Department of Pediatrics

Department of Pediatrics

Policy and Procedure Manual September 2007

TABLE OF CONTENTS

1.0 General Information

Purpose & Mission

Organizational Chart

2.0 Personnel

Ethics and Standards of Conduct

Conflict of Interest

Faculty Recruitment and Appointment

Change in Employment Status (Faculty)

Classified Personnel Recruitment

Personnel Records

Job Manuals (Classified Staff)

Time Sheets

Equivalent Time (Faculty)

Overtime for Classified Employees

Vacation Time

Procedures for Approval and Reporting of Compensatory Time

Performance Evaluations

Reporting Professional Services and Outside Activities

Outside Employment and Nonelective Positions of Honor, Profit or Trust

Legislative Lobbying

Faculty Development Program

Risk Management Training for Physicians

3.0 Operations

Records Management

Work Schedules

Personal Phone Calls

Long Distance Access Codes and Telephone System

Time and Effort Reporting

Fire Drill/Emergency Procedures

Equipment Management

Inventory Control

Consultant Prior Approval Forms/Persons of Interest

Travel

4.0 Computers

5.0 Fiscal

Pediatric Accounts & Property Management Office (APMO)

Petty Cash Funds

Petty Cash Purchase/Reimbursement

Cash/Checks received in non-clinical areas

Outside Consultation or Employment

Check Distribution

6.0 Laboratory Policies

General Compliance

Internal Controls – Research Activities

1.0 General Information

1.1 Purpose & Mission

The Department Manual is intended to supplement the official UTHSCSA Handbook of Operating Procedures (HOP), which can be found on line at www.uthscsa.edu/hop2000/.

The mission of the Department of Pediatrics is to serve the needs of the state of Texas by:

·  providing medical education and training to medical students, residents, fellows, and practicing physicians as well as students and practitioners of other disciplines;

·  delivering high quality pediatric primary care and specialty pediatric care primarily to patients of Bexar County and South Texas;

·  conducting basic, clinical, and other bio-medical research;

·  serving on a variety of University, community, state, and national and international committees, boards, agencies, and other administrative bodies;

·  developing a network of pediatric specialty care services in support of the children and pediatric primary care providers throughout South Texas;

·  striving to increase the number of under represented minority medical students and pediatric house staff; and

·  striving for a majority of graduating medial students and pediatric house staff to commit to generalist careers, particularly in medically underserved areas

1.2 Org Chart

2.0 PERSONNEL POLICIES AND PROCEDURES

2.1 Employees are expected to read and comply with the “Ethics and Standards of Conduct: A Reference Guide” which can be read online at www.uthscsa.edu/HOP2000/ (Chapter 2, 2.4.1). Employees are also expected to be familiar with the policies and procedures in the HOP.

·  During employment, there may be times when an individual will have knowledge of confidential information regarding patients, students, fellow employees and others. Inquiries for any information deemed confidential should be brought to the attention of the supervisor. Due to the number of visitors to the Department, information such as this should not be discussed in hallways or in public areas.

·  All confidential matters such as patient, student or personnel information should be locked up at the close of each working day. During work hours, confidential material will not be left unattended in an open area (such as a community or office hallway mail box). In addition, electronic information must be protected in accordance with Health Science Center standards for electronic information security.

·  Incoming calls requesting information that appears to be of a confidential nature should be referred to the Chairman’s Office.

·  Employees in the Department are encouraged to become familiar with the Health Science Center HIPAA policies www.uthscsa.edu/hipaa and all employees are required to take Level III training as of June, 2007. Individuals who had taken other levels previously will be required to take Level III training at the renewal opportunity. HIPAA training is to be completed within 30 days of employment. General Compliance Awareness Training (GCAT) is also required within 30 days of employment. Clinical Documentation Training (CDT) is required for MSRDP providers within 2 months. It is the Division Chief’s responsibility to remove an individual from patient care or research activities if required training has not been accomplished within the established timelines. Refer to HIPAA/GCAT policies and procedures for more information on training and disciplinary action process for failure to attend required training. Student Associates do not go through a formal orientation with the Office of Human Resources. Thus, communication regarding HIPAA training must be communicated by the Division to the Institutional Compliance Office and the Division must ensure that the individual takes the required level of training in a timely fashion.

·  Each Chief Administrative Staff member is responsible for maintaining a spreadsheet in which all required training is documented for his/her division. HIPAA training should be included. Division Chiefs should check periodically to make sure that the spreadsheet is up to date as this will be audited routinely.

2.2  Conflict of Interest

University employees may accept outside employment or consultation as long as:

·  The additional responsibilities do not conflict with their primary obligations to the Health Science Center

·  The additional activities are approved in advance within the Department and by the Office of the President

·  The activities conform with all applicable State laws and University regulations

·  The activities do not constitute a conflict of interest.

2.3  Faculty recruitment and appointment procedures

·  Division completes the notification of vacancy form (www.uthscsa.edu/eeo/Att1notifofvacancy-FA.pdf) and attaches the copy of the advertisement and recruitment sources. The division will obtain price quotes for advertisements since the pricing information must be submitted with the paperwork to EEO/AA Office. If there are new recruitment sources planned during the course of a recruitment, a revised notification of faculty vacancy form needs to be completed and turned into the Personnel Coordinator and approval received from the EEO/AA Office before executing additional recruitment activities.

·  Completed paperwork is submitted to the Department’s Personnel Coordinator for review and submission to EEO/AA.

·  Once approval is received, Personnel Coordinator will notify division and the division will place the advertisement and will process the voucher for payment. A copy of the voucher should be made for the Personnel Coordinator’s file.

·  As cvs are received, the division will submit to the EEO/AA Office the recruitment log (original) and the individual’s cv (no faxes permitted) and will send the Personnel Coordinator a copy of the recruitment logsheet for the Department file. Support staff are encouraged to obtain the specific address from candidate to which recruitment communication is to be sent to avoid any issues of confidentiality.

·  If it is anticipated that the candidate will be coming in at a faculty level of associate or full professor, it is imperative that an interview be scheduled with the Department’s Chairman of the Tenure and Promotions Committee.

·  The division should initiate an Authorization for Security Background and Sanction Check form when there is reason to believe that the Chairman will be requested to send an offer of employment. This typically occurs at the time of a second visit but can be obtained at a first visit. The Personnel Coordinator can begin the process using a faxed, signed form but the original must be provided to the Department for filing.

·  The Chairman’s Office prepares the offer letter once the security check is completed.

·  Once an acceptance is received, the Personnel Coordinator will email to the division the necessary forms for completion for the faculty appointment and for UPG/MSRDP/UHS credentialing and privileging.

·  Completed packets are to be returned to the Personnel Coordinator for submission to the Dean’s Office.

2.4 Change in Employment Status (Faculty)

Any change in employment status for faculty requires the approval of the Chairman. Individual faculty members are requested to submit a memorandum through their respective Division Chief to the Chairman explaining the nature of the change requested and the timeframe in which the requested change is to take place. This new process is to ensure that such changes are in alignment with the goals of both the Division and Department. This new process also enables the Department to have prior notification in order to prepare the necessary paperwork, once approval is received. The faculty member will receive a copy of the initial request back indicating the Chairman’s approval or indicating a request for discussion. A copy of this will also be provided to the Division Chief and to the Department’s personnel coordinator.

2.5 Classified Personnel Recruitment

·  Personnel Requisition (on-line document) will be completed by the Personnel Coordinator or Division Designee and will be routed to the Hiring Manager. The PI for the account on which the position is being open is responsible for sending an email to the personnel coordinator that approves the use of funds indicated on the personnel requisition and notifies her that the requisition is pending for review and formal submission. This email designates the PI’s acknowledgement that there are sufficient funds to support the position and that the position is appropriate for the funding source.

·  The Department Personnel Office will enter the requisition into the system.

·  The Department Personnel Office or Division Designee will be able to check the status of the job and can pull applications daily and print them out and provide copies to the supervisor in charge of hiring.

·  After interviews have concluded, the Division shall submit the Selection of Candidate form and submit to the Department Personnel Office. If a desired salary offer is different from the base, this needs to be indicated and the PI must indicate that funds are sufficient to cover the increase from the base salary. A salary request of greater than 15% into the range must be requested in a memo written to the Assistant Vice President for Human Resources through the Dean’s Office.

·  The official employment offer comes from the Office of Human Resources after the necessary background checks have been completed and paperwork approved.

2.6  Personnel Records

All personnel records are considered extremely confidential and will be treated as such. Faculty, classified, and A&P records are maintained in the Chairman’s suite. Volunteer faculty records are also maintained in the Chairman’s Suite. The Chairman’s administrative support team is responsible for assembling faculty appointment packets, and therefore must have access to these files to maintain and readily extract information. Faculty records are released to the Chairman, the Administrator, or to the faculty member requesting his/her own file. Classified records are released to the Chairman, the Administrator, the Division Chief, the employee’s direct supervisor, or to the employee requesting his/her own file. The Chairman’s administrative support team is responsible for assembling classified staff files, and therefore must have access to those files to maintain and extract information.

2.7  Job Manuals (Classified Staff only)

Each chief administrative officer in the division (usually an AAII or AAI) will have a job manual at his or her workstation which must be updated as procedures or responsibilities change. The Division Chief or the Chief Administrative Officer in the Division shall identify other classified staff members of whom job manuals are required. The manual should contain enough information to permit any other department employee to perform the basic functions of the job. Individuals must ensure that the security of the position is not compromised through the manual.

2.8 Time Sheets

Completion of a monthly time record is the responsibility of every member of the Department of Pediatrics. Information submitted on the monthly time report must be accurate and validated by an original signature of the employee. A supervisor’s signature is also required on each time record. Time recorded as administrative leave MUST match the dates on the peoplesoft travel requisition submitted for that leave. The Division Chief should approve, in advance, use of administrative leave. A brief description of administrative leave should be noted on the back of the monthly time record. Remember: A peoplesoft travel requisition must be filled out for time spent away from the regular work place. Signed time records are to be turned in to the Department of Pediatrics Personnel Coordinator by the end of the first day of the following month. It is the responsibility of the divisional secretaries, in conjunction with the Division Head, to assure that monthly time sheets are submitted by each member of the division, even for those who were on leave during any given month. Staff and faculty are required to document hours worked and hours taken as leave/other time. The hours entered daily must total to the last column for the week. Holidays are recorded in 8-hour days for full-time status employees. Holiday time is not counted as worked time for the week. If a holiday is actually worked a “floating holiday” can be used within the calendar year. It is the individual’s responsibility to know whether or not he/she has unused holidays.

2.9 Equivalent Time (ET) (full-time faculty)

Faculty employed in full-time positions must, as a minimum, document a 40-hour week (between worked, sick, vacation, administrative leave, other, etc.). Each Division Chief is responsible for creating a divisional policy, and communicating that policy in writing to division faculty members, that indicates the number of regular work week hours that need to be fulfilled beyond which ET would apply. Assuming ET has been earned, each full-time faculty member will be able to utilize up to 80 hours of ET during the fiscal year after all current fiscal year’s accruals of vacation/personal time have been utilized. For example if a faculty member is expected to earn 144 hours of vacation/personal time in the current fiscal year, ET may be utilized after 144 hours of vacation/personal time are used.
Equivalent Time is not to be used prior to having earned it. ET does not carry over at the end of the fiscal year and use of ET must be approved in advance by the Division Head. Utilization of equivalent time shall not cause the division or Department to incur additional expense for coverage needs; thus the workload within the division must be such that the additional time off can be accommodated without additional expense. Accrual of ET should be managed at the Division level according to the defined divisional policy. When ET is used, it should be recorded in the “other” row.

2.10  Overtime for Classified Employees

Employees in either exempt or non-exempt positions will follow the Health Science Center policies on overtime and comp time, including the requisite prior approval.