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Policies and Procedures

Please visit the Johns Hopkins Multi-Entity Policies & Procedures page to view all up-to-date policies.

  • Confidentiality Agreement for Workforce Members Who Are Consultants, Contractors or Vendor

    Download PDF Version

    I understand that I require information to perform my duties at the Johns Hopkins University or Johns Hopkins Health System entity by which I am engaged or for which I am performing services ("Johns Hopkins"). This information may include, but is not limited to, information on patients, employees, students, other workforce members, donors, research, and financial and business operations. Some of this information is made confidential by law (such as "protected health information" or "PHI" under the federal Health Insurance Portability and Accountability Act) or by Johns Hopkins policies. Confidential information may be in any form, e.g., written, electronic, oral, overheard or observed. I also understand that access to all confidential information is granted on a need-to-know basis. A need-to-know is defined as information access that is required in order to perform my work. 

    I will not disclose confidential information to patients, friends, relatives, co-workers or anyone else except as permitted by Johns Hopkins policies and applicable law and as required to perform my work as a consultant, contractor or vendor for Johns Hopkins.

    I will protect the confidentiality of all confidential information, including PHI, while at Johns Hopkins and after I leave Johns Hopkins. All confidential information remains the property of Johns Hopkins and may not be removed or kept by me when I leave Johns Hopkins except as permitted by Johns Hopkins policies or specific agreements or arrangements applicable to my work as a consultant, contractor or vendor for Johns Hopkins.

    If I violate this agreement, I may be subject to adverse action up to and including termination of my ability to work at or on behalf of Johns Hopkins. In addition, under applicable law, I may be subject to criminal or civil penalties.

    I have read and understand the above and agree to be bound by it. 

    Name: ___________________________________________

    Company: ________________________________________

    Signature: ________________________________________ 

    Date: ___________________________

    Johns Hopkins Dept/School for which providing services: __________________________________

  • Download Contract Management System and Contract Review policy

    I. Purpose

    The purpose of this policy is mitigate risk by establishing procedures to manage the Ecteon Contraxx Contract Management
    System (“CMS”) and assign responsibilities to Johns Hopkins staff to enter into legally binding contracts and store contracts
    for safekeeping.

    The CMS will facilitate the safekeeping of Johns Hopkins contracts in accordance with finance policies by (1) tracking Johns
    Hopkins contracts in review through the Supply Chain Procurement Department; and (2) serving as a repository for all Johns
    Hopkins executed contracts effective on or after January 1, 2014.

    II. Exclusions

    Employment and independent contractor contracts are excluded from this policy.

    III. Definitions

    Contract: A written agreement which binds Johns Hopkins to legal and financial terms and executed by an authorized Johns Hopkins’ signer.

    Contract Administration Manager: The Johns Hopkins staff member responsible for managing the operation of the CMS.

    DocuSign: Authorized signers may sign contracts through DocuSign, a secure electronic signature platform.

    IV. Contract Review

    A. All Johns Hopkins contracts must be in writing in accordance with finance policies.

    B. Contract Administration staff are responsible for negotiating and drafting contracts and must be knowledgeable of Johns Hopkins contract policies and procedures.

    C. All purchase contract requests are to be submitted to Supply Chain Contract Administration by email to, and upon receipt, will be assigned to a contract administrator for review.

    D. Standard terms and conditions as provided in the Johns Hopkins contract templates should be used for all contracts, if possible. If variations to the standard terms and conditions are requested, the contract administrator will review and consult with the Corporate JHHS Legal Department, as necessary, in accordance with finance policies.

    E. Once contract negotiations are complete, the contract will be signed by an authorized signer in accordance with finance policies.

    F. All executed contracts must be entered (with the exception of those exclusions noted above) into the CMS for safekeeping. Contract Administration is responsible for entering contracts and contract related information into the CMS.

    V. Safekeeping Contracts

    Contracts will be managed in accordance with the Contract Management Procedures set forth below.

    A. Track Contracts Reviewed through Contract Administration

    1. CMS will track workflow of each contract reviewed by the Contract Administration team. The CMS contract record will include, as applicable, the following contract related information:

    a. Data fields: including contract description, value, and relevant dates.

    b. Negotiation communications

    c. Internal notes and correspondence

    d. Relevant documents related to the contract

    e. Workflow status

    f. Contract expiration alerts

    g. Executed contract

    B. Serve as Safekeeping Repository of all Johns Hopkins Contracts

    1. The CMS will be the safekeeping repository for all Johns Hopkins contracts, except for exclusions noted above.

    2. All Johns Hopkins’ contracts are confidential, and Johns Hopkins is legally and contractually bound to permit access only on a need to know basis to perform job duties. An employee may request contract information by contacting the employee’s Supply Chain representative, emailing, or contacting the Contract Administration Manager in Supply Chain. To protect contract confidentiality, guidelines for access to Ecteon, subject to the discretion of General Counsel or CFO, will be as follows:

    a. Hospital Affiliates Contracts (defined as JHHS, JHH, JHBMC, JHACH, HCGH, JHCP, SMH, SHI, JH Imaging): All Hospital Affiliate Vice President’s and above, Hospital Affiliate Vice Presidents’ designees, as well as Supply Chain JHHS staff which includes JHHS Contract Administration, can view the Contract Record for all Hospital Affiliates contracts, except those CSAs, NDAs, and MOUs noted below.

    b. Non-Hospital Affiliates (defined as those not listed as Hospital Affiliates above, including JH Home Care Group, JH HealthCare): All Non-Hospital Affiliate Vice Presidents and above, Supply Chain JHHS staff which includes JHHS Contract Administration, and Non-Hospital Affiliate Vice Presidents’ designees would be able to view only their own Non-Hospital Affiliate’s Contract Records, except those CSAs, NDAs, and MOUs noted below.

    c. Restricted Access: Consulting Services (CSA), Non-Disclosure (NDA), and Memorandum of Understanding (MOU) Agreements: Only Vice Presidents and above and JHHS Contract Administration staff would be able to view the Contract Record for CSAs, NDAs, and MOUs.

    d. User CMS Access. CMS login will expire if a user has not logged into the CMS during a calendar quarter.

    VI. Reference

    Johns Hopkins Finance Policies:

    VII. Responsibilities

    Supply Chain Procurement

    1. Manage Contract Management System and related processes. Upon request, process and review new purchase contracts, engaging JHHS Legal Department or other staff, as necessary

    VIII. Procedures

    A. Contract Requestor

    1. Obtain quote and related documentation to draft contract.

    2. Submit request with quote and related documentation to, or for All Children’s, Sibley Memorial, and Suburban Hospitals, submit to affiliate Supply Chain representative who will submit through

    B. Supply Chain Procurement

    1. New Contract Requests:

    a. Upon receipt of new contract request from Requestor, Contract Administration team will review contract, track review in CMS, and store executed contract in CMS.

    b. Upon full execution of contract, Contract Administrator will return executed contract to Requestor with instructions to enter shopping cart.

    IX. Review Cycle

    Three (3) years

    X. Approval

    Mike Larson
    Senior Vice President of Finance/CFO, JHHS

  • Download Competitive Bidding Policy

    I. Policy

    This policy applies to The Johns Hopkins Health System Corp. (JHHS) and all affiliates. It does not apply to energy purchases made by JHMI Utilities LLC.

    II. Purpose

    Purchases Under Federal Grants

    Competitive bidding must be performed for all purchases under federal grants that exceed $3,000. For expenditures under federal grants that are greater than $3,000 but less than $150,000, quotes must be obtained from an adequate number of qualified sources (per the Federal Acquisition Regulation), and no cost or price analysis is required. For all purchases under federal grants, this policy should be followed, but Policy FIN028, Grant Accounting, should also be referenced for any additional requirements.”

    Purchases Not Under Federal Grants

    Competitive bidding is required for the procurement of supplies, equipment, furniture and services with total estimated costs of $100,000 and higher. Rationale to waive the requirement for competitive bidding may be provided through an appropriately completed Sole Source Justification Form or identification of a current and appropriate JHHS or GPO contract. Reference to a current JHHS or GPO contract should be documented within the internal notes section of the SAP shopping cart (or affiliate equivalent materials management information system tool).

    For transactions from $10,000 to $100,000, benchmarking and/or competitive quotes are required. Transactions below $10,000 do not require benchmarking or competitive quotes to be obtained, although Purchasing Departments should seek to obtain products or services at competitive prices. Prior to executing a purchase for a transaction up to $100,000, the respective Purchasing Department must determine whether: a) an appropriate contract exists, under which the product/service can be purchased; b) the product/service is on a bid schedule; and/or c) the product/service can be grouped with another transaction to realize additional cost savings. “Purchasing Departments”, for the purposes of this policy, include Supply Chain Shared Services (SCSS), Facilities Design & Construction (JHH, JHBMC, HCGH) and Facilities Management (JHH, JHBMC, HCGH). Additionally, each affiliate shall implement procedures/processes to comply with this policy.

    The following guidelines apply to the procurement of goods and services. See below for guidelines specific to construction  projects.

    A. Total estimated cost of less than $10,000:

    1. Transactions below $10,000 do not require benchmarking or competitive quotes to be obtained. However, the respective Purchasing Department must determine whether: a) an appropriate contract exists, under which the product/service can be purchased; b) the product/service is on a bid schedule; and/or c) the product/service can be grouped with another transaction to realize additional cost savings.

    2. Purchasing Departments should perform a commensurate level of due diligence on pricing options to ensure that products or services are obtained at competitive prices.

    B. Total estimated cost of $10,000 to $100,000:

    1. If the requestor believes that the requested product/service should be sole sourced, he/she should document the requested vendor and rationale within the shopping cart (or affiliate equivalent materials management information system tool). However, the respective Purchasing Department will review the rationale and determine whether:

    a. the sole source decision is appropriate;

    b. a sole source may be appropriate, but the Sole Source Justification Form should be completed to fully document the rationale and conclusion; or

    c. a sole source is not appropriate, and the steps below should be followed

    2. The respective Purchasing Department must determine whether: a) an appropriate contract exists, under which the product/service can be purchased; b) the product/service is on a bid schedule; and/or c) the product/service can be grouped with another transaction to realize additional cost savings.

    3. If an applicable contract exists, the Purchasing Department will award the purchase order in accordance with the contract. If condition (b) or (c) in #1 applies, the Purchasing Department will further analyze the relevant opportunity.

    *Note: If the Purchasing Department or the requestor believes that the product/service may be available from another vendor that a price lower than an existing contract, then the potentially lower price should be documented within the shopping cart (or affiliate equivalent materials management information system tool). The Purchasing Department will then verify whether the lower price warrants the alternative vendor being selected, based upon the products/services requested. The Purchasing Department will provide the rationale for its determination to the requestor and the parties will discuss until resolution, if required.

    4. The Purchasing Department, through benchmarking, negotiation, and/or bidding, will identify the preferred vendor and pricing. The steps and results of these activities will be documented in a summarized fashion and communicated to the requestor.

    5. If the requestor does not agree with the Purchasing Department’s vendor recommendation, the parties will work together to reach an agreement. Summarized documentation of any alternative decisions should be added to the internal notes section of the shopping cart (or affiliate equivalent materials management information system tool).

    6. A purchase order will be issued to the agreed upon vendor.

    C. Total estimated cost equal to or greater than $100,000, with the exception of purchases under an existing and appropriate JHHS or GPO contract1, requires that:

    1. For capital procurement requests, the requestor will review and adhere to the purchasing capital quote guidelines found in JHHS Supply Chain Website, (Capital Quotation Guidelines).

    2. For time sensitive procurements, the requestor will communicate timeline and related project information to the Purchasing Department.

    3. The requestor will provide to the Purchasing Department all relevant information to facilitate the competitive bidding process and/or negotiation, including, if known, suggestions of competing vendors and budgetary price quotations. The Purchasing Department will recommend the bid documents and criteria to be used for the requestor’s approval.

    4. The Purchasing Department will conduct the competitive bidding process, requesting additional required information from the requestor. The competitive bidding process will include the solicitation of bids from no less than three legitimate vendors. In any case where bids are obtained from less than three vendors, the Purchasing Department will document the rationale within the internal notes section of the shopping cart (or affiliate equivalent materials management information system tool).

    5. Once the bid evaluations have been completed, a vendor recommendation will be communicated to the requestor. Upon the requestor’s acceptance and execution of any required agreements, a purchase order will be issued.

    It is important to note that this document includes the overall JHHS policies related to competitive bidding and related activities, including the exceptions noted below. Each Purchasing Department should establish procedures by which it will execute each type of purchase, including roles and responsibilities of those involved in the process. These procedures should be approved by the respective Vice President or higher.

    III. Policy Exceptions

    A. In certain cases, the policies listed above may not be appropriate to satisfy the particular business requirements or needs. Exception to, or variations on, those policies fall under the following categories:

    1. Emergency Procurements

    2. Compatible Product Requirements

    3. Recently Bid Products/Services

    B. Emergency Procurement Process

    1. Definition: An emergency procurement under this policy is required when circumstances dictate the need for a purchase to fill an immediate, unexpected need when there is insufficient time to conduct competitive bidding. These procurements should be reserved for situations in which there is an immediate threat to the safety of patients, staff and/or visitors, or when the ability to conduct core operations is in jeopardy.

    2. For all procurements, approval must be obtained in accordance with the authority limits within Policy No. FIN004, Required Levels of Approval Authority: Purchases for Non-Capital Goods and Services.

    3. When requesting an emergency procurement, the requestor should:

    a. Document the need for the emergency procurement, including:

    i. The issue necessitating the emergency procurement

    ii. Rationale for the emergency – i.e., the specific threat to JHHS operations, personnel, patients, visitors, etc.

    iii. The product/service required

    iv. The preferred vendor and a brief explanation of why the vendor should be used

    v. Price/Quote

    b. Obtain written (i.e., via email) approval from an authorized approver

    i. If the emergency requires immediate attention and only verbal approval can be obtained from an authorized approver, then the requester should document the verbal conversation and obtain written confirmation of the approval as soon as possible.

    c. Submit the written approval (or documentation of verbal approval) to the respective Purchasing Department for authorization to proceed.If the emergency requires immediate attention and it is not possible or feasible to obtain Purchasing Department authorization before procuring the product or service, then the Purchasing Department should be notified as soon as possible.

    d. Upon authorization to proceed from the Purchasing Department (if applicable, per #3), engage the vendor.

    e. Submit a Purchase Order as soon as possible to formally document and record the purchase request, approval and details.

    C. Compatible Product Requirements

    1. In some cases, an existing product may require specific replacement parts, supplies, or compatible equipment that can only be purchased from a single vendor. In such cases, rather than completing a Sole Source Justification Form, the requestor should indicate within the shopping cart notes that the specific item requested is required and why no substitute product or vendor will suffice.

    D. Recently Bid Products/Services

    1. If a specific product or service was procured through the competitive bidding process within the past six months, the same product or service may be procured without engaging in the bidding process again. If known to the requestor, he/she should indicate within the shopping cart (or affiliate equivalent materials management information system tool) notes that the product/service was bid within the past six months and request that the purchase be made without conducting competitive bidding.

    IV. Responsibilities

    A. Requesting Department

    1. Provide Purchasing Department with all required request and vendor documentation, as well as all required departmental approvals for the purchase request. As required, also complete and provide Sole Source Justification Form.

    2. Comply with the required steps above for Emergency Procurements.

    B. Purchasing Department

    1. Review submitted shopping carts and verify that all required information is included. Review requests for sole sourced products/services, and per the guidelines above: determine whether requested products/services can be procured under an existing contract, are on a bid schedule and/or can be grouped with other procurement requests; determine validity of sole source request; conduct additional research/benchmarking, if required; work with the requesting department to resolve any disputes over the applicability of sole sourcing. Conduct competitive bidding events when required.

    2. Authorize Emergency Procurements in accordance with guidelines above.

    V. Sponsor

    Director of Procurement, JHHS

    VI. Review Cycle

    Three (3) years

    VII. Approval

    Mike Larson
    SVP Finance & CFO of JHHS

    See #2 in the section above related to the procurement of items under existing contracts. Similar to that process, should
    the Purchasing Department or the requestor believe that a lower cost is available with another vendor such that a competitive
    bidding process would be practical, then the below process may be conducted.

  • All employees of Johns Hopkins Health System Materials Management Division shall exercise the utmost goodfaith in all transactions touching their duties to the Health System and its property and shall be held to a strict rule of honesty and fair dealing between themselves and the Health System. They shall not use their position(s) to secure any item or benefit which would not ordinarily accrue to them in the performance of their official, professional or clerical duties. They shall not accept gifts, favors or hospitality which might influence their decision making.

    All persons shall promptly report and make a full disclosure of the possible existence of a conflict of interest for themselves or any other person subject to the policy, and should any duality of interest exist, it shall not influence their decision making on behalf of the Health System.

    Employees engaged in consulting or other outside employment shall avoid the use of any information and or any appearance of a conflict of interest with assigned Health System responsibilities. This policy also applies to sponsored research programs with contractual restrictions, patents, copyrights, and to any outside employment which may interfere with satisfactory job performance in their Materials Management Position(s).

    I have read the above Conflict of Interest statement, understand its content, and agree to abide by the directives set forth therein. I shall promptly report any information and/or any appearance of conflict in interest to my Administrative Chief.

    Download the PDF

  • Supply Chain Procurement and Materials Managers occupy a special position of trust and responsibility. In order to avoid the potential problems of unethical behavior, strict adherence to a sound code of ethics is required and practiced.

    Ethics demand that we, as employees of the Johns Hopkins Health System Procurement and Supply Chain Departments, make or influence decisions for our Health Care System with complete fidelity to the institutions and respect the valid rights of others.

    The Corporate Procurement Department subscribes to the following standards:

    • Support the Mission of the Johns Hopkins Health System and Johns Hopkins Medicine.
    • Strive to conduct all business with honesty, fairness, integrity, and loyalty to the Health System and our profession.
    • Decline all gifts or gratuities and do not enter into any transactions resulting in our personal benefit.
    • Conduct business with potential and current suppliers in an atmosphere of good faith.
    • Demand honesty and integrity in sales representation.
    • Conduct ourselves in such a manner as to merit the respect of our employer, co-workers, and peers.
    • Exercise skill and good judgment to obtain the maximum value for each dollar of expenditure.
    • Treat with discretion all information obtained in confidence.
    • Foster fair, ethical and legal business practices.
    • Protect Johns Hopkins Health System’s interest by ensuring our suppliers honor all terms and conditions of their contracts.
    • Strive for standardization to reduce cost and further the development and methods of products that emphasize high quality, safety, and effectiveness of patient care.

    Corporate Procurement Staff Members Will Follow This Code of Ethics at All Times and Will Be Required to Sign a Conflict of Interest Statement Annually.

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