CC-160103303-2021-02-Code of Conduct Brochure-FIN - Page 12

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 .
Harassment
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 )
General Confidentiality
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 .
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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) Resource Stewardship We responsibly and efficiently use our many resources including people, finances, environment, time, and materials/ supplies for Children’s Colorado business purposes only. Financial Reporting 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) (Purchasing Authorization) 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 Colorado Foundation. 12 Hazardous Waste 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. (Information Security) 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 Inventions 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) 13