Code of Conduct martinhealth.org
CODE OF CONDUCT Table of Contents A Note from the CEO 1 Mission Statement 2 Vision Statement 2 ICARE Values 2 The Corporate Compliance Program 3 Introduction 3 Corporate Compliance Mission 3 Confidential Reporting 3 Non-Retaliation 3 Marketing Practices 4 Gifts/Patient Relationship 4 Emergency Treatment 4 Charity Care 4 Purchasing Practices 5 Proprietary Information 5 Conflicts of Interest 5 Security of Information 5 Privacy of Patient Information 5 Confidential Business Information 6 Leadership Responsibility 6 Gifts/Business Relationship 6 Business Practices 6 Billing and Coding Practices 7 Prevention of False Claims 7 Tax-Exempt 7 Political Activity 8 Workplace Safety 8 Financial Reporting 8 Anti-Trust 9 Dignity and Respect 9 Open, Honest Communication 9 Non-Discrimination and Anti-Harassment 9
A Note from the CEO Martin Health System (MHS), including all of its affiliated corporations, has an impressive reputation as an organization that does the right thing on behalf of its patients, community, family of associates (including contract staff), physicians, volunteers and approved business partners/vendors. This reputation is tested every day in every decision that is made within Martin Health, whether in the board room, a clinical area,or the business office. Through the Corporate Compliance Program, the Code of Conduct (The Code) is a platform to describe how the board of directors, executive team, leadership team, medical staff, associates, volunteers and approved business partners/vendors uphold Martin Health s reputation for integrity and ethical behavior. The purpose of The Code is to ensure that the organization demonstrates the highest standards of legal and ethical excellence. The Code consolidates, into one document, the general principles by which the organization does business and provides all board of director, executive team, leadership team, and medical staff, as well as associates, volunteers, and approved business partners/vendors, with a set of guidelines for performing their assigned duties. It is the responsibility of everyone to ensure that the principles outlined in The Code are upheld. Following the Corporate Compliance Program is essential. Therefore, all members of the board of directors, executive team, leadership team, and medical staff members, as well as associates, volunteers, and approved business partners/vendors, are required to cooperate with this effort by ensuring that The Code is followed. Sincerely, Mark E. Robitaille President and Chief Executive Officer Code of Conduct 1
Mission To provide exceptional health care, hope and compassion to every person, every time. Vision An innovative healthcare system nationally recognized for clinical excellence and improving the health and well-being of the communities we serve. Values Innovation Collaboration Accountability Respect Excellence By incorporating ICARE into every interaction with patients, families, physicians, volunteers and each other, we will achieve our vision. PATIENT CENTERED Leadership Leader Rounding/ Coaching MISSION VISION METHOD Strategy Deployment PHILOSOPHY Alignment Daily Management Continuous Process Improvement VALUES FOCUS Code of Conduct 2
The Corporate Compliance Program Introduction Martin Health System (MHS) Corporate Compliance Program was developed with the support of its board of directors. The Corporate Compliance Program establishes internal policies, procedures and mechanisms to help guide members of the board of directors, executive team, leadership team, medical staff, associates (including contract staff), volunteers and approved business partners/vendors in complying with the legal and ethical standards applicable to the healthcare environment. Corporate Compliance Mission To develop, promote and provide an atmosphere where open reporting is met with non-retaliation. To enhance communication among associates, the leadership team and the community. To reinforce the health system s commitment to compliance with legal requirements and ethical business standards. Confidential Reporting Associates have an obligation to report suspected failure to comply with laws, regulations or departmental policies. Failure to report compliance violations will result in disciplinary action. Reporting concerns is everyone s responsibility. MHS protects, to the fullest extent of the law, the confidentiality of any individual placing a compliance report. Individuals have various resources available for reporting compliance concerns. The preferred method is to follow the appropriate chain of command. However, associates who do not feel comfortable reporting concerns to their immediate supervisor also may utilize other resources such as the chief compliance officer, the compliance line at (877) 785-0002, or by visiting the website MyComplianceReport.com. The compliance line is a service operated by an independent organization. This service is available 24 hours a day and can be used anonymously by the caller. The Compliance Line or hotline (877)785-0002, is available 24/7, and can be used anonymously by the caller. Non-Retaliation MHS promotes a work environment that encourages associates to feel at ease when bringing forth concerns regarding legal or regulatory issues, policies and procedures. Any form of retaliation against an associate who identifies a perceived problem or concern, in good faith, is strictly prohibited. When unsure, question. When concerned, report. MHS has a policy of non-retaliation for good-faith reporting. Code of Conduct 3
Marketing Practices Marketing, advertising and community events are used to inform and educate the community on the services provided by MHS. Marketing and advertising activities must be truthful and supported by evidence to substantiate any claims. Information released to patients, physicians, business partners/vendors, the media, or the community should not knowingly contain inaccuracies nor should there be an intentional misrepresentation of the services of the health system. In addition, marketing efforts will not discredit the service or business of a competitor and will refrain from negative or harmful characterization of any events or individuals. Marketing efforts will concentrate on customer education about services available and the benefits of those services within the organization. Gifts/Patient Relationship MHS provides excellent care without regard to a patient s age, race, ethnic origin, religion, gender, disability, profession or ability to pay. Members of the board of directors, executive team, leadership team, medical staff, associates or volunteers should not accept gifts or courtesies from patients, their family members or friends, if they are intended to influence the quality of care provided. Under certain circumstances, however, it is appropriate to accept gifts from patients. Occasionally, patients or family members express a strong desire to reward caregivers for excellent care. As long as gifts are unsolicited, nominal in value and able to be shared with co-workers, they may be accepted. Monetary contributions to departments, individual projects, and/or MHS should be directed through the Martin Health Foundation. If you have any questions regarding the nature of a gift, contact your immediate supervisor or the Corporate Compliance Office. Monetary contributions to departments, individual projects and/or the health system, should be directed through the Martin Health Foundation. Emergency Treatment MHS adheres to the requirements of the Emergency Treatment and Labor Act (EMTALA) in providing a medical screening examination and stabilizing treatment to all patients who come to a MHS hospital, including the Martin Memorial Emergency Center at St. Lucie West, for emergency medical treatment or who are in labor, regardless of the patient s ability to pay or lack of insurance, race, color, religion, age, gender, national origin, or physical disability. Patient s with emergency medical conditions are only transferred to another facility at the patient s request, or if MHS does not have the capacity or capability to meet the patient s needs and appropriate care is available at another facility. Charity Care MHS was established with the mission to meet the health care needs of its community. MHS, through its health care facilities and related activities, provides quality care to all individuals regardless of ability to pay. MHS will assist uninsured and under-insured community members seeking non-emergent services through its charity care procedures. Code of Conduct 4
Purchasing Practices All purchasing determinations are made with the intent of obtaining the highest quality goods, products, supplies, and/or services for MHS and its patients at the optimum price. Purchasing decisions will not be made based upon any consideration that a member of the board of directors, executive team, leadership team, medical staff, an associate or a volunteer, including family members, will benefit either directly or indirectly by the business transaction. Goods, products, supplies or services will not be purchased in return for a referral or the inference of a referral of patients. In addition, MHS will not process or negotiate personal purchases for the board of directors, executive team, leadership team, medical staff, associates or volunteers. Goods, products, supplies or services will not be purchased in return for a referral or the inference of a referral. Proprietary Information MHS exercises care to ensure that intellectual property rights, including patents, trademarks, copyrights and software, are carefully maintained and managed to preserve and protect their value. Associates are prohibited from misappropriating confidential or proprietary information belonging to another person or entity. Copyrighted, trademarked or licensed materials will not be copied or used without written permission from the holder of the proprietary right or, if not classified, under the fair use exemption. Conflicts of Interest A conflict of interest will arise if an associate s business judgment is, or will be, influenced by personal interests which will compromise the interests of MHS. All decisions and actions should be based on sound business or clinical judgment, not personal gain. Employed physicians, as well as members of the board of directors, board committees, and leadership team, are required to disclose outside business and/or financial arrangements that may give the appearance of a conflict of interest with MHS business operations. To avoid the appearance of a conflict of interest, associates are encouraged to disclose a potential conflict to their immediate supervisor or to the individuals involved with business or clinical decisions. Security of Information The delivery of health care will result in the compilation of a large amount of clinical and financial information. To maintain cost effectiveness and efficiency in its operations, MHS has a substantial reliance on information systems. Associates, and any individual granted access to these systems, will abide by the system s security policies. Computer passwords must be kept confidential and sharing of passwords is strictly prohibited. Privacy of Patient Health Information MHS is dedicated to protecting the privacy and confidentiality of protected health information (PHI). PHI includes clinical, financial or demographic information that may identify a patient. It includes information that is spoken, written or in electronic systems. PHI should be accessed, used or disclosed according to job responsibilities and only to the extent necessary. These responsibilities must involve patient treatment, payment or health care operations (cont). Code of Conduct 5
The health system will not violate the trust that its patients, their families or fellow associates place in the organization. PHI should not be discussed in public areas such as cafeterias, elevators and corridors. Associates in a position to access, use or disclose PHI are required to understand applicable federal and state laws that govern the privacy of our patients and their health information, as well as related MHS policies and organizational standards. Associates are held accountable and violations can lead to disciplinary actions, up to and including termination. MHS and its associates are accountable for maintaining the privacy and security of protected health information. Confidential Business Information MHS and its associates are in possession of, and have access to, a broad variety of confidential, sensitive and proprietary information. Confidential business information includes personnel data maintained by the organization, pricing and cost data, information pertaining to acquisitions and affiliations, financial data, strategic plans, marketing strategies and techniques, supplier and subcontractor information, and proprietary software. The inappropriate release of such information could injure or otherwise damage individuals, business partners of MHS, and/or the health system itself, and should therefore be avoided. Leadership Responsibility While all associates are obligated to follow The Code, the board of directors, executive team and leadership team must promote MHS s ICARE values. The leadership team must create a culture that promotes the highest standards of ethics an compliance and maintain a work environment in which concerns shall be raised and openly discussed. Gifts/Business Relationship Business courtesies (gifts) offered by business partners/vendors with the intent to influence a decision should not be accepted by members of the board of directors, executive team, leadership team, associates or volunteers. Likewise, associates will not offer business courtesies to business partners/vendors with the intent to induce the purchase or lease of any goods, facility or service. MHS permits the acceptance of non-cash, unsolicited courtesies provided that the value of the gratuity is nominal in relation to the circumstances in which it is offered and it is not intended to influence a business transaction or the decision making of an associate. Business Practices MHS is committed to ethical business conduct and integrity. Associates are obligated to conduct themselves in a manner that is consistent with the highest business practices. Associates are required to represent the health system accurately and honestly and never purposely cheat anyone, including other companies or the government, of money, property or services. Even if an activity, communication or transaction is in technical compliance with the law, it is not right for MHS if it is contrary to traditional notions or a common sense approach of what is the ethical thing to do. MHS is committed to ethical business conduct and integrity. Code of Conduct 6
Billing and Coding Practices MHS will ensure that all billings to government and private insurance payers accurately represent the services provided while conforming to all pertinent federal and state laws. MHS will bill only for services actually rendered and properly documented in the medical record. MHS will encourage physicians to order only medically necessary tests, so that reimbursement sought from any payor, whether a federally funded health care program, private insurer or patient, is appropriate. MHS prohibits its leadership team, medical staff and associates from knowingly presenting, and/or causing to be presented, claims for payment or approval, which are false, fictitious or fraudulent. Prevention of False Claims MHS has implemented internal controls, including routine monitoring and audits, to help prevent and detect fraud, waste and abuse. The Federal False Claims Act penalizes anyone who knowingly makes a false or fraudulent claim to the government under any federal contract or program, including Medicare and Medicaid. Examples of false claims include, but are not limited to, making false statements to the government, falsifying medical records to maximize payment, double billing, billing for services not performed, falsely certifying the medical necessity of a service, altering or forging checks, falsely reporting costs or submitting claims for services resulting from improper referrals. Any violation of the Act may result in MHS or individuals being subject to fines, additional damages, and/or possible exclusion from the federal Medicare and Medicaid programs. A similar Florida False Claims Act applies to Medicaid and other state programs. In accordance with both the Federal and State False Claims Acts, the health system may not impose any form of retaliation against an individual who lawfully reports false claims to a governmental entity or who participates/cooperates in legal actions or governmental investigations. Tax-Exempt MHS and many of its affiliates are non-profit corporations exempt from taxation under the Internal Revenue Code. As such, the health system must comply with Internal Revenue Service regulations, engage in activities that further its tax-exempt charitable purpose and use its resources to promote such purpose as opposed to serving the personal interests of any individual. MHS assets are to be used exclusively to further its mission and tax-exempt purpose. Therefore, use of corporate assets is restricted for business purposes only, and compensation and other business arrangements must be granted on an impartial and fair basis (cont). In addition, MHS must deal with insiders of the organization in a manner that does not violate or give the appearance of violating these tax-exempt rules and regulations. An insider is any individual in a position to influence control over the affairs of the organization. Accordingly, any direct or indirect payments provided to insiders by MHS must be at arm s-length and at fair market value with the services rendered. Use of corporate assets is restricted for business proposes only, and compensation and other business arrangements must be granted on an impartial basis. Code of Conduct 7
Political Activity Members of the board of directors, executive team, leadership team and associates are encouraged to participate in, and contribute to, a political candidate, organization or campaign. However, while acting in the capacity as a representative of MHS, these individuals will contact the chief compliance officer prior to making any agreement to contribute money, property or services to a political candidate, organization or campaign. Where the organization s experience may be helpful, MHS may comment on legislation and/or regulations under consideration. MHS may also analyze and take public positions on issues that relate to MHS s operations and/or mission. Workplace Safety MHS s internal policies protect associates and patients from potential workplace hazards and promote compliance with government rules and regulations. Associates should know these policies and understand how they apply to specific jobs. MHS conducts a comprehensive Work Place Safety Program including, but not limited to, ergonomic assessments, education, evaluations of fitness for duty, protective and preventive equipment and annual screenings. Associates should be knowledgeable of the Work Place Safety Program initiatives, must follow the requirements, and know their department work place safety representative. MHS promotes health and wellness, and encourages individuals to care for their own health needs through access to its health and fitness centers. Associates must perform their duties and responsibilities free from the influence of intoxicants, non-prescribed narcotics, illegal drugs or other controlled substances. Financial Reporting MHS maintains a high standard of complying with accounting and financial reporting regulations that emphasize internal controls, prevention of fraud, and adherence to generally accepted accounting principles. The organization s financial records are necessary for the future viability of the organization. MHS will maintain a system of internal controls with the intent to prevent fraud. All transactions will be executed in accordance with leadership team s authorization and recorded properly to maintain accountability of the organization s assets. All financial reports, accounting records, payments collected, expense accounts, time sheets and other documentation will accurately and clearly represent the relevant facts or the true nature of the transaction. Associates will perform their duties and responsibilities free from engaging in any fraudulent activity or theft of company funds or assets. All transactions will be executed in accordance with leadership team s authorization and recorded properly to maintain accountability of the organization s assets. Code of Conduct 8
Anti-Trust Anti-trust laws are designed to create a level playing field in the marketplace and to promote fair competition. These laws could be violated by discussing, with a competitor, MHS business on topics such as how prices are set, disclosing the terms of supplier relationships, allocating markets among competitors or agreeing with a competitor to refuse to deal with a supplier. MHS applies sound financial judgment in establishing the pricing of services in the health care market. It does not collaborate with its competitors in determining prices. In general, associates should avoid discussing confidential business information with competitors or suppliers unless they are proceeding with the advice of the Legal Services Department. Dignity and Respect Associates commit to principles of fairness and respect for the dignity of the individual. This creates an environment that allows MHS to achieve its mission. MHS is committed to cultivating a work environment that values people. MHS respects the dignity of each individual and strives to treat others with courtesy. It celebrates the diversity of its associates, patients and the community. Open, Honest Communications Everyone at MHS is on the same team, and honest communication among team members is critical to the success of MHS s mission. MHS expects and requires honesty from individuals, in the performance of their job responsibilities and in communication with others. Non-Discrimination and Anti-Harassment As an equal opportunity employer, MHS believes that associates have the right to work in an environment that is free from discrimination and harassment. This includes discrimination or harassment based on race, creed, color, religion, gender, national origin, age, disability, marital status or any other legal classification. MHS does not tolerate any form of sexual misconduct and/or harassment such as offensive comments or jokes, unwanted sexual advances, requests for sexual favors and any verbal or physical conduct of a sexual nature. MHS does not tolerate any form of sexual misconduct and/or harassment such as offensive comments or jokes, unwanted sexual advances, requests for sexual favors and any verbal or physical conduct of a sexual nature. 2401-14 Code of Conduct 9