CODE OF CONDUCT
Standards of Behavior
Quality and Safety We commit to quality and safety in everything we do .
Communication We use words and actions to communicate our commitment to excellence and integrity .
Ownership We take ownership of opportunities and challenges .
Relationships We build relationships to provide care and service with respect , compassion , and integrity .
Professionalism We demonstrate professionalism in how we act , what we know , and how we treat others .
Teamwork We work together toward a common vision .
Conflict of Interest
We have an obligation to conduct business within guidelines that prohibit actual or potential conflicts of interest . We rely on your judgment and discretion to avoid conflicts of interest and to seek guidance from management whenever you have doubt . Conflicts of interest may occur if your outside activities or personal interests influence or appear to influence your ability to make objective decisions relative to your job responsibilities . If the demands of any outside activities hinder or distract you from your job performance or cause you to use Children ’ s Colorado resources inappropriately , a conflict of interest may also exist . If you are unsure whether an outside activity might constitute a conflict of interest , please speak with your manager or contact the Compliance and Business Ethics Department ( CaBE ). ( Conflict of Interest – General Guidelines )
We are required to disclose potential conflicts of interest to ensure important decisions are not influenced by such circumstances . If you are concerned that a potential conflict of interest may have a direct implication on patient care , please reference the Ethical Issues policy . ( Ethical Issues Policy )
Q . In appreciation of our business , a vendor occasionally invites me to dinner or other entertainment activity . Is it appropriate for me to accept the invitation ?
A . It depends , extending or accepting business courtesies may raise legal and ethical issues . Such activities may be undertaken only when they align with Children ’ s Colorado ’ s gift policy . ( Gifts and Other Business Source Interactions )
Q . A vendor has offered to pay for some of our team members to attend a conference to learn about a new product . They will pay all travel expenses . Is this a conflict of interest ?
A . Accepting this offer could be construed as accepting a gift of greater than nominal value or an inducement for business from the vendor and therefore should not be accepted . If Children ’ s Colorado feels that learning about the new product is worthwhile , the hospital may elect to pay for team members to attend . When in doubt , discuss the situation with your supervisor or CaBE .
Q . A vendor we do business with brings my department personnel lunch on occasion . Is this a conflict of interest ? A . Children ’ s Colorado does not allow vendors to bring in meals to team members per policy . ( Gifts and Other Business
Source Interactions )
CODE OF CONDUCT
CHILDREN’S HOSPITAL COLORADO
Patient Care Standards continued Ethical Business Standards
Patient Privacy and Confidentiality Gifts and Business Courtesies
We are committed to following federal and state laws that require us to protect patients’ Protected Health Information
(PHI). We take this seriously and exercise caution when accessing and discussing PHI. You must not abuse your access to
confidential information or abuse your position to discover confidential information that your job does not require you
to know. Any violations of the confidentiality or HIPAA policies must be reported to the Privacy Officer. If questions arise
regarding an obligation to maintain the confidentiality of information or the appropriateness of releasing information, you
should seek guidance from your manager or the Privacy Officer. (HIPAA Privacy Rights)
Q. I work in the Village Pavilion and do not provide direct
patient care. Do I need to lock my computer when I
leave my workstation unattended? Q. One of my child’s classmates was admitted to the
hospital. Since I am a team member, may I look at the
child’s medical record?
A. Yes, you must lock your computers when you leave any
workstation unattended to avoid any breaches of PHI
and/or confidential information. Regardless of your
specific role within the organization and whether or
not you provide direct patient care, you must lock your
workstation when leaving it unattended. A. It depends. If you are directly involved with the care of the
child, the answer is yes, but only to the extent necessary
to perform your job functions. You may not share this
information with any individuals not authorized to receive
the patient’s PHI, including anyone at your child’s school.
If you are not involved with the child’s care, you may not
read the child’s medical record as this would constitute a
snooping violation. For example, if you work as a physical
therapist and have not been consulted to provide care,
reading the chart would breach patient confidentiality.
When accessing PHI, ask yourself: Do I really need to know
this information in order to do my job? (HIPAA - Uses and
Disclosures of PHI)
Q. I am a pharmacist and accidentally faxed a prescription
to the incorrect external pharmacy. What should I do?
A. This incident is considered an impermissible disclosure.
An impermissible disclosure is defined as any disclosure
of PHI to a person or entity that does not have lawful
rights to such information. If you are aware of an actual
or potential impermissible disclosure of PHI, immediately
contact the Privacy Officer within the Corporate
Compliance Program. All impermissible disclosures must
be reviewed by the Privacy Officer to determine if they
meet the requirements for notification under the HIPAA
Breach Notification Rule and to develop a risk mitigation
plan. In all cases, Children’s Colorado is required to take
immediate mitigating actions, such as contacting the
recipient to request that they confirm destruction of the
information mistakenly received. (Breach Determination
Q. I am a nurse who works in the Center for Cancer and
Blood Disorders. A patient’s legal guardian requested
I print off medical records from the patient’s last two
clinic appointments. Am I allowed to print and provide
such medical records as requested?
A. No. Per Children’s Colorado policy, patients and individuals
who have the legal right to access the patient’s medical
records must obtain records through the Health
Information Management (HIM) representative located at
the Registration Desk in the main hospital lobby. (Access
to PHI by Patients and Their Personal Representatives)
Q. My child is currently a patient at Children’s Colorado.
I would like to know his lab results, but I do not want
to wait for his doctor to call me. Since I have access to
Epic, is it okay for me to look it up?
A. No. You should not use your access granted through your
professional role for personal reasons. In this particular
situation, you are the consumer of healthcare and must
access your child’s PHI only through the proper channels
per Children’s Colorado policy just as any other patient’s
parent/legally authorized representative would. (Access
to PHI by Patients and Their Personal Representatives)
Q. I was once a patient at Children’s Colorado (or think I
may have been). Since I have access to Epic, is it okay
for me to look up my own information?
A. No. You are not permitted to use your access granted
through your professional role for personal reasons.
You may access your own PHI only through the proper
channels, such as MyChart or contacting the HIM
department per Children’s Colorado policy just as
any other patient or their parent/legally authorized
representative would. (Access to PHI by Patients and
Their Personal Representatives)
To avoid influencing patient care and/or business decisions, you are discouraged from accepting gifts from or giving gifts to
vendors, patients, and/or families. We have developed a policy to help guide you in determining when gifts can be accepted
or given – if in doubt, talk to your manager or call the Corporate Compliance Program. (Gifts and Business Courtesies to
Potential Referral Sources)
Q. I work in an inpatient unit as a bedside nurse. A patient’s mother brought the unit team members donuts for
breakfast. Are we allowed to accept them?
A. Yes. You may accept food or beverages from family members. If you are considering accepting any other type of gift, please
refer to Children’s Colorado’s policy or contact CaBE. (Gifts and Business Courtesies to Potential Referral Sources)
Conditions of Participation/Accreditation/Licensure
The Centers for Medicare and Medicaid Services (CMS), a federal agency, sets standards called “Conditions of Participation”
to improve quality and protect the health and safety of patients. Children’s Colorado must meet these standards in order to
continue participating in Medicare and Medicaid programs.
The Joint Commission (JC) is an independent, not-for-profit organization that accredits organizations, including hospitals.
Children’s Colorado is JC accredited, and we therefore must follow the JC’s performance standards. The Joint Commission
also investigates concerns reported by patients, families, team members and the general public. If you feel that any concern
you have raised is not being resolved by Children’s Colorado, you may also contact the Joint Commission either through their
website (email@example.com) or by calling 1-800-994-6610.
The Colorado Department of Public Health and Environment (CDPHE) is the State agency that grants Children’s Colorado its
license to operate as a hospital, as well as its certification to receive reimbursement from Medicare and Medicaid. Thus, we
must adhere to federal and state laws and meet all regulatory requirements to maintain these licensures and certifications. If
you feel that any concern you have raised is not being resolved by Children’s Colorado you may also contact CDPHE.
Team members in positions that require professional licenses, certifications, or other credentials are responsible for
maintaining the current status of their credentials and complying with federal and state requirements applicable to their
Responding to Investigations and Inquiries
We cooperate with all lawful investigations and inquiries from governmental agencies. We must never conceal, destroy, alter,
delay, or falsify any documents or information when responding to investigations or inquiries. Should you be contacted by a
governmental agency representative, please contact your manager, Accreditation, Compliance and Business Ethics Program,
and/or Legal Affairs so you may receive guidance on how to respond appropriately. Throughout all investigative processes,
Children’s Colorado preserves and protects the legal rights of the organization, team members, and patients.
Proper Coding and Billing
We are committed to accurately coding and billing for services rendered at Children’s Colorado. Due to federal law and payer
contracts, we are required to identify the services performed, document medical necessity, and meet any pertinent electronic
transaction requirements. The submission of improper claims for payment may subject Children’s Colorado to criminal and
significant financial penalties and exclusion from the Medicare and Medicaid programs. We must try our best to prevent errors. If
you have any concerns regarding errors, improprieties, or suspicious circumstances, you must report them to your manager, the
Executive Director of Revenue Cycle, and/or CaBE so that they can be investigated, and appropriate actions taken.