Table of Contents
Mission, Vision, Values 4
Introduction 5 oo oo
Ethics / Integrity
Requesting Guidance / Reporting Ethics and Compliance Concerns / Non-Retaliation
Team Member Standards 6
oo oo oo oo
oo oo
Conflict of Interest Harassment Alcohol and Drug-Free Environment
Non-Discrimination and Equal Employment Opportunity
General Confidentiality Appropriate Workplace Conduct
Patient Care Standards 8 oo Patient Rights and Responsibilities oo
Admission, Transfer, Discharge / Non-Discrimination oo oo
oo oo oo
Patient Safety
Emergency Medical Treatment and Labor Act( EMTALA)
Informed Consent Decision Making / Advance Directives Patient Privacy and Confidentiality
Ethical Business Standards 10 oo Gifts and Business Courtesies oo
Conditions of Participation / Accreditation / Licensure oo oo oo oo oo oo oo oo oo oo oo oo oo
Responding to Investigations and Inquiries Proper Coding and Billing Document Retention Information Security and Data Security Resource Stewardship Financial Reporting Purchasing and Contracting Practices Relationships with Competitors Exclusion / Sanction Checks Fundraising Lobbying and Political Activity Hazardous Waste Copyrights, Intellectual Property, and Inventions
Fraud, Waste, and Abuse 14 oo
oo oo oo
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
Corporate Compliance Program 16 oo oo
oo oo oo oo
Purpose / Infrastructure
Open Lines of Communication for Reporting Concerns
Communication, Training, and Education Auditing and Monitoring Response and Prevention Responsible Conduct of Research
3