A GUIDE FOR RELATIONSHIPS IN SERVICE TO LOCAL AND GLOBAL COMMUNITIES

Transcription

1 CODE OF ETHICS A GUIDE FOR RELATIONSHIPS IN SERVICE TO LOCAL AND GLOBAL COMMUNITIES Third Edition: January 2007 (3.2 Edition: September 2011 Minor Updates)

2 SPONSORSHIP: OUR HERITAGE CHRISTUS Health is sponsored by the Sisters of Charity of the Incarnate Word of Houston and the Sisters of Charity of the Incarnate Word of San Antonio. These congregations were founded in 1866 and 1869 respectively, in response to Bishop Claude Marie Dubuis call: Our Lord Jesus Christ, suffering in the persons of a multitude of sick and infirm of every kind, seeks relief at your hands. MISSION STATEMENT: WHY WE EXIST To extend the healing ministry of Jesus Christ. CORE VALUES: WHAT WE BELIEVE IN Dignity: Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. Integrity: Honesty, justice and consistency in all relationships Excellence: High standards of service and performance Compassion: Service in a spirit of empathy, love and concern Stewardship: Wise and just use of talents and resources in a collaborative manner VISION: WHAT WE ARE STRIVING TO DO CHRISTUS Health, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God's healing presence and love. Cover illustration courtesy of the Catholic Health Association of the United States

3 C H R I S T U S H E A L T H TABLE OF CONTENTS CODE OF ETHICS A BASIS FOR RELATIONSHIPS I. INTRODUCTION... 3 II. SPONSORSHIP... 4 III. GOVERNANCE AND LEADERSHIP... 4 IV. RESPONDING TO THE CALL... 5 V. ETHICAL AND LEGAL RESPONSIBILITY... 5 n RESPONSIBILITIES OF CHRISTUS HEALTH... 6 n RESPONSIBILITIES OF ASSOCIATES AND HEALTH CARE PARTNERS... 7 n RESPONSIBILITIES OF PATIENTS AND FAMILIES... 8 VI. ORGANIZATION/BUSINESS ETHICS... 9 n RELATIONSHIPS WITH OTHERS... 9 Relationships with the Community... 9 Relationships with Physicians Relationships with the Church n COMMITMENT TO ETHICAL BUSINESS PRACTICES Access to Care Admissions and Transfers Safety Documentation, Billing and Records Privacy and Security of Information Cost Reporting Communication and Marketing n CONFLICTS OF INTEREST n INTEGRITY OF CLINICAL DECISIONS n DENIAL OF CARE n STEWARDSHIP OF RESOURCES Human Resources Associate Selection and Development Compensation and Benefits Performance Evaluation Issue Resolution Harassment Environmental and Financial Resources O N E

4 C O D E O F E T H I C S VII. PATIENT RIGHTS AND CLINICAL ETHICS npatient RIGHTS Respecting Patient Rights Privacy and Security of Patient Dignified Environment Care for the Beginning of Life Complaint Process n PATIENT PARTICIPATION IN CARE Involvement in Care Pain Assessment and Management Refusal of Care End of Life Care Organ Donation n INFORMATION PROVIDED TO PATIENTS Information About Patient Rights Informed Consent Filming and Recording Effective Communication Information About Caregivers Information Concerning Outcomes n PROTECTING PATIENTS Freedom from Abuse Protective Services Research Projects VIII. APPENDIX IX. CROSS REFERENCE T W O

5 C H R I S T U S H E A L T H INTRODUCTION CODE OF ETHICS A BASIS FOR RELATIONSHIPS CHRISTUS Health and its System Participants ( CHRISTUS ) form a Catholic, faith-based health system with the Mission to extend the healing ministry of Jesus Christ and is committed to the Core Values of Dignity, Integrity, Excellence, Compassion, and Stewardship. As CHRISTUS strives to fulfill its Mission and to live in accord with its Core Values, it seeks to improve the health of communities and to enable those it serves to experience God s healing presence. CHRISTUS seeks to provide effective, compassionate care, especially to persons who are poor and underserved, and is committed to promote and defend human dignity. The Code of Ethics describes the expected behaviors of CHRISTUS and all who serve as Associates and health care partners (physicians, residents, fellows, students, other health professionals, volunteers, vendors, and those with contractual relationships) through the intentional use of the Mission and Core Values as the basis for these relationships. The Code of Ethics enables and directs CHRISTUS, its Associates and health care partners to adhere to all system policies, management directives, guidelines, and procedures as applicable; to comply with laws and governmental regulations; to meet the standards of The Joint Commission (TJC); and to observe the Catholic moral tradition, the Ethical and Religious Directives for Catholic Health Care Services (ERD) approved by the National Conference of Catholic Bishops, and the relevant requirements of the Code of Canon Law. CHRISTUS is gifted with a spirit of mutual respect, which encourages and disposes Associates and health care partners to interact with those they serve and their families with compassion (ERD #2). The Code of Ethics is also intended to guide and enhance relationships with the communities CHRISTUS serves. CHRISTUS values its relationships with Associates and health care partners, patients and their families, community members, and all who assist in furthering this healing ministry. Working together in an ethical and legal manner, CHRISTUS Associates and health care partners continue to provide quality service to patients/residents ( patients ) and communities. This Code of Ethics documents how Associates and health care partners relate to one another and perform work. Please keep this booklet available as it details how Associates and health care partners are to conduct themselves, work in the ministry, and transact business. T H R E E

6 C O D E O F E T H I C S SPONSORSHIP The health care needs of post-civil War Texas were overwhelming when Bishop Dubuis issued the call: Our Lord Jesus Christ, suffering in the persons of a multitude of sick and infirm of every kind, seeks relief at your hands. Three young sisters from France generously answered that call and arrived in Galveston in 1866 to begin the Catholic health care ministry in Texas. As a result of their response, the Congregations of the Sisters of Charity of the Incarnate Word, Houston and San Antonio, were established and their Catholic health care ministries have flourished for almost 140 years. As a Catholic health care ministry, CHRISTUS is sponsored by these two congregations of women religious. The Sponsors ensure that the ministry remains true to the Catholic tradition and the charisms of the sponsoring congregations. The Sponsors appoint Members who have defined reserved powers and set direction for the ministry. GOVERNANCE AND LEADERSHIP The responsibility for the direction of CHRISTUS involves two primary tiers governance, and system and regional leadership. Each tier has defined roles, responsibilities and expectations. (CHRISTUS Policy 5.01) The Board is responsible for the governance of CHRISTUS. The Board has defined responsibilities related to governance and policies of the organization. Regional Boards have similar roles in their respective regions. F O U R

7 C H R I S T U S H E A L T H The Senior Leadership Team creates an environment that enables CHRISTUS to fulfill its Mission, achieve strategic goals, define responsibilities, and provide processes for accountability. Effective leadership is measured through operational outcomes related to the Three-Dimensional Integrated Model and the Four Directions to Excellence defined as Clinical Quality, Service Excellence, Community Value, and Business Literacy. Regional leadership teams fulfill similar roles in their regions. While all Associates and health care partners are obligated to follow the Code of Ethics, system and regional leadership are expected to set the example and create an environment conducive to organizational integrity. RESPONDING TO THE CALL Healing physical, spiritual, emotional, and social healing was an integral element of the ministry of Jesus. Faithful to this ministry, the Church has served the sick, suffering, and dying in various ways through the centuries. Catholic health care ministry is rooted in a commitment to promote and defend human dignity, which is the foundation of its concern to respect the sacredness of human life from conception until death. Today, the Associates and health care partners of CHRISTUS continue to extend the healing ministry of Jesus Christ in the communities we serve. This Mission and the Core Values flowing from it provide a foundation and give direction to the work of each person as we strive to fulfill our responsibilities to those we serve. ETHICAL AND LEGAL RESPONSIBILITY Everyone must work together to ensure that CHRISTUS is an ethical organization. The Mission is fulfilled by enhancing each patient s experience through compassionate care, treatment, and services which result in outcomes that recognize and respect the rights and responsibilities of each patient, fostering dignity, integrity, and service quality. CHRISTUS recognizes that health care delivery is enhanced when patients and families are partners in the health care process. CHRISTUS has established an Associate Covenant to ensure that CHRISTUS and its Associates focus on the development of positive relationships in the workplace. This Covenant is a set of commitments, rather than a contract, to guide relationships. Many elements of the Associate Covenant are expressed F I V E

8 C O D E O F E T H I C S throughout the Code of Ethics and are critical in defining commitments between CHRISTUS and its Associates. The Code of Ethics further defines responsibilities and related expectations among CHRISTUS, Associates and health care partners, focused on enhancing the delivery of patient care and ensuring compliance with all applicable laws and regulations. (ERD #1,7) To accomplish organizational goals, the following have specific responsibilities. CHRISTUS, AS AN ORGANIZATION, HAS THE RESPONSIBILITY TO: Ensure Associates and health care partners are aware of and understand the Code of Ethics and their specific responsibilities: (CHRISTUS Policy 1.06) Implement and maintain programs with policies, management directives, and guidelines and procedures that support organizational integrity and are designed to detect and prevent fraud, waste and abuse; (CHRISTUS Policy 7.01) Provide interdisciplinary Ethics Committees to address clinical/organizational ethical issues through education, policy development, and patient care consultation and review; (CHRISTUS Policy 1.05, ERD #37) Create an environment which promotes the common good and is oriented to the growth and development of persons; Recognize that learning is a continuous process which occurs throughout life and encourage appropriate risk-taking and diverse views; Ensure that our organization respects and reflects the rich heritage of the diverse communities that we serve; Ensure that the Mission and Core Values permeate the development and enrichment of Associates and health care partners and provide opportunities for education on relevant laws, regulations, policies and procedures, and the Ethical and Religious Directives for Catholic Health Care Services; S I X

9 C H R I S T U S H E A L T H Respect, protect, and enhance all resources of CHRISTUS including the heritage and tradition of its Sponsors and its human, environmental, and financial resources; (ERD #6) Utilize the Decision-Making Process provided for boards and leadership teams as they make major decisions so that the CHRISTUS Mission, Vision, and Core Values are foundational for such decisions; (CHRISTUS Policy 1.04) Provide a process for Associates and health care partners to voice concerns or relate problems in a safe and confidential way, through the Problem and Concern Resolution process, which details suggested methods of resolving issues, including the use of the Integrity Line and Integrity Link. The Integrity Line number is and the Integrity Link website address is (CHRISTUS Management Directive #0015) Ensure that Associates and health care partners understand and adhere to the expectations on reporting concerns related to the CHRISTUS work environment as detailed in Management Directive #0036 with knowledge that retaliatory behavior is not tolerated; Educate Associates and health care partners regarding the Federal and State False Claims Acts, including the whistleblower protection it provides; (CHRISTUS Guideline #15.18) Develop and sustain organizational structures, policies, management directives, guidelines and procedures, and programs consistent with the Mission, Core Values, applicable laws and regulations, TJC standards, and the Ethical and Religious Directives for Catholic Health Care Services; (ERD #4) Maintain structures and processes which enable CHRISTUS to provide excellent quality of care, consistent with current medical knowledge, to increase the likelihood of desired outcomes for every patient; Provide patients and their families information about their responsibilities. EVERY ASSOCIATE AND HEALTH CARE PARTNER HAS THE RESPONSIBILITY TO: Read, understand, and support the Code of Ethics and seek advice when its meaning or application is not clear; Respect and uphold the Mission and Core Values of CHRISTUS, adhere to the Ethical and Religious Directives for Catholic Health Care Services, maintain professional standards, and promote the commitment of CHRISTUS to human dignity and the common good; (ERD Part Three; ERD #5) Protect, respect, and enhance the various resources available for the ministry; Meet all responsibilities and obligations in a conscientious and honest manner; Learn from mistakes and continually strive to improve; Influence and impact the patient experience by providing compassionate care that promotes healing and offers hope; S E V E N

10 C O D E O F E T H I C S Maintain ethical standards that follow all CHRISTUS policies, management directives, guidelines and procedures, laws, regulations, and the Code of Ethics; Understand the Problem and Concern Resolution process for reporting violations, and resolve concerns as they become known; Strive to provide quality and compassionate care and services with consistent and predictable outcomes; Respect the worth of all and treat all persons with dignity and respect, supporting a work environment which seeks to identify, acknowledge, and utilize the gifts and talents of all; (ERD #23) Remain current on professional licenses, certifications, or other credentials required of the role in which the Associate or health care partner serves. PATIENTS AND THEIR FAMILIES HAVE THE RESPONSIBILITY TO: (TJC RI ) Provide adequate and complete information about present and past illnesses, hospitalizations, and medications; Inform caregivers of perceived risks in their care and unexpected changes in their conditions; Follow the care, treatment, and service plan developed and ask questions when aspects of the care are not understood; Understand that unfavorable outcomes may be experienced when they do not follow the care, treatment, and service plan; Follow the facility s rules and regulations affecting the patient and family; E I G H T

11 C H R I S T U S H E A L T H Be considerate of the staff of the facility and their property as well as other patients and their property; Fulfill financial obligations promptly. ORGANIZATION/BUSINESS ETHICS CHRISTUS has an ethical responsibility to its patients and to the communities it serves. To fulfill this responsibility, ethical care, treatment, and service practices must be supported by ethical business practices. This adherence to ethical care and business practices significantly enhances the patient s experience of, and response to, care, treatment, and services. RELATIONSHIPS WITH OTHERS (ERD #8) Relationships with the Community CHRISTUS is called to an awareness of and involvement in our world, recognizing that its facilities do not exist in isolation but act in communion with local and global communities. CHRISTUS acknowledges its responsibility to work for the common good improving economic, political, and social conditions to ensure the fundamental rights of all to attain their full development and to reach their common goals. CHRISTUS seeks to contribute to the common good by strengthening the overall health of the communities it serves. This includes service to, and advocacy for, those persons whose social and economic conditions place them at the margins of society. (ERD Part One) Creating healthy communities is a core strategy for CHRISTUS. As such, CHRISTUS is aware of its responsibilities in the community and is committed to programs that nurture a safe and healthy environment and other activities such as participation in emergency preparedness plan initiatives. NEW VENTURES When considering new business affiliations, joint ventures, and partnerships, etc., CHRISTUS must use both a screening process and a due diligence process to ensure that the new venture strengthens the Mission and Vision and that the proposed partner is compatible with its Core Values and moral tradition. (CHRISTUS Policy 6.02) SOCIALLY RESPONSIBLE INVESTMENT PROGRAM CHRISTUS has a responsibility to use its assets to promote health and human dignity. Therefore, CHRISTUS has adopted guidelines to direct its investment managers to invest its N I N E

12 C O D E O F E T H I C S assets in an ethical and socially responsible manner. The guidelines acknowledge the responsibility that CHRISTUS has to those it serves and to the broader community and the environment. (CHRISTUS Policy 2.08) COMMUNITY BENEFIT CHRISTUS ensures that it fulfills its Mission and its Vision of creating healthier communities and increasing access to care for the poor and underserved through a uniform system of social accountability. Measures include uniform budgeting and reporting of community benefit as well as initiatives that reach out to the communities served through social action and advocacy programs that emphasize human dignity and seek justice. (CHRISTUS Policy 1.01) Community Direct Investment Program This program invests directly in our communities to support affordable housing and other community development projects that empower persons who are economically disadvantaged and that seek to improve the health and quality of life of vulnerable communities. (CHRISTUS Policy 1.02) CHRISTUS Fund CHRISTUS is committed to working with communityled partnerships in the communities it serves in order to achieve measurable, sustainable improvements in well-being. The intent of the CHRISTUS Fund is to provide resources to not-for-profit agencies and groups whose vision, mission and goals are consistent with the Mission, Core Values, and Vision of CHRISTUS. (CHRISTUS Policy 1.03) ADVOCACY The biblical mandate to care for the poor requires CHRISTUS to express this concern by advocating in the national, state, and local legislatures to ensure that the health care delivery system provides health care for all persons. (ERD #3) Relationships with Physicians CHRISTUS values its relationships with physicians and has adopted a Physician Compact that details mutual commitments to be demonstrated through organizational and personal behavior. In particular, CHRISTUS and physicians commit to behaviors that exhibit respect and honor the dignity of all Associates and health care partners, patients and their families. Physicians and their patients enter into a relationship that requires mutual respect, trust, honesty, and appropriate confidentiality. Ideally, neither the health care professional nor the patient acts independently of the other; both participate in the healing process. (ERD Part Three) Each facility has an organized, self-governing medical staff that provides oversight of care, treatment, and services provided by practitioners who are credentialed or have privileges to care for patients. The medical staffs, cooperating with the T E N

13 C H R I S T U S H E A L T H CHRISTUS office of Quality and Patient Safety Improvement (QPSI), develop tools to monitor and provide a uniform quality of patient care. As trusted partners, physicians affiliated with CHRISTUS participate in the development and implementation of evidence-based protocols to provide quality care as shown through outcome measures. CHRISTUS is committed to strengthening relationships with physicians while also ensuring compliance with laws and regulations and has policies and procedures in place to ensure that: Associates and health care partners who interact with physicians in leasing space, recruitment, and arranging for physicians to serve in a leadership position in the facilities must be aware of the requirements of the laws, regulations, and policies that address relationships between facilities and physicians; CHRISTUS does not pay for referrals. Referrals and admissions of patients are based on the patient s needs and the facility s ability to provide the service needed. CHRISTUS does not pay or provide anything of value to Associates or health care partners, or other persons or entities, for referral of patients; CHRISTUS does not accept payments for referrals. No Associate or health care partner of CHRISTUS or any other person acting on behalf of CHRISTUS is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of patients. E L E V E N

14 C O D E O F E T H I C S Relationship with the Church As a Catholic health care system, CHRISTUS embodies and gives public expression to the healing ministry of Jesus and, thus, has an integral and essential relationship with the Church. Consequently, CHRISTUS: Gives contemporary expression to the Church s long tradition of serving the sick, the suffering, and the dying; (ERD Part Five) Carries on the Church s witness to the sanctity of life through its reverence and care for new life from the moment of conception; (ERD Part Four) Attends to the physical, psychological, spiritual, and social dimensions of persons as it fulfills its ministry; Is committed to adhering to the Ethical and Religious Directives for Catholic Health Care Services as promulgated by the United States Conference of Catholic Bishops; (ERD #5) Fosters a collaborative relationship with the local bishop who is responsible for coordinating ministry in the diocese and consults with the local bishop when partnerships are being considered with organizations that are not Catholic. (ERD Part Six; ERD #67-71) COMMITMENT TO ETHICAL BUSINESS PRACTICES (TJC LD ) CHRISTUS is committed to maintaining ethical business practices and has processes in place to identify and resolve ethical issues and issues prone to cause conflict. Access to Care Admissions and Transfers CHRISTUS recognizes the right of patients to treatment or service as long as that service is within the defined services of the facility and is in accord with the Catholic moral tradition. For example, CHRISTUS facilities do not provide abortion procedures, specified reproductive services, euthanasia or physician-assisted suicide. (ERD #40, 41, 42, 45, 48, 50, 51, 52, 53, 60) In the above-mentioned instances when CHRISTUS cannot treat patients, CHRISTUS: Has policies and mechanisms to arrange for the prompt and safe transfer of patients consistent with regulatory requirements; Makes sure that transfers of patients are never based on patient s inability to pay for the services, but on the local health care center s inability to render the type and quality of care required by the patient s condition or diagnosis; T W E L V E

15 C H R I S T U S H E A L T H Involves the patients or the patient s agents and attending physicians in transfer decisions, including the necessary informed consent for the transfer. Safety CHRISTUS is committed to providing a safe environment for Associates, health care partners, and patients, and will: Strive to provide a safe, secure, and hazard-free environment consistent with national standards and established federal, state, and local regulations; Maintain an effective infection control process managed by qualified persons in order to identify and reduce the risks of acquiring and transmitting infections; Require Associates and health care partners to report accidents to the proper supervisor in accord with established guidelines; Not tolerate the unlawful manufacture, distribution, possession, or use of a controlled or illegal substance in the workplace or while conducting company business; Not tolerate persons reporting for work under the influence of alcohol or an unlawful controlled substance. Associates and health care partners will not be allowed to work under such influence. Additionally, individuals reporting for work under the influence of prescribed medications which impair their ability to perform duties will not be allowed to work. Maintain a tobacco-free environment as indicated; Not tolerate unauthorized persons bringing firearms, explosives, knives or weapons onto CHRISTUS property; Strictly follow all laws and regulations governing the disposal of hazardous waste and radioactive materials. T H I R T E E N

16 C O D E O F E T H I C S Documentation, Billing, and Records Recognizing the trust placed in CHRISTUS by its patients, physicians, payors and others engaged in business, Associates and health care partners will document business activity accurately and completely, will safeguard the information provided, protect the confidentiality of CHRISTUS information, and will: Prepare and maintain data, records, and reports of the patient and the organization accurately and truthfully, and adhere to applicable standards in maintaining all records; Provide patients with advance information, where applicable, about charges for which they will be responsible; Maintain complete and accurate medical records of each patient and protect this information from breach of confidentiality or loss; Submit claims for payment or reimbursement only for services actually rendered and make sure that claims submitted for payment or reimbursement are for services that are medically necessary; Submit claims for payment or reimbursement which are not knowingly false, fraudulent or incorrect, and establish an audit function to validate accuracy of claims submission; Make sure that all submitted claims are properly coded and documented, and filed according to all applicable laws and regulations. Privacy and Security of Information ( ERD #34) CHRISTUS has implemented policies, procedures, and processes to protect and secure information. Information utilized in the course of business is considered a CHRISTUS asset, and all Associates and health care partners will: Protect and maintain the confidentiality of all patient records as required by applicable laws, regulations, policies and procedures; Maintain the security and integrity of information through the administration of appropriate controls to protect CHRISTUS information from unauthorized disclosure, modification, destruction or use; F O U R T E E N

17 C H R I S T U S H E A L T H Protect, access, use, disclose, and distribute CHRISTUS information consistent with CHRISTUS policies, management directives, and guidelines and procedures; Be knowledgeable about information protection standards affecting job function, recognizing that confidential information is valuable, sensitive, and protected by law and CHRISTUS policy; Protect CHRISTUS information from disclosure to third parties, unless the third parties have a demonstrated need-to-know and such disclosure is consistent with privacy policies, laws and regulations. No CHRISTUS Associate or health care partner has a right to any patient information other than that which is necessary to perform assigned job function; Discuss information about patients conditions, care, and personal affairs only with those directly involved in their care, or with Associates and health care partners whose job responsibilities make access to such information essential, or as otherwise required by laws and regulations. Cost Reporting (CHRISTUS Management Directive #0028) CHRISTUS has implemented policies, procedures and processes to facilitate accurate cost report completion and submission to the appropriate governmental agency. CHRISTUS requires: Careful selection and focused development of Associates and health care partners with cost reporting responsibilities; Timely response to concerns and correction of identified errors; Respectful and honest dialogue and interaction with governmental agencies, commercial insurance companies, and patients; The engagement of contractors who demonstrate appropriate skills, quality control processes, and systems to ensure accurate completion of assigned duties. Communication and Marketing CHRISTUS communications, as well as its promotional and marketing activities, are conducted in accord with accepted ethical standards and will: Maintain the appropriate confidentiality and privacy of all patients, Associates and health care partners, customers and clients; Be truthful and provide information and education which is beneficial to the audience as well as to CHRISTUS and which is designed to inform and persuade, not to mislead; Be based on facts that are supportable by reliable data and within applicable legal requirements; Maintain research integrity so that pertinent research data is not misrepresented or omitted; F I F T E E N

18 C O D E O F E T H I C S Not mislead patients or the public or cause them to request services they do not need; Not attack the reputation of another institution or system; Present claims which are fair and which can be supported when making comparisons to competitors or competitive offerings. CONFLICTS OF INTEREST (TJC LD and LD ; CHRISTUS Management Directive #0041) CHRISTUS reviews its relationships, as well as those of its Associates and health care partners, with other care providers, educational institutions, payors, and vendors to ensure that those relationships are ethical and comply with applicable laws and regulations. A conflict may occur if outside activities, financial or other interests influence the ability of persons to make objective decisions in the course of job responsibilities. Additionally, all Associates, health care partners, Board and Board Committee Members are required to sign a conflict of interest statement and disclose existing or potential conflicts of interest. The Board and Board Committee Member disclosures must be consistent with organizational and regulatory requirements. CHRISTUS will address actual conflicts of interest when they arise. Associates will evaluate activities or contracts that constitute a conflict of interest or the appearance of a conflict and will: Conduct themselves in such a manner that there is no occasion for distrust of their integrity, impartiality, or loyalty to the best interests of CHRISTUS; Not solicit personal business or gratuities from patients, their families, physicians or others doing or seeking to do business with CHRISTUS; Not accept cash, cash equivalents, or loans from any outside concern, which does, or is seeking to do business with, or is in competition with CHRISTUS; Not disclose or use CHRISTUS business information or assets for the personal gain or advantage for themselves, or others; Not provide payments or benefits of any kind to any Associate, physician or health care professional or their family members in an effort to induce referrals; Not gain employment from any outside concern, which does, or is seeking to do business with, or is in competition with, CHRISTUS unless such employment will not interfere with job responsibilities and conflict of interest policies; Not provide supervisory or consulting services to any outside concern that does business with, or is in competition with CHRISTUS without the expressed authorization of the chief executive officer or administrator of the facility or region; S I X T E E N

19 C H R I S T U S H E A L T H Not knowingly compete, directly or indirectly, with CHRISTUS in the purchase or sale of real or personal property, interests or services; Not knowingly hold, directly or indirectly, a position or significant financial interest in any non-christus business that provides goods or services to CHRISTUS or competes with CHRISTUS in providing services; Comply with CHRISTUS guidelines in accepting gifts, gratuities, meals, entertainment or other favors from any concern that does business with, seeks to do business with, or is in competition with CHRISTUS. Health care partners will evaluate activities or contracts that constitute a conflict of interest or the appearance of a conflict and will: Conduct themselves in such a manner that there is no occasion for distrust of their integrity, impartiality, or loyalty to the best interests of CHRISTUS; Not solicit personal business or gratuities from patients, their families, physicians, or others doing or seeking to do business with CHRISTUS; Not disclose or use CHRISTUS business information or assets for the personal gain or advantage for themselves, or others; Not provide payments or benefits of any kind to any Associate, physician or health care professional or their family members in an effort to induce referrals; Comply with CHRISTUS guidelines in giving gifts, gratuities, meals, entertainment, or other favors to CHRISTUS Associates. S E V E N T E E N

20 C O D E O F E T H I C S INTEGRITY OF CLINICAL DECISIONS (TJC PC and PC ) Clinical decisions are based on the identified needs of the patient. Each entity has implemented guidelines and procedures that address the relationship between the use of services and financial incentives. These guidelines and procedures are available on request to all patients, clinical staff, licensed independent practitioners and hospital personnel. CHRISTUS will: Provide treatment and service based on the needs of the patient without regard to the patient s ability to pay for such services; Ensure that clinical decisions are based on the identified health needs of patients, regardless of how the health care center compensates or shares financial risk with its leaders, managers, clinical staff, and licensed independent practitioners; Ensure that, if an Associate s or health care partner s request to be excused from participating in an aspect of care, treatment, and services is granted, the patient s care, treatment and services are not affected negatively. DENIAL OF CARE (TJC LD ) At times, a conflict may arise between the professional and ethical responsibility of CHRISTUS and health care partners to provide care, treatment, and services and the recommendations of an external entity performing utilization review. If such a conflict arises, decisions about care, treatment, services, and discharge should be based on the patient s identified needs. The patient and/or legal agent, family, close friend, and attending physician shall be involved in these decisions. STEWARDSHIP OF RESOURCES (ERD #6) CHRISTUS is a responsible steward of available health care resources. As a responsible and just health care system CHRISTUS promotes both the equity of care, ensuring that the right of each person to basic health care is respected, and the good health of all in the community. Participating in the health care ministry of CHRISTUS is a privilege for all Associates and health care partners, and is also an awesome responsibility a responsibility to respect, protect, and enhance all the resources of CHRISTUS, including the Mission and heritage of CHRISTUS. E I G H T E E N

21 C H R I S T U S H E A L T H Human Resources The Associates and health care partners of CHRISTUS are its most important resource. CHRISTUS values the diversity of the Associates and health care partners within the organization and understands how this diversity enhances the patient experience. CHRISTUS respects the dignity of each Associate and health care partner, and is committed to treating them respectfully and justly. CHRISTUS creates an atmosphere where relationships are built on trust, enabling Associates to recognize and appreciate each other s contributions. (ERD #7, CHRISTUS Policy 4.01) Associate Selection and Development CHRISTUS is committed to establishing processes and practices which address selection, development and enrichment of Associates and will: Define the required competencies for Associates who provide care, treatment, and services to patients and ensure that staffing of these positions is adequate; (TJC HR ) Provide effective orientation for new Associates to CHRISTUS with a focus on the heritage and tradition of the sponsors, the Associate Covenant, and the specific job function; Promote diversity and inclusiveness and make employment and promotion decisions without regard to race, color, religion, gender, orientation, disability, age, or national origin; N I N E T E E N

22 C O D E O F E T H I C S Promote the growth of persons through providing opportunities for development and use of talents and skills so that individuals may develop to their fullest potential. Compensation and Benefits CHRISTUS provides its Associates with just compensation and benefits. (ERD #7) CHRISTUS will: Establish a just wage and other benefits which are intended to safeguard and promote the quality of life and health of workers and their families; Provide, to eligible Associates, benefit packages that emphasize affordable health care, retirement, disability, life insurance, adequate time off for rest, opportunities for self-development, and safety in the workplace; Require the continual assessment and re-assessment of the impact that the wage/benefit package has on the individual, the family, and individual markets in light of the obligation to promote the common good. Performance Evaluation CHRISTUS will: Objectively evaluate Associate performance outcomes in a timely manner, provide meaningful feedback and recognize the outstanding performance of individuals; (TJC HR ) Support and encourage Associates to develop skills, knowledge and talents in an effort to continually provide quality care to patients; Support and encourage Associates to balance their personal and professional lives. Issue Resolution CHRISTUS will: Strive to resolve issues through direct discussion with appropriate supervisors and if an issue remains unresolved, follow the Problem and Concern Resolution process; Take disciplinary action for violations of the Code of Ethics; Provide a written process to address an Associate or health care partner s request not to participate in an aspect of patient care because of their cultural, ethical, or religious beliefs. Harassment CHRISTUS will not tolerate harassment in any form and will take all appropriate measures to prevent such behavior and is committed to take corrective action for violations identified. T W E N T Y

23 C H R I S T U S H E A L T H Environmental and Financial Resources Associates and health care partners will respect, protect, and enhance environmental and financial resources, and will: Respect the relationship with the earth, and implement programs which nurture a safe and healthy environment; Ensure that actions and decisions maintain the future viability and vitality of the ministry; Protect all assets against misuse, loss or theft, and report inappropriate use of assets; Use property, equipment, and supplies in a responsible manner in order to protect and steward available resources; Dispose of surplus or obsolete property in accordance with established procedures. PATIENT RIGHTS AND CLINICAL ETHICS PATIENT RIGHTS Respecting Patient Rights (TJC RI ; ERD #23) CHRISTUS respects the inherent dignity of each person and recognizes the rights of patients. Because of this dignity, persons are obliged to use ordinary means to preserve his/her health as long as, in the patient s judgment, procedures offer a reasonable hope of benefit without imposing excessive risk or burdens on the patient or excessive expense to the family or community. (ERD #32; #56-59) CHRISTUS fosters a culture in which Associates and health care partners, patients, and families interact in a mutually respectful environment. (ERD Part Three) CHRISTUS will: Respect and support the rights of all and treat all patients with dignity, respect, and compassion; Strive for excellence in the quality of care and service provided to all served, regardless of race, color, religion, gender, orientation, disability, age, or national origin; T W E N T Y - O N E

24 C O D E O F E T H I C S Respect each patient s cultural, psychosocial, spiritual, and personal values, beliefs, and preferences and recognize the rights of patients and families to express these within the confines of applicable law as long as patient treatment is not interfered with and others are not harmed; Honor the right of patients to be involved in all aspects of their care and treatment and make provision for their involvement; Maintain policies which address the rights of patients with longer lengths of stay to perform or refuse to perform tasks in or for the facility; (TJC RI ) Provide spiritual care Associates to minister to the religious and spiritual needs of the faith traditions it serves, including the availability of sacraments for those who request them. The CHRISTUS Guidelines for Spiritual Care express the standards for the departments of Spiritual Care. CHRISTUS requires spiritual care Associates to have appropriate professional preparation and credentials. (ERD Part Two, #10-22) Privacy and Security of Patient (TJC RI and IM ) Confidentiality, use, maintenance and disclosure of patient information is based on all applicable laws and regulations. CHRISTUS ensures that patients are informed of the facility s policy on the privacy and confidentiality of protected health information upon admission. (ERD #34) Privacy of patients is respected. CHRISTUS provides for the comfort of patients and provisions are made for the safety and security of certain personal property of patients. Patients who desire private telephone conversations are given access to space and telephones appropriate to their needs considering the care, treatment, and services provided. Dignified Environment (TJC RI ) Patients have a right to an environment that preserves dignity and contributes to a positive self image. CHRISTUS facilities create a supportive environment for patients and/or residents. CHRISTUS facilities provide sufficient storage space for the patient s personal needs and allows patients to keep and use personal clothing and possessions, unless this infringes on the rights of others or is medically or therapeutically contraindicated. Care for the Beginning of Life CHRISTUS fosters respect for marriage and the family and witnesses to the sanctity of human life from the moment of conception. Children are the supreme gift of marriage and conjugal love. Parents are cooperators with the love of God, the Creator, and are interpreters of that love. CHRISTUS provides prenatal, obstetric, and postnatal services consistent with these values. (ERD Part Four, #44) T W E N T Y - T W O

25 C H R I S T U S H E A L T H As a result of advances in the biological and medical sciences, new technologies are now available to address the problem of infertility. Certain reproductive technologies that assist conception and respect the unitive and procreative meanings of the marital act may be offered. (ERD #38-44) Because of our respect for human dignity from the moment of conception, CHRISTUS does not provide abortion services. Direct abortion the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus is never permitted. In order to treat a serious pathological condition of a pregnant woman, certain medical treatments may be permitted when they can not be safely postponed until the unborn child is viable, even though the treatments will indirectly result in the death of the fetus. (ERD #45-50) Prenatal diagnosis is permitted when the diagnosis can provide information to guide preventative care for the mother or pre- or postnatal care for the child. (ERD #50) CHRISTUS recognizes the right and duty of each person to protect and preserve bodily and functional integrity, which can only be sacrificed indirectly to preserve the life and health of the person. Direct sterilization of men or women is not permitted. (ERD #29, 53) Complaint Process (TJC RI ) CHRISTUS informs patients, families, legal agents, Associates and health care partners about the complaint resolution process, and responds to such concerns from patients and their families when brought to its attention. Formal processes for addressing grievances and resolving conflicts are available. CHRISTUS is committed to adjust current practices and communicate with Associates and health care partners to make sure corrections occur in a timely manner. T W E N T Y - T H R E E

26 C O D E O F E T H I C S CHRISTUS informs patients about their right to file a complaint with both federal and the state authorities. Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or interruption of care, treatment, and services. PATIENT PARTICIPATION IN CARE (ERD #24) Involvement in Care (TJC RI ) CHRISTUS recognizes the right of patients to be involved in care, treatment, and service decisions. Dilemmas, questions, or conflicts concerning care decisions sometimes occur. CHRISTUS maintains procedures to make sure patients are involved in the resolution of these issues or concerns. CHRISTUS will ensure that: Patients are involved in making decisions and in resolving questions and dilemmas about their care, treatment, and services; Patients have the right to exclude any or all family members from care decisions; If the patient cannot make decisions, a legal agent is identified according to law. This legal agent approves the care, treatment, and service decisions; Family members and close friends are involved in decisions with the permission of the patient or legal agent and as allowed by law; T W E N T Y - F O U R

27 C H R I S T U S H E A L T H Multidisciplinary patient care consultation teams are available through the Ethics Committee to assist in the resolution of care, treatment, and service dilemmas; (ERD #37) When patients are not able to direct their care, especially when the patient is a child or does not have the mental or physical capacity to make care decisions, CHRISTUS has policies and procedures which permit family, guardians, close friends, and legal agents to participate in care decisions and sign the proper consent forms as permitted by law. Pain Assessment and Management (TJC RI and PC ; ERD #61) CHRISTUS recognizes that patients have a right to pain management and has guidelines and protocols to properly assess and to effectively manage pain which ensure that: Pain is assessed initially and periodically; Pain is addressed appropriately in accordance with the care, treatment, and services provided; Pain assessment management education is provided for all relevant caregivers; Education is available for patients and families regarding the process of pain management as well as potential limitations and side effects; There is sensitivity to personal, cultural, spiritual, and ethnic beliefs in communicating with the patient about pain management. Refusal of Care (TJC RI ) CHRISTUS recognizes the patient s right to refuse care, treatment and services in accordance with law, regulation, and the parameters of his/her moral tradition. When the patient is not legally competent, the legal agent, as allowed by law, has the right to refuse care, treatment, and services on the patient s behalf. (ERD #32, 57, 58, 59) End of Life Care (TJC RI ; ERD Part Five, ERD #55, 59) As a Catholic, faith-based health care system, CHRISTUS is a community of respect, love, and support to patients and their families as they face the reality of death. CHRISTUS Associates and health care partners are aware of the special needs of patients during the final stages of life. Associates and health care partners respect the dignity of these patients and give compassionate care that provides comfort and offers hope. CHRISTUS has policies and processes to assure that the: Psychological, social, emotional, spiritual, and cultural needs and concerns of the patient and family are respected and addressed; Patient s advance directives are reviewed and honored; (ERD #24) Spiritual care Associates are available to assist the patient and family; T W E N T Y - F I V E

28 C O D E O F E T H I C S CHRISTUS has policies and provides mechanisms to address the withholding of resuscitative services and the forgoing or withdrawal of life-sustaining treatment when they do not offer a reasonable hope of benefit or impose or entail an e x c e s s i v e b u rd e n o r excessive expense to the patient or family. The Ethics Committee of the facility provides education, gives direction, and facilitates a process to address these issues. (ERD #32, 33, 37, 56-58) Organ Donation (TJC RI and TS ; ERD #30, 63-66) CHRISTUS facilities work with the appropriate organizations and have a policy and procedure for requesting and obtaining the donation of organs and tissue. INFORMATION PROVIDED TO PATIENTS Information About Patient Rights (TJC RI ) CHRISTUS will: Give patients a written statement of their rights and responsibilities; Inform patients of their rights and responsibilities in a manner that will be understood, if the written statement is perceived to be ineffective; Determine, upon admission, whether the patient has made or wishes to make advance directives, and make sure advance directives are honored within the limits of its moral tradition and the law, and documented in the medical record; (TJC RI ; ERD #24, 25) Recognize that the patient has the right to access, request amendment to or restriction of their health information, and receive an accounting of disclosures regarding his/her own health information as permitted under applicable law. T W E N T Y - S I X