What information does a Supplier need to know before coming onsite?

Behavioural Expectations 

1. Maintain a professional attitude.

2. Please respect staff and affiliate time by making an advance appointment with any staff/affiliate before arriving at the hospital.

3. Enter and exit an area of the hospital according to specific departmental guidelines provided to you prior to your visit.

4. Log in at each visit according to specific departmental guidelines.

5. Wear corporate identification badge displaying your name and company at all times.

6. Provide a current and valid certificate of liability insurance, and WSIB or employers’ liability coverage if required to perform staff training. The terms and conditions for provision of a certificate of insurance are located on HMMS website.

7. The hospital paging system can only be used if you are specifically instructed to do so by a specific staff/affiliate during a visit.

8. Hospital house telephones are not to be used for personal matters or for making other sales contacts.

9. Refrain from marketing product(s) to staff or affiliates. 

Practice Expectations

1. Do not carry out any function that is the responsibility of staff and affiliates including operate/control or touch/handle any equipment/products/implants being used on a patient.

2. Do not actively participate in patient care.

3. Perform calibrations/synchronization as a clinical or technical specialist to adjust program devices, instruments and supplies only at the request of and/or under the supervision of the area leader or delegate.

4. Provide verbal guidance and technical direction to staff and affiliates when asked if specific approved products, instruments, or equipment requiring support will expedite the procedure and facilitate desired patient outcomes. 

5. Do not bring equipment, instruments, devices, implants, supplies or hazardous substances onto the premises for evaluation by the hospital without valid and approved documentation from HMMS (e.g. purchase order).

6. Do not remove or add equipment, instruments, or implants without permission of departmental delegate.

7. Ensure that any equipment or instruments approved for removal from the department have been cleaned appropriately before being taken off the unit. Consult with staff and affiliates about appropriate cleaning protocol.

8. Operate at all times subject to the direction of all persons qualified and authorized to prescribe or authorize equipment for patients, and with their immediate family members, in accordance with all applicable laws and all applicable professional and ethical standards.

9. Do not bring equipment, instruments, devices, tools or supplies into restricted areas without approval from the area leader. If approved, follow departmental guidelines provided by the area leader.

10. Only deliver equipment or interact with patients in the presence of the prescribing therapist, unless the therapist has given direction that the supplier may see the patient without the therapist present. If the prescribing therapist is not present, the supplier must update the patient’s therapy or nursing staff on their activities with the patient prior to leaving the facility.

11. When working in an area where there is x-ray use, supplier representatives are required to be designated an x-ray worker and are required to wear dosimeters. Supplier representatives may be required to produce proof of x-ray worker status at any time if they are planning to work in an area where there may be x-ray use. Failure to produce documentation of x-ray worker status may result in access to the area being denied. Dosimeters are non-transferable between work sites. A separate dosimeter must be used at each LHSC site, and dosimeters worn at those sites cannot be worn outside of the site.

12. Do not document in the patient’s health record. 

Privacy and Confidentiality

All suppliers are required to comply with Ontario’s Personal Health Information Protection Act (PHIPA), Canada's Personal Information Protection and Electronic Documents Act (PIPEDA).

Suppliers are not permitted to use any hospital computer, information system or access patient-identifiable information unless the supplier is providing services (e.g., maintenance or upgrades) that are supported by an HMMS-approved service contract/agreement. This type of activity must be authorized and supervised by the information technology services (ITS) department, or in the case of non-ITS supported systems/equipment, by the relevant leader or delegate.

A supplier's presence in a room with a patient in any department requires informed documented consent from the patient, if capable, or the incapable patient's substitute decision maker as well as approval by the area leader. It is the responsibility of staff and affiliates to obtain patient consent prior to the supplier entering the room. Informed consent must include informing the patient aware of the reason for the supplier's presence.

Patients have the right to refuse a supplier's presence unless the supplier's presence is essential to the procedure, e.g. where the supplier is educating staff/affiliates on the use of a new product.

Suppliers are required to hold in confidence any information about patients, residents, clients, and their families, hospital staff and affiliates, as well as the confidential business information of the organization which may come to their attention by means of their presence in the organization while carrying out duties as agreed within the organization. Confidential business information refers to any information about the organization that is not publicly disclosed by the organization.

Suppliers must commit to continue to respect and maintain the confidentiality of patients, residents, clients and their families, and staff and affiliates of the organization, as well as the confidential business information of the organization even after my employment or affiliation with the organization ends.

Suppliers must comply with the organizations' photography policy. Suppliers are strictly prohibited from taking photos or recordings of patients and hospital staff.

Failure of suppliers to comply with these expectations may be considered a breach of confidentiality which may result in disciplinary action, up to and including immediate removal from the premises, loss of contract, and refusal of entry to the hospital or affiliate organization.

In the event of a suspected breach of confidentiality, suppliers are required to collaborate on the breach investigation involving their agents and address any related concerns that may result in the recurrence of a similar incident in the future.

Gifts from Suppliers

Hospital personnel are discouraged from accepting loans or prizes from suppliers for a personal nature.

Any payment or “perk” intended to influence or provide for favourable consideration to the benefit of a supplier in a contractual or other business relationship is not permitted.

Gifts or other favours that could in any way influence or appear to influence business or care decisions are not to be provided.

Under no circumstances is it appropriate for staff to solicit suppliers for additional funds, sponsorships or gratuities to support special projects, staff or patient events such as luncheons, education days, or recognition events. suppliers may decline such solicitations and should notify HMMS of all such requests.

If suppliers wish to donate to the hospital foundations in accordance with their corporate charitable giving practices, this is acceptable. However, such choices will have no impact on the evaluation of competitive bidding events.

Infection Control

Contractors shall be familiar with infection control standard precautions in all areas of the hospital particularly, if they are working in clinical/laboratory areas. Standard precautions are designed to reduce the risk of transmission of infectious diseases and should be used whenever there is a risk of an exposure to anybody fluid. With respect to contractors, standard precautions include the use of disposable gloves, gowns, masks and eye protection when appropriate, and frequent washing of hands that have contacted environmental surfaces that may be contaminated. When contractors are to be working in all areas of the hospital particularly within patient/resident care units, project leads shall provide them with additional information on transmission-based precautions (contact, droplet and airborne).

COVID-19 Protocols — Contractors shall be familiar with all federal and provincial COVID-19 regulations that apply to their workers when conducting business at the hospitals. Contractors are responsible for maintaining and retaining documentation of vaccine status of their employees including all COVID-19 tests results that adhere to the hospital policies. Contractors are required to provide documentation to the hospital on request.

Any construction activity that has the potential to create dusts and/or a disruption of water supply must be assessed and comply with the Construction Policy. Contractor staff must not under any circumstances track mud/dirt/dust from areas under construction or spread dust in the hospital buildings from Contractor staff with dust contaminated clothing/tools/supplies.

Contractor staff that are ill with acute onset fever, respiratory or gastrointestinal symptoms should not be working in St. Joseph's facilities for a minimum of 48 hours, until symptoms have resolved.

When influenza is circulating in our community, all non-vaccinated staff, physicians, service providers, volunteers and visitors at the hospitals will be required to wear a procedure mask when in an area where patients may be (including outside areas of the organization). In addition, when an outbreak is declared at any hospital, any non-vaccinated contracted workers or service providers will not be able to enter the outbreak area.

It is our expectation that all persons contracted to work at the hospitals will comply with this policy. This requires the contractor to ensure their workers are vaccinated against influenza, and to keep a record of proof. If the contracted worker is not immunized against influenza, and does not wear a mask when required they will be asked to leave the hospital. Once immunized, the worker is not considered immune until antibodies develop, which is 14 days after immunization.

Supplier Sponsored Training and Education

The MEDEC Code of Conduct (http://www.medec.org/code) defines education and training in the following manner:

  •  “Education” means communicating information directly concerning or associated with the use of the supplier's medical technologies e.g., information about disease states and the benefits of medical technologies to certain patient populations.
  • “Training” means training on the safe and effective use of medical technologies.

HMMS encourages suppliers to make product education and training available to our staff and affiliates in support of awarded contracts for goods or services. However, we expect suppliers to ensure that the primary purpose of the program is to address the educational needs of our staff or affiliates, and that any hospitality, such as meals and refreshments, should be modest in value and subordinate in time and focus to the educational component of the program.

Samples and Trial/Loaner Equipment for Evaluation by the Hospital

A purchase order (PO) number must be included with all shipped supplies, instruments, devices, implants, or equipment, including trial or loaner equipment and supplies. If items are shipped without a PO number, the hospital is not responsible for any charges, and has the right to refuse acceptance at the dock.

Under no circumstances may drug samples be left in patient care areas. Under no circumstances may electrical / electronic medical devices be left in patient care areas unless first approved for use by Biomedical Engineering, and an HMMS PO has been issued. 

Non-drug samples may not be left in patient care areas unless an HMMS PO has been issued.

Unauthorized selling or lobbying of products is grounds for refusal of entry to the specific area(s) and/or the entire organization.

Medical Devices / Equipment

Electrical/electronic medical devices must have appropriate electrical certification and must be inspected and approved for use by biomedical engineering. It is the supplier's responsibility to present devices to biomedical engineering for inspection, and it is requested that this be done as far in advance as possible.

Prior to the use of any medical devices/equipment, the following information must be provided:

  • The Health Canada medical device license number or proof of a Health Canada investigation testing exemption;
  • Information about the design of the medical device/equipment;
  • Manuals/directions for use;
  • Device-specific recommendations for cleaning and reprocessing of the medical device/equipment; 
  • Education for staff on use, cleaning and the correct reprocessing of the medical device/equipment; 
  • Recommendations for auditing the process for cleaning, disinfection, and/or sterilization of the medical device/equipment.

The leader of a clinical area (or designate), in consultation with the Hospital's Central/Sterile Processing Department must ensure that devices are adequately reprocessed, according to their use and risk category (critical, semi-critical, non-critical) before being reused.

Latex Products

When possible, latex-free products should be used in the hospital. Suppliers should refrain from bringing products containing latex into the hospital. This includes latex-related packaging materials (e.g. latex rubber bands). In a case where suppliers provide products that are not latex free, the area leader must be notified and prior authorization must be obtained prior to bringing the product into the hospital environment. When latex free products are not available, staff must exercise caution when using latex containing products. HMMS assists with compiling a list of latex products and devices commonly used in each patient care and support service area as well as a list of possible substitutes. Suppliers must adhere to precautions when a patient is identified, or staff member self identifies as being latex sensitive/allergic and at risk. In some areas, signage 
will be posted.

Handling and Transport of Dangerous Goods / Hazardous Substances

Suppliers responsible for packaging, shipping and/or receiving a product, substance or organism which is capable of posing a risk to health, safety, property or the environment must be trained and certified to do this by an approved course of training.

Suppliers who bring or use approved hazardous substances on hospital premises must be WHMIS trained, and must ensure containers are properly labeled and stored when not in use, according to applicable regulations, hospital policies and departmental guidelines.

Dress Code

Suppliers must comply with dress code policies according to the area(s) being visited. The hospital will supply the appropriate uniform and other personal protective equipment (PPE) as required (e.g. scrubs, gloves, masks, gowns), including appropriate protective footwear when a risk of a foot injury may exist.

Fragrance Free Environment

All suppliers are asked to refrain from using, wearing, and bringing products and materials with fragrance into HMMS and hospital premises and events.

Health and Safety

All suppliers must comply with the Occupational Health and Safety Act (OHSA) and Regulations.

All suppliers must carry out their business in a safe manner and follow the hospital and departmental policies and procedures. This includes but is not limited to the use of safety equipment and devices (i.e. PPE and sharps containers) and understanding of isolation signage.

All injuries, occupational illnesses and hazards on hospital premises must be reported immediately to the staff member under whose supervision the supplier is functioning. All suppliers will participate in the investigation of events as required.

Anyone that carries on activities within the hospital who has been exposed to a potentially communicable disease or illness should refrain from visiting the hospital until medical clearance has been given.

Hand Hygiene

Alcohol-based hand rub is the preferred method for hand hygiene. When hands are visibly soiled washing with soap and water is required. Hand sanitizer stations are located throughout the hospital and are to be used upon entering the hospital, when in patient care areas, and when leaving patient care areas.

The hospital follows the Ministry of Health and Long-Term Care's Just Clean Your Hands program. Suppliers must ensure they understand the 4 Moments for Hand Hygiene, and adhere to the program when on hospital premises.

Waste Management / Housekeeping

All non-hazardous and hazardous waste materials must be handled in a safe and environmentally responsible manner. All suppliers must ensure waste material generated while conducting business on hospital premises, is removed from the hospital or deposited into the appropriate waste stream (i.e. biomedical, chemical, radioactive, narcotics and controlled substances, confidential, recyclable and general waste).


All hospital sites are completely smoke free.

Use of Cell Phones

Except for designated areas, the use of cellular phones and other wireless technologies is prohibited inside any buildings or in close proximity to any patient using a medical device. Signs indicating where cellular phones and other wireless technologies can and cannot be used are posted throughout the hospital.

Parking and Traffic

The hospital reserves the right to maintain full jurisdiction over all vehicles parking and traffic. This includes paying the posted parking fees and following the proper reporting procedures when visiting sites where sign-in is required. Visitors are responsible for paying tickets issued for violations and any towing fees that may arise with failing to comply with our hospitals' policies.

Workplace Violence and Harassment

Any persons on hospital premises must act in a civil manner, treating others with consideration and respect and observing all hospital rules and regulations. All individuals are expected to take responsibility and accountability for their behaviours and to maintain an environment within the hospital that is free of abusive, aggressive, bullying, violent or other inappropriate behaviours.

Any Supplier who witnesses inappropriate behaviour should report it immediately to the area leader or to HMMS. Suppliers will participate in the investigation of events, as required. Any supplier who participates in inappropriate behaviour will be reported to their supervisor and may face disciplinary action up to and including immediate removal from the premises, refusal of entry to hospital or affiliate organization, or civil or criminal charges.

Patient and Resident Wandering System and Access Control

Across our health care facilities, we have patients and residents who may be at risk from wandering, becoming lost or leaving our care facilities. We also have vulnerable populations of patients and residents who rely on us to provide a safe and secure facility while they are in our care.

Please be aware of the environment you are working in. Ensure you appropriately access our facilities. Maintain all levels of access control which are required across our facilities. This includes keeping doors closed, not propping doors open, and not providing access in or out of our buildings.

If you are assigned keys or access cards, you must appropriately handle and return this property. If this property becomes lost, you must report this immediately.

Consequences of Non-Compliance

Suppliers must be aware of their obligations as professional visitors to our organization.

First time offenses for non-compliance will receive a verbal warning and further education/reiteration of hospital policies. Any staff member has the right to ask the supplier to leave the premises, and this request must be respected.

HMMS will notify the supplier's supervisor requesting immediate action as a result of continued non-compliance with a policy, and will conduct all communication regarding non-compliance with the affected company.

Repeated non-compliances will result in disciplinary action up to and including immediate removal from the premises, loss of contract and refusal of entry to the hospital or affiliate organization.