CHILDREN ’ S HOSPITAL COLORADO
Q . I have been asked to give a presentation on child wellness to a professional group on a day during my work time . They have offered me an honorarium . May I accept the honorarium ?
A . You may decline such payment or accept and submit it to Children ’ s Colorado since you are speaking during your regularly scheduled work hours . There are certain circumstances where you may be allowed to personally accept honoraria . Please contact Human Resources or CaBE in advance if you are considering personally accepting an honorarium .
Q . I work in our emergency department and I am considering starting a business selling resuscitative equipment over the Internet . Is this considered a conflict of interest ?
A . Your type of second employment may be a conflict of interest , and it is best to consult with CaBE and your manager for clarification before proceeding .
We have the right to work in an environment free of harassment and disruptive behavior . We do not tolerate conduct by any team member that harasses , disrupts , or interferes with another team member ’ s work performance or that creates an intimidating , offensive , or hostile work environment . ( Discrimination / Harassment , Harassment )
Alcohol and Drug-free Environment
We are committed to an alcohol and drug-free work environment to protect our patients and each other . Children ’ s Colorado prohibits the unlawful manufacture , distribution , dispensation , possession , and / or use of a controlled or illegal substance , or any other substance that causes impairment , while working and / or while present at any Children ’ s Colorado location . We recognize you may take prescription or over-the-counter drugs which could impair judgment or other skills required in job performance . However , you are expected to report to work in a fit condition to perform your duties . ( Drug and Alcohol , Practitioner Health )
Non-discrimination and Equal Employment Opportunity
We are committed to providing an equal employment opportunity environment . We must not discriminate against any individual based on age , race , ethnicity , national origin , ancestry , sex , creed , religion , pregnancy , disability ( mental and physical ), marital status , genetic information , gender expression , sexual orientation , veteran status , or any other protected classification to the extent required by applicable laws . ( Equal Opportunity Employment )
We recognize the need to maintain business and personnel information in the strictest confidence . If you have such information , you are expected to handle it in a manner to protect against improper access or use . We maintain confidentiality by only accessing information needed to do our jobs , keeping passwords private , and prohibiting unauthorized access and use of confidential information . ( Confidentiality )
Appropriate Workplace Conduct
We act in an appropriate , professional , and collaborative manner while working at and / or while representing Children ’ s Colorado . We focus on providing high-quality and compassionate care through expertise , service , and creativity .
CODE OF CONDUCT
CHILDREN’S HOSPITAL COLORADO
Fraud, Waste and Abuse
Ethical Business Standards continued
Document Retention Lobbying and Political Activity
We use, maintain, and store complete and accurate records.
All records will be destroyed after a retention period
according to the procedures outlined in Children’s Colorado’s
Records Retention policy. (Records Retention) We cannot engage in lobbying and political activities that may
jeopardize the tax-exempt status of Children’s Colorado. We
must ensure our political activities are not viewed as actions
taken on behalf of the organization. We may not contribute
Children’s Colorado resources to any political activity or
otherwise act in violation of applicable federal laws. All
lobbying and political activity must be coordinated through
Child Health Advocacy. (Advocacy and Government Affairs)
We responsibly and efficiently use our many resources
including people, finances, environment, time, and materials/
supplies for Children’s Colorado business purposes only.
We are committed to engaging in best business practices
through accurate and detailed financial reporting as
mandated by regulatory agencies. In order to promote the
safeguarding of assets we must maintain an effective system
of internal controls, including auditing and monitoring,
to ensure that records and accounts accurately reflect
Children’s Colorado’s financial transactions.
Purchasing and Contracting Practices
We make purchasing and contracting decisions based on
what is most appropriate for Children’s Colorado. Should you
have any questions or concerns regarding such practices,
please contact Materials Management. (Agreement Types)
Relationships with Competitors
We comply fully and completely with all federal and state
antitrust laws to ensure fair competition. To avoid the
appearance of anti-competitive conduct, do not discuss
pricing, salaries, or the market with competitors or
potential competitors. You should avoid seeking or receiving
information about a competitor through non-public means
if you know or have reason to believe the information is
proprietary or confidential.
Fundraising and Philanthropic Efforts
Any activity with the purpose of soliciting or raising
philanthropic support for the benefit of Children’s Colorado,
including monetary donations, specific in-kind donations,
and sponsorships, is considered fundraising. All fundraising
efforts must be coordinated through Children’s Hospital
We respect the environment and strive to conserve
natural resources while managing our daily operations.
We utilize resources appropriately and efficiently, recycle
when possible, dispose of all waste as mandated by laws
and regulations, and work cooperatively with appropriate
authorities to remedy any environmental contamination for
which Children’s Colorado may be responsible. If you have
any questions regarding hazardous waste, please contact
the Sustainability Specialist or refer to relevant policies.
(Pharmaceutical and Chemical Waste Management Plan)
(Hazardous Waste and Medical Waste Management)
Information Security and Data Security
We value the importance of data integrity, information
security, and confidentiality of data/information and follow
all relevant policies and procedures. You are responsible
for signing and abiding by the Security User Agreement
to protect yourself, the organization, as well as patient
and business data that reside in your workplace. You must
also maintain the confidentiality and security of access to
your computer. Equal attention should be given to both
patient and business data that resides in your workplace.
We are committed to preventing and detecting fraud, waste, and abuse. You are expected to refrain from conduct that may
violate fraud and abuse laws. Such laws prohibit payments in exchange for referral of patients. It is also illegal to submit false,
fraudulent, or misleading claims to the government or a third party payer such as claims for services not rendered, claims
which characterize the service differently than the service actually provided, or claims which do not otherwise comply with
applicable program or contractual requirements. Making false representations to any person or entity in order to gain or
retain participation in a program or to obtain payment for any service is also strictly prohibited.
Various federal and state laws protect team members who in good faith report suspected fraud, waste, or abuse from
adverse action including discharge, demotion, suspension, threats, harassment, or discrimination. (Corporate Compliance
Investigations of Potential Fraud and Abuse)
The main federal and state false claims laws are summarized below. Additional information, including information on how to
report fraud, waste, or abuse can be accessed at Deficit Reduction Act (DRA) Special Report.
Relationships and Agreements with Physicians and other Business Partners
We do not provide incentives to community physicians, other health care providers, or anyone else in exchange for referrals.
The regulations that govern our relationships with any business partner who is a potential referral source are harsh and
complex. Violations of these laws have grave consequences for the organization and any individuals involved. We are
not allowed to engage in any activity that could be construed as an improper referral or payment without prior review by
appropriate Children’s Colorado leaders and legal counsel. If you are contemplating making or accepting a referral and may
receive something in return, or if you are entering any type of financial relationship with a physician, please contact CaBE
department immediately. Some of the federal laws that govern these issues include:
The Anti-Kickback Statute
The federal Anti-Kickback Statute is a criminal statute that prohibits the exchange (or offer to exchange), of anything of
value, to reward the referral of federal healthcare business. “Anything of value” includes things like gifts, free or reduced
cost services, use of Children’s Colorado’s assets without fair market value payment. Such remuneration or “kickbacks” are
expressly forbidden. The Anti-Kickback Statute provides safe harbors for certain arrangements at fair market value such as
personal services, rental agreements, investments in ambulatory surgery centers, and payments to bona fide employees.
The Physician Self-Referral Law
The Physician Self-Referral Law, commonly referred to as the “Stark Law,” prohibits a physician from making referrals for
certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family
member) has a financial relationship (ownership, investment, or compensation), unless an exception applies. The Stark
Law provides exceptions for certain arrangements at fair market value such as personal services, rental agreements, non-
monetary compensation, medical team members incidental benefits, and payments to bona fide employees.
Copyrights, Intellectual Property and
Children’s Colorado owns the rights to copyrights,
intellectual property, and inventions created by team
members who utilized the organization’s resources. We
respect laws and regulations pertaining to our own and
others’ educational and research property. (Copyright
Infringement and Protection) (Intellectual Property
Developed by Children’s Colorado Staff)