Peninsula Regional Medical Center - Part of Peninusula Regional Health System

Standards of Performance & Expected Behavior


Peninsula Regional Medical Center has developed performance standards that each employee is expected to practice while on duty. 

These behaviors and standards are incorporated as a measure of overall work performance.   Peninsula Regional Medical Center makes it clear that all employees are expected to adhere to and practice the Standards of Performance.

Make a Positive Impression

  • Be clean and professional looking.
  • Follow dress code and wear your identification badge at all times.
  • Greet patients and co-workers with a smile.
  • Offer to assist customers when a visitor or patient appears to be lost. Offer to escort them to their destinations.

Respect and Caring

  • Make sure that patient information is kept confidential.
  • Never discuss patients and their care in public areas.
  • Listen to customers with empathy; be courteous and do not use jargon.
  • Keep noise to a minimum; never "talk over" a patient.
  • Treat other employees as professionals deserving courtesy, honesty and respect.
  • Welcome new employees.
  • Knock before entering a patient's room.


  • Apologize for poor service, and fix what is in your control.
  • Identify ways to solve problems.
  • Offer suggestions.
  • Follow up and follow through to get problems resolved.
  • Take a personal interest in meeting the needs of the customers.


  • Take pride in the organization as if you own it.
  • Accept the responsibilities of your job.
  • Support your co-workers. Do no chastise or embarrass fellow employees.
  • Participate in staff meetings and Medical Center events.
  • Be an ambassador for the Medical Center.
  • Adhere to policies and procedures.
  • Arrive to work on time.
  • Do the right thing.
  • Pick up litter and dispose of it properly.
  • Use protective clothing, gear and procedures when necessary.
  • Practice infection control procedures, in particular hand washing.

Exceptional Service

  • Our job is to serve our customers and provide high quality service with care and courtesy.
  • Treat patients as if they are your most beloved relative.
  • Anticipate and exceed all customer expectations - "Go The Extra Mile."
  • Demonstrate enthusiasm and a high degree of professionalism while performing your job.
  • Make a difference.
  • Consider the safety and well being of patients in all actions.

Peninsula Regional Medical Center

(code of Conduct Summary)

The Code of Conduct is intended to provide guidance and to reflect behaviors consistent with the law, regulations and our commitment to exceptional customer service.

Patient Care

  • Peninsula Regional Medical Center is committed to providing patients with quality care and services in a considerate, respectful and cost-effective manner.
  • We will respect the rights of our patients as individuals, as well as the rights of their families and/or significant others.
  • We will provide care with a spirit of compassion and concern.
  • We are committed to providing our patients with the highest quality care, without regard to their race, color, creed, national origin, sexual orientation, age, sex, handicap or financial status.
  • We will encourage professional advancement through continuing education, so as to ensure that all patient care treatments and procedures conform to the most current standards of practice and are individualized to best meet each patient's needs. 
  • We require all staff to maintain a current license, certification or registration as indicated by their professional organization and as indicated by applicable regulatory bodies, to deliver care, practice and to bill for that service. 
  • We will maintain medical records that reflect complete, accurate and legible accounts of all care and treatment provided to patients.
  • We will comply with all requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) by providing emergency medical treatment to all patients who present to the Emergency Department requesting treatment or evaluation, regardless of ability to pay. 


  • Peninsula Regional Medical Center will strive to protect the privacy and confidentiality of its patients, employees and physicians.
  • We will treat all information pertaining to patient care in a confidential manner and disclose such information only as authorized by Medical Center policy or by law. 
  • We will comply will all laws concerning privacy and confidentiality. 

Patients' Rights

  • We shall treat patients with dignity and respect.
  • We will honor our patients' right to information concerning medical diagnoses, treatment and prognosis. 


  • We will comply with all laws, regulations and Hospital policies regarding workplace safety.
  • We are expected to practice and encourage safe work habits and are expected to identify safety hazards and to report unsafe conditions to our supervisors.
  • We will promptly report the failure of any medical device.
  • We will practice universal precautions.

Information Technology/Proprietary Information

  • Peninsula Regional Medical Center will protect its information technology, and proprietary information documents from improper use and access.
  • We will not perform acts designed or intended to circumvent or defeat security measures, including, but not limited to sharing, guessing or "cracking" passwords.
  • We will not use computers, telephones, photocopiers, fax machines or other Peninsula Regional Medical Center supplied technology to conduct a business concern outside of Peninsula Regional or for personal financial gain.

Conflicts of Interest

  • Employees are expected to pursue the best interests of Peninsula Regional Medical Center at all times and under all circumstances.  No employee should pursue any personal interests which might conflict, or appear to conflict, with the interests of Peninsula Regional Medical Center.  A conflict of interest exists whenever the performance of an employee's official duties has, or appears to have, a direct or predictable effect upon his/her financial interests or the financial interests of his/her immediate family, business partner, or person, firm or corporation with which he/she is otherwise associated.
  • No employee should accept or solicit any benefit from an existing or potential supplier that might compromise, or appear to compromise, his/her objective assessment of the supplier's products or services.
  • We will not offer or accept anything of more than token value from an individual or organization that does business with, or is a prospective vendor of, Peninsula Regional.  Business luncheons or dinners are permitted but should be limited in frequency.
  • Confidential or proprietary information will be kept confidential.  Information may not be distributed or sold to organizations without a direct, authorized need for that information.
  • We do not prohibit employees from doing outside work, as long as the employee can effectively fulfill the requirements of his/her job, and the outside employment does not create a conflict of interest.  


  • We will follow all federal and state documentation, charging, coding and billing regulations, including, but not limited to, the requirements of the Medicare Participation Agreement for all our services.
  • We will follow sound business practices and fulfill our fiduciary responsibilities.

Human Resources

  • We will comply with employment laws and regulations.
  • We will strive to create a work environment that is free from sexual harassment or harassment based on race, color, religion, sex, age, marital status, national origin, sexual orientation, veteran status or disability.  Any instance of a violation of this standard of conduct should be reported immediately to a supervisor, other management level employee or through the hotline.
  • We will not employ those individuals who are sanctioned or have been removed from participation in the Medicare/Medicaid Programs, or those whose previous history or experiences make them unsuitable for assuming certain responsibilities.
  • Every supervisor and manager has the responsibility to encourage a work environment in which ethical concerns can be raised and openly discussed without fear of retribution or retaliation.