Handbook of Operating Procedures

I. POLICY AND GENERAL STATEMENT

The University of Texas Health Science Center at Houston (“University”) requires the highest standards of professionalism, ethics, integrity, and accountability from all individuals who are covered by this policy as listed in the Scope (hereinafter “University community members”). Students accepted, enrolled, registered, or with continued enrollment in the University are not covered by this policy, but are covered by HOOP #186, Student Conduct and Discipline. Students with employment appointments are covered by this policy when acting within the scope of their employment; however, they are covered by HOOP #186, Student Conduct and Discipline when acting within the scope of their student status (see HOOP #167, Student Employment Appointments and the Student Job Titles listed on the Human Resources web site). The Standards of Conduct Policy and its Guide (“Standards of Conduct” or “this policy”) require compliance with University policy and federal, state, and local laws and regulations.

This policy incorporates the Standards of Conduct Guide (“Guide”) in its entirety. The Guide contains applicable information to clarify the requirements for those covered by this policy. This includes information on making a report regarding violations of this policy. Violations of this policy, including failure to report a violation, may result in disciplinary action up to and including termination or dismissal.

II. DEFINITIONS

Behavior or Conduct: The University uses these terms interchangeably. Behavior is the way an individual acts or conducts themselves, especially toward others. Conduct is the manner in which a person behaves, and occurs mainly on a particular occasion or in a particular context.

Professionalism: The behavior or conduct of a University community member that conveys respect and dignity for all. It extends to all with whom an individual interacts and includes both verbal and non-verbal actions.

Ethics: The moral principles that govern a person’s behavior.  This includes making ethical decisions by exercising good judgement, care, and consideration.

Integrity: An individual’s adherence to honesty and moral and ethical principles.

Accountability: An individual’s obligation or willingness to accept responsibility for their actions.

Good Faith Report: Making a disclosure of University-related misconduct with a sincere belief in the truth of the report. A sincere belief is one that a reasonable person in the reporter’s position would similarly believe based upon the facts.  

False Information or False Complaints: Knowingly (a) making a report in bad faith, (b) filing a false complaint under University policy, or (c) providing materially false information. An investigation finding that an individual is not responsible for allegations made against them does not imply a false complaint. It also does not imply that information provided was false. Similarly, an investigation finding that an individual is responsible for allegations made against them does not imply that their statements disclaiming responsibility were false.

III. PROCEDURE

The University is committed to creating a caring and healthy environment for all. Treating others with dignity and respect is of the utmost importance and is required from all University community members.

This policy focuses on the expectations required to uphold the University’s mission and vision. This includes the University’s commitment to compliance with federal health care programs and the standards set by applicable regulatory bodies and professional organizations.

A.  Confidential, Private, or Sensitive Information

Confidential, private, or sensitive information (such as student education information, patient information, etc.) should not be disclosed except in limited circumstances. The University’s policies and procedures, as well as relevant laws, govern when disclosures may be permissible or required and to whom disclosures may be made. When in doubt, University community members should consult with the Handbook of Operating Procedures (“HOOP”), their supervisor, another member of management, the Chief Compliance Officer, or other Office of Institutional Compliance team member.

B.  Responsibility

University community members are required to understand this policy to ensure work is performed in an ethical and legal manner.  This includes knowing and observing all University policies concerning appropriate treatment of others. Failure to review, understand, or seek guidance on policies and regulations is not a valid reason for noncompliance

C.  Behavior and Conduct

Engaging in prohibited behavior may interfere with the ability of others to carry out their duties. It also undermines confidence in the University. A reasonable person standard will be applied to determine whether certain behavior violates this policy.

Types of prohibited behaviors that violate this policy may include, but are not limited to:

• Offensive materials and actions, including writings; text messages; emails; computer screen displays; posters; photography; cartoons; drawings; gestures; jokes; or comments whether intended to be offensive or not and whether made directly or indirectly.
• Overt actions, such as verbal or written outbursts or physical threats.
• Failure to perform assigned tasks or exhibiting uncooperative attitudes.
• Fraud, abuse or inappropriate/unauthorized use of university funds or resources.

These types of behaviors may negatively affect the University. Such negative effects may include, but are not limited to:

• Ineffective teamwork;
• Unproductive conflict;
• Increased medical or other types of errors and/or preventable, adverse outcomes;
• Poor student, employee, and/or patient satisfaction;
• Increased cost of operations; and
• Turnover due to qualified employees seeking new positions in more professional and inclusive environments. 

D.  Duty for Good Faith Reporting

Unprofessional and unacceptable behaviors sometimes go unreported and therefore unaddressed. The University is unable to address a situation when it is not aware of specific incidents that have occurred, including lack of awareness of the supportive details surrounding such situations.

All University community members have a duty to make a good faith report if they are aware of behavior that may violate provisions of the University of Texas System Policies; Regent’s Rules and Regulations; the University’s Standards of Conduct; Handbook of Operating Procedures; federal health care program requirements; or other applicable laws,  regulations, or policies. Such individuals must immediately make a report to their supervisor, another member of management, the Chief Compliance Officer, or other Office of Institutional Compliance staff member. University community members may also call or submit a report to the Compliance Hotline. The Compliance Hotline offers anonymity as an option for reporting issues covered by this policy. Any person with a concern regarding a breach of ethics or a possible compliance matter should report it to the Compliance Hotline or notify the Chief Compliance Officer or other Office of Institutional Compliance staff member.

Individuals who engage in making false complaints may be subject to disciplinary action, up to and including termination or dismissal. The process for handling any instances of suspected false complaints involving University policy should include consultation with Human Resources or the Office of Institutional Compliance prior to any department or school taking any administrative action based upon those instances.

The Guide provides information to address situations when individuals: 

• Are uncertain whether behavior would be considered a violation of policy;
• Are unaware of what information is most helpful when reporting concerns or complaints;
• Fear retaliation or are uncomfortable reporting a colleague’s conduct; or
• Are unaware of how to report concerns or complaints.

E. Corrective and Disciplinary Actions

Corrective and/or disciplinary action may be imposed when conduct violates the requirements outlined within the University of Texas System Policies; Regent’s Rules and Regulations; the University’s Standards of Conduct; the Handbook of Operating Procedures; federal health care program requirements; other applicable laws, regulations, or policies; or any other applicable policy or handbook, such as the Graduate Medical Education Resident Handbook which applies to residents and fellows. Corrective and/or disciplinary action(s) may include, but is not limited to:

• Training;
• Coaching;
• Documentation within a performance evaluation, corrective action, or performance improvement plan;
• Loss of merit, incentive, or reward compensation;
• Probation;
• Suspension without pay;
• Demotion;
• Termination or dismissal;
• Termination of contractual relationship;
• Barring from reemployment;
• Restitution for damage to or misappropriation of University or UT System property; or
• Other reasonable sanctions deemed appropriate under the circumstances.

Implementation of corrective and/or disciplinary action against employees will be handled in accordance with University policies and procedures. These include, but are not limited to:

• HOOP Policy #44, Faculty Reappointment and Non-Reappointment
• HOOP Policy #133, Faculty Termination
• HOOP Policy #153, Termination of Employment: Administrative and Professional
• HOOP Policy #187, Discipline and Dismissal of Classified Employees 

F.  Protection from Retaliation

The University requires good faith reports of University-related misconduct. The University will not tolerate retaliation or threat of retaliation against those who make good faith disclosures of actual or perceived misconduct. Acts or threats of retaliation in response to such reports may subject the person retaliating to disciplinary action, up to and including termination or dismissal. Refer to HOOP #108, Protection from Retaliation for additional information.

G.  External Investigations

University community members should notify the Office of Institutional Compliance if they learn of an investigation being conducted by affiliate partners, e.g., UT MD Anderson Cancer Center, Memorial Hermann Health System, Harris Health System, that involves a University community member (specifically, alleging that a University community member has violated an applicable regulation or policy belonging to either the University, the affiliate partner, or any other regulation or law). Legal processes, however, require notification to the Office of Legal Affairs. Legal processes include external investigations or inquiries from governmental agencies, research sponsors, or other official investigators; oral or written requests for documents or information related to University business; claims or possible claims against the University; and receipt of any citation or notice of suit, subpoena to appear and/or for records, demand for payment, and/or notice of claim (including claims filed with administrative agencies such as the Equal Employment Opportunity Commission). Refer to HOOP #147, Handling Legal Processes for additional information.

IV. CONTACTS

• • Office of Institutional Compliance
  • 713-500-3294
  • mailto:compliance@uth.tmc.edu
  • https://www.uth.edu/compliance/contact/
  • https://www.uth.edu/compliance/reporting-issues/hotline.htm

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