Policies & Procedures

  • Code of Conduct

    Sentara Healthcare (SHC) requires all Vendor Representatives / Suppliers / Traders (Representatives) to adhere to the Sentara Healthcare Code of Business Conduct and its policies and procedures.

    Sentara Healthcare strives to exercise the highest standards of conduct in dealing with vendors. We expect that our vendors will also use these same high standards when conducting business with Sentara Healthcare.

  • General Provisions
    1. Representatives will comply with the rules of Sentara Hospitals, Sentara Materials Management, and Sentara Finance in all dealings. These expectations are addressed in the Non-Employee Orientation.
    2. Representatives are prohibited from interacting with patients and/or their families without approval from a department director, manager, or provider.
    3. Representatives are prohibited from requesting or attempting to gain access to confidential patient or product information. Representatives may visit patient care areas only when invited by an authorized Sentara staff member (i.e. Case Manager) or when an appointment has been scheduled.
    4. All contracts and dealings between Sentara Healthcare and Vendor Representatives /Suppliers /Traders shall be conducted in a manner that avoids the appearance of impropriety and the violation of
      any laws or regulations.
    5. All Vendors must complete the designated credentialing process to be eligible to conduct business with Sentara Healthcare. The credentialing requirement applies to the Company and the individual representative. Circumventing the credentialing process, providing false documentation and misrepresenting complacence are actions which will result in sanctions and could lead a suspension and revocation of access privileges.
    6. In addition to system wide credentialing, vendors will be required to complete department level orientations for each facility and department where access is granted.
    7. Sentara has developed a travel policy to provide contractors and vendors, whose travel-related expenses are to be reimbursed by Sentara, with an exceptional level of service and comfort while controlling travel expenses. Review the policy and ensure you have a clear understanding of how to set up business travel incurred on Sentara’s behalf.
  • Site Access Provisions
    1. Individual representatives must complete the designated system-wide and departmental Orientation and Training for Non-employed Staff of Sentara Healthcare. All credentialing requirements must be fulfilled prior to
      scheduling appointments and onsite visits. Exceptions to this policy will be granted on a case-by-case bases for imperative and emergent situations. All vendor visits must be documented.
    2. Visitation to a Sentara facility is by invitation only. Visitation to Sentara staff is by scheduled appointment only. Representatives are authorized to visit only the designated area to which they are invited and have a scheduled appointment.
    3. All Representatives are required to check in at the time of each visit prior to conducting business at Sentara. Multiple points of registration may be required at each facility. Check-in may include:
      • Registration through a kiosk or electronic portal
      • Signing a visitor’s register or logbook
      • Checking in with a designated point of contact at a front desk or reception area.
    4. All Representatives are required to check out of the site upon completion of business.
    5. Representatives will not be permitted to enter any area without proper identification and approval of the Department Director or Department Manager and/or the Physician. Proper badging is required at all times on Sentara property.
    6. Loitering in any area, including staff and physician lounges, for the purpose of meeting or discussing products, equipment, or services without prior approval is prohibited. Use of facility telephones within the department without requesting permission is prohibited.
    7. Representatives will observe the general hours of operation of each facility and/or corporate entity unless prior arrangements are made in advance with the appropriate party.
    8. At the discretion of the manager/director/physician leader, representatives may be required to report to the site-specific department (e.g. Pharmacy, Radiology, Office, etc.) or other approved locations prior to visiting other areas.
    9. Representatives shall never loiter or in any manner attempt to “catch up” with SHC employees without scheduling an appointment
    10. Representatives shall never attempt to see any physician, nurse, pharmacist or any other person in a patient care environment unless prior arrangements have been made and appropriate permission secured.
    11. Representatives shall not attempt to see any physician, nurse, pharmacist or any other person in the outpatient setting (SMG, Life Care, or Rehab Network) during patient care hours.
    12. Representatives must park their private or company vehicles in appropriate visitor parking areas.  Vehicles parked in unauthorized areas will be towed at the driver’s expense.
    13. Representatives must complete department specific orientations prior to scheduling visits and appointments.
  • Marketing Provision
    1. Representatives are prohibited from displaying company information, advertisements, or pharmaceuticals without prior permission from the appropriate facility staff or the Materials Management Department.
    2. Solicitations, displays, presentations, or other promotional materials are prohibited without prior review and approval of the Manager of the respective department (e.g. Pharmacy, Radiology, Office, etc.) or designee.
    3. Gifts or inducements of any kind, including providing food or meals, are prohibited and could negatively impact future business.
    4. Representatives shall limit visits to providing educational information and reference materials only.
      Food, snacks, or beverages (or any other “gifts”) are not to be offered or provided on any SHC campus, department, clinic/practice, or at any SHC sponsored event.
    5. Representatives will not request anyone other than a designated member of the Materials Management Department to sign any type of purchasing agreement or contract. Agreements or contracts signed by a non-authorized agent will not be honored.
    6. Representatives may not provide comparative cost data to physicians. Representatives do not have
      access to the actual acquisition prices of the healthcare organization, and therefore cannot provide accurate price comparisons of their competitors (e.g. medications, supplies, equipment, etc.).
    7. Sentara utilizes MedApprovedTM as the clearinghouse for all new product submissions. Using MedApprovedTM is the only method of submitting new products to Sentara Healthcare Value Analysis Committees/Commodity Groups/Taskforces for approval.
  • Clinical Provisions
    1. Representatives do not have clinical privileges at Sentara and shall not engage in any type of independent clinical activity.
    2. Admission to Sentara Operating Rooms and Surgical Procedural areas is granted on a case by case basis only.
    3. Representatives are expected to adhere to all SHC Operating Room policies and all departmental policies as   outlined in specific departmental orientations.
    4. Surgical and Procedural Vendor Representatives:
      • Taking any tray, equipment, and/or supply to the operative or procedural area or SPD Decontamination without notifying the department manager or designee is prohibited.
      • Removal of any product from inventory without documentation reviewed by the department manager or designee is prohibited. This includes consignment and vendor managed inventory.
      • Entering a sterile or procedural environment without proper attire is prohibited. Scrub attire worn outside of the facility is prohibited. Briefcases, satchels, handbags, electronic devices, etc, are not permitted in the operative or procedural areas without requesting permission.
      • Approved clinical footwear must be worn at all times while in the sterile and procedural areas.
      • Vendor trays will be delivered to the Central Sterile Supply (CSS) Decontamination area by a credentialed representative. No vendor trays will be dropped off less than 24 hours before a scheduled procedure during the regular business work week without prior approval by CSS leadership in conjunction with other members of the Surgical Services management team if necessary.
      • Surgical trays must contain a complete inventory list. The representative shall confirm contents with a Sterile Processing Department representative or Inventory Tech when dropping off the tray(s). The Vendor Representative will verify, reconcile, and confirm the tray contents when picking up tray(s) prior to removal from the premises. Claims of missing instrumentation without following the procedure will not be accepted.
      • Product invoices must be submitted no later than 4 PM of the business day following the actual procedure. When the vendor does not follow the appropriate guidelines, products used will be considered a donation.
    5. Representatives shall be responsible for communicating all changes in the legal or therapeutic status, new labeling or product formulation to the respective department for medications, supplies, or equipment products currently stocked.
  • Regulatory Provisions
    1. Representatives shall exhibit the highest standards of professional conduct and provide information that is requested, meaningful, factual, approved by the FDA (if applicable) and pertinent.
    2. Confidentiality of patient identity and information must be respected in accordance with HIPAA guidelines.
    3. Under no condition shall a representative make an offer that would have the potential to or would compromise Sentara Integrity Compliance and Ethics Standards. This includes meals, trips, and other
      types of “gifts.”
    4. No representative shall attempt to interpret or communicate policies of SHC to any staff member.
    5. No pharmaceutical representative shall attempt to interpret or communicate policies of the pharmacy
      department or Pharmacy and Therapeutics committee to any member of SHC staff or hospital medical staff - all such communication must be referred to the appropriate member of the Pharmacy department.
    6. Medications not approved by the Pharmacy and Therapeutics committee for addition to the formulary cannot be promoted or detailed in Sentara Hospitals. Medications that are restricted to indication or medical specialty cannot be detailed in the Hospital to physicians outside of those restrictions.
    7. Violations of any of the above may result in suspension or revocation of representative visitation privileges. Representatives must act in accordance with:
      • PhRMA Code on Interactions with Healthcare Professionals
      • Department of Health and Human Services OIG Compliance Program Guidance for Pharmaceutical Manufacturers
      • ASHP Guidelines on Pharmacists’ Relationships with Industry
      • Health Industry Group Purchasing Association Code of Conduct Principles
      • Novation Code of Conduct for Pharmaceutical Representatives
  • Sanctions
    1. Sentara Healthcare strives to exercise the highest standards of conduct in dealing with its vendors.  We ask that our
       vendors use these same high standards when conducting business with Sentara. Failure to follow these guidelines will
       result in a conduct review that may result in sanctions being applied to an individual representative or a vendor. Sanctions
       may include censure, suspension or permanent revocation of access privileges to system facilities.
    2. Examples sanctions and non-compliance of conduct are listed below. This list represents types of examples only and is not intended to be an inclusive or exhaustive list. Suspension or permanent revocation of access privileges to system facilities will be determined by the Managers/Directors of the SHC departments, office practices, or sites in which the infraction occurred.


    • No or improper identification
    • Loitering
    • Failure to return call and/or e-mails
    • Failure to attend meetings
    • Inappropriate dress
    • Inappropriate speech and/or behavior


    • Participation in direct patient care
    • Removal of product from inventory without documentation/approval
    • Contamination of a sterile field
    • Entering a sterile or procedural environment without proper attire
    • Inappropriate physical contact with another individual
    • Making false and/or malicious statements concerning employees or the organization.
    • Violation of organizational safety, security, fire, traffic, or parking regulations.
    • Offering gifts, money, or other forms of remuneration to patients, staff and/or physicians
    • Violation of organizational or departmental policy


    • Conviction of a felony or of a crime involving moral turpitude, or admission of guilt or entry of a plea of no contest to such a crime.
    • Failure to maintain required current license or credentials, or providing false information concerning credentials.
    • Violation of organizational or departmental policy, procedure and/or practice
    • Theft
    • Gambling on organizational premises.
    • Subjecting patients, visitors, or employees to physical or verbal abuse
    • Breach of confidentiality
    • Sexual harassment
    • Falsification of organizational records, or providing false or misleading information.
    • Insubordination, or refusal to follow the reasonable request of a manager, director and/or physician.
    • Threatening or abusive language
    • Committing or threatening to commit an act of violence 
    • Unauthorized possession, use, or distribution of intoxicating liquors or drugs on organizational property, or reporting to work under the influence of intoxicants or drugs.
    • Possessing explosives, firearms, or dangerous weapons on organizational premises