CHILDREN ’ S HOSPITAL COLORADO
Table of Contents
Mission , Vision , Values 4 Introduction 5
• Ethics / Integrity
• Requesting Guidance / Reporting Ethics and Compliance Concerns / Non-Retaliation
Employee Standards 6
• Standards of Behavior
• Conflict of Interest
• Harassment
• Alcohol and Drug-Free Environment
• Non-discrimination and Equal Employment Opportunity
• General Confidentiality
• Appropriate Workplace Conduct
Patient Care Standards 8
• Patient Rights and Responsibilities
• Admission , Transfer , Discharge / Non- Discrimination
• Patient Safety
• Informed Consent
• Emergency Medical Treatment and Labor Act ( EMTALA )
• Target Zero Safety Practices
• Decision Making / Advance Directives
• Patient Privacy and Confidentiality
Ethical Business Standards 11
• Gifts and Business Courtesies
• Conditions of Participation / Accreditation / Licensure
• Responding to Investigations and Inquiries
• Proper Coding and Billing
• Document Retention
• Resource Stewardship
• Financial Reporting
• Purchasing and Contracting Practices
• Relationships with Competitors
• Fundraising and Philanthropic Efforts
• Lobbying and Political Activity
• Hazardous Waste
• Information Security and Data Security
• Copyrights , Intellectual Property and Inventions
Fraud , Waste and Abuse 13
• Relationships and Agreements with Physicians and Other Business Partners - Anti-Kickback Statute - Physician Self-Referral Law
• False Claims
• The Exclusion Authorities
• The Civil Monetary Penalties Law
Compliance and Business Ethics ( CaBE ) 15
• Purpose / Infrastructure
• Open Lines of Communication for Reporting Concerns
• Communication , Training and Education
• Auditing and Monitoring
• Response and Prevention
• Responsible Conduct of Research
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