D.6 Code of Conduct VA Central Iowa MCP 39.pdf

CODE OF CONDUCT

MCP 39

VA Central Iowa Health Care System Des Moines, Iowa 50310

Signatory Authority:

Sara Ackert, Director (Acting)

Responsible Owner:

Human Resources

Rescinded Document:

See paragraph 7.

Effective Date:

June 13, 2022

Recertification Date:

June 13, 2027

1. POLICY

Reinforce an atmosphere of mutual respect for all who work at VA Central Iowa Health Care System (VACIHCS). Ensure that staff members conduct themselves with dignity and integrity, and that they strive to improve their own competence as well as those of their peers.

a. Outline and address behaviors that undermine a culture of safety and quality. This policy applies to all employees, students, volunteers and without compensation employees at all levels of the organization.

b. Outline options to report and address problem behavior, as well as the requirement to report actual or possible violations of criminal law or other violations related to VA programs.

c. Prevent conduct that interferes with an individual's ability to work safely, creates a hostile or intimidating work environment, or disrupts the delivery of safe patient care.

2. JUSTIFICATION

a. VACIHCS will provide a safe and healthy workplace environment that promotes dignity and respect for all. Conduct and behaviors at any level of employment that are not in line with this objective and are not acceptable by a reasonable person are not tolerated. This includes but is not limited to verbal abuse; sexual harassment; physical abuse; intimidating behavior; reportable violations, and any criminal violation of law.

b. VACIHCS will promote communication and a collaborative work environment based on civility, respect, engagement, and professionalism by ensuring problem behaviors that threaten the performance of the work unit are addressed.

c. Employees will report Code of Conduct violations to their supervisor, any

June 13, 2022 MCP 39 management official, the VA Police, Equal Employment Officer, Compliance and Business Integrity Officer, or via an Ethics Consult. Criminal violations involving felonies shall be immediately reported to the VA Office of Inspector General (VAOIG).

3. RESPONSIBILITIES

a. Executive Leadership. Responsible for encouraging teamwork and creating structures, processes, and programs that allow a positive culture to flourish. Must address behaviors that undermine a culture of safety of individuals working at all levels of the organization. Regularly evaluates the culture of safety and quality using valid and reliable tools. Ensures that VACIHCS employees comply with regulations pertaining to reporting of criminal violations to VAOIG.

b. Service Line Directors/Program Officers/Supervisors. Responsible for communicating and modeling this policy to their employees, students, volunteers, without compensation employees, interns, and residents. Will encourage the good conduct of employees by setting the example, by dealing with them timely, considerately, and impartially and by showing sincere concern for them as individuals.

Enforce staff adherence to this policy, and ensure their staff are trained on the Code of Conduct and the procedures for reporting. Ensure that VA Police are notified in a timely manner of possible or actual criminal violations or other reportable violations on VA premises.

c. Employees, Students, Volunteers. Without Compensation Employees, Interns. Responsible for adhering to the Code of Conduct to ensure a safe and healthy workplace environment. Responsible to report Code of Conduct violations at any level of the organization. Immediately report any possible or actual criminal violations or other reportable incidents occurring on VA property, to their supervisor, any management official, or the VA Police. VA employees have an obligation to inform the VA Police of any threat of violence (i.e., duty to warn). The employee has discharged the duty if after the threat, he/she informs his/her immediate supervisor of the threat. If the supervisor is not available, the employee should report the threat directly to the VA Police. The VA Police will investigate the complaint and will keep the threatened party informed of the ongoing investigation.

d. Human Resources. Responsible for furnishing requested assistance and information on Code of Conduct matters to management, supervisors, and individual employees. Ensures that the Code of Conduct is provided to new employees.

e. Public Affairs Officer. Acquire information necessary regarding any activity requiring reporting an issue brief in accordance with Network Memorandum V23- DND- 018, Urgent Communications Process.

4. OTHER PARAGRAPHS

a. Expected behaviors include but are not limited to:

(1) Towards employer:

(a) Be ethical and safeguard confidentiality with respect to sensitive information regarding services and activities.

(b) Be ethical and respect confidentiality regarding information on other personnel.

(c) Be ethical and respect confidentiality regarding own department's work if questioned by colleagues or outsiders.

(d) Adhere to conventional standards of acceptable work behavior:

1. Be punctual in reporting for duty.

2. Use leave appropriately.

3. Adhere to the agency dress code.

4. Be free from intoxicants.

5. Use resources wisely. Treat the property and resources/equipment of agency with due care, regard, and respect. These items must also be used honestly and not to one's own benefit.

6. Follow safety guidelines.

7. Be productive every workday and perform duties as assigned.

8. Collaborate and communicate with fellow employees as necessary while performing assigned duties.

9. Inform individuals in the supervisor chain if additional skills training or coaching is needed in performing assigned duties.

10. Conduct oneself at all times in a professional, respectful, and civil manner.

(e) Report any untoward behavior of colleagues or customers that may impact one's own integrity or on the integrity and well-being of the agency.

(f) Refrain from engaging in unruly work practices and/or encouraging other workers to engage in such behavior.

(g) Conduct oneself appropriately and professionally at public functions and events organized by the agency.

(2) Towards own manager/supervisor and other superiors:

(a) Carry out all lawful and reasonable instructions given by manager in a proper and efficient manner according to the agency's work practices and rules.

(b) Treat all supervisors and managers with civility and respect.

(3) Towards co-workers and peers:

(a) Treat all co-workers and peers with civility and respect.

(b) Set an example to other professions regarding professional conduct and attitude.

Examples of this may include, but are not limited to:

1. Be respectful and considerate of all fellow employees. Keep an open mind and listen constructively. Demonstrate active engagement in issues and discussions.

Criticize only ideas, not people. Resolve disagreements and differing views constructively and at the lowest level possible.

2. Communicate (spoken remarks, written documents, and emails) in a timely fashion: involve the appropriate person(s), in an appropriate setting. Be honest and direct. Be professional, constructive, respectful and efficient. Understand that a variety of experience levels exist in the workplace and have tolerance for those who are learning.

3. Assist, willingly, any other employee who asks for help, assistance or advice.

4. Behaviors which should be avoided include, but are not limited to:

(c) Misuse of opportunities and information (employees expected to share information freely, not to withhold or malign).

(d) Gossip or "water cooler'' talk is considered disrespectful workplace behavior.

Gossip involves spreading rumors or speaking malicious untruths about co- workers or about an employer. It is a form of slander and has a negative impact on the image and reputation of an employer or an employee. Gossip often escalates to abusive behavior, such as harassment or workplace violence.

(e) Inappropriate Internet Usage - Individuals who misuse the Internet while at work display disrespectful behavior towards their employer as well as to co-workers who can see what the individual is doing on his computer. Inappropriate Internet usage includes, but is not limited to, sending illicit e-mails, visiting social websites, spending excessive amounts of non-break time conducting personal business, or viewing unauthorized websites that contain illicit or pornographic content.

(f) Bullying is harassment and intimidation that creates a negative and unproductive work environment. Bullying may come in the form of verbal abuse or intimidation.

Examples of verbal abuse include: vulgar, profane, or demeaning language; screaming;

sarcasm; or criticism directed at an individual. It is often intimidating to the recipient, and often causes the recipient or others around him or her to become ineffective in performing their responsibilities; i.e., the individuals become afraid or unwilling to question or communicate concerns, or to notify the involved individual or others when problems occur.

(4) Towards internal and external customers:

(a) Treat all customers ethically and with respect and integrity.

(b) Maintain the mutual goodwill that exists between the agency and its customers.

(c) Be cordial in all dealings and circumstances with customers.

b. Expected Action if Unacceptable Behavior Occurs (may include, but is not limited to):

(1) The recipient of unacceptable behaviors is responsible for bringing the behavior to the attention of the offending employee. The offending employee is expected to acknowledge his/her behavior and take appropriate action to prevent its recurrence.

(2) In situations where the recipient of unacceptable behavior is unable to approach the employee or resolve the situation at the lowest level, the recipient is expected to report to his/her Supervisor, Service Line Director, Quad Member or the Health Care System Director. Any evidence or information that gives him/her reasonable cause to suspect violations of the Code of Conduct needs to be included when reporting at this level.

(3) In circumstances where additional resources are needed, consider the following options:

(a) Employee Assistance Program (EAP)

(b) Ethics Consultation Team

(c) Mediation/Alternative Dispute Resolution (ADR)

(d) Additional in-house training

(e) EEO Program

(f) Union AFGE Local 1228

(g) Union NNU

(h) Civility, Respect, Engagement in the Workforce (CREW)

(4) Violations of the Code of Conduct may result in disciplinary actions up to and including removal.

c. Reporting of Criminal Activity, Protections and Sanctions:

(1) Employee's Duty to Report (38 CFR Part 1 Section 201). All VA employees with knowledge or information of possible or actual criminal violations occurring on VA premises related to VA programs, operations, facilities, contracts,or information technology systems, shall immediately report such knowledge or information to their supervisor, any management official, the VA Police, or directly to the VAOIG. Serious crimes (felonies) must be reported immediately to the VAOIG. Reportable crimes include but are not limited to:

(a) Waste, fraud, and abuse.

(b) Violations of laws, rules, or regulations.

(c) Physical harm to an employee, patient, Veteran, or any other individual.

(d) Corruption and mismanagement.

(e) Any evidence or information that gives a reasonable cause to suspect serious irregularity or criminal violation.

(2) Management Official Reporting Responsibility (38 CFR Part 1 Section 203):

Information about actual or possible violations of criminal laws related to VA programs, operations, facilities, or involving VA employees, where the violation of criminal law occurs on VA premises, will be reported by VA management officials and the VA Police.

Reportable violations include but are not limited to:

(a) Theft of government property over $1,000.

(b) False Claims.

(c) False Statements.

(d) Drug Offenses.

(e) Crimes involving information technology systems.

(f) Serious crimes against persons.

(3) Failure to report possible or actual criminal activity by any employee may result in disciplinary action. Sanctions can range from reprimand to removal of duty. Lack of reporting could be considered a contributing factor to the criminal activity, resulting in additional consequences, regardless of the individual's involvement in the activity.

(4) Whistleblower Protection Laws (5 USC 2302(b)(8)): Retaliation against an employee or applicant for making a protected disclosure, which is information reasonably believed to evidence violations of law, rule or regulation, gross mismanagement , gross waste of funds, abuse of authority or a substantial and specific danger to public health and safety, is prohibited by any supervisor/ management official or other employee with authority to take, direct others to take, recommend or approve any personnel action.

5. DEFINITIONS

a. Verbal Abuse. Verbal abuse is usually in the form of vulgar, profane, or demeaning language; screaming; sarcasm; or criticism directed at an individual. It is often intimidating to the recipient, and often causes the recipient or others around him or her to become ineffective in performing their responsibilities, i.e., the individuals become afraid or unwilling to question or communicate concerns or notify the involved individual(s) when problems occur.

b. Sexual Harassment. Unwelcome comments or contacts of a sexual nature or characterized by sexual overtones, whether overt or covert.

c. Physical Abuse. Intentional maltreatment of an individual which may cause physical injury. Examples include hitting, slapping, pinching or kicking.

d. Intimidating Behavior Statements. Actions or behavior that cause a reasonable person or persons around him/her to become ineffective in performing their responsibilities. For example: disparaging someone's reputation or relationships, excluding persons on purpose from meetings, spreading rumors, or purposefully embarrassing someone in front of co-workers or supervisors and threats to another's physical or emotional safety or property.

e. Reportable Violations. Examples include, but are not limited to: fraud, waste and abuse; violations of law, rules or regulations; threats; physical harm to any individual;

corruption and mismanagement; or any evidence or information that gives a reasonable cause to suspect a serious irregularity or criminal violation.

f. Criminal Violations Involving Felonies. Examples include but are not limited to:

theft of government property over $1,000 in value; false claims; false statements; drug offenses; crimes involving technology systems; serious crimes against persons, such as homicides, armed robbery, rape, aggravated assault, or physical abuse of a Veteran.

6. REFERENCES

a. U.S. Office of Government Ethics, Standards of Conduct for Employees of the Executive Branch.

b. 5 United States Code (USC) Chapter 73, 5 CFR 2635, and 5 CFR 735.

c. VA Privacy Practices and HIPAA CFR 45 pt. 160 and 164, 1996.

d. Procurement Integrity Act.

e. VA and Federal Acquisition Regulations.

f. Department of Veterans Affairs (VA) Directive and Handbook 5021, Employee Management Relations.

g. Department of Veterans Affairs (VA) Directive and Handbook 5363, VA Drug Free Workplace Program.

h. Master Agreement between Department of Veterans Affairs and American Federation of Government Employees (AFGE).

i. The Joint Commission Accreditation Manuals, current editions.

j. HCSM RM-24 Orientation of Employees.

k. HCSM RM-27 Disciplinary and Adverse Actions.

l. HCSM RM-37 Employee Leave System.

m. HCSM CD00-05 Equal Employment Opportunity (EEO) Program.

n. HCSM CD00-10 Management of Information.

o. HCSM CD00-24 Organizational Business Integrity and Compliance Program.

p. HCSM CD11-05, Bylaws, Rules, and Regulations of the Medical and Clinical Professional Staff.

q. HCSM CD11-31 Code of Organizational Ethics.

r. HCSM CD135-02 Gifts, Donations, and General Post Funds.

s. HCSM BUS-07 Obtaining Consents for Use of Picture or Voice.

t. HCSM ED-01 Staff Education.

u. IL 2010-002 Intimidating and Disruptive Behaviors That Undermine a Culture of Patient Safety.

v. v. 38 CFR 1.201 - 38 CFR 1.205.

7. RESCISSION

Workforce Memorandum-39, Code of Conduct dated February 2014 is rescinded.

8. REVIEW

This MCP will be reviewed at minimum at recertification, or when there are changes to any applicable governing document.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of June 2027. This MCP will continue to serve as local policy until it is recertified or rescinded.

In the event of contradiction with national policy, the national policy supersedes and controls.

10. SIGNATORY AUTHORITY

Sara Ackert VA Central Iowa Health Care System Director (Acting) Date Approved:

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: All MCPs are available on the VACIHCS Policies SharePoint Site.