatient visits. babies, admittednearly30,000inpatientsandcompleted 200,000 HOUSTON METHODIST WEST HOSPITAL addition tomultispecialtyphysicianpractices. and sportsmedicine,wellnessservicesoutpatientlaboratory, in following services:cancer, infusionandbreastcarecenters,orthopedics 400 beds.MedicalOfficeBuilding1openedMarch 1,2016,housingthe square feetandwillopenwith187beds,thecapacitytoexpand The master-plannedfacilitywillbe470,000 Houston MethodistHospital. The hospital has193operating bedsand15operatingrooms,including The hospital 12 delivered nearly7,000 catheterization procedures, surgeries and5,500heart performed morethan20,000 in theemergencydepartment, more than100,000patients hasseen opening, thehospital than 1,500employees.Since in 2010andnowhasmore openedtopatients Hospital Houston MethodistWest edge technologies offeredat care andmanyoftheleading- will offerexceptionalmedical Houston Methodistsystem inthe The eighthhospital and MontgomeryCounty. footprint intoThe Woodlands expand HoustonMethodist’s Woodlands will Hospital Houston MethodistThe Opening inJuly2017, ABOUT HOUSTON METHODIST -recognized ® Houston Methodist Hospital is a Willowbrook 312-licensed bed, tertiary care facility providing a full continuum of services to Northwest Houston, including emergency care, imaging, cardiovascular cardiology, orthopedic surgery surgery, and sports medicine, pain and accredited chest 13 U.S. News & World Report ranked the . In 2015, U.S. News & World ® The campus reflects Houston Methodist’s approach of delivering patient- approach Methodist’s campus reflects Houston The medical staff is highly trained and Hospital’s Houston Methodist West Houston hospitalThe to leading medicine in the West is committed health care facility by the American Nurses Credentialing Center’s Magnet health care facility by the American Nurses Credentialing Center’s Recognition Program HOUSTON METHODIST WILLOWBROOK HOSPITAL WILLOWBROOK METHODIST HOUSTON cancer center, collaborative neurosurgery, stroke centers, neurology, and more. The services, general medicine comprehensive women’s hospital on a 52-acre campus and has the capacity to grow to 360 sits Hospital is a Magnet beds. Houston Methodist Willowbrook expand key services lines, including cardiology and cardiovascular surgery, cardiovascular surgery, cardiology and services lines, including expand key birthing surgery, minimally invasive advanced and surgery, orthopedic cancer, rehabilitation, outpatient neurosurgery, neurology and center, health women’s primary care and urology, surgery, imaging, reconstructive services. care, combining a hospitality-likeand family-centered environment with State-of-the-art the latest medical technologies. patient rooms have been floor plans comfort and healing. The patient safety, designed to promote to the patient, providing a sense of proximity place caregivers in close their families. comfort to patients and hospital specialties. The experienced in all medical also has nurses and clinical staff professionals who follow Houston who are skilled and trained I CARE values. Methodist’s standard of Methodist’s and Katy communities by delivering Houston safety we serve. and innovation to the patients unparalleled quality, hospital No. 4 in Houston and No. 8 in Texas. hospital No. 4 in Houston and No. 8 in Texas. ABOUT HOUSTON METHODIST are notlimitedto:theGoldSealofApproval consecutive years.Otherprestigiousawardsanddesignations includebut an“A”maintained ScorefromThe LeapfrogGroupfor three Safety Hospital awards andrecognitionamongthemedicalcommunity. has The hospital serving othershasenabledHoustonMethodistWillowbrook toachieve demonstrate thehospital’s valuesdaily, ICARE andthiscommitmentto imaging, ultrasoundandfullon-sitelaboratoryservices. treatment rooms,generalradiologycapabilities,computerizedtomography Emergency CareCenteropenedin2015topatientsofallages,with10 office openedinCypress,Texas, in2014.The HoustonMethodistCypress area residents.AnewHoustonMethodistPrimaryCareGroupphysician of servicesoffcampus,deliveringhigh-qualitycareandconvenienceto biopsies; fewcentersacrossthecountryearnthislevelofdistinction. biopsiesandstereotactic ultrasound imaging,mammography, breastMRI, all oftheACR’s programs,includingbreast breastimagingaccreditation in awarded tocentersthatachieve excellencebyearningaccreditation Thisby theAmericanCollegeofRadiology(ACR). tremendoushonoris alsoearnedrecognition asaBreastImagingCenterofExcellence hospital surrounding normaltissueandmayresultinfeweroverallsideeffects.The of radiationtobedeliveredtumorsquickly, which islesstoxic to launched ahigh-doseradiationprogram,allowinghighlylocalizeddoses on patientneeds.The HoustonMethodistCancerCenteratWillowbrook to criticalcarebedsinthefuture,withnoadditionalconstruction,based the structuresandtechnology requiredtoconvertmedical-surgicalbeds bed architectural design,with care unit,featuringaninnovativeuniversal community. Advancementsin2014includetheopeningofanewpatient specialized careandbestpracticestothegrowingNorthwestHouston expand significantlytoprovidethelatestresearch, technology, education, Pain Centers. Surgery, fromtheSocietyofChest andChestPainCenter Accreditation country, andBariatric designationasCenter ofExcellenceinMetabolic Nurses CredentialingCenteras a“bestplacestowork”fornursesinthe Achievement Award, PathwaytoExcellence™designationbytheAmerican Stroke Association’s GetWith theGuidelines—GoldPlusQuality for PrimaryStrokeCenters,theAmericanHeartAssociation/American More than 1,800 employees and 824 medical staff members More than1,800employeesand824medicalstaff Houston MethodistWillowbrook isalsoadvancingcarewithanexpansion openeditsdoorsinDecember2000andcontinuesto The hospital 14 ® fromThe JointCommission ABOUT HOUSTON METHODIST Houston Methodist’s mission Houston Methodist’s of leading medicine is grounded in a commitment to patients to make real progress in lifesaving medical this in mind, the With research. Houston Methodist Research Institute was designed to be different from other research institutions. Integrated into finest one of the nation’s 15 HOUSTON METHODIST RESEARCH INSTITUTE METHODIST HOUSTON hospitals, institute coordinates more than 540,000 square the research medical center, space embedded throughout the academic feet of research and turning knowledge intokeeping the primary focus on patient care and support its doctors and institute provides the technology action. The need to effectively and efficiently bring cures from the laboratory researchers through all stages of clinical trials and to patients around the world. HOUSTON METHODIST SPECIALTY PHYSICIAN GROUP PHYSICIAN SPECIALTY METHODIST HOUSTON Physician Group is an integral part of Houston Methodist Specialty The leading strategy to become one of the nation’s overall Houston Methodist’s medical centers. Established as a nonprofit corporation certified by the State Board of Medical Examiners, the specialty physician group Texas enables physicians to maintain autonomy with respect to clinical practice environment. while growing their practice within an academic With locations throughout the Greater Houston area, Houston Methodist Houston Methodist Greater Houston area, throughout the locations With patient to providing the highest-quality Group is dedicated Primary Care Group is proud Methodist Primary Care Houston entire family. care for the Methodist and its family of hospitals,to be a part of Houston ensuring and hospitalefficient access to specialty services whenever the need Houston Methodist of the Greater Houston community, arises. As members is committed to the well-being of its patients, Primary Care Group throughout at the right time in convenient locations providing the right care the Houston area. HOUSTON METHODIST PRIMARY CARE GROUP CARE PRIMARY METHODIST HOUSTON ABOUT HOUSTON METHODIST SERVICES HOUSTON METHODIST GLOBAL HEALTH CARE patients frommorethan90countriesaroundtheworld. Each year, HoustonMethodist’s of andphysicianstreatthousands hospitals and sharinglocalinstitutionalknowledgewithitsinternationalpartners. physicians andhealthcareorganizationsaroundtheworldbyleveraging and initiativesforHoustonMethodist.Methodistservespatients, 16 drives internationalactivities services. The organization collaboration andadvisory education andtraining,clinical in patient-centeredcare, ofexcellence standard dedicated tosettingaglobal is Methodist Hospital, a subsidiaryofHouston Health CareServices, Houston MethodistGlobal THE HOUSTON METHODIST EXPERIENCE 17 Our Service goal is to provide an exceptional culture of personalized provide an exceptional culture of personalized Our Service goal is to and personal in ourIn order for us to be progressive, passionate A sense of personal connection between patients and their health connection between patients and their health A sense of personal as importantcare providers is just their physical health. At Houston as A of our patients to feel special and unique. Methodist, we want all addressing experience fosters these feelings by personalized health care patients spiritual needs. Our commitment to our physical, emotional and on care is driven by our continued focus Excellent remains our priority. and innovation. service quality, unparalleled safety, service, satisfaction, for patients, families, employees, and and engagement physicians in the safest environment. One of our service strategies is to to our community at large through enhance a culture of exceptional service Houston Methodist Experience. organizational integration of The a seamless patient experiencecaregiving, we must guide our guests through respect compassion, accountability, that uses our I CARE values — integrity, level and enhance their safety. and excellence — to serve patients at every advanced goals with Houston Methodist’s patient’s will link each This experienced professionals and superior facilities. research, EXPERIENCE THE HOUSTON METHODIST METHODIST THE HOUSTON THE HOUSTON METHODIST EXPERIENCE I CARE VALUES care andhospitality. for patient andguestdeservestobetreatedwithourhigheststandards values areessentialtocreatingapersonalizedpatientexperience.Every In conjunctionwithanemphasisonserviceandsafety, HoustonMethodist We strivetobethebestatwhatwedoandamodelforothersemulate. Excellence We treateveryindividualasapersonofworth,dignityandvalue. Respect We forouractions. holdourselvesaccountable Accountability spiritual concernsaswellphysicalneeds. We embracethewholepersonandrespondtoemotional,ethical Compassion We anddo. arehonestandethicalinallwesay Integrity Experience: totheHoustonMethodist valuesarefundamental Methodist ICARE As essentialsharedobjectivesthatwecarryouteveryday, theHouston 18 THE HOUSTON METHODIST EXPERIENCE 19 and Guests. AIDET and their families as It is a framework to communicate with patients It is a simple acronym that represents a very other. well as with each who are often nervous, powerful way to communicate with people anxious and feeling vulnerable. A — Acknowledge I — Introduce D — Duration E — Explanation T — Thank Demonstration of Keywords supporting the use of demonstrated and consistent language The ensure the overall quality of Houston Methodist Experience is a way to care is being delivered. Safe, are: Comfort, Private, Always and My Pleasure Keywords • Smile, make eye contact Guests. and greet all our • be their guide. Seek out Guests to assist them; • names, to personalize their experience. Use our Patients’ preferred • Guests; we are here for them. Interact with our Patients and • Display On-Stage and patient areas. behaviors in all public • individuals. Honor diversity as we are all • five minutes every day to go above and beyond for our Patients Take • them. Anticipate Patients’ and Guests’ needs and address • all our Patients and Guests; they have a choice. Thank • • Service Standards and exposed to our culture of Every Houston Methodist employee is trained as: behaviors such excellence that advocates practicing expected Every patient should receive the best possible service in both inpatient in both inpatient best possible service should receive the Every patient fundamental Methodist has developed settings. Houston and outpatient service standardsthe journey of the patient to personalize techniques and care process. PERSONALIZED SERVICE PERSONALIZED THE HOUSTON METHODIST EXPERIENCE proven waytoimprovesafety. appropriate, patientsandfamilies, fosterstrustandempowerment,isa and,when risk events.Regularcommunication amongallcaregivers,staff risks helpsprotectyourpatients andcolleaguesworkstopreventhigh- andreportingpotentialsafety alert atalltimes.Payingattention todetail focusedand tostay practices,itisimportant safe to observingstandard ensure thatpatientsandemployeesfeelsecureprotected. Inaddition throughactionandawareness,wehelp By promotingacultureofsafety CULTURE OFSAFETY • • • • Discharge phonecalls • Roundinginwaitingareas • Bedsidereport • Leaderrounding • Hourlyrounding • Positive language • ofPractice Standards meets them. creates apositiveimpressionofothersbeforethepatientorfamily comes toouremployees,departmentsandservicedeliveries,which Managing upothersiscommunicatingaboutourexpertisewhenit Patients andFamily Demonstration ofManage-UpBehaviorsWhen Talking to focus. Itisallaboutthepatientexperience! of ourpatientsandguests.When, ourcustomersarethe On-Stage Employees willALWAYS beprofessionalatalltimeswheninfront Behavior Demonstration ofOn-Stage • • • H.O.P toIt! at HoustonMethodist.Each employeepracticestheacronymof Patients andtheirfamiliescomefirst,evenwhenusingtheelevator Elevator Etiquette Patients first Off beforeon Hold thedoor 20 BUSINESS PRACTICES: ETHICS AND COMPLIANCE

21 PROGRAM VISION: All actions taken in the name of strong moral values, Houston Methodist are consistent with high ethical standards, and the law. This vision is supported throughout Houston Methodist. The audit and audit and The vision is supported throughout Houston Methodist. This for directing Business Practices officer is responsible entity’s Each BUSINESS PRACTICES PROGRAM BUSINESS PRACTICES committed to building and maintainingHouston Methodist is a culture of compassion, with its core values: integrity, integrity and ethics consistent of the Business purpose The respect and excellence. accountability, commitment of Houston Practices Program is to demonstrate the Methodist to the highest standards of ethics and compliance with the law. employees make this Business Practices Program (Program) helps all The vision a reality. and the Business Practices compliance committee of the board of directors and entity representatives,committee, consisting of senior management vice president, of this effort. The provides direction, guidance and oversight leads the officer, audit and chief who is also the Business Practices officer to the board of Business Practices officer reports functionally program. The and reports administratively to directors’ audit and compliance committee Methodist. legal officer of Houston the executive vice president and chief working through the entities’ Business Business Practices officer, The Practices Offices, is responsible for the implementation of the Program. Program website The entity. Business Practices activities within their Business provides the name and contact entity’s information for each Practices officer. ETHICS AND COMPLIANCE ETHICS about Houston Methodist’s section contains information following The is which practices and compliance with the law, commitment to ethical the Businessdemonstrated through Practices Program. BUSINESS PRACTICES: BUSINESS BUSINESS PRACTICES: ETHICS AND COMPLIANCE questionable practiceforthreereasons: . values —ICARE manner consistentwiththeProgram’s visionandHoustonMethodist’s core to performpatientcareactivities,research andbusinessoperationsina members andemployeesofallHoustonMethodistentitiesareexpected 1. NOTE: onpage 83. These numbersthroughoutthehandbook refertoReferencesstarting be therightthing,youshouldreportsituation. If youlearnaboutasituationthatmayviolatethelawor not Do theRightThing! —ReportQuestionablePractices Complete BusinessPracticesProgram Training All employeesmust: EMPLOYEE RESPONSIBILITIES Business PracticesProgramPlan. 713.383.5124 torequestanin-service. training uponrequest.ContacttheBusinessPracticesOfficeat The BusinessPracticesOfficestaffisavailabletoprovideadditional training forMedicareAdvantagePlanparticipantshere on theirjobresponsibilities.CMShasprovideditsownGeneralCompliance online. Employeesmayberequiredtoattendadditionaltraining,depending thiscourseeach year our onboardingprocess.Continuingemployeestake theBusinessPracticesProgramCourseaspartof New employeestake focuses onbusinesspractices,ethics,andlegalregulatoryissues. The BusinessPracticesProgramprovidestrainingtoemployees.Training • • • • • • • The boardofdirectorsadopted theBusinessPracticesPolicy andthe leads toresolutionoftheseissues. Reporting identifiesissuesthat mightnototherwiseberaisedand addressed. believed toviolateHoustonMethodist’s valuesorthelawsoitcanbe Management wantstobeawareofanypracticeorconcernthat is Report questionablepractices Live HoustonMethodistvaluesinallaspectsofYour work Follow approved policiesandprocedures Do therightthing! Complete BusinessPracticesProgram training 1 22 All directors, officers, medical staff Alldirectors,officers,medicalstaff 2 You shouldreporta . BUSINESS PRACTICES: ETHICS AND COMPLIANCE 23 Houston Methodist better. Houston Methodist Business: Practices EthicsLine • Call 1.800.500.0333, or • tmhs.myethicsline.com Visit Inspector General Inspector General • make responsibility to employee’s each Reporting is part of supervisor or other practice to your report a questionable should You • matters) Human Resources (for employment-related • Business Practices officer entity’s Your • Practices officer at 713.383.5124 Houston Methodist Business • • Services Office of Department of Health and Human • Office of Health and Human Services Commission Texas EthicsLine, you will If you report a concern to the Business Practices Practices EthicsLine web reporting system to may use the Business You individual in your chain of command. If this is inappropriate or makes you is inappropriate or makes of command. If this your chain individual in uncomfortable, contact you may the following: Information about Business Practices EthicsLine and Follow-up your name when you use the Business Practices do not have to give You A report of each EthicsLine. Incoming calls or web reports are not traced. Business Practices Office, which concern is sent to the Houston Methodist coordinates the investigation. with the Business number you can use for follow-up receive a tracking For Practices EthicsLine or the Business Practices Office (713.383.5124). example, to provide additional information about may want to call back you the concern or inquire about the status of the investigation. Additionally, information to facilitatethe investigator may post requests for additional until the anonymous requests will remain in the file the investigation. These with Business Practices or the Business Practices back caller checks Business Practices EthicsLine if you want should call the EthicsLine. You on the status without revealing your identity. of an investigation to check calls to the Business Practices Office are not traced or recorded, While caller ID may reveal your identity. follow up on the status the “Follow of an investigation, as well. Simply click Up on a Reported Concern” link at tmhs.myethicsline.com. BUSINESS PRACTICES: ETHICS AND COMPLIANCE when yourprivateinterestsinfluence youractionsatworkinawaythatis be inthebestinterestsofHouston Methodist. As aHoustonMethodistemployee, youractionsatworkareexpectedto CONFLICTS OFINTEREST Inadditiontothoseresponsibilities listedabove,managementmust: example. in theBusinessPracticesProgram,managersareexpectedtoset While allHoustonMethodistemployeesareexpectedtoactivelyparticipate MANAGEMENT RESPONSIBILITIES to requestabiomedicalethicsconsultation. laws. andbyfederalstate Practices Procedure BP07 faith are protected from byHoustonMethodistBusiness retaliation investigated. Employeeswhoreport questionable practicesingood Bearolemodel—LiveHoustonMethodistValues inAllofYour Work • CompletetheonlineBusinessPracticesProgramCoursefor • completeappropriateBusinessPracticestraining. Ensurethatstaff • practicesandworkoutcomestobesurepolicies Monitorstaff • Train tofollowpoliciesandprocedures. staff • Continuouslyevaluate,reviseanddevelopunitpolicies,procedures • Reportquestionablepracticeswhentheyarise. • toreportquestionablepractices. Encouragestaff • CreateaculturewithinHoustonMethodistthatpromotesthehighest • entity’sNote: Forassistancewithend-of-lifeissues,follow your process All reports ofquestionablebusiness practicesare promptly and Do theRightThing! and Do Management. procedures arebeingfollowed. classifications, orinstituteanyotherlanguagedeemednecessary. Houston Methodistreservestherighttochange practices,modifyjob andchange orwritethemwhennecessary.standards, Therefore, and practicesforcompliancewiththelawHoustonMethodist ofethicsandlegalcompliance. standards 24 3 Aconflictofinterestexists BUSINESS PRACTICES: ETHICS AND COMPLIANCE 4 6 A conflict of interest can A conflict 3 25 5 Houston Methodist follows the highest business standards Houston Methodist follows the highest business 6 interest as they arise. You should disclose a potential conflict of should disclose You interest as they arise. the appropriate management member, interest to your supervisor, of any or the chair Practices officer, Houston Methodist Business decision-making body you serve. conflict of interest survey. Procedure (RE)14requirements outlined in Research . Houston Methodist employees are encouraged to contactHouston Methodist employees are encouraged their Employees and others associated with Houston Methodist who have Employees and others associated with Houston Because Houston Methodist is dedicated to conducting business is dedicated to conducting business Because Houston Methodist • potential conflicts of employee is responsible for disclosing Each • in the annual If requested, employees are expected to participate • are subject to additional disclosure Individuals involved in research Business Contracts organizations or individuals with Houston Methodist will not contract with of conflicts Potential interests that conflict with Houston Methodist’s. management person(s) for interest will be disclosed to the appropriate evaluation. supervisor or the Business Practices Office for further information and supervisor or the Business Practices Office situations. guidance on potential conflicts of interest a conflict of interest must not vote on the conflicted matter but, following a conflict of interest must not vote on the participate in the decision- proper disclosure and prior approval, may making process. not in the best interests of Houston Methodist. interests of Houston not in the best in contracting with third parties. All contracts must be consistent with in contracting with third parties. All contracts In contracting with third Houston Methodist policies and procedures. and all disclosure rules, laws parties, Houston Methodist will comply with regulations. also occur when your private interests appear to influence your actions appear to influence when your private interests also occur Methodist. best interests of Houston a way that is not in the at work in Examples or family relationships interests” include personal of “private Houston Methodist, outside of or vendors, employment with competitors outside boards, and certainmembership on some outside ownership interests. must be ethical principles, conflicts of interest according to the highest harm to and managed to assure they cause no recognized, disclosed, Houston Methodist. BUSINESS PRACTICES: ETHICS AND COMPLIANCE clinical consultingengagements. typesofnon- income fromcertain and researchers arepermittedtoretain Principles Governing OutsideActivities, which addresseswhenphysicians the HoustonMethodistResearch InstituteshouldreviewProcedureBP34, physicians employedtoprovidepatientcareandresearchers employedby any value,eitherforthemselvesortheirdepartmentsunits. Foundation, employeesmaynotsolicitorappearto giftsof Hospital With theexceptionoffundraisingeffortssupportedbyHoustonMethodist patient caredecision,ortoserveanyotherimproperunlawfulpurpose. induce referralofpatientsorpurchases, toinfluenceanybusinessor business partner. Employeesshallnotacceptoroffergiftsintendedto gain orshowingfavoritismtoanindividualand/orcurrentpotential Accepting giftsorgratuitiesmaygivetheappearanceofprovidingpersonal Business CourtesiesandGifts be paidorassignedtoHoustonMethodist. expenses relatedtoyourpositionoroccupationatHoustonMethodist must above. For mostemployeesallhonoraria,consultingfeesandreimbursable or executive withinyourchain ofcommandwitharelativerankEX03 or occupationatHoustonMethodist,youmustreceiveapproval froman engagements. Priortoacceptinganengagementrelatedyour position Employees mayoccasionallyparticipateinoutsidespeakingand consulting Outside Activities amount ofcashofferedasagratuityforservice. supervisor. toyoura patientorvisitor, ortalk consultPolicyandProcedureBP19 care totheirfamilythanotherpatients.Beforeyouacceptagiftfrom avisitormayoffergift toyouinhopesthatwillgivebetter example, a giftfrompatientorvisitormaygiveanunfavorableappearance.For who offergiftstoHoustonMethodistemployees.However, accepting Houston Methodistappreciatesthegenerosityofitspatientsandvisitors Accepting GiftsandTips from PatientsandVisitors . Procedure BP19 business partnerorofferingacourtesy, consultPolicyand Employees maynotaccepttipsfrompatientsandvisitors.Atipisasmall Before acceptingagiftorbusinesscourtesyfromanindividual 7 26 9 HM PhysicianOrganization HM 8 7 BUSINESS PRACTICES: ETHICS AND COMPLIANCE 27 10 Q&A son is a salesperson adult Z with Company Your are asked chemistrywhich makes analyzers. You to participate is committee The on a committee. a chemistrytasked with recommending analyzer for laboratories. Do you have purchase by the Hospital If you do, what should you do a conflict of interest? about it? opinions Your may have a conflict of interest. you Yes, about by your analyzers may be influenced chemistry this should disclose Company Z. You position with son’s selection of the the chair to interest potential conflict of to determine what with the chair committee and work with this for you to play is appropriate if any, role, committee. Houston Methodist does not pay for referrals. Patient referrals and Houston Methodist does not pay for referrals. admissions are based on the patient’s medical needs and Houston medical admissions are based on the patient’s Methodist does not pay ability to meet that need. Houston Methodist’s Houston Additionally, or offer to pay anyone for the referral of patients. referrals. Employees may not Methodist does not accept payments for of patients. for the referral ask for or receive anything of value in exchange Houston Methodist making a referral to another health care provider, When does not take into account the volume or value of referrals the provider has made or may make to Houston Methodist. Business arrangements with physicians must be structured to ensureBusiness arrangements with physicians must must be in writing. arrangements compliance with legal requirements. These arrangements prior Department of Legal Services must approve these The to implementation. INTERACTIONS WITH PHYSICIANS AND OTHER WITH PHYSICIANS INTERACTIONS PROVIDERS CARE HEALTH BUSINESS PRACTICES: ETHICS AND COMPLIANCE procedures. Research misconductwillnotbetolerated. responsible forfollowingthelawandHoustonMethodistpolicies Employees andothersinvolvedinresearch atHoustonMethodistare operationsandpatientprivacy.impact ofresearch projectsonhospital intheconductofresearch. HoustonMethodistmustreviewthe standards care mission.HoustonMethodistiscommittedtofollowinghighethical Clinical andbiomedicalresearch arepartofHoustonMethodist’s health RESEARCH INTEGRITY . information, consultResearchProcedureRE15 are notconsidereddata research misconduct.For more honest differences orjudgmentsof ininterpretations all considered research misconduct.Honesterrors or ideas from anothersource withoutgivingcredit are or orusing data makingupdata, Falsifying data, What isresearchmisconduct? formore information. See ResearchProcedureRE11 knowledge. or studythatisintendedtofurthermedical Houston Methodistdefinesresearch asaninvestigation there isnopatientcontact? Is reviewingrecordsconsideredresearchwhen Q&A 28 11 CAREER OPPORTUNITIES 29 At HM, their we believe that leaders should not only help others reach Center for Professional Excellence (CPE)The provides necessary PROFESSIONAL DEVELOPMENT PROFESSIONAL Houston Methodist (HM)In the spirit of excellence, is committed to the of development of all employees. As an employer continuing growth and we know how importantchoice, training opportunities that help it is to provide and professional skills, and at the same technical, develop your business, an in-depth orientation, offer employees We grow. time help the organization beginning their first day focusing on HM Culture and expected behaviors. needs and available time, weRecognizing that everyone has different learning courses on a wide range of topics. also offer employees more than 100 online of their own to learn and potential, but also be given unique opportunities is the purpose of the HM That Academy of Leadership and Learning, grow. The leaders create a Houston Methodist Experience. through which all stagesacademy has an offering for all leaders at in their careers, from geared toward each nurses and team leads to senior executives, charge health care fast-paced success in today’s helping participants achieve environment. education and training to nursing staff for providing excellence in patient efforts, aims with research care. Evidence-based education, in conjunction the hospital.to provide an expert nursing workforce for CPE provides nurses as CE such and allied health professionals online resources, Direct, for certification prep courses.unlimited continuous education credits, including leadership, and computerIn addition, education events for bioethics, education for clinical and specialty service line topics offer on-site technology staff and career goals. Furthermore, CPE their clinical to achieve has ongoing our staffprofessional development programs to help to obtain professional development tools and access funding resources. CPE has served as a facilitator for nursing and allied health staffs in Houston Methodist for their professional development and ensure their career progression. Employment opportunitiesEmployment are updated on a daily at Houston Methodist and via on the Houston Methodist Careers website basis and are posted MARS, System. Resource the Methodist Administrative CAREER OPPORTUNITIES CAREER CAREER OPPORTUNITIES another position,youmust: your entityfortransferinformation. theHumanResourcesDepartmentat Methodist Careerswebsite.Contact andontheHouston employment opportunitiesarepostedinMARS for promotionsandtransferswhenopeningsbecomeavailable.Current development. Currentemployeeswillbegiventheopportunitytoapply Houston Methodistiscommittedtosupportingyourcontinuedgrowthand PROMOTIONS AND TRANSFERS the organizationtoenableemployeesrealizetheircareerpotential. improve theirprofessionalcompetenceandbenefittheorganization. employees whochoose tocontinue theirformaleducationinorderto Immediately notify your current manager upon acceptance ofinternal Immediatelynotifyyourcurrentmanageruponacceptance • Notifyyourcurrentmanagerpriortoattendingascheduled interview • Completeaformalonlineapplication • • Haveaminimumofsixmonthsactiveemploymentincurrentrole • Meettheminimumexperience,background andeducation • In ordertobeeligibleforatransferwithinHoustonMethodist into Houston Methodistrecognizesandencouragespromotionfromwithin programsmaybeprovidedto In addition,educationalassistance transfer offer with hiringmanager Have no formal counseling record for misconduct in the last six months requirements 55 30 COMPENSATION AND PAYROLL PRACTICES 31 An exempt employee is salaried and not eligible for overtime. A nonexempt based upon the duties and Exempt and nonexempt designations are Students, interns, trainees, and observers are unpaid individuals who Students, interns, trainees, and observers managers and employees Houston Methodist provides guidelines to Houston Methodist employees are paid on a biweekly basis. Pay periods for Houston Methodist employees begin on Sunday and end 14 days later following the last day of the pay cycle. Payday is the Thursday on Saturday. PAY PERIODS PAY EXEMPT AND NONEXEMPT STATUS NONEXEMPT AND EXEMPT as either exempt or nonexempt, Houston Methodist designates all positions based upon applicable federal and state laws. she works over 40 hours in aemployee is eligible for overtime once he or work week. responsibilities of the position. APPROPRIATE USE OF UNPAID PERSONS PERSONS USE OF UNPAID APPROPRIATE their services, usually are individuals who volunteer or donate Volunteers for public service, religious or humanitarianon a part-time basis, reasons without expectation of compensation. learning and for in exchange participate in activities at Houston Methodist course credit. development opportunities, oftentimes for to ensure compliance with regarding the appropriate use of unpaid persons the Fair Labor Standards Act. Refer to Policy HR guidelines also 44. These may appropriately serve as address how Houston Methodist employees activities. volunteers for Houston Methodist-related The following section contains information about your salary, which which about your section contains information following salary, The as well as information compensation policy, includes Houston Methodist’s on pay periods, overtime, pay-related issues. on-call pay and other PRACTICES COMPENSATION AND PAYROLL PAYROLL AND COMPENSATION COMPENSATION AND PAYROLL PRACTICES PAYROLL DEDUCTIONS downgrades within the context of our salary structures. downgrades withinthecontextofoursalary application foradifferentjoborbecauseofchanging businessneeds. employees makejobchanges withintheorganizationeitherthroughvoluntary Houston Methodisthasguidelinesthatensurefairpaypractices when PAY CHANGESDUE TO JOBCHANGES similar skillandexperience. that theybringtotheposition,incomparisoncurrentemployeesof employees willbeappropriatelypaidbasedontheskillsandexperience arecompetitive.New policies andprocedurestoensurethatoursalaries surveys andfollowsappropriate Methodist conductsregularcompensation program thatisfairtoallemployees.Houston carry outawageandsalary It isHoustonMethodist’s ratesandto competitive salary policytomaintain PAY ADMINISTRATION institution orHoustonMethodistdesignatedPayrollCardeach payperiod. to havetheirnetpayrouteddirectlyintodesignatedbank/financial Employees arerequiredtoparticipateinautomaticpayrolldirectdeposit PAYROLL DIRECT DEPOSIT orloanpayments. gift shopcharges; orcredituniondeductionsforsavings orlife insurance;parkingfees;cafeteriacharges; premiums forhealth,dental Those deductionsthatmaybeauthorizedbytheemployeeinclude debtowedtothegovernment. by thefederalgovernmentforoutstanding child support,bankruptcy, federalincometax, Security tax, andmonieslevied be withheldfromyourpay. DeductionsrequiredbylawincludefederalSocial Only payrolldeductionsrequiredbylaworthosethatyouhaveauthorizedwill For voluntary downgrades,paywillusuallydecrease. This For includes voluntary • For lateralmovesthere shouldbenochange inpayrate,unless the • For promotionsthereareguidelinesthatspecifyasetrangeofpay • Houston Methodist’s policydefinespromotions,laterals,and voluntary transferstoajobwithlowerpayrange,ormoving between voluntary grade. salary another withinthesame change inpositionisconsidereda“progression”fromonelevel to change opportunitiesbasedonthedifferencebetweenmidpoints. 32 COMPENSATION AND PAYROLL PRACTICES 12 54 15 33 hospitals where the salary job may be midpoint for a similar range equity values. scales or internal of different market lower because Human Resources. Merit increases for regular status (non-PRN, non-temporary) employees merit increases are awarded once a year. Generally, • involuntary For with must be discussed the pay decision downgrades, impact provide more information about potential Human Resources can ONCALL PAY ONCALL In some departments, it is necessary to retain employees on an “on-call” status in order for the department to be covered for all emergency situations. establishes department Each on-call policies and practices to manage If you are required to be on call, your supervisor will review the schedules. Because Houston Methodist provides service to the community 24 hours Because Houston Methodist provides service many employees must work evening and night shifts. Employees a day, salaryworking these shifts may be paid an additional called shift differential, with your Check a flat hourly rate determined by job classification. Please refer to Policy this pay. supervisor to find out if you are eligible for HR 48 (Shift Differential) for additional details. SHIFT DIFFERENTIAL SHIFT The annual merit process has been designed to reward employees in annual merit process has been designed to reward The jobs. accordance with their effectiveness in their organizational merit budget, incorporate three key factors: the approved performance rating, employee’s market competitiveness, and an individual Review process. Point as determined through the annual Focal MERIT INCREASES MERIT PERFORMANCE EVALUATIONS PERFORMANCE for employees to receive an objective policy It is Houston Methodist’s their job performance on an annual basis during written review of their in performance changes Review or whenever significant Point Focal process will provide the basis for the performance evaluation warrant. The merit salaryadministration of the program. increase on base salary if you are considering a job change. You may also reference may also on base salary You a job change. if you are considering Policy HR37 (Compensation and Job Changes) for additional information. COMPENSATION AND PAYROLL PRACTICES Policy HR52 (OnCallPay). refer toPolicyHR52 policies withyouand,ifappropriate,theon-callpayrateforyourjob.Please the organizationtobestserveour patients. shift, hoursandworkassignment maychange, dependingontheneedsof thatyourunitschedule, employment, youdosowiththe understanding week, toprovideexcellentcare toourpatients.Therefore, whenyouaccept Houston Methodisthasfacilities thatoperate24hoursaday, sevendaysa WORK HOURS,SCHEDULESANDLOCATIONS supervisors immediately. each payperiod.Employeeswhofinddiscrepanciesshouldnotifytheir for each payrollperiod.Employeesshouldalsoreviewtheirpaystubs the timekeepingsystem.Managementreviewsandapproves time records period toensureworkedtimeandoff(e.g.,PTO) areaccuratelyrecorded. the Time andAttendanceSystemforaccuracyfrequentlythroughoutthepay to andincludingtermination.Allemployeesshouldreviewtheirtime cardsin another employeetoreporttimeforyouwillresultindisciplinaryactionup are properlyrecordingallhoursworkedeveryday. paperwork. Nonexemptemployeesareresponsibleforensuringthatthey calls relatedtoworkmatters,andcompletingorreviewingdepartmental phone to andsendingemailsrelatedHoustonMethodistwork,taking department management.This includesactivitiessuch asresponding commute toandfromwork)unlesstheyhavepriorapprovaltheir of theirprimaryHoustonMethodistworklocation(e.g.,athome,orduring (eligible forovertime)employeesarenotpermittedtoperformworkoutside Nonexempt Act(FLSA). work timeaccordingtotheFairLaborStandards Employees mustbepaidforalltimeworkedthatisdefinedascompensable TIME RECORDS authorizationfrommanagement priortoworkingovertime. obtain andfederal laws.Employeesshould accordance withapplicablestate Houston Methodistprovidesovertimepaytononexemptemployeesin OVERTIME Employees arehighlyencouragedtousetheemployeesign-off featurein Reporting falseinformation,reportingtimeforanotheremployeeorallowing 34 13 14 INFORMATION MANAGEMENT 15 35 Q&A I signed a At another hospital for which I worked, allow me to confidentiality agreement that will not hospital while share information I learned about that working there. My department is working on a new where I procedure. I worked on a similar procedure previously worked. My supervisor asked me to give as a reference. her a copy of their procedure to use Is it okay to give her a copy of this procedure? to your commitment No, your supervisor should respect may ask you to supervisor Your employer. your previous call information and employer for the current your former the procedure. to get permission to share Houston Methodist is committed to following applicable federal and state committed to following applicable federal Houston Methodist is designed to promote fair competition. laws are antitrust laws. These with competitors private Houston Methodist information about Talking antitrust in the Houston area) may violate (other health care institutions discuss how Houston Methodist sets its prices or should not laws. You should not agree with a competitor to boycott a supplier. salaries. You relationship you should not discuss Houston Methodist’s Additionally, with suppliers and payers, including usage rates, financial information and other contractual terms. ANTITRUST LAWS ANTITRUST The following section contains direction and guidance on dealing with section contains direction following The information, personnel records, and as business such sensitive information this section outlines procedures Additionally, medical and billing records. retention and disposal of records. regarding the accuracy, INFORMATION MANAGEMENT INFORMATION INFORMATION MANAGEMENT are correctandcomplete. Employees areresponsibleforensuringthattherecordscreatedorused andcomplywithregulatorylegalrequirements.research data, records areneededtoprovidequalitypatientcare,developvalid forrecordstobecorrect andcomplete.Correct,complete important We createmanyrecords,charts andfilesaspartofourwork.Itis DOCUMENTS ACCURACY OFRECORDS,CHARTS ANDOTHER must bedatedwiththedate it iswritten. but thenoteshouldnotbechanged andtheaddendum not bealtered. Anaddendummaybemadetothenote, Yes. Onceapatient’s chart hasbeencompleted,itmay policies? a bill.Would thisactionviolateHoustonMethodist’s sothatwecansubmit progress noteinapatientchart askedmetochangethedateona My supervisor Q&A ensure thatotherswitnessyourdeparture. the discussion.Itwouldbebesttoleavethissessionand participatein recorded, thatyoucannot youshouldstate there orifthemeetingisbeing are minutesbeingtaken You shouldnotparticipateinthisdiscussionanyway. If level. WhatshouldIdo? acceptable salary By doingso,wemightallbeabletoagreeonan share howmuchwepayalliedhealthprofessionals. suggestedthatwe health professionals.Oneperson levelsforallied discussing theincreaseinsalary at thismeeting.Duringonesession,wewere werealso Representatives fromourcompetitors I wasatatradeassociationmeetinglastweek. 36 INFORMATION MANAGEMENT You should not use You 17 If the Schedule does not does If the Schedule 16 37 Q&A My department is very and I need low on file space, files to make room for some new to throw away old away everythingones. Can I throw is greater that than three years old? Retention No. Houston Methodist has a formal Records that should be followed by everyone. The Schedule must be details Retention Schedule what records Records Retention Schedule Records kept and for how long. The is part of Information Management Procedure IM15 , which the Houston through can Tech in Policy be accessed talkMethodist intranet. If you have any questions, to your supervisor or call the Business Practices Office. list a certain should ask their supervisor or the type of record, employees should You how long the record should be kept. Business Practices Office Procedure when destroying records. follow the Records Retention Sensitive information about Houston Methodist’s strategies and operations Sensitive information about Houston Methodist’s is a valuable asset. Examples of sensitive Houston Methodist information include personnel data; patient lists and clinical information; patient financial information; passwords; pricing and cost data; information pertaining to financial data;acquisitions, divestitures, affiliations and mergers; strategic information;plans; marketing strategies; supplier and subcontractor data.and research may have access to and use sensitive Employees private is a sensitive information information to perform their jobs. Keeping legal requirement and an important ethical obligation. If you have access to sensitive Houston Methodist information, Houston Methodist trusts that Sensitive information should not you will use this information appropriately. be shared with others without appropriate permission. INFORMATION SECURITY AND CONFIDENTIALITY SECURITY INFORMATION All Houston Methodist records must be kept as long as directed by the must be kept as long Methodist records All Houston and Schedule. Procedure Records Retention RETENTION AND DISPOSAL OF RECORDS, CHARTS AND AND CHARTS OF RECORDS, AND DISPOSAL RETENTION DOCUMENTS OTHER INFORMATION MANAGEMENT information systems and sensitive data can be taken awayatanytime. can betaken information systemsandsensitivedata isaprivilege.Your data and proprietary accesstoHoustonMethodist Access toinformationsystems information andsystemssafe. Methodist’s policiesandprocedurestokeepHoustonMethodist Agreement. When yousignthisAgreement,agreetofollowHouston course ofdoingbusinesswithoronbehalfHoustonMethodist. sensitive HoustonMethodistinformationyoulearnatyourjobexceptinthe Each employeesignsaConfidentialityandInformationSecurity keep sensitiveinformationprivate. ex-husband), youare notfulfillingyourresponsibility to her husband(whoisyour the newemployeeabout in herpersonnelrecord. aconversationwith Ifyoustart No. You maynotdisclosethatyousawthisinformation husband? to myex-husband.CanItalkheraboutex- of myjob,Inoticedthatanewemployeeismarried While accessingsomeemploymentrecordsaspart Q&A 38 18 INFORMATION MANAGEMENT Employees must never 19 39 Q&A My supervisormy password so that she asked me for drive if I get sick and am unable can access my hard it okay to give her my password? to come to work. Is drive for shared No, a better practice would be to use a department working documents. Contact the Help Desk drive. for information on how to set up a shared use or disclose sensitive information that violates the privacy rights of our use or disclose sensitive information that Protected patients. (Also see Patient Care and Patient Rights: Right to Health Information.) MEDICAL AND BILLING RECORDS MEDICAL is contained most sensitive information in Some of Houston Methodist’s types of records containmedical and billing records. These information medication, family illnesses and medical condition, history, about a patient’s financial information. It is important that these records are secure and kept in a safe Access to this type of information should be limited only location. jobs. to those employees who need it to do their Much of Houston Methodist information is kept on our computer systems. systems. is kept on our computer information of Houston Methodist Much It is very important One way systems remain secure. these computer that secure is by safeguarding computer systems we keep our computer our secret and not share it with should keep your password passwords. You you should not allow your User IDanyone. In addition, to be used by password down or keep it in an should not write your another person. You secure, believe that your password is no longer accessible place. If you and inform your supervisor. it immediately you should change COMPUTER PASSWORDS COMPUTER INFORMATION MANAGEMENT administer itsemploymentandbenefitprograms. the personalinformationitneedstoconductbusinesseffectively and any employee’s fileorrecord.HoustonMethodistonlycollectsandretains disclosuresofinformationfrom and preventinappropriateorunnecessary makes everyefforttoprotectanemployee’s privacyrightsandinterests, anddisclosingpersonnelinformation,HoustonMethodist maintaining Methodist whohaveavalidneedtoreviewthefiles.Incollecting, Access topersonnelfilesispermittedonlyindividualswithin Houston operations such asattendancerecords. nature pertinenttodepartmental documentsofamoretemporary filethatcontains and adepartmental byHuman Resources records consistofofficialmaintained sensitiveinformation.PersonnelPersonnel recordsoftencontain PERSONNEL RECORDS worship service,etc.). announcement at family tellsyouofhishospitalization, from sources thatdonotviolatehisrighttoprivacy(his hishospitalization asked youto,oriflearnabout directory forvisitors,ifheorhisfamilyhas hospital law. ifheislistedinyour isokay Visiting yourneighbor your neighbor’s privacyrightsunder federalandstate to performyourjob.Accessingthisinformationviolates No. You donotneedtoaccessthishealthinformation how heisdoing? admitted to.CanIcheckhismedicalrecordtosee the hospital.Idonotworkonunithehasbeen Myneighbor has beenadmittedto I amanurse. Q&A 40 20 DISCIPLINARY ACTION 41 21 Day-to-day coaching and counseling are positive forces in helping and counseling are positive forces Day-to-day coaching treatment when Employees have the right to fair and consistent MANAGING PERFORMANCE MANAGING standards,All employees have the responsibility to follow as those such policies, procedures, departmentalestablished practices and by law, to report to employee also has the responsibility job descriptions. Each standards.management any violation of such of counseling type This employees do their best job for the organization. before formal make changes is used as a means to help the employee are considered corrective measures corrective discipline is applied. Formal necessary with repeated and/or serious violations of Houston Methodist standards.policies and procedures and performance measures These of job duties and performance include, but are not limited to, being advised expectations, counseling with formal documentation, following a on suspension without pay, performance improvement plan, being placed or other disciplinary body, being reported to the appropriate licensing action up to and including termination. Methodist has establishedprogressive discipline is initiated. Houston progressive discipline is carried performance management to ensure that out in an appropriate manner. PENALTIES FOR NONCOMPLIANCE PENALTIES for maintainingEveryone is equally responsible high standards of lawful to disciplinary regulatory compliance violations will lead Legal and behavior. termination of employment and may involve action that may include governmental, prosecution, in addition to exclusion from civil and/or criminal business. and other federal health care program participation in Medicare The following section contains information about disciplinary action that section contains information following The Methodist to violations of the law or Houston may be taken in response standards. DISCIPLINARY ACTION DISCIPLINARY DISCIPLINARY ACTION WORKPLACE VIOLENCE . PolicyHR03 appropriatesteps.See HR Methodist take promptly aspossibleandprovideavailableinformationtohelpHouston management,HumanResources ortheSecurityDepartmentas contact terminationofemployment. Methodist, which mayincludeinvoluntary the workplace.Violators maybesubjecttocorrectiveactionbyHouston indirect threatsoraggressiveactsofviolentbehaviorwillnotbetolerated. effectively intheeventsuch actsorthreatsofviolenceoccur. Anydirector environment freefromverbalthreatsoractsofviolenceandtorespond andproductivework It isHoustonMethodistpolicytopromoteasafe If yoususpectthataviolationofthispolicyhasoccurred,should in Acts ofintimidation,bullyingandcoercionarealsounacceptable 42 EMPLOYEE BENEFITS 22 23 43 platform and retirement plans. TM Many of the benefit plans and programs are paid entirely by Houston Many of the benefit plans and programs are This section highlights the many benefit plans available to eligible section highlights the many This Methodist. Some of the voluntary benefit plans and programs are paid as shown on page 45. either partially or fully by you, the employee, Employees are encouraged to continue their formal education in order Employees are encouraged to continue their Houston Methodist provides to improve their professional competence. eligible dependents to assist programs to benefited employees and their with educational expenses. EDUCATIONAL ASSISTANCE PLANS ASSISTANCE EDUCATIONAL BEREAVEMENT LEAVE BEREAVEMENT (maximum of 24 hours) absence Bereavement leave pay of up to three days employees when a death per occurrence may be granted for eligible be reflected accordingly on the occurs in the immediate family and should time card. Please refer to Policy HR47 (Bereavement for additional leave) immediate family. information, including who is considered Houston Methodist is proud to offer a comprehensive employee benefits proud to offer a comprehensive employee Houston Methodist is represent a sizable portion of totalprogram. Our benefits rewards and is employees protection and a measure of security for designed to provide and their families. HR questions, please direct them to your employees. If you have or HRdepartment at your entity . Most benefits Benefits at 832.667.6211 you have standardprograms require that hours of at least 20 hours, and not be considered PRN to be eligible. Exceptions include or temporary the employee assistance program, transportation, and parking subsidy Employee through YouDecide’s program, wellness, and volunteer benefits Advantages The following section contains information about the benefits that are section contains information following The families. and their available to employees EMPLOYEE BENEFITS EMPLOYEE EMPLOYEE BENEFITS requirements, isavailablefromtheTuition 45. ReimbursementPolicy HR oneligibility class. Informationonthisprogram,aswellspecificdetails any pre-approval forreimbursementisrecommendedbeforetaking Courses mustberelatedtothebusinessofHoustonMethodistand accredited institutionandreceivesanequivalentgradeofCorbetter. reimbursed iftheemployeeisenrolledinadegreedprogramatan Eligible tuitionexpensesforemployeesinaneligibleclasswillbe Tuition Reimbursement regular biweekly contribution toward the cost of the coverage. An employee regular biweeklycontributiontoward thecostofcoverage.Anemployee maycontinuegrouphealthinsurancecoverage andpaythe approved FML leave.Anemployeeon backward fromthedateanemployeeusesanyFMLA illness. The 12weeksaremeasuredina“rolling”12-monthperiod measured leaveorseriouspersonalfamily a rolling12-monthperiodforparental of unpaidleave,or480hoursifusedoccasionally, butnotall at once,in of1993providesupto12 weeks The FamilyMedicalLeaveAct(FMLA) FAMILY MEDICAL LEAVE Practices andWorkplace AlcoholandDrugsintheWorkplace. Behavior: ) theHumanResourcesDepartment.(SeealsoEmployment or contact counseling sessionsfreeofcharge. Askyoursupervisorformoreinformation and yourimmediatefamilymaybeprovidedwithuptothreeprofessional problems, familyalcohol/drugabuseandfinancialproblems. You families forawiderangeofissues,includingstress,depression,relationship to provideprofessional,confidentialcounselingforemployeesandtheir energy andenthusiasmintotheworkplace.The EAPisabenefitdesigned in relievingpersonalstress,which willenabletheemployeetobringmore Program(EAP)toassistemployees and providestheEmployeeAssistance Houston Methodistbelievesthatitsemployeesaremostvaluableresource EMPLOYEE ASSISTANCE PROGRAM approved programsleadingtoadegreeinhealthcare-relatedfields. College scholarships areprovidedtoapprovedchildren whoareenrolledin College Scholarships forChildren ofEmployees continuous yearsinafull-timeorpart-timeposition. child’s parentmusthavebeenemployedwithHoustonMethodistfortwo 44 27 The 27 EMPLOYEE BENEFITS • • • • • • Employee Employee Before-Tax • • • • • Aer-Tax Employee Employee CONTRIBUTION • • • • • • • • ••• • • • • • • Houston Methodist 45

HEALTH AND WELFARE PLANS WELFARE AND HEALTH Drug plan Medical and Prescription 403(b) Tax-Sheltered Annuity Plan Tax-Sheltered 403(b) RETIREMENT PLANS RETIREMENT Defined Contribution plan ADOPTION ASSISTANCE PLAN ADOPTION ASSISTANCE Back-Up Care/Concierge Care Legal Assistance College Coach Benefit Programs Voluntary Flexible Spending Accounts (Health and Spending Accounts Flexible Dependent Care) Short-Term and Long-Term Disability plans and Long-Term Short-Term and Parking Transportation Subsidy program Employee Assistance program Employee programs Wellness Educational Assistance plans Paid Time Off program Time Paid Holidays Optional Employee Life Insurance plan Insurance Life Optional Employee plan Insurance Optional Dependent Life plan AD&D Insurance Voluntary Dental plan Death and Accidental Life Basic Employee plan & Dismemberment (AD&D) BENEFITS PROGRAM BENEFITS Vision plan HOUSTON METHODIST HOUSTON EMPLOYEE BENEFITS supervisor or contact theHuman ResourcesDepartmentattheirentity.supervisor orcontact eligibility withtheir orFML encouraged todiscussquestionsregardingFML position thantheywouldhavehadifremainedatwork.Employeesare these employeeshavenogreateremploymentprotectionforaspecific ortoanequivalentposition.However,employee atthetimeleavestarted tothepositionheldby willnormallybereinstated returning fromFML arrangements topayforbenefits whileonleave. BenefitsDepartmenttomake theHR the leaveofabsence.Contact benefitsduring leave. Eligibleemployeesmaycontinue healthanddental leave,orpersonal ormedicalleave,military absence mayincludedisability work withoutgivingupseniorityandemployeebenefits.Unpaid leavesof A Leaveofabsencemaybegrantedtoallowemployeestime away from LEAVE OFABSENCE premium willbepaidforworkingontheseextradaysdesignated asholidays. after theseholidayswillbeawardedasadditionalholidays.No holiday holidays. When ChristmasandNewYear’s DayfallonaThursday, theFridays Tuesday, theMondaysbefore theseholidayswillbeawardedasadditional time workedontheactualholiday. holiday differsfromtheactualholiday, holidaypremiumwillonlybepaidfor holidays oronthefollowingMondayforSundayholidays.Ifobserved the holidaywillbeobservedeitheronprecedingFridayforSaturday holiday itselfunlessthefallsonaweekend.Insuch acase,usually the eveningshiftonactualholiday. Holidaysareobservedontheactual the nightshiftimmediatelyprecedingactualholidayandendingwith with holiday premiumispaidtoeligibleemployeesfortimeworkedstarting pay (includingshiftdifferential)forhoursworkedontheactualholiday. The additional holidaypremiumpayatarateofone-halftimestheirregularbase day afterThanksgiving, ChristmasDayorNewYear’s Daywillbepaidan holidays. Nonexempt regular employees who work onThanksgiving Day, the appropriate patientcare,someemployeesmayberequiredtoworkon for holidaysimmediatelyuponemployment.However, inordertoprovide All full-timeandpart-timeemployeesareeligibleforpaidtimeoff(PTO) HOLIDAYS EXTRA HOLIDAYS:EXTRA When ChristmasandNewYear’s Dayfallona 46 24 EMPLOYEE BENEFITS 47 26 25 HEALTHYDIRECTIONS wellness programs to supportHouston Methodist offers a wide variety of to wellness. A variety ofour employees and spouses in their journey vendors, including Houstonwellness programs are available through multiple more information Methodist facilities. For at all Houston Methodist Wellness, MyHR.HoustonMethodist.orgon these programs, go to the Hot Spot on . Houston Methodist recognizes the importance of its employees. To Houston Methodist recognizes the importance of its employees. To reward their dedication and outstanding performance, Houston Methodist recognition programs and sponsors a variety of employee reward and activities, may include service awards, holiday season events, which departmental recognition programs and other special events that are care industry. typically celebrated throughout the health REWARD AND RECOGNITION PROGRAMS REWARD Houston Methodist provides retirement savingsHouston Methodist provides plans for employees to program The program for their retirement years. help them build a financial Annuity Sheltered Plan and 403(b) Tax includes a Defined Contribution Plan. Specific details for and provisions of this program regarding eligibility may be obtained from MyHR.HoustonMethodist.org or the Human Resources Department at your entity. RETIREMENT Houston Methodist offers time off with pay, which may be used for which off with pay, offers time Houston Methodist emergencies (or other severe weather personal reasons, vacation, holidays, All short-term illness. family or personal disruption), and types of business employees whose standard are greater than 20, and not in a PRN hours beginning the are eligible to use their accrued PTO or temporary position, with the must be in accordance Requests for PTO first day of employment. guidelines. department’s PAID TIME OFF
PTO TIME PAID EMPLOYEE BENEFITS WORKERS’ COMPENSATION INSURANCE information: Benefitsforfurther HR have oneofthefollowingqualifyingevents,contact otherwise wouldhavestopped.Ifyouand/oryoureligibledependent(s) periodwherecoverage This provisionextendsyourcoverageforacertain spending accountcoverageforanextendedperiodthroughCOBRA. Coverage willendforthefollowingreasons: TERMINATION OFBENEFITSCOVERAGE Act. Compensation injury withbenefitsequaltothosedefinedundertheTexas Workers’ anoccupational Methodist willprovideanemployeewhosustains by anemployeeinjurypolicyprovidedHoustonMethodist. Employees arecoveredagainstlossofearningsduetoinjuriesonthejob Deathofemployee • Dependentchild reaches age ofineligibilityorbecomesineligibleby • Divorce • Reductioninworkinghoursplacingyouineligiblestatus • Termination orinvoluntary) ofemployment(voluntary • You andhealthcare mayhavetherighttocontinuemedical,dental Additionalreasonsidentifiedinplandocumentsforspecific • Termination ofabenefitplan • Unpaidpremiumpaymentseitherduringactiveemploymentorleave • • Termination ofemployment •

plan provision benefit plans of absence hoursoremployee typethatisineligibleforbenefits Change instandard 48 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR Employee Benefits: (Also see Employee 28 49 Employee Assistance Program.) Employee To create a safe environment — free from infection/transmission of To disease — and to protect our patients, employees, and the community, ANNUAL INFLUENZA IMMUNIZATION ANNUAL As part of Houston Methodist’s commitment to safeguarding commitment to the health of As part of Houston Methodist’s employees, providing a safe place for employees to work, and supplying care and service possible, our customers with the highest-quality patient manufacture, distribution, Houston Methodist prohibits the unlawful controlled substancesuse or possession of alcohol, drugs or other on encourages prevention its premises or worksites. Houston Methodist and treatment of substance abuse through education, counseling and rehabilitation programs. Assistance is available through Houston Employee Assistance Program. Methodist’s ALCOHOL AND DRUGS IN THE WORKPLACE THE AND DRUGS IN ALCOHOL ACCOMMODATIONS FOR DISABILITIES ACCOMMODATIONS reasonable accommodations to qualifiedHouston Methodist provides individuals with disabilities job. may perform the essential functions of a so they disabilities employees requiring accommodations for Any Houston Methodist to their manager and/orshould provide a written request for accommodation disabilitiesHuman Resources Department. For that are not known or obvious, will be requested. explanation of the required accommodation a physician’s will be discussedRequests that cannot be reasonably accommodated Human Resources, andin an interactive process between the employee, (Refer to HRManagement to identify alternatives when possible. Policy 36.) The following section contains information to serve section contains information following guide and as a The management, in carrying out their including reference for all employees, and equitable manner. duties in a consistent WORKPLACE BEHAVIOR WORKPLACE EMPLOYMENT PRACTICES AND AND PRACTICES EMPLOYMENT EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR termination ofemployment. deadlines each yearincludesuspensionwithoutpayandcanalsoleadto failure tocomplywiththeannualinfluenzaimmunizationprogrambystated protocolsasinstructed by HoustonMethodist.Consequencesfor safety from immunizationmustfollowingspecificinfluenzatransmissionprevention immunization orsubmissionofannualrequestforexemption.Those exempt with theannualinfluenzaimmunizationprogram.Complianceincludes mustcomply students, volunteersandvendorswithdirectpatientcontact all HoustonMethodistemployeesandanycontractedclinicalpersonnel, encourage the presentation offactualandbalancedstories. encourage thepresentation through thenewsmedia.Houston Methodistcooperateswiththemediato Houston Methodist’s imageisportrayedto currentandpotentialpatients CONTACTS WITH THE MEDIA as-needed basis. reviews ofeducation,credentials,drivingand/orconvictionrecords onan (CredentialsMonitoring). accordance withPolicyHR79 certifications willresultinunpaidsuspensionandpossiblytermination in allrequiredlicensesand and certificationsuptodate.Failuremaintain appropriate. Employeesarerequiredtokeepallregistrations, licenses licensure orcertifications),drivingrecordsandconviction as related toeducation,credentials(such asprofessionalregistration, current andformeremployersaboutyourworkrecordverify information willask Upon employment,HoustonMethodistoritsrepresentatives BACKGROUND ANDCREDENTIALS VERIFICATION performance review. fellow employees.Your attendancerecordisamajorconsideration in your work and placeanundueburdenon patient care,interferewithnecessary assigned workday. impairtheeffectivenessof Absenteeismandtardiness breaks ormealperiodsandremainatworkuntilthecompletionof workdays, beontimereportingtoworkandreturningfromauthorized Employees havetheobligationtobepresentatworkonallassigned ATTENDANCE Houston Methodistreservestherighttoperformadditional,updated 33 29 50 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR

31 30 51 Q&A A reporter He is gathering called me at work. Houston information on a rumor he heard about he would Methodist. He stated he called me because like my opinion. What should I do? ask a System spokesperson, you should Unless you are to contactthe reporter Public Relations at 832.667.5809. However, since Houston Methodist’s first responsibility is to protect its first responsibility is since Houston Methodist’s However, Employees, other than designated spokespersons, should not talk designated spokespersons, should not Employees, other than to the Methodist business or patient information news media about Houston guidelines the Public Relations Department. These without clearance from (IM)13are found in Information Management . COPYRIGHT or alteration of copyrightedUnauthorized duplication, reproduction, distribution is a violation of the owner, materials, without the express written consent This of federal copyright law and could result in civil and/or criminal liability. includes computer programs, databases and related documentation owned by the party with whom you are dealing or by another party. Houston Methodist provides guidance to management on the appropriate Houston Methodist provides guidance to Methodist to ensure compliance use of contingent workers within Houston with federal and state laws and regulations. All contract and temporary must be screened by HRworkers, including independent contractors, for Houston Methodist. before they are allowed to perform any services Refer to Human Resources Policy 82. CONTINGENT WORKERS
INDEPENDENT CONTRACTORS, CONTRACTORS, WORKERS
INDEPENDENT CONTINGENT EMPLOYEES TEMPORARY AND AGENCY, patients’ well-being and privacy, it has developed guidelines for releasing has developed guidelines it and privacy, patients’ well-being It is important for Houston privacy. and protecting patient information to maintainMethodist the news the public through consistent image with a exposure to it is necessarymedia. At times, Methodist’s to limit Houston this reason, comments could be inappropriate. For the news media where are designated to speak to the news media. official spokespeople EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR at theirentityforassistance. the Human ResourcesDepartment Employees areencouragedtocontact employee whoexerciseshisorherrighttoresolveconflictsinthismanner. againstany confidential asthelawpermits.There willbenoretaliation treatment willbeinvestigatedpromptly, thoroughlyandsecurelykept to-day problemsolvingchannels. Concernsofunfair, orunlawful unsafe andtheirdisputescannot beresolvedthroughnormalday- inequitably Department tovoicetheirconcernsiftheyfeelhavebeentreated Employees areprovidedanavenuethroughtheHumanResources DISPUTE RESOLUTION software onHoustonMethodistcomputerequipmentisprohibited. loading ofunauthorizedcopiescomputersoftwareorusingpersonal patent, tradesecretlawsorasconfidentialinformation.The creationor that ariseduringyouremployment. Please callyourHumanResourcesDepartmentforhelpwithanysituations supervisor, isalwaysavailable. theHumanResourcesDepartmentstaff Questionable Practices.) Software isprotectedbycopyrightlawsandmayalsobe If thereareanyquestionsorissuesyoucannotfirstresolvewithyour 36 Ethics and Compliance: Report Report (AlsoseeEthicsandCompliance: 52 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR 32 53 Communications that may defame Houston Methodist, employees, Communications that may defame Houston Use of Social Networking Sites while using Houston Methodist Employee use of a social networking site time should be restricted computing resources and while on work and objectives, and are in to activities that support Methodist goals and policies. Posting values accordance with Houston Methodist’s patient is strictly prohibited information related to a Houston Methodist and may be a violation of HIPAA Houston Methodist laws. Posting confidential or proprietary information is also strictly prohibited. that in any way imply Employees may not present personal opinions are found in guidelines endorsement by Houston Methodist. These Information Management (IM) 26. Houston Methodist policy regarding the use and monitoring of communicationsHouston Methodist policy and telephone communications systems,systems includes electronic systems, to mail, email, courier services, telephone including but not limited video equipment and tapes, fax machines, voice mail, answering machines, tape and recordings, pagers, cellular and smartphones, computer recorders Houston Methodist technology networks, and computer directories and files. for business purposes onlyand/or equipment should be used primarily transmitted, received, orand all communications and stored information containedin the Houston Methodist information systems are the property of Houston Methodist. as offensive, harassing, vulgar, customers, vendors or competitors as well are prohibited. obscene or threatening communications ELECTRONIC COMMUNICATIONS SYSTEMS USE SYSTEMS COMMUNICATIONS ELECTRONIC It is the policy of Houston Methodist that solicitation of Houston Methodist It is the policy of employees and/or or solicitations in any manner, matter, by employees of printed distribution or Methodist property within Houston will not be permitted including email, non-work premises, except in non-work areas during on Houston Methodist materials are prohibited from soliciting or distributing time. Nonemployees premises at all times, although some vendor on Houston Methodist’s Policy HR21 See exclusions may apply. . DISTRIBUTION AND SOLICITATION DISTRIBUTION EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR EMPLOYEE IDENTIFICATION Methodist hastherighttosearch andinspectallHoustonMethodist to knowandreviewactivitiesconducted inoronitsproperty. Houston operatingconditions.HoustonMethodisthastheright by lawandsafe An employee’s righttoprivacywillberespected totheextentpermitted INFORMATION IN THE WORKPLACE EMPLOYER’S RIGHT TO ACCESS EMPLOYEE participants tobecomeeffectivemanagersatHoustonMethodist. informationandproceduresfor provides aconciseoverviewofnecessary program.The session is requiredtoattendamanagementorientation are employed. level,dependingontheentityatwhich you program oratthedepartmental employee willbeworking. specific policiesandproceduresthatapplytothedepartmentinwhich the withinthefirsttwoweeks ofemploymentforinstructionon orientation practice compliancestandards. responsibilities, performanceimprovementprinciplesandethicalbusiness and goalsofHoustonMethodisttheirrespectiveentity, departmental to familiarizeallnewemployeeswiththehistory, mission,vision,values In additiontoabenefitsoverview, programisdesigned theorientation program. months) arerequiredtoparticipateinanemployeeorientation are rehiresandhavenotworkedforHoustonMethodistmorethansix volunteers andinternsnewtoHoustonMethodist(includingthosewho New employees(full-time,part-timeandtemporary),contractpersonnel, EMPLOYEE ORIENTATION identification orthemagneticbadgereader, ifapplicable. may beaffixedtothebadgeholderwithoutobstructingpicture,name however, anofficialservicepinorotherprovidedbyHoustonMethodist tothebadge; badge displayed.Nodecorationsorjewelrymaybeattached above thewaist,preferablynearcollar, witheach picture sideofthe Two badgesareprovidedtoyoubyHoustonMethodistandmustbeworn Employees arerequiredtowearanidentificationbadgewhileonduty. Each newmanagementhireorinternalpromotioninto placeeitherinthenewhireorientation in-servicemaytake A safety Employees arealsorequiredtoattendandparticipateinadepartmental 54 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR 55 discouraged. to another relative. and balance” processes that minimize financial/legal/ of “check noncompliance risk to the organization. For purposes of this policy, “relatives” will include an employee’s spouse, will include an employee’s “relatives” purposes of this policy, For but may limit certainHouston Methodist may hire relatives of employees, . Employment of relatives within the same department is strongly . of command Employees may not report directly or through the chain . Employment of relatives in areas where there could be an erosion EQUAL EMPLOYMENT OPPORTUNITY EMPLOYMENT EQUAL and just concept to which Equal employment opportunity is a sound Methodist will not engage in Houston Methodist is firmly bound. Houston person employed or seeking discrimination against or harassment of any religion, basis of race, color, employment with Houston Methodist on the or mental national origin, physical sex, sexual orientation, gender identity, marital status, medical condition, ancestry, citizenship, or statusdisability, veteran or special disabled Methodist veteran. Houston as a Vietnam-era will ensure that all applicants and employees receive equal employment including policy applies to all employment practices, This opportunity. training merit increase, salary, recruitment, selection, promotion, transfer, and development, demotion, and termination of employment. Houston Methodist recognizes that from time-to-time employees may that from time-to-time employees Houston Methodist recognizes our members who may seek employment with have immediate family and/ the course of their personal relationships organization, or through may become related to other Houston changes, or job or organizational with whom they work. It is Houston Methodist’s Methodist employees policy to select and retain qualified individuals for all positions and the best to maintain that promotes teamwork and fair treatment a work environment of favoritism or conflicts of interest. while minimizing perceptions grandparents (including in-law and step siblings, parents and children, relation in-laws). situations to reduce potential conflict of interest. EMPLOYMENT OF RELATIVES EMPLOYMENT premises, property, equipment and work products occupied, held, used or held, used or work products occupied, equipment and property, premises, employees. by Houston Methodist generated EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR for HoustonMethodistemployees andsponsoredvisitors.With theexception responsible fortheoversightand processingofallpetitionsforsponsorship Servicesinthe SystemHumanResourcesDepartmentis HR-Immigration Sponsorship ofForeign Nationals Houston Methodistworkoractivities. being grantedaccesstoHoustonMethodistpremisesorparticipating in visitorsmustbescreenedforexportcontrolcomplianceprior to HMHRI ensure compliance,allemployees,observers,students,volunteers and lawsandregulations.Toin accordancewithexportcontrolandsanctions granted accesstoinformationorlocationsonHoustonMethodist premises activitiesorbeing nationals mayberestrictedfromparticipatingincertain Foreign card holder),orisapersongrantedU.S.refugeeasyleestatus. who isnotaU.S.citizenorlawfulpermanentresidentofthe U.S.(green . PolicyBP32 Control the U.S.orabroad.RefertoExport technology verbally, inwriting,or anyotherwaytoaforeignnationalin transporting ofphysicalitemsaswellprovidinginformationor This includestheshipping/ and informationoutsideoftheUnitedStates. regulations governandsometimesprohibitthetransferofitems,software, lawsand governmentexportcontrolandsanctions The UnitedStates Export Control andSanctionsCompliance FOREIGN NATIONALS improvement andneverallowsittoreflectagainstanyperson. practices. HoustonMethodistusesthisinformationtopromote to theimprovementofpatientcare,workingconditionsandmanagement you endemployment.Informationgatheredthroughthisprocesswilllead Houston Methodistmayrequestyoutoparticipateinanexitinterviewwhen EXIT INTERVIEW of management. If youfeelhavebeendiscriminatedagainst,pleaseseektheassistance other kindofharassmentpatients,visitorsorco-workersisprohibited. Within HoustonMethodist,theterm“foreignnational”referstoanyone Engaging indiscriminatorypracticesorsexual,racial,religious,any 34 56 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR 57 Employment Practices and Workplace Behavior: Practices and Workplace (Also see Employment 34 Foreign nationals sponsored by Houston Methodist are required to Methodist are required by Houston nationals sponsored Foreign Regulations regarding conflicts of interest may impact Houston Methodist’s may impact Houston Methodist’s Regulations regarding conflicts of interest ability to hire former or current United States government employees or Resources before hiring a fiscal intermediary employees. Consult Human person with this background. HIRING FORMER AND CURRENT GOVERNMENT AND AND GOVERNMENT HIRING FORMER AND CURRENT EMPLOYEES INTERMEDIARY FISCAL HARASSMENT a work environment free Houston Methodist is committed to providing from all forms of harassment, exploitation or intimidation, including sexual, Methodist member of the Houston racial and/or religious harassment. Each respect, for being familiar community is responsible for fostering mutual This and for refraining from conduct that violates this policy. with this policy, employees, patients, members, policy applies to all individuals, including staff,visitors, members of medical and/or house students, volunteers, any employee is strictly contractors and vendors. Harassment by/of prohibited. Employees on Visas Not Sponsored by Houston Methodist by Not Sponsored Employees on Visas work authorization in the United StatesEmployees with temporary are and the expiration of their work authorization responsible for monitoring with USCISapplying for extensions who as soon as permitted. Employees evidence authorization and/or who fail to present fail to renew their work acceptable no later than the last I-9 will be terminated for renewing Form day of their work permission. of legal counsel, no employees outside the HR-Immigration no employees of legal counsel, Services advice or to provide immigration-related have the authority to Department federal government. to be filed with the or petitions prepare applications maintain their visa with the provisions of compliance at all categories these provisions include but are not sponsored foreign nationals times. For to prohibition work locations, hours, activities, and the limited to permissible prior approval by HR-Immigration. activities without transfer or change Equal Employment OpportunityEqual Employment .) EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR JURY DUTY from workingduringthisperiod. Ifyouaresubjecttoanautomaticmeal should generallybeanuninterrupted periodoftime20minutesormore. themealperiod Act(FLSA), employee undertheFairLabor Standards from workedhours).For amealperiodtobeunpaidfornonexempt scheduled bymanagement. relax. The timeformealsand,ifopportunitypermits,restperiodswillbe during each scheduled workdayshouldhaveanopportunitytoeatand Although notlegallyrequired,employeeswhoworkatleasteight hours MEAL ANDREST PERIODS care isnotcompromised. concerns orconflictswillbeevaluatedandresolvedsothatthe qualityof concerns mayrequestnottoparticipateinanaspectofpatient care.Such aspect ofapatient’s planofcareortreatment.Employeeswhohavesuch strongly heldvaluesandbeliefsthatcauseconcernorconflictwithsome available. HoustonMethodistalsorecognizesthatemployeesmayhave Houston Methodistisdedicatedtoprovidingthebestmedicalcare MANAGING STAFF REQUESTS employeeswhileatwork. forlactating sanitation required toprovideaccessiblelocation(s)allowingforprivacy, and safety continue workingandbreastfeeding.AllHoustonMethodistentitiesare Management istoencourageandsupportemployeesintheirefforts as ameansofpromotingthehealthbothchild andtheparent. pregnant andpostpartumemployeestoconsidernursingtheirchildren Houston Methodistisafamily-friendlyemployerandencouragesallofits LACTATION ACCOMMODATION (JuryDuty). noted onthetimecardinaccordancewithPolicyHR69 Check withyoursupervisorforeligibilityrequirements.Jurydutymustbe employees whoarerequiredtoreportforjurydutyonascheduled workday. tofull-timeandpart-time Houston Methodistwillpayregularbasesalary In recognizinganemployee’s responsibilitytoperformhisorhercivicduty, Your unpaidmealperiodisyour owntimeandyoushouldrefrain Meal periodsaregenerallyunpaid (i.e.,timespentat“lunch” isdeducted 37 58 36 35 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR 59 If I work an eight-hour shift, how many paid breaks If I work an eight-hour shift, how many am I guaranteed? that employees receive FLSA does not require The Depending on operation needs, some paid breaks. per breaks departments allow one or two brief paid manager can additional information provide shift. Your departmental breaks. regarding Q&A If visiting a patient, please observe the visiting hour schedule and guest If visiting a patient, please observe the visiting hour schedule Some departments allow, but are not required by the FLSA to offer, but are not required by the FLSA to offer, Some departments allow, Employees who are off-duty are not to remain on the premises of the Employees who are off-duty are not to remain hospital other buildings unless they are visiting a patient or unless and/or they have official business to conduct. procedures. Please refrain from interrupting the work of any check-in friends or co-workers who are on duty. OFFDUTY EMPLOYEES OFFDUTY deduction in the Time and Attendance System and you takeand Attendance System in the Time deduction a meal period deduction, you must than your automatic of time more or less for an amount your time card Review accordingly. your time card is corrected ensure that meal periods are to ensure unpaid throughout the pay period frequently to use the employee are highly encouraged reflected. Employees accurately with their timekeeping system to indicate agreement sign-off feature in the calculated hours. less than short duration running from 5 minutes to one or two breaks of It is up to the discretion of department workday. 20 minutes during the if breaks are allowed based on operational management to determine are breaks from unpaid meal periods. When needs. Breaks are different 20 paid as work time unless they exceed allowed, they are generally breaks with an unpaid meal period may not combine paid rest minutes. You leave work or forego the meal period in order to to extend the meal period periods. Any may not leave the work premises during paid rest You early. be addressed breaks or meal periods may late returns from scheduled through Policy HR04 additional information on meal and (Attendance). For rest periods, please see Policy HR67 and Hour Compliance) (Wage . EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR OUTSIDE EMPLOYMENT supplies (such asemailsystem,officesupplies,andphonesystem), and byHoustonMethodist,money,time compensated space,equipmentand organization. HoustonMethodist resources,includingbutnotlimitedto office isstrictlyprohibitedbecause HoustonMethodistisanonprofit Campaigning, directlyorindirectly, fororagainst anycandidateforpolitical opposition topoliticalcandidatesandtheoutcomeof campaigns. authorization byHoustonMethodistVice PresidentforGovernmentAffairs. Methodist, letterheadorbusinesscards,maybeusedwithout prior Houston Methodist,includingemail,personaldevicesprovided byHouston Even whenactingasanindividualinapersonalcapacity, noresourcesof toadvocateonaparticularissue. theirpoliticalrepresentatives contact orpatientsto Government Affairs.This includesencouragingotherstaff a positiononanyissuewithoutfirstconferringwiththeVice Presidentfor fororagainst personnel shallnotadvocatetogovernmentofficialsorstaff positions onissuesthatimpacttheentireorganization.Houston Methodist its GovernmentAffairsDepartment,engagesincommunicatingpolicy apositionfororagainst anissue.HoustonMethodist,through to take activity orcommunicationthatattemptstoinfluenceofficialsthepublic Government communications,alsoknownaslobbyingoradvocacy, isan PARTICIPATION INPOLITICAL ACTIVITIES have questionsregardingparkingandtransportation. optionsmaybeavailable. Check withmanagementifyou transportation to anemployee’s automobilewhileinparkingfacilities.Othersubsidized Houston Methodistdoesnotassumeresponsibilityfortheftordamage regulations. Failuretodosomayresultinrevocationofparkingprivileges. Employees areexpectedtocomplywithallparkingfacilityrulesand either adjacenttotheworksiteorataremotefacilityfewminutesaway. Where applicable,subsidizedparkingmaybeavailableforemployees PARKING AND TRANSPORTATION ofInterest.) Conflicts Methodist. (SeealsoEthicsandCompliance: activity orfull-timeworkthatinterfereswiththeirdutiesatHouston Houston Methodist.Full-timeemployeesmaynotparticipateinanoutside Outside employmentmustnotinterferewithyourrequireddutiesat Political activity, alsocalledelectioneering,involvessupportor 60 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR 61 Q&A to emailMy friend is running for office. Is it okay some of my co-workers and friends at Houston campaign event? Methodist to let them know about a should not use Houston Methodist resources, No. You or Houston fax machine, as email, copy machine, such Methodist letterhead for political purposes. mandatoryIs it okay to bring my friend to our next staff meeting so she can meet my co-workers and tell them about her campaign? co-workers to to force No. It is not appropriate co-workers participate in any political activities. Your would you must attend this staff meeting. Therefore, them to participate in this politicalbe forcing activity. this political activity would takeAdditionally, place during you with work. Therefore, work hours and interfere should not bring your friend to the staff meeting to talk about campaign. her has beenA bill on limiting smoking in public places CEO communicates the importance proposed. Your of this legislation to promote reduced smoking with the attendant health benefits. He asks you to communicate with your state representative Houston Methodist respects its employees’ right to vote and to take its employees’ right to vote and Houston Methodist respects reputation, of anyone oppose the election used to promote or may not be state campaigns for local, prohibitions apply to These for public office. and as well as offices committees (PACs), and political action national offices, Under no circumstancesin other countries. Houston you represent should in any political activity. Methodist these activities must take place on However, part in political activities. a personal time and at their own expense. If making the employees’ own never statecampaign contribution, or imply that the political contribution is or appear to pressure co- should not force You from Houston Methodist. Houston Do not involve in or support political activity. workers to participate in your personal political causes. Methodist or co-workers EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR have knowledgethatanotherHouston Methodistemployee,acontractor vendors musttelltheappropriate HoustonMethodistpersonnel.Ifyou your supervisor. members,alliedhealthprofessionalsand Medicalstaff that havebeenexcludedfromfederal healthcareprograms. Methodist cannotemployordo businesswithindividualsororganizations grants. BecauseHoustonMethodistparticipatesintheseprograms, Houston and research fundedbyfederalgrantssuch asNationalInstitutesofHealth participating ingovernment-fundedprogramssuch asMedicare,Medicaid, governmentscankeepindividualsandorganizationsfrom Federal andstate FUNDED PROGRAMS MEDICARE, MEDICAID ANDOTHER GOVERNMENT PERSONS ORORGANIZATIONS EXCLUDED FROM Mailboxes foroutgoingpersonalmailareavailableyourconvenience. facilities asyourpersonalmailingaddress,exceptforprofessionaljournals. Houston Methodistrequeststhatyounotuseanyofthe PERSONAL MAIL anduniformrequirements. concerning safety the appropriatedressfortheirdepartment,includingspecificregulations grooming duringworkhours.Managementwillinformemployeesasto required toexercisegoodjudgmentinmattersofappearance,attireand at alltimesandwearappropriateprofessionalapparel.Each employeeis All employeesarerequiredtopresentthemselvesinaprofessionalmanner PERSONAL APPEARANCE If youcannotparticipateingovernment-funded programs,youmusttell as grassroots advocacy or“spreadingas grassroots theword.” advocacy others youknowonthesameissueisalsowhatknown purpose oftheinstitution.Your to furthercommunication purpose, which hasadirect relationship tothehealthcare peopleonthebillandits toeducate communication Yes. Your CEOhasinitiateda“grassroots advocacy” thebill? friends whileatwork,askingthemtosupport and thisbill.Isitokaytoemailco-workers supporting 62 39 45 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR 40 63 We have a vacant position in our department. have a vacant position We We the interviewhave gone through process and found Human Resources However, a qualified candidate. says because he is we can’t hire this candidate that mean? excluded. What does means the candidateThis cannot participate in include programs These government-funded programs. funded by grants from Medicare, Medicaid, and research government agencies. Because Houston Methodist or do it may not employ participates in these programs, who has been business with anyone or any company suspended are “excluded.” Sanctioned, debarred and . for excluded other words Q&A Houston Methodist screens all employees, physicians, vendors and employees, physicians, screens all Houston Methodist Houston Methodist has a tobacco-free environment policy. The use of The Houston Methodist has a tobacco-free environment policy. tobacco is not permitted on any Houston Methodist property. SMOKING/ TOBACCO TOBACCO SMOKING/ REPORTING CONCERNS TO DNVGL TO CONCERNS REPORTING to seek all internal avenues for Houston Methodist encourages employees contacting include These resolving concerns regarding patient care. the nursing Resources, the chief Business Practices Ethics hotline, Human contacting advocate or patient the operator and asking for a patient officer, liaison, and contacting the office of Legal Services. Employees who do not after pursuing internal feel the patient care concern is being addressed may contactreporting channels DNV-GL by calling 866.496.9647. or a vendor doing business with Houston Methodist cannot participate Houston Methodist doing business with or a vendor information to the you must report this programs, in government-funded and resolution. Office for verification Business Practices the government basis against on a monthly and annual contractors exclusion lists. EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR SUBPOENAS ANDSERVICE OFLEGAL PAPERS time aretobekeptaminimum. When answeringanyphoneforHouston away fromworkandpatientcare. Personal phonecallsonscheduled work time equipment forpersonaluseinterferes withefficientoperationsandtakes Methodist businessandnotpersonal use.The useofHouston Methodist The useoftelephonesandothercommunicationsequipment isforHouston TELEPHONES ANDCOMMUNICATION EQUIPMENT Policy66. Refer toHR approved, hoursworkedmustberecordedonthetimecardappropriately. Resources, andapprovedbytheappropriateexecutive.Iftelecommuting is Houston Methodistguidelines,implementedwithguidancefrom Human operating expensesinsomecases. workforce,improvingproductivity,a diverseandtalented andreducing better meetingbothbusinessandemployeeneeds,attracting andretaining department orfunction.Telecommuting maybenefitHoustonMethodistby assignment thataidstheefficiencyand/oreffectivenessofaparticular telecommuting isregardednotasabenefit,butanalternativework totheemployee, a telecommutingarrangementmaybeadvantageous that supportstheefficiencyandeffectivenessofitsoperations.Although Houston Methodistassignsemployeestoworksitelocationsinamanner TELECOMMUTING enforcement toensureproperproceduresarefollowed. partnership withHoustonMethodist’s Department andlaw PublicSafety your entity’s willworkin Departmenttoassistwiththisprocess.HR HR dignity totheemployeewhentheserequestsaremade.Pleasecontact and nondisruptivefashiontoensureweprovideprivacy, respectand these requestsinanorderly Houston Methodistwillassistwithfacilitating employees whileonHoustonMethodistpremisesforalllegalmatters, be servedbyacivilian.With regardtolawenforcementagencyvisits premises, weprovideemployeeswiththeoptionwhethertobeornot legal paperstobeservedHoustonMethodistemployeeswhileonour to HoustonMethodistbusiness.While wearenotlegallyobligatedtoallow Methodist propertytomeetwithouremployeesforlegalmattersnotrelated On occasionprocessserversorlawenforcementwillcomeontoHouston All telecommutingarrangementsmustbestructuredinalignment with 64 EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR 48 65 You must return all property (I.D. badge, keys, etc.) to the Human must return all property You UNIONFREE WORKPLACE WORKPLACE UNIONFREE Houston Methodist is a union-free employer and maintains a voluntary agreement to provide working conditions, wages and benefits that are competitive with those offered by other employers in the health care REFERENCES AND EMPLOYMENT VERIFICATIONS VERIFICATIONS REFERENCES AND EMPLOYMENT you end employment, you may use the organization as a reference When the only information that when you seek other employment. Generally, employers outside of Houston Houston Methodist will verify with future Houston and final salary. Methodist is dates of employment, job title on current or former Methodist outsources requests for information Human Resources Department for employees. Please contact your entity’s the employment verification vendor contact information. Resources Department or your supervisor before your last day of Resources Department or your supervisor employment. Please contact the Human Resources Department in distribution, final paycheck advance to discuss your benefit continuation, Please note that all outstanding and arrangement for your exit interview. deductions will be taken from your final payment. If your forwarding address your income tax after you leave, tell Human Resources and changes form (W-2) will be mailed to the appropriate address. TERMINATION TERMINATION mutual Houston Methodist is based upon continuing Since employment at terminate or the employee is privileged to consent, either the employer reason for termination should for any reason. The employment at any time to resign who choose departing employees. Those be documented for all the provide a letter of resignation or complete their positions should form at the time of notice. designated resignation Methodist, it is importantMethodist, image. convey a positive to be courteous and answering or placing and in promptly, should answer phones Employees of personal phones and department. Use themselves and their calls, identify while on work music or for other purposes devices to enjoy other electronic take focus away interfere with productivity, work areas must not time and in or cause a disruption in the workplace. from the patient or customer, EMPLOYMENT PRACTICES AND WORKPLACE BEHAVIOR Business Practices. matters canbesharedwithyourdirectsupervisor, HumanResourcesor management. hisorherindividualright todealdirectlywithHoustonMethodist maintains not signaunioncardorpetition.Inthisway, each employee facts andhisorherrelationshipwithHoustonMethodistand,ifsolicited, will strivetoprotecttheindividualrightsofallitsemployees. HoustonMethodist Act iftheyareconsideringthird-partyrepresentation. problems, andsupportsemployeerightsundertheNationalLaborRelations by respondingtotheirconcernsandworkingtogetheraddress environment. high-quality, cost-effectivehealthcaretoourpatientsinacaring tofulfillingHouston Methodist’semployees isvital missionofproviding responsibility andthesystemasawhole.This directrelationshipwith enabling itsemployeestoplayakeyroleinshapingboththeirareasof our successasahealthcaresystem. communication betweenitsmanagementandemployeesisinvaluableto organization’s values. ICARE employee fairlyandwithdignityrespectinaccordancethe industry. HoustonMethodistisfurthercommittedtotreatingeach Department attheirentity. who maybecarryingaweapon toasecurityofficerand/orPublicSafety on thepremises.HoustonMethodist employeesshouldreportanyone executive officerofHoustonMethodist arepermittedtocarryweapons officers andpersonsgrantedwritten permissionbythepresidentandchief Texas DepartmentofPublicSafety. Onlycommissionedlawenforcement a personhasbeenissuedlicensetocarryconcealedhandgun bythe includes allopenlycarriedandconcealedhandgunsregardless ofwhether prohibits thepossessionofanykindlethalweapononitspremises; this from riskofviolencewithfirearmsandweapons.HoustonMethodist workingenvironmentfree Houston Methodiststrivestoprovideasafe WEAPONSFREE ENVIRONMENT Any concernsaboutworkingconditionsoranyotherwork-related Houston Methodistbelievesthateach employeeshouldconsiderthe Houston Methodiststrivestodemonstrateourcommitmentemployees Houston Methodistseekstoempoweremployeesthroughpartnership, Houston Methodistbelievesthatadirectrelationshipwithopen 66 GOVERNMENT INVESTIGATIONS 67 any time If you are approached by a government investigator regarding a Houston by a government investigator regarding If you are approached • card Ask the investigator for a business card or identification • the interview at Agree to be interviewed as requested and then end • but only with a lawyer present Agree to the interview, • but only at work during normal business hours Agree to the interview, • notes about the conversation Take • Decline to be interviewed you should contactIf the investigator does present you with a subpoena, your “I am willing to If you agree to be interviewed, tell the investigator, This section contains guidance regarding employees’ responses to regarding employees’ section contains guidance This inquiries. governmental and cooperate with all government audits Houston Methodist will auditors information will be provided to external investigations. Accurate should immediately report any non-routine and investigators. Employees to the Methodist from a government agency request related to Houston agents Services or Business Practices. Government Department of Legal at any time and request any individuals approach have the authority to by a government investigator while at approached information. If you are contactwork, you should immediately your supervisor and the Department questions, Business Practices. Before answering any of Legal Services or Legal Services supervisor, you have the legal right to consult with your or conducting nationals working, learning or Business Practices. Foreign other business or visitation to Houston Methodist on a visa by sponsored contactHouston Methodist should also immediately the HR-Immigration Department. Requests for immigration documentation should be provided visa during the individual’s in accordance with instructions provided orientation. If unsure, refer all investigators to HR-Immigration. time and away from Houston Methodist matter while on your personal for a subpoena or court order Methodist, you should ask the investigator subpoena or court If there is no requiring you to talk with the investigator. have the right to: You you have certain rights regarding the interview. order, Department of Legal Services or Business Practices immediately. supervisor, contactcooperate with you, but I would like to make some calls first.” Then, the number and administrator on call listed here for your entity for help: GOVERNMENT INVESTIGATIONS GOVERNMENT GOVERNMENT INVESTIGATIONS directions onhowtoprotecttheprivacyofpatientandpersonnelinformation. listedabovetoget tothecontacts totalk requirements aremet.Itisimportant cannot bereleasedbyHoustonMethodistoritsemployeesunlesscertain information thegovernmentagentisseekingmaybeconfidentialand out whatinformationcanlegallybegiventoagovernmentagent.Some Methodist anditsemployeesarerespected.Itmaybedifficulttofigure investigators. However, thatthelegalrightsofHouston itisimportant at832.667.6288or832.667.6240. nationals shouldcallHR-Immigration Business Practicesofficeroncall.HoustonMethodist-sponsoredforeign Houston Methodist requires its employees to cooperate with government Houston Methodistrequiresitsemployeestocooperatewithgovernment All otherHoustonMethodistentities,call713.790.2201toreach the • • • • • • • Legal Services or Business Practices for assistance. Legal ServicesorBusinessPracticesforassistance. theDepartment of HR-Immigration, should immediatelycontact first.Youthem, butthatyouneedtomake somephonecalls You shouldtelltheagentsthatyouare willingtocooperatewith What shouldyoudo? contact ofaforeignnationalemployeeinyourbuilding. arepostedinyourbuilding,andforthe labor certifications comes toyourofficeandasksyoushowthemwhere the ofHomelandSecurity An agentfromtheDepartment Legal Services,orBusinessPracticesforassistance. yoursupervisor,should immediatelycontact theDepartmentof first.Youthem, butthatyouneedtomakesomephonecalls You shouldtelltheagents that youare willingtocooperate with to them.Whatshouldyoudo? They askyoutohandoverHoustonMethodistdocuments OfficeofInspector Generalcometoyouroffice. Services, Two ofHealth&Human agentsfromtheDepartment Q&A Houston Methodist St. John Hospital: 281.333.5503 Houston MethodistSt.JohnHospital: 281.420.8600 Houston MethodistSanJacintoHospital: 832.522.1000 Houston MethodistSt.CatherineHospital: Houston MethodistWest 832.522.1000 Hospital: Houston MethodistWillowbrook 737.477.1000 Hospital: 281.274.7000 Houston MethodistSugarLandHospital: 713.790.2201 Houston MethodistHospital: 68 MARKETING PRACTICES 69 The brand guide should be used brand guide should be used Houston Methodist Brand Guide: The directions on brand usage.as your first resource for any questions or resources available, such It also includes a section on other brand how to order approved as where to get templates and logos, and promotional items and stationery. style guide is the standards Editorial Style Guide: The manual for language usage and stylistic questions related to writing, produced across Houston Methodist. content publications and Web for all Email [email protected] Brand Approvals: video, etc. of various brand reviews of design, writing, proofing, is printed or distributed to projects for final approval before project the public.

• • • Houston Methodist markets its services and products in an honest and products in an honest Houston Methodist markets its services and available services, information on materials provide Marketing manner. follow licensure and accreditation requirements. Marketing information correct and truthful. Houston Methodist will respect the welfare, is clear, any marketing efforts. privacy and confidentiality of patients in COMMITMENT TO TRUTH IN MARKETING TO COMMITMENT Houston Methodist has a well-establishedHouston Methodist has brand supported by a and innovation. It is importantproud history of excellence that our marketing efforts maintaincommunication and and a consistent look, feel name. As the quality of the Houston Methodist voice in order to reflect brand ambassadors, a critical role in upholding our employee plays each has established this reason, marketing brand. For several resources so help maintainthat employees can its integrity. HOUSTON METHODIST BRAND METHODIST HOUSTON AND MARKETING PRACTICES MARKETING AND HOUSTON METHODIST BRAND BRAND METHODIST HOUSTON MARKETING PRACTICES Department at your hospital oratcorporate. Department atyourhospital engage inthistypeofactivity, consulttheMarketing However, communications. regulate before certain you privacylawsdonot federalandstate purpose because health informationwithouttheirpermissionforthis Yes, butyoumayalsobeable tousepatients’protected in thismanner? permission tousetheirprotectedhealthinformation this condition.Isokay?Doweneedthepatients’ health informationtoidentifywhichpatientshad condition. We hadtoreviewpatients’protected sending thisinformationtopatientswithaparticular Methodist canprovideforthem.We areonly information onalternativetreatmentsthatHouston issending patients wehavetreated My department Q&A 70 PATIENT CARE AND PATIENT RIGHTS

71 Houston Methodist strives to ensure that all patient Houston Methodist strives to ensure that 50 42 Houston Methodist also demonstrates its commitment to providing Houston Methodist also demonstrates its Houston Methodist will work with the patient and family to develop a Houston Methodist will work with the patient ADMISSION, TRANSFER AND DISCHARGE TRANSFER ADMISSION, Houston Methodist core values. Respect is one of Houston Methodist’s dignity and value. Houston treats every individual as a person of worth, against any person Methodist will not exclude or otherwise discriminate national origin, age, sex or religion disability, on the basis of race, color, to or treatment in any programs, from participation in, admission to, access activities or benefits. PATIENT CARE PATIENT in a committed to providing quality health care Houston Methodist is by living demonstrate this commitment of caring. We spiritual environment compassion, activities. Integrity, Houston Methodist values in our daily work levels of the Houston respect and excellence are found at all accountability, values makes Houston Methodist organization. Living Houston Methodist visitors. Methodist a better place for patients and quality health care by maintaining an active patient safety program and by hiring and granting medical staff privileges to properly licensed and credentialed providers. The following section containsThe patient care and certain information about Methodist In keeping with our mission, Houston basic rights of patients. certainrecognizes and promotes rights of patients in accordance basic regulations and accreditationwith applicable laws, standards. PATIENT CARE AND CARE PATIENT PATIENT RIGHTS PATIENT transfers are done in a medically appropriate manner from physician to transfers are done in a medically appropriate physician, as well as hospital to hospital. plan based on patient need for post-hospitaldischarge care. Information and/or others who will and instructions will be given to the patient, family, be involved in home care. As needed, referrals to appropriate resources will be made. PATIENT CARE AND PATIENT RIGHTS evaluated andresolvedtoensure thatthequalityofcareisnotcompromised. conflict withsomeaspectofpatient care.Such concernsorconflicts willbe maycauseconcern or values orbeliefsofemployees medicalstaff The capabilities ofHoustonMethodist, itsemployeesandmedicalstaff. directive willbehonoredtotheextentpermittedbylawandwithin the or refusetreatment,andtomakeadvancedirectives.Apatient’s advance care. Patientswillbegiveninformationdescribingtheirrightsto request Patients havetherighttomakeadvancedirectivesregardingtheir health ENDOFLIFE DECISIONS will betreatedconsistently. patient’s abilitytopay. Allindividualswhohavesimilarmedicalconditions treatmentregardlessofthe patients requiringemergencyorlifesaving room tocareforthisperson.HoustonMethodistwillattempt to stabilize the hospital’s hastheabilityand emergencydepartmentifthe hospital Emergency medicalserviceswillbeprovidedtoindividualswhocome EMERGENCY MEDICAL TREATMENT to thepayer. The patients’freedom tochoose willberespected. itemorservice iftheyhavenotassignedthisright provider ofthenecessary havetherighttochoose thesupplieror from aHoustonMethodisthospital Patients whoneedhealthcareitemsorservicesfollowingdischarge are followingthecorrect process. tomakesure you Safety(PC/PS)29 Patient Care/Patient making suggestionsofthisnature toapatient,consult the patientanddoesnotbenefityoupersonally. When as theinformationyouprovide isinthebestinterest of Yes, tohelppatientsinthismanneraslong itisokay the provideroftheseitemsorservices? provider touse.Isitokayhelpthepatientchoose discharged oftenaskmyhelpinchoosingwhat aftertheyare Patients whoneeditemsorservices Q&A 44 72 52 PATIENT CARE AND PATIENT RIGHTS 46 73 47 Access to review Patients have the right, with certain exceptions provided by law, and receive a copy of their health information contained within Houston medical this is the patient’s designated recordset. Generally, Methodist’s record and billing record. Patients have rights, with certain exceptions provided by law, with respect Patients have rights, with certain exceptions provided by law, them at Houston Methodist. to the health information that is created about and Houston Methodist’s Notice of Privacy Practices Houston Methodist’s If you have questions or need policies and procedures explain these rights. privacy Houston Methodist’s information regarding your legal duties or Business Practices officer or the practices, please contact your entity’s Business Practices Office. RIGHT TO PROTECTED HEALTH INFORMATION HEALTH PROTECTED TO RIGHT RESEARCH patients will be fully informed study, Before participating in a research beneficial to them. All known of other treatment options that may prove and alternatives must be potential risks, discomforts, expected benefits understand.explained to patients in a manner they can All patients and staff any without compromising have the right to refuse to participate in research will not be affected by his treatment other services or functions. A patient’s or her refusal study. to participate in a research REPORTING OF SUSPECTED/ALLEGED ABUSE OR NEGLECT ABUSE SUSPECTED/ALLEGED OF REPORTING victim family member is a that a patient or patient’s Employees who suspect contactof abuse or neglect should Adult Protective Services or Children’s hospitalSocial workers are available at each Protective Services. to help and any subsequent investigation. employees with the report Patients have the right to be informed of their medical condition. of their medical the right to be informed Patients have terms that the patient to patients in should be communicated Information can understand. collaboration with their have the right, in Patients the involving their health care, including physicians, to make decisions acceptance or refusal of treatment. INFORMED CONSENT INFORMED PATIENT CARE AND PATIENT RIGHTS health careoperations. or disclosureofthepatient’s healthinformation for treatment,paymentor Patients havetherighttorequest thatHoustonMethodistrestricttheuse Restrictions Methodist entityandplacedoneach HoustonMethodistentity’s website. future. The mostcurrentversionofthenoticewillbepostedateach Houston aswellanyinformationHoustonMethodistreceivesinthe maintained, including addingprovisionsthatapplytoallhealthinformation iscurrently certain circumstances, asprovidedbylaw. circumstances, certain Houston Methodistmaydenyapatient’s requestforamendmentunder if theybelievethattheirhealthinformationisincorrectorincomplete. Patients havetherighttorequestanamendmenttheirhealthinformation Amendment other disclosures. authorized bythepatientandcertain disclosures madefortreatment,paymentorhealthcareoperations,those Methodist hasmadeofthepatient’s healthinformationwiththeexceptionof Patients havetherighttorequestalistofdisclosuresthatHouston Accounting ofDisclosures Practices. Patients havetherighttoreceiveapapercopyofNotice Privacy Notice ofPrivacyPractices will trytoaccommodatethepatient’s requestforalternatecommunications. health careproviders,includingtheirprivatephysician.Houston Methodist communications shouldalsobecommunicatedbythepatienttoalloftheir other thantheirhomeaddressandtelephonenumber. Requestsforalternate health informationtothembyanalternatemeansorlocation Patients havetherighttorequestthatHoustonMethodistcommunicate Confidential Communications privacy rightshavebeenviolated. Office ofCivilRightsifthepatientbelievesthathisorherhealthinformation DepartmentofHealthandHumanServices oftheUnitedStates Secretary Patients havetherighttofileacomplaintwithHoustonMethodistor Complaint patient’s restrictions. requestforcertain 52 HoustonMethodistmaychange theNoticeofPrivacyPractices, 53 HoustonMethodistisnotrequired toagreethe 50 74 49 51 CODING, BILLING, AND CHARGING FOR SERVICES 75 57 CORRECTION OF PAYMENT ERRORS OF PAYMENT CORRECTION must be Methodist charges All patient and payer questions about Houston If billing errors are found, employees should reviewed in a timely manner. and/or refunds billing office will make corrections tell the billing office. The promptly. CLINICAL DECISIONMAKING CLINICAL Integrity means, “We core values is integrity. One of Houston Methodist’s are honest and ethical in all we say and do.” Integrity in clinical decision- based on patient health care making means that clinical decisions are how Houston Methodist pays needs. Clinical decisions are not based on clinical staffor shares financial risk with its leaders, managers, or licensed independent practitioners. APPROPRIATE CHARGING OF MEDICAL SUPPLIES CHARGING OF MEDICAL APPROPRIATE AND SERVICES supplies, procedures and other for charging Employees responsible These Houston Methodist policies and procedures. services should follow for cost centers will receive revenue which explain what is chargeable, to prices, and how to resolve issues related how to change charges, are for services Institutional charges outpatient and institutional charging. provided to other hospitals or sponsors of research. The following section contains information about billing, charging for about billing, charging section contains information following The supplies/services, and the submission of claims payments, reimbursement and cost reports. FOR SERVICES CODING, BILLING AND CHARGING AND CHARGING BILLING CODING, CODING, BILLING, AND CHARGING FOR SERVICES Practices Officeformoreinformation. theHoustonMethodistResearch InstituteortheBusiness Contact related proceduresmustcarefullyfollowallpoliciesandprocedures. company. Individualsinvolvedinaccountingandcharging ofresearch- a research sponsorratherthanbyMedicare,Medicaidoraninsurance Costs andcharges associatedwithresearch willfrequentlybepaidby REIMBURSEMENT RELATED TO RESEARCH costdata. centers, andsupportedbyverifiableauditable these reportsmustbeproperlyclassified,allocatedtothecorrect cost theinformation requiredbylaw.Reports mustcontain Allinformationon and complete.Reportsmustreflectservicesrenderedsuppliesused. other informationaboutitsoperations.These reportsmustbeaccurate By law, reportsaboutcostsand HoustonMethodistmustpreparecertain COST REPORTS 76 59 58 CODING, BILLING, AND CHARGING FOR SERVICES any 60 77 Private parties known as qui tam relators may bring actions on behalf of illegal claim activity to the Houston should report suspected You in good faith are protected Employees who report illegal claim activity Under the federal False Claims Act and Texas false claims laws, Claims Act and Texas Under the federal False person who knowingly submits, or causes someone else to submit, illegal submits, or causes someone else to submit, person who knowingly is subject to government fines and claims for payment of government funds penalties. It is also a false claim to retain money that you should not have to $11,000 per fines and penalties can range from $5,000 received. These for triple the actual damages. claim and can be accompanied by penalties qui tam These law. and Texas the government under the False Claims Act of the proceeds from a false relators may share in 15 percent to 30 percent claims action or settlement. ) or through Houston Methodist Business Practices officer (713.383.5124 1.800.500.0333), or through Business Practices EthicsLine ( Methodist’s Department of Health and . The reporting at tmhs.myethicsline.com Web Health and Human and Texas Human Services Office of Inspector General also accept reports of Office of Inspector General Services Commission’s illegal claim activity. Business Practices Procedure from retaliation by Houston Methodist’s BP07 and by federal and state Claims Act provides for False The laws. certain for retaliation remedies against qui tam include relators. These amount of any back two times the reinstatement with comparable seniority, and compensation for any special damages pay, interest on any back pay, sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees. Houston Methodist submits claims for payment to the federal and for payment to the submits claims Houston Methodist statemedically be made only for for payment can governments. Claims necessary contain Claims cannot were actually performed. services that codes Diagnostic, procedural, and billing false or misleading information. payer uses what services were performed. The are used to tell the payer money to pay to Houston Methodist. how much the codes to determine must accurately represent the services the codes assigned Therefore, bills are used as evidence to support the provided. Medical records Making a false statementHouston Methodist submits. in a medical record can be a crime. Medical record documentationused to support billing and accreditationmust follow all regulatory requirements and conform to professional standards. SUBMISSION OF CLAIMS SUBMISSION CODING, BILLING, AND CHARGING FOR SERVICES Houston Methodist. and couldcreate legalproblems foryou,thepatientand No. Changingtheirbillinthismannerconstitutesfraud their bill? insurance ratherthanonethatisnot.CanIchange rendered tolistaprocedurecoveredbytheir A patientaskedmetochangeabillforservice ensures proper payment. Yes. necessityand Adiagnosiscodejustifiesmedical services? forancillary onorders Is adiagnosiscodenecessary Q&A 78 SAFETY AND EMPLOYEE HEALTH 61 79 — When an emergency does arise, you must know — When — You are expected to be aware of fire, disaster, and disaster, are expected to be aware of fire, — You AWARENESS safety policies and procedures. PREVENTION for unsafe — It is up to you to look conditions, report also includes maintaining are corrected. This them, and see that they and to reduce risk of injury or illness for you your own optimal health our patients. PREPAREDNESS how to act to prevent or reduce injuries, damage and loss. how to act to prevent or reduce injuries, damage Employee Health Services is available to all employees for services, such employees for services, such Employee Health Services is available to all • • • If You Become Ill While on the Job Become Ill While If You If you become ill while you are on the job and are unable to do your work, must tell you supervisor before You please tell your supervisor right away. Ongoing Health Assessments working in certainGovernment health regulations require employees annual) employer sponsored, departments to participate in regular (usually but are NOT programs may include, medical surveillance programs. These physical examinations,limited to, TB screening, radiation monitoring, and/or to takelaboratory tests. All employees are required an annual TB test and the annual TB testing, flu shot flu shot. Employees who fail to comply with will be placed on unpaid campaign, or other required health screenings action up to and including suspension and may be subject to disciplinary notification so as respond to testing termination. Employees must quickly not to exceed the anniversary of the previous testing date. as post-offer physical exams, TB testing, vaccines, counseling for illnesses illnesses or injuries. and injuries, first aid and follow-up of work-related EMPLOYEE HEALTH SERVICES HEALTH EMPLOYEE The success of our safetyThe on employee commitment to program depends can help promote safety by focusing on these key areas: You safety. Safety is a top priority at Houston Methodist and we commit substantial at Houston Methodist and we commit Safety is a top priority possible physical environment for all. the safest resources to providing SAFETY AND EMPLOYEE HEALTH EMPLOYEE AND SAFETY SAFETY AND EMPLOYEE HEALTH permission. (unlessallowableor requiredbylaw)withoutyourwritten from thehospital strictly confidential.This meansthatyourrecordsmaynotbereleased the goodofourpatients. aswellfor you arewellenoughtodoyourjob.This isforyourownsafety supervisor maystillaskyoutovisittheEmployeeHealthClinicmakesure of absence,youmust: If youareoffworkduetoawork-relatedinjuryoranytypeofmedicalleave Your ReturntoWork your shift. Health Clinicforevaluationbeforeallowingyoutoleavetheendof you leaveyourworkarea.Your supervisormaysendyoutotheEmployee All employee health records retained inthe EmployeeHealthClinicare All employeehealthrecordsretained If youwereillorinjured,butnotonamedicalleaveofabsence,your Visit theEmployeeHealth Clinicwhenyoureturntowork.Please • Haveawrittenreturn-to-workreleasefromyourdoctorallowingyouto • Employee HealthClinic. remember tobringyourdoctor’s notewithyouwhengotothe return towork,and 80 SAFETY AND EMPLOYEE HEALTH 81 61 Rescue. Rescue anyone in immediate danger. Alarm. Pull the nearest fire alarm. Pull stations are usually located near elevators, stairwells and nurses stations. Call an emergency number internal emergency number. as 911 or your entity’s such Contain. Contain and smoke by closing doors. fire Extinguish. Extinguish the fire if it can be done safely. Fire safety and prevention are responsibilities of all employees. An easy- While Houston Methodist buildings have been constructed to be as safe While depends in great measure on as possible, effective response to any fire fire or fire drill, you should know employee preparedness. In the event of a and carry out appropriate procedures. , is a guide that helps prevent panic and avoid to-remember acronym, RACE catastrophe in a fire emergency. FIRE PLAN The mission of Houston Methodist reflects a social responsibility to the reflects a social responsibility to the mission of Houston Methodist The the environment and minimize the environmentalcommunity to protect with Houston Methodist strives to comply impact of its operations. environmental and will implement other appropriate laws and regulations environmental strategies that do not unreasonably increase the cost of health care. ENVIRONMENTAL MANAGEMENT ENVIRONMENTAL If you see anyone injured, give assistanceanyone injured, give If you see any get help. Always report and immediately. to your supervisor injuries or unusual incidents accidents, are how minor, accident, no matter who have an on-the-job Employees supervisor will immediate supervisor at once. The required to notify their is taken.see that the proper action Employees who contract an illness within 24 be job-related must notify their supervisor that they suspect may diagnosis. hours of discovery or ACCIDENTS AND INJURY REPORTING AND INJURY ACCIDENTS SAFETY AND EMPLOYEE HEALTH SAFETY TRAINING department expectsfromyouduringaninternalorexternaldisaster. review andbepreparedtofollow. Findoutfromyoursupervisorwhat planthatemployeesareto each individualdepartmenthasadisaster strikesorthreatensHouston Methodistorthecommunity,In casedisaster SEVERE WEATHER AND EMERGENCIES and proceduresparticulartoitsarea. policies tofamiliarizeitsemployeeswithsafety orientation conducts safety and materials.Recognizingtheseindividualconditions,each department entity isuniquelyspecializedandvariedintermsofprocedures,equipment informationandprocedures.Each HoustonMethodist safety departmental programsforcorporate-wide and for employeesincludesorientation training program thatiscontinuouslymonitoredforitseffectiveness.Safety resource. HoustonMethodistconductsacomprehensivesafety-training Trained andmotivatedemployeesareHoustonMethodist’s greatest 82 REFERENCES

The references below refer to Houston Methodist policies and procedures and to federal and state laws that Houston Methodist must follow. The policies and procedures are posted on the Houston Methodist intranet at tmh.tmc.edu. You can find the laws listed below on the Internet. Contact Human Resources, your entity’s Business Practices officer or the Houston Methodist Business Practices Office for more information.

1 Business Practices 01 16 Information Management 15 2 Business Practices 07 17 Human Resources 12; Information Management 07 3 Business Practices 08 18 Human Resources 12 4 Research Procedures 14 19 Information Management 06 5 Business Practices 08 20 Human Resources 59 6 Business Practices 13; Business Practices 19; Anti-kickback 21 Human Resources 01 Statute: Civil Monetary Penalties 22 Human Resources 40 — Social Security Act §1128A, see also 42 U.S.C. §1320a-7a; 23 Human Resources 47 Criminal Penalties — Social 24 Human Resources 29 Security Act §1128B, see also 42 U.S.C. §1320a-7b; Exclusion 25 Human Resources 25 — Social Security Act §1128, 26 Human Resources 38 see also 42 U.S.C. §1320a-7; and, Safe harbors 42 C.F.R. 27 Human Resources 45, Human §1001.952 Resources 64 7 Business Practices 19 28 Human Resources 88; 8 Business Practices19 29 Human Resources 04 9 Human Resources 46 30 Information Management 13 10 Business Practices 25; Stark/ 31 Information Management 01 Physician Self-Referral Law 32 Information Management 01 42 U.S.C. §1395nn; Stark Exceptions 42 C.F.R. §411.350 33 Human Resources 42 11 Research Procedures 34 Human Resources 08; Human Resources 09; Human 12 Human Resources 41 Resources 42; Human 13 Human Resources 52 Resources 87 14 Human Resources 60 35 Human Resources 69 15 Human Resources 48 36 Human Resources 92

83 37 Human Resources 05 §3729; False Claims and Statements; Liability 31 38 Business Practices 11 U.S.C. §3802; Texas Human 39 Human Resources 16 Resources Code, Chapter 32. 40 Human Resources 50 Medical Assistance Program; Texas Human Resources Code, 41 Human Resources 31 Chapter 36. Medicaid Fraud 42 Patient Care/Patient Safety 17; Prevention; Texas Government Patient Care/Patient Safety 29 Code, Chapter 531. Health and Human Services Commission 43 Patient Care/Patient Safety 29 59 Research Procedures 04; 44 Patient Care/Patient Safety 02; Research Procedures 16; EMTALA Research Procedures 32 45 Business Practices 10 60 False Claims Act 31 U.S.C. 46 Research Procedures 12 §3729; False Claims and Statements; Liability 31 47 Information Management 08 U.S.C. §3802; Texas Human 48 Human Resources 31 Resources Code, Chapter 32. Medical Assistance Program; 49 Information Management 09 Texas Human Resources Code, 50 Business Practices 06 Chapter 36. Medicaid Fraud 51 Information Management 04 Prevention; Texas Government Code, Chapter 531. Health and 52 Business Practices 17 Human Services Commission 53 Information Management 07 61 Human Resources 03; Human 54 Human Resources 41 Resources 18 55 Human Resources 24 56 Human Resources 45 57 Financial 40 58 False Claims Act 31 U.S.C.

84 ACKNOWLEDGMENT RECEIPT

This Employee Handbook has been prepared for your information in order to help answer some of your employment questions on personnel topics such as policies, procedures and benefits of Houston Methodist. This handbook is also a practical summary of how to conduct business operations and patient care activities in compliance with the law, and Houston Methodist values and organizational ethics. Please read it carefully. Upon receipt of this handbook, please sign the statement below and return as directed by your New Employee Orientation facilitator. I, , have received the handbook, and understand that it is my responsibility to read and comply with the policies contained in this handbook and any revisions made to it. I also understand that failure to abide by the provisions in the handbook may lead to disciplinary action as identified in Houston Methodist’s Managing for Performance Policy (Human Resources-01), or other enforcement action under applicable law. I will familiarize myself with the contents of this handbook. By my signature below, I acknowledge, understand, accept and agree to comply with the information found in this handbook. I understand that this handbook is not intended to cover every situation that may arise during my employment, but is a guide to the goals, policies, practices, benefits and expectations of Houston Methodist. I understand that I have a personal duty to bring all real or suspected violations of the law, and Houston Methodist’s values and organizational ethics to the attention of my supervisor, Human Resources, my entity’s Business Practices officer, and/or the Business Practices officer or to call the Business Practices EthicsLine. I understand that I cannot be punished or retaliated against for upholding the provisions in the handbook or for obeying the laws and regulations that apply to my job. Houston Methodist reserves the right to modify or terminate any or all plans, rules, policies and procedures at any time and without notice. Houston Methodist policies and procedures are published on the Houston Methodist intranet. The website tmh.tmc.edu will contain the most current revision of this Employee Handbook and a link to Policy Tech, the document control system that contains the most current version of all new and existing policies and procedures. In the event of any conflict between hard copy and intranet procedures, the intranet procedure will take precedence. I understand that the Houston Methodist Employee Handbook is not a contract of employment. Houston Methodist retains all its rights under the employment-at-will doctrine.

EMPLOYEE SIGNATURE DATE

EMPLOYEE PRINTED NAME ID NUMBER

85 ACKNOWLEDGMENT RECEIPT

This Employee Handbook has been prepared for your information in order to help answer some of your employment questions on personnel topics such as policies, procedures and benefits of Houston Methodist. This handbook is also a practical summary of how to conduct business operations and patient care activities in compliance with the law, and Houston Methodist values and organizational ethics. Please read it carefully. Upon receipt of this handbook, please sign the statement below and return as directed by your New Employee Orientation facilitator. I, , have received the handbook, and understand that it is my responsibility to read and comply with the policies contained in this handbook and any revisions made to it. I also understand that failure to abide by the provisions in the handbook may lead to disciplinary action as identified in Houston Methodist’s Managing for Performance Policy (Human Resources-01), or other enforcement action under applicable law. I will familiarize myself with the contents of this handbook. By my signature below, I acknowledge, understand, accept and agree to comply with the information found in this handbook. I understand that this handbook is not intended to cover every situation that may arise during my employment, but is a guide to the goals, policies, practices, benefits and expectations of Houston Methodist. I understand that I have a personal duty to bring all real or suspected violations of the law, and Houston Methodist’s values and organizational ethics to the attention of my supervisor, Human Resources, my entity’s Business Practices officer, and/or the Business Practices officer or to call the Business Practices EthicsLine. I understand that I cannot be punished or retaliated against for upholding the provisions in the handbook or for obeying the laws and regulations that apply to my job. Houston Methodist reserves the right to modify or terminate any or all plans, rules, policies and procedures at any time and without notice. Houston Methodist policies and procedures are published on the Houston Methodist intranet. The website tmh.tmc.edu will contain the most current revision of this Employee Handbook and a link to Policy Tech, the document control system that contains the most current version of all new and existing policies and procedures. In the event of any conflict between hard copy and intranet procedures, the intranet procedure will take precedence. I understand that the Houston Methodist Employee Handbook is not a contract of employment. Houston Methodist retains all its rights under the employment-at-will doctrine.

EMPLOYEE SIGNATURE DATE

EMPLOYEE PRINTED NAME ID NUMBER

86 HOSPITALS Long-Term Acute Care Hospital: Houston Methodist Hospital Houston Methodist 6565 Fannin St. St. Catherine Hospital Houston, TX 77030 701 S. Fry Road T: 713.790.3311 Katy, TX 77450 T: 713.441.7465 T: 281.599.5700

Houston Methodist San Jacinto Hospital EMERGENCY CARE 4401 Garth Road CENTERS Baytown, TX 77521 T: 281.420.8600 Houston Methodist Cinco Ranch Emergency Care Center Houston Methodist 26000 FM 1093 St. John Hospital Katy, TX 77494 18300 St. John Drive T: 832.522.6070 Nassau Bay, TX 77058 T: 281.333.5503 Houston Methodist Cypress Emergency Care Center Houston Methodist 27560 Hempstead Hwy. Sugar Land Hospital Cypress, TX 77433 16655 Southwest Frwy. T: 281.737.2424 Sugar Land, TX 77479 T: 281.274.7170 Houston Methodist Kirby T: 281.242.7465 Emergency Care Center 2615 Southwest Frwy., Suite 140 Houston Methodist Houston, TX 77090 West Hospital T: 713.441.3724 18500 Katy Frwy. Houston, TX 77094 Houston Methodist Pearland T: 832.522.1000 Emergency Care Center 11525 W. Broadway St. Houston Methodist Pearland, TX 77584 Willowbrook Hospital T: 713.441.3724 18220 State Hwy. 249 Houston, TX 77070 T: 281.737.1900

87 Houston Methodist Sienna Plantation Emergency Care Center 8200 Hwy. 6 Missouri City, TX 77459 T: 713.441.3724

Houston Methodist Voss Emergency Care Center 1635 S. Voss Road Houston, TX 77057 T: 713.441.3724

IMAGING CENTERS

Houston Methodist Kirby Breast Care Center 2615 Southwest Frwy., Suite 104 Houston, TX 77090 T: 713.441.PINK (7465)

Houston Methodist Imaging Center 83333 Katy Frwy. Houston, TX 77024 T: 713.797.9729 T: 713.441.8940 Scheduling: 713.441.8946

88

LIVING HOUSTON METHODIST VALUES A Handbook for Employees | 2016

houstonmethodist.org