Corporate Compliance Code of Conduct - Baystate Health
Corporate Compliance Code of Conduct - Baystate Health
Corporate Compliance Code of Conduct - Baystate Health
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Baystate</strong> <strong>Health</strong><br />
<strong>Code</strong> <strong>of</strong> <strong>Conduct</strong><br />
••••••••
<strong>Baystate</strong> <strong>Health</strong><br />
<strong>Code</strong> <strong>of</strong> <strong>Conduct</strong><br />
What’s inside<br />
2 Message from the President<br />
3 Our Mission<br />
3 Our Operating Principles<br />
4 <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong> Overview<br />
4-5 Asking Questions and Reporting Concerns<br />
6 Identifying Concerns<br />
6 Non-Retaliation<br />
7 Quality <strong>of</strong> Care and Services<br />
8 Conflicts <strong>of</strong> Interest<br />
9 Joint Commission<br />
10 Employment Practices<br />
11 <strong>Health</strong> and Workplace Safety<br />
12 Accuracy <strong>of</strong> Financial Records,<br />
Transactions and Reports<br />
13 Billing and Reimbursement<br />
14 Confidentiality and Privacy<br />
15 Information Security<br />
16-17 Key Policies in Support <strong>of</strong> Our<br />
<strong>Code</strong> <strong>of</strong> <strong>Conduct</strong>
Mark R. Tolosky, J.D., FACHE<br />
President and CEO, <strong>Baystate</strong> <strong>Health</strong><br />
Dear <strong>Baystate</strong> <strong>Health</strong> Colleague,<br />
We have a complete, values-based <strong>Compliance</strong><br />
Program, which serves to guide how<br />
we conduct ourselves at <strong>Baystate</strong> <strong>Health</strong>.<br />
The <strong>Compliance</strong> Program is built on our<br />
mission and values and is a part <strong>of</strong> our daily<br />
activities, supporting our tradition <strong>of</strong> caring – for our patients,<br />
our communities, and our colleagues. All <strong>of</strong> us at <strong>Baystate</strong><br />
strive to deliver health care compassionately and to act with<br />
absolute integrity in the way we do our work.<br />
This <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong> <strong>of</strong>fers guidance to ensure our work is<br />
done in an ethical and legal manner. It also contains resources<br />
to help you resolve any questions about appropriate conduct at<br />
<strong>Baystate</strong>. Please review it thoroughly. Your commitment to its<br />
message and meaning is crucial to our success and future.<br />
If you have questions regarding this <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong>, or<br />
encounter any situation which you believe violates this <strong>Code</strong>,<br />
you should immediately consult your supervisor, another member<br />
<strong>of</strong> management, your Human Resources Consultant (HRC),<br />
a <strong>Compliance</strong> Coordinator (if applicable), the <strong>Baystate</strong> <strong>Health</strong><br />
Hotline 1-877-874-RIGHT (7444), or the <strong>Baystate</strong> Alertline at<br />
https://baystatehealth.alertline.com. You have the assurance<br />
there will be no retribution for asking questions or raising<br />
concerns about possible improper conduct.<br />
In our organization, corporate compliance means more than<br />
just following laws, policies, and procedures. It means practicing<br />
strong ethical standards in everything we do. It allows us to<br />
deliver excellent care. Simply stated, our philosophy is to do<br />
the right things, right. Your commitment will greatly benefit<br />
<strong>Baystate</strong> <strong>Health</strong> and the community we are privileged to serve.
Our Mission<br />
The charitable mission <strong>of</strong> <strong>Baystate</strong> <strong>Health</strong> is to improve<br />
the health <strong>of</strong> the people in our communities every day,<br />
with quality and compassion.<br />
Our Operating Principles<br />
We strive to meet our mission and perform all <strong>of</strong> our<br />
work with our operating principles <strong>of</strong>:<br />
• Trust<br />
• Integrity<br />
• Respect<br />
• Collaboration<br />
• Communication<br />
And Our Key Capabilities <strong>of</strong>:<br />
• Service Oriented<br />
• Committed to Continuous Improvement<br />
• Stewards <strong>of</strong> Our Resources<br />
• Engaged<br />
2
<strong>Code</strong> <strong>of</strong> <strong>Conduct</strong> Overview<br />
To fulfill the goals <strong>of</strong> our mission successfully and<br />
ethically, and to provide excellent patient care,<br />
<strong>Baystate</strong> <strong>Health</strong> has established helpful guidelines<br />
for employees to follow. This handbook is the <strong>Code</strong><br />
<strong>of</strong> <strong>Conduct</strong> and summarizes the values, policies and<br />
practices that guide our conduct.<br />
Find this <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong> and <strong>Baystate</strong> <strong>Health</strong> policies<br />
on eWorkplace.<br />
Asking Questions and Reporting Concerns<br />
<strong>Baystate</strong> <strong>Health</strong> employees, physicians, residents, students,<br />
contractors, consultants, volunteers, and other on-site<br />
agents are expected to report any violation <strong>of</strong> the<br />
<strong>Baystate</strong> <strong>Health</strong> <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong>, Statement <strong>of</strong><br />
Organizational Ethics, policies and procedures, and<br />
laws and regulations. We owe it to our patients, our<br />
colleagues, and the communities we serve to report<br />
known or suspected violations.<br />
3
You may ask a question or report a concern or<br />
violation by:<br />
• Telling your supervisor<br />
• Calling your HR consultant or local Human Resources<br />
Office with human resources-related issues<br />
413-794-5655 (Springfield)<br />
413-773-2295 (Greenfield)<br />
413-967-2113 (Ware)<br />
If you are not comfortable reporting issues to your<br />
supervisor or Human Resources, you can:<br />
• Call the <strong>Baystate</strong> <strong>Health</strong> <strong>Corporate</strong> <strong>Compliance</strong><br />
Office at 413-794-5840 or<br />
• E-mail <strong>Baystate</strong> <strong>Health</strong> <strong>Corporate</strong> <strong>Compliance</strong><br />
at compliance<strong>of</strong>fice@baystatehealth.org or<br />
• Call the <strong>Compliance</strong> Hotline at 877-874-RIGHT (7444)<br />
or<br />
• Report an issue online at the <strong>Baystate</strong> Alertline -<br />
https://baystatehealth.alertline.com<br />
You are not required to reveal your name or department<br />
when you report an issue. All reports will be<br />
investigated and action taken as appropriate. Depending<br />
on the issue, we may ask to contact you for further<br />
information during the course <strong>of</strong> an investigation.<br />
4
Identifying Concerns<br />
If you are not sure whether to report a concern or<br />
possible issue, consider the following:<br />
• Is this issue in conflict with the <strong>Baystate</strong> <strong>Health</strong><br />
<strong>Code</strong> <strong>of</strong> <strong>Conduct</strong>, values, polices and practices<br />
• Would others question this concern/issue<br />
• Are you repeatedly questioning the propriety<br />
<strong>of</strong> an action<br />
If the answer is “yes” to any <strong>of</strong> these questions, please<br />
report the issue or seek further guidance.<br />
Non-Retaliation<br />
<strong>Baystate</strong> <strong>Health</strong> does not permit any form <strong>of</strong> retaliation<br />
against an employee who reports a suspected violation<br />
in good faith, participates in an investigation, or makes<br />
a report to a supervisor, the Human Resources Office,<br />
the <strong>Compliance</strong> Office, the <strong>Compliance</strong> Hotline, or the<br />
<strong>Compliance</strong> Alertline.<br />
5
Quality <strong>of</strong> Care and Services<br />
<strong>Baystate</strong> <strong>Health</strong> is committed to providing high quality<br />
health care to our patients and to delivering health<br />
services in an ethical, pr<strong>of</strong>essional and cost effective<br />
manner. We treat patients with respect and dignity<br />
and provide care that is necessary and appropriate.<br />
• We provide equal access to care for all patients<br />
regardless <strong>of</strong> gender, gender identity or expression,<br />
color, age, sexual orientation, disability status, ancestry,<br />
race, religious or cultural beliefs, source <strong>of</strong> payment,<br />
or any other classification protected by law.<br />
• We maintain complete and thorough records <strong>of</strong><br />
patient information.<br />
• We recognize the rights <strong>of</strong> patients to formulate an<br />
advance directive and we comply with that directive.<br />
• All individuals employed to care for our patients are<br />
properly licensed and credentialed, have the necessary<br />
experience and expertise, and act in a respectful,<br />
collaborative and pr<strong>of</strong>essional manner.<br />
• All persons entering a <strong>Baystate</strong> <strong>Health</strong> emergency<br />
department and requesting a medical examination<br />
receive a medical screening exam to determine if<br />
an emergency situation exists. If one does exist,<br />
the patient is provided with medical treatment to<br />
stabilize the condition, without regard to the<br />
patient’s ability to pay.<br />
6
Conflicts <strong>of</strong> Interest<br />
<strong>Baystate</strong> <strong>Health</strong> expects and requires employees to act<br />
honestly and ethically, and to avoid both actual and<br />
potential conflicts <strong>of</strong> interest with <strong>Baystate</strong> <strong>Health</strong>.<br />
• We do not engage in any activity, practice or act<br />
that creates an actual or apparent conflict with the<br />
interests <strong>of</strong> <strong>Baystate</strong> <strong>Health</strong>.<br />
• We disclose any actual or potential conflicts <strong>of</strong><br />
interest to <strong>Baystate</strong> <strong>Health</strong> in accordance with policy.<br />
• We act solely in the best interest <strong>of</strong> <strong>Baystate</strong> <strong>Health</strong>,<br />
whenever acting as an agent <strong>of</strong> <strong>Baystate</strong> <strong>Health</strong>, in<br />
dealings with suppliers, customers or government<br />
agencies.<br />
• We may not accept personal gifts <strong>of</strong> any kind in any<br />
value from vendors. We may participate in business<br />
entertainment as long as there is a business purpose<br />
for the event and participation does not influence,<br />
or could be construed as influencing, any business<br />
decision. Please see our gifts policy for additional<br />
information.<br />
7
Joint Commission<br />
The Joint Commission accredits and certifies healthcare<br />
organizations and programs in the United States. They<br />
conduct regular accreditation surveys to evaluate<br />
compliance with nationally established standards. The<br />
survey results are used to determine whether, and the<br />
conditions under which, accreditation will be awarded.<br />
Anyone who has a complaint about the quality <strong>of</strong><br />
care received at a Joint Commission-accredited healthcare<br />
facility may contact Joint Commission Complaint<br />
Information at:<br />
Office <strong>of</strong> Quality Monitoring<br />
The Joint Commission<br />
One Renaissance Boulevard<br />
Oakbrook Terrace, IL 60181<br />
Toll free number 800-994-6610<br />
E-mail: complaint@jointcommission.org<br />
Fax: 630-792-5636<br />
8
Employment Practices<br />
At <strong>Baystate</strong> <strong>Health</strong>, our greatest strength is our employees.<br />
Our reputation as an institution <strong>of</strong> outstanding<br />
patient care is built by our employees. We must<br />
encourage and support each other as we work toward<br />
common goals.<br />
• We are an equal opportunity employer and we do<br />
not discriminate against employees or potential<br />
employees on the basis <strong>of</strong> gender, gender identity or<br />
expression, color, age, sexual orientation, disability<br />
status, ancestry, race, religious or cultural beliefs or<br />
other classifications protected by law.<br />
• We comply with the contents <strong>of</strong> this <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong>,<br />
as well as with the policies and procedures applicable<br />
to our employment and responsibilities at <strong>Baystate</strong><br />
<strong>Health</strong>.<br />
• We comply with our harassment policies and behave<br />
appropriately in the workplace.<br />
• We abide by <strong>Baystate</strong> <strong>Health</strong> policies prohibiting<br />
illegal possession, distribution, use or being under<br />
the influence <strong>of</strong> illegal drugs, alcohol or other substances.<br />
We support an alcohol-free, drug-free and<br />
smoke-free workplace.<br />
9
<strong>Health</strong> and Workplace Safety<br />
<strong>Baystate</strong> <strong>Health</strong> is committed to providing all employees<br />
and patients with a clean, safe and healthy work environment.<br />
To achieve this goal, we must recognize our<br />
shared responsibility to follow all safety rules, policies<br />
and practices.<br />
• We wear our identification badges visibly above<br />
the waist.<br />
• We act responsibly and collaboratively and treat<br />
everyone in a respectful and pr<strong>of</strong>essional manner.<br />
• We report any suspicious activity to <strong>Baystate</strong><br />
<strong>Health</strong> Security.<br />
• We follow laws and regulations relating to the<br />
environment, including those laws and regulations<br />
regarding the handling, storage, use and disposal<br />
<strong>of</strong> hazardous materials and infectious wastes.<br />
• We wear proper protective equipment for our jobs,<br />
report spills and safety hazards promptly, and engage<br />
in hand hygiene.<br />
• We follow emergency plans and know what to do<br />
in the event <strong>of</strong> a disaster or fire.<br />
10
Accuracy <strong>of</strong> Financial Records, Transactions<br />
and Reports<br />
<strong>Baystate</strong> <strong>Health</strong> financial records, transactions (including<br />
patient bills), and resulting financial statements and<br />
regulatory reports must be accurate, complete, and in<br />
accordance with institutional and regulatory requirements.<br />
• We will continue to observe the most stringent standards<br />
in keeping our financial records and transactions. Our<br />
records must reflect all components <strong>of</strong> transactions, as<br />
well as our own standard <strong>of</strong> insisting upon an honest<br />
and forthright presentation <strong>of</strong> the facts.<br />
• We provide current coding, billing and reimbursement<br />
updates and training to our coding, billing, and clinical<br />
staff in the areas <strong>of</strong> proper documentation, code<br />
selection, charge capture and reimbursement issues.<br />
• If we discover errors or notice areas for improvement,<br />
we notify the appropriate personnel to correct the<br />
issue in a timely manner.<br />
• Related, to the issuance <strong>of</strong> tax-exempt bonds we will<br />
not directly or indirectly affect securities transactions<br />
on the basis <strong>of</strong> ‘insider information.’<br />
11
Billing and Reimbursement<br />
<strong>Baystate</strong> <strong>Health</strong> prepares and submits bills that accurately<br />
reflect the medically necessary services provided.<br />
These bills are supported by documentation in the<br />
medical record and are compliant with applicable rules,<br />
regulations, and standards.<br />
• We accurately document care.<br />
• We submit bills that accurately reflect the medically<br />
necessary <strong>of</strong> services provided. These bills are supported<br />
by documentation in the medical record and<br />
are compliant with applicable rules, regulations and<br />
standards.<br />
• If we discover errors or notice areas for improvement,<br />
we notify the appropriate personnel to correct the<br />
issue in a timely manner.<br />
• We provide confidential financial assistance/ counseling<br />
for those patients who qualify through our financial<br />
assistance <strong>of</strong>fice.<br />
12
Confidentiality and Privacy<br />
<strong>Baystate</strong> <strong>Health</strong> is committed to safeguarding our<br />
medical and business information. We only may access<br />
Protected <strong>Health</strong> Information for patients if we need<br />
the information to do our job. Access for any other<br />
reason is prohibited and may result in termination.<br />
• We keep patient information confidential.<br />
• We do not release patient information unless the<br />
release is supported by a legitimate clinical or business<br />
purpose, or a patient authorization.<br />
• We do not discuss patient information in any public<br />
area such as elevators, common areas, dining halls, etc.<br />
• In addition to patient information, access to sensitive<br />
business information, which may include salary,<br />
personnel and financial information, is protected<br />
and its dissemination is strictly limited.<br />
Overhead Paging<br />
A patient’s name should not be linked with a hospital<br />
service when overhead paging.<br />
13
Information Security<br />
<strong>Baystate</strong> <strong>Health</strong> protects its information and information<br />
systems from accidental or unauthorized access, disclosure,<br />
modification or destruction.<br />
• We log <strong>of</strong>f our workstations and applications; never<br />
share our passwords, and always double check fax<br />
numbers before sending patient information.<br />
• We do not install, share, copy s<strong>of</strong>tware programs, or<br />
perform any other acts that would violate a vendor’s<br />
s<strong>of</strong>tware license agreement or organizational policies.<br />
• We comply with the regulatory requirements, accreditation<br />
standards and organizational policy for the<br />
creation, management, retention, and destruction <strong>of</strong><br />
records.<br />
• We report information security weaknesses and<br />
suspected or actual instances <strong>of</strong> computer and<br />
information theft or abuse to <strong>Baystate</strong> <strong>Health</strong>'s<br />
Information Security Officer.<br />
• All equipment provided to employees remains the<br />
property <strong>of</strong> <strong>Baystate</strong> <strong>Health</strong>, should be used for work<br />
purposes only, and must be returned when employment<br />
ends.<br />
• Please see the <strong>Baystate</strong> <strong>Health</strong> Patient Privacy and<br />
Security handbook for more details on privacy and<br />
information security.<br />
14
Key Policies in Support <strong>of</strong><br />
Our <strong>Code</strong> <strong>of</strong> <strong>Conduct</strong><br />
All policies are available on eWorkplace on the Policies tab. Policies<br />
starting with CO and BC policies can be found in the <strong>Corporate</strong> Policy<br />
Manual (BH), CO policies will be found in the Clinical Ops Manual(s),<br />
HR policies are found in the Human Resources Policies, AA policies<br />
are found in the Academic Affairs Administrative Policies, and BI, LD,<br />
and RI policies are found in the <strong>Baystate</strong> Medical Practices Policies.<br />
While these pages provide a list <strong>of</strong> key policies in support <strong>of</strong> our <strong>Code</strong><br />
<strong>of</strong> <strong>Conduct</strong>, all policies exist to guide our conduct and activities.<br />
GO 04<br />
GO 06<br />
GO 07<br />
GO 10<br />
GO 11<br />
BC 1.123<br />
BC 1.137<br />
BC 1.150<br />
BC 3.600<br />
BC 4.200<br />
BC 5.110<br />
BC 5.200<br />
BC 5.600<br />
BC 6.840<br />
BC 6.920<br />
Conflict <strong>of</strong> Interest Policy<br />
<strong>Corporate</strong> <strong>Compliance</strong> Policy<br />
Credit and Collection Policy<br />
Intellectual Property Policy<br />
Organizational Values and Ethics Policy<br />
Business Gifts and Business Entertainment<br />
Unrestricted Gifts Policy<br />
Statement <strong>of</strong> Organizational Ethics<br />
Hospital Advertising and Promotions Policy<br />
Record Retention Policy<br />
<strong>Baystate</strong> <strong>Health</strong> Vendor Policy<br />
Tax Exempt Bonds Post Issue <strong>Compliance</strong><br />
Charge Reversal, Adjustments and No Charge<br />
Policy<br />
Password and User ID Policy<br />
Disposal <strong>of</strong> Confidential Hardcopy (paper)<br />
Information<br />
15
BC 7.010<br />
CO 1.655<br />
CO 10.200<br />
HR 100<br />
HR 206<br />
HR 211<br />
HR 212<br />
HR 700<br />
HR 802<br />
HR 803<br />
HR 804<br />
HR 807<br />
HR 808<br />
HR 810<br />
HR 814<br />
HR 1001<br />
AA 2.01<br />
AA 2.02<br />
AA 2.04<br />
BI 001<br />
LD 014<br />
RI 014<br />
Privacy Policy (Minimum Necessary)<br />
Examination, Treatment, and Transfer <strong>of</strong><br />
Patients to Other Facilities<br />
Patient’s Rights and Responsibilities<br />
Employee Relations Philosophy<br />
Hiring <strong>of</strong> Relatives/Nepotism or Persons in<br />
the Same Household<br />
License Verification<br />
Non-Employment <strong>of</strong> Excluded Individuals<br />
Competence<br />
Confidentiality<br />
Conflict <strong>of</strong> Interest<br />
Corrective Action<br />
Drug-Free Work Place<br />
Duty to Report Criminal, illegal, or<br />
Unethical <strong>Conduct</strong><br />
Harassment in the Work Place<br />
Non-Retaliation and Non-Retribution for<br />
Reporting Actual or Potential Wrong-Doing<br />
Business gift and Business Entertainment<br />
Noncompliance<br />
Conflicts <strong>of</strong> interest in Research<br />
Scientific Misconduct<br />
Credit and Collection Policy<br />
Statement <strong>of</strong> Organizational Ethics<br />
Confidentiality Policy<br />
16
<strong>Baystate</strong> <strong>Health</strong> is a leading not-for-pr<strong>of</strong>it<br />
health system with the charitable mission <strong>of</strong><br />
improving the health <strong>of</strong> the people in our communities<br />
every day, with quality and compassion.<br />
No matter what your role is at <strong>Baystate</strong> <strong>Health</strong>,<br />
you are important in delivering the<br />
best possible care to our patients.
Through the depth <strong>of</strong> our compassion,<br />
through the breadth <strong>of</strong> our diversity,<br />
by raising the standard for excellence,<br />
we unite our talents to deliver<br />
a higher state <strong>of</strong> caring.<br />
Together, we deliver a higher state <strong>of</strong> caring.