Johnson Memorial Medical Center Corporate Compliance Program
CODE OF CONDUCT
Statement of Policy
Johnson Memorial Medical Center is committed to a Corporate Code of Ethical Behavior (Code) that requires all of its staff, medical staff members, representatives, contractors, vendors, and partnering entities to act and perform their duties in compliance with all existing federal and state laws, statutes and government regulations. Johnson Memorial Medical Center considers ethical behavior to be its corporate responsibility, since integrity in all business, employment and patient care delivery practices is at the heart of Johnson Memorial Medical Center's Mission, Vision and Values.
A Code of Ethical Behavior serves the following purposes:
Ethical statements and practice standards provide guidelines that assist an organization in deciding what actions to take from an ethical viewpoint.
A Code of Ethics is the expression of values and principles of a particular organization for its members and the general public. It is an important element in the uniqueness of that organization.
A Code of Ethics permits the self-regulation of an organization by providing a basis for developing practice standards and for reviewing the actions of its members.
A Code of Ethics has educational value in assisting an organization and its members to develop their judgment in weighing alternative courses of action in difficult situations.
Johnson Memorial Medical Center adopted this statement of ethics to ensure that all facets of the organization's mission are performed according to the highest standards of personal and professional conduct. Adherence to these standards is neither optional nor selective. Johnson Memorial Medical Center shall not trade or compromise for financial, professional, or other gain, any of the standards contained herein. Each individual action is judged by considering whether the action is honest, legal, and proper, and whether it could withstand scrutiny. It is the responsibility of every member of Johnson Memorial Medical Center to act in a manner that is consistent with the organization's mission and standards.
Johnson Memorial Medical Center is directed to perform our daily activities in a way that is honest and proper. It is the responsibility of every staff member, physician, volunteer, contractor, vendor, representative, or partnering entity to:
Avoid illegal or dishonest acts, and take responsibility for his or her own actions;
Quickly report any potential or suspected compliance violations; and
Cooperate with investigations of any suspected violations.
The principles of the Corporate Compliance Program shall be distributed to the staff and updated, if necessary, on an annual basis.
The Corporate Compliance Program shall be reviewed regularly with the Board of Trustees, via the Administrative Council, selected staff members and medical staff members having administrative or managerial responsibilities.
Johnson Memorial Medical Center's values incorporate the principles of the Code of Ethical Behavior.
These values are:
Johnson Memorial Medical Center affirms the rights, dignity, and individuality of each person we serve and of each other. Johnson Memorial Medical Center's practices include compassion and respect for the inherent worth and uniqueness of every individual, unrestricted by consideration of social or economic status, personal attributes or the nature of health problems.
We maintain an unrelenting drive for excellence, quality and safety
and strive to continually improve all that we do.
We care for each person and each other with dignity, respect and courtesy.
We believe in fairness, honesty and are guided by our Code of Ethics that requires uncompromising standards of honesty and integrity.
We wisely care for the human, physical and financial resources entrusted to us and manage those considerations in the most effective and economical ways that will improve the quality of care for patient outcomes and asset conservation.
Johnson Memorial Medical Center's commitment to ethical behavior includes these standards:
A. Staff acknowledgment of and commitment to all federal, state or local laws and regulations that relate to the delivery of health care services.
B. All financial reports, accounting records, research reports, expense accounts, time sheets, and other documents must accurately and clearly represent the relevant facts or the true nature of a transaction. Improper or fraudulent accounting, documentation, or financial reporting is contrary to the policies of Johnson Memorial Medical Center and may be in violation of applicable laws.
C. Staff members must remain free of any outside influences and outside activities that would interfere with their job performance or pose conflicts of interest of any kind at any level.
D. Staff members must be careful to avoid violating any fraud or abuse laws as they relate to billing for services not documented, unbundling, up coding, duplicate billing, and falsely certifying services as medically necessary, etc.
E. Staff is prohibited from knowingly and willingly seeking, receiving or offering money, gifts, resources, or services with the intent to influence patient referrals or services covered by federal or state health care programs.
F. Members of Johnson Memorial Medical Center may not retain or solicit gifts from vendors, suppliers, contractors or other persons, even those which have a nominal value, including meals or entertainment.
G. Staff will maintain positive working relationships with Johnson Memorial Medical Center physicians. All treatment and interaction with physicians will be without discrimination on any basis.
H. Salary, benefits and other personal information relating to Johnson Memorial Medical Center employee shall be treated as confidential. Personnel files, payroll information, disciplinary matters, and similar information shall be maintained in a manner designed to ensure confidentiality in accordance with applicable laws. Johnson Memorial Medical Center will exercise due care to prevent the release or sharing of information beyond those persons who may need such information to fulfill their job function.
I. All patients will be treated with dignity and respect and with regard to all provisions of Patients' Rights. All patients will be informed of their Rights and these Rights will be honored without discrimination of any kind.
J. Information, ideas and intellectual property assets of Johnson Memorial Medical Center are important to organizational success. Information pertaining to Johnson Memorial Medical Center's competitive position or business strategies, payment and reimbursement information, and information relating to negotiations with Johnson Memorial Medical Center members or third parties should be protected. Johnson Memorial Medical Center will exercise care to ensure that intellectual property rights, including patents, trademarks, copyrights, and software, is carefully maintained and managed to preserve and protect its value.
K. All business relations with contractors must be conducted at arm's length both in fact and in appearance and in compliance with Johnson Memorial Medical Center policies and procedures. Staff, directors, and medical staff members must disclose personal relationships and business activities with contractor personnel or organizations that may be construed by an impartial observer as influencing the person's Johnson Memorial Medical Center-related performance or duties.
L. Johnson Memorial Medical Center and its staff, and medical staff members, will respect at all times a patient's personal privacy and preserve the confidentiality of a patient's medical treatment program, including the patient's medical records. Johnson Memorial Medical Center will respect the patient's right to confidentiality, except when this right conflicts with responsibility to the law, or when the maintenance of confidentiality would result in a significant risk of substantial harm to others or to the patient if the patient is incompetent; in such cases, all reasonable steps will be taken to inform the patient that confidentiality will be breached
M. Staff will provide all persons seeking emergency medical care with medical screening exams and emergency care services regardless of their ability to pay.
N. All forms of harassment, including sexual harassment and harassment based on race, color, religion, ancestry, national origin, ethnicity, age, disability, medical condition, marital status, sex (including gender identity), sexual orientation or any other characteristic is prohibited at Johnson Memorial Medical Center. All Johnson Memorial Medical Center staff will be required to maintain a drug, smoke and alcohol free healthcare environment.
O. All staff will avoid activities that illegally reduce competition by not discussing prices with competitors; not using one product or service as bait to sell or deliver something else; not speak badly of a competitor's services; not accept discounts, rebates or other price adjustments or conditions of service provisions.
P. All staff, medical staff members, volunteers, representatives, contractors and vendors are expected to contribute to maintaining a safe and healthy environment, free from hazards.
Q. Johnson Memorial Medical Center and its staff will not use funds or services for political purposes.
R. All staff will keep private all business information about Johnson Memorial Medical Center's finances, trade secrets and other commercially proprietary information.
A. All staff will be trained in the Johnson Memorial Medical Center Corporate Compliance Program, which includes the Code of Ethical Behavior, via new employee orientation. Thereafter, staff will receive annual education of varying degrees, dependent upon job function(s).
B. Staff members are expected to report all suspected violations of the Johnson Memorial Medical Center Corporate Compliance Program. When staff members might not feel at ease reporting a violation directly to a supervisor, Johnson Memorial Medical Center has established an anonymous Corporate Compliance Hotline, 860-684-8504. Staff should understand that reporting a violation will not result in retaliation.
C. The Corporate Compliance Officer enforces the integrity of the Johnson Memorial Medical Center Corporate Compliance Program, including the Hotline.
D. The Administrative Council, comprised of executive management, is charged with providing oversight to the Corporate Compliance Officer, developing and implementing the Corporate Compliance and HIPAA programs and will meet at least quarterly, and whenever necessary, to review the Corporate Compliance program as well as any applicable ethical dilemmas, new laws, and audit reviews and report thereon to the Board of Trustees.
E. All staff, medical staff members, volunteers, representatives, contractors or vendors may access the Corporate Compliance Hotline at 860-684-8504. All staff is assured that there is no retaliation for any reporting of violations or suspected violations.
F. All suspected violations of the Johnson Memorial Medical Center Corporate Compliance Program will be investigated and corrective action taken, when appropriate. Violations will be treated in a confidential manner within the limits of the law. Staff members are expected to cooperate in all investigations.
G. Provision for on-going auditing and monitoring bills and medical records will be established and maintained, with independent outside reviews used to augment and validate internal auditing and chart review practices.
H. The Corporate Compliance Officer will regularly report to Administrative Council concerning procedures regarding monitoring adherence to the Code of Ethical Behavior.