In compliance with Choctaw Memorial Hospital’s Compliance Plan and with the U.S. Department of Health and Human Service’s, Office of Inspector General’s Plan, all employees must read and attest to this Code of Conduct. After reading, please complete the Code of Conduct Attestation Form.
Choctaw Memorial Hospital is committed to the highest standards of business ethics and integrity. Therefore, we have adopted the following Code of Conduct to provide you with a guide to proper workplace behavior. Included are guidelines for ethical behavior and business conduct that are consistent with the law and the Hospital’s vision, mission, and core values. We are all responsible for making sure our actions adhere to the laws governing health care as well as our own high standards.
This Code of Conduct book outlines our pledges to the many people that we serve and who surround us. It establishes the standards that we expect each one of our colleagues to perform. Compliance with the Code of Conduct and all of its provisions, along with our “Heart”, is a perfect way for us to maintain a warm caring team and accomplish our mission.
A Pledge to Our Patients
Quality of Care
Our ultimate goal is to provide “Professional Care”. We will treat all patients with respect, dignity and provide care that is both necessary and appropriate. We strive to deliver high quality care by utilizing technological advancements, techniques proven to ensure patient safety and an overall culture of service. As a general principle, we promote excellence from all of our employees, medical staff members and business associates. The commitment to quality of care is a responsibility of every employee. We have an obligation to report any inappropriate care or treatment of patients, and question any possible activities that may appear to be in violation of our values by using the available channels of communication.
We will treat patients in a manner that preserves their dignity, autonomy, self-esteem, civil rights and involvement in their own care. We do not discriminate among patients based on race, ethnicity, religion, gender, sexual orientation, national origin, age, disability or veteran status. Patients will receive a statement of patient rights, which notifies them of, but not limited to, their right to make decisions regarding medical care, the right to refuse or accept treatment and the right to informed decision-making. We do not conduct medical procedures unless doing so is in accordance with good medical practices. In the promotion and protection of each patient’s rights, each patient and his or her representatives are provided with appropriate confidentiality, privacy, security, advocacy and protective services, opportunity for resolution of complaints, and pastoral or spiritual care.
Confidentiality of Patient Information
We understand that the information we obtain from a patient is sensitive and personal information. We strive to maintain the confidentiality of patients in accordance with applicable legal and ethical standards, including the Health Insurance Portability and Accountability Act, known as “HIPAA.” Every patient will be provided with a Notice of Privacy Practices. This Notice establishes the patient’s rights related to his or her health information maintained by the Hospital. We will refrain from accessing or revealing any personal, confidential or protected health information concerning patients unless authorized to do so, as required to perform treatment, payment or healthcare operations, or as required by law. We will release information to business associates only in accordance with legal standards and internal policies, which typically requires express written consent of the patient. We have an obligation to actively protect and safeguard confidential and sensitive information in a manner designed to prevent unauthorized disclosure of information. If an unauthorized disclosure occurs, we will report this issue to your Director or Manager, the Privacy Officer or the Compliance Officer immediately to remedy the disclosure. The Compliance Officer will then begin the process of complying with HITECH rules and regulations.
We follow the Emergency Medical Treatment and Labor Act, (commonly called “EMTALA”), which requires an emergency medical screening examination and necessary stabilization of all patients, prior to obtaining financial information and regardless of the ability to pay. We do not admit, discharge, or transfer patients with emergency medical conditions based on their ability or inability to pay or any other discriminatory factor. Patients are only transferred in compliance with Federal and state EMTALA statutory and regulatory provisions. Any intentional failure or refusal to comply with the regulations will result in disciplinary action. Should you feel an EMTALA violation has been committed please contact your Director or Manager or the Compliance Officer.
There are some instances when a health care worker must break the "confidential' relationship with the patient/resident because of reporting laws. When the welfare or safety of one or more persons is jeopardized or when required by the government to provide such information, extreme caution must be taken to assure the proper procedures are followed and the proper authorities notified. Your department manager or supervisor should be notified of any suspected reportable incident. Communicable disease concerns should be addressed through the Infection Control Nurse.
Types of cases that must be reported for individual safety purposes are:
Suspected abuse of the mentally and/or physically incapacitated
Suspected child abuse
Deaths of an uncertain nature
Reportable communicable diseases as required by the OK Department of
Environment, Health, and Natural Resources
Work related injuries deemed reportable by OSHA
Pledge to Our Business Associates
The modern healthcare system is comprised of many components that work in collaboration to provide the highest quality benefit to those we serve. Each party in the process serves important roles and responsibilities. As we select business associates to partner with for necessary services and materials, we will be very careful to ensure that they continually embrace and demonstrate high standards of ethical business behavior. Our business associates, whether they are members of our great medical staff or third parties, are encouraged to work in a respectful and supportive manner. We appreciate this caring attitude and we will expect it to continue.
As the focus on healthcare increases in importance nationally, it is imperative that we compete fairly in the marketplace. We will comply with applicable antitrust and similar laws that encourage fair competition and prevent monopolies. The antitrust laws were founded on the belief that the public interest is best served by vigorous competition that is free from collusive agreements among competitors on both price and service terms. Examples of conduct prohibited by the law include, but are not limited to: agreement to fix prices; bid rigging; collusion (including price sharing) with competitors; boycotts; and bribery. We do not illegally obtain or use proprietary or confidential information concerning competitors, nor do we use deceptive means to gain such information. When confronted with business decisions involving risk of anti-trust violations, we will seek advice from Legal Services or the Compliance Officer to ensure fair competition.
Marketing and Advertising
Consistent with laws and regulations that govern such activities, we may use marketing and advertising activities to educate the public, provide information to the community, increase awareness of our services, and to recruit business associates. We present only truthful, fully informative and non-deceptive information in these materials and announcements.
Gifts and Entertainment
Business transactions, whether offered, provided or received from vendors, contractors, other healthcare providers, physicians and other third parties, shall be conducted free from offers or solicitations of gifts and favors or other improper inducements in exchange for influence or assistance in a transaction.
Receiving Gifts and Entertainment
We do not solicit tips, personal gratuities or gifts from patients, their family members, or any other business associate. We may not accept cash or its equivalents (checks, gift certificates, stocks, coupons, etc.). We will not accept gifts, favors, services, entertainment or other items of value to the extent that the Hospital’s decision-making or actions might be influenced. Knowledge of any such conduct must be reported immediately to Administration or the Compliance Officer. If a gift is received that exceeds our guidelines, the person who received the gift will return it with an explanatory note and report the action to Administration or Compliance Officer. Examples of gifts that would be inappropriate include, but are not limited to, the following: tickets to sporting events with a face value over $50.00; multiple gifts from a single giver that create more than a nominal aggregate total; and gifts to an employee’s family members because of the employee’s position.
We may accept non-monetary gifts of nominal value, (defined as a value up to $50.00), upon a Director or Manager’s approval (e.g., perishable items, free samples, training sessions, coffee mugs, etc.). We may accept an invitation to attend a vendor-sponsored meal, workshop, seminar or training session, which is geographically close to the Hospital. Attendance at out-of-town workshops, seminars and training sessions is permitted only with Director or Manager and Administrative approval. If there is any concern whether a gift or invitation should be accepted, consult your Director or Manager, Administration, or Compliance Officer.
Providing Gifts and Entertainment
Federal and state laws and regulations, including the Stark Law and the Anti-Kickback Law, govern the relationship between the Hospital and its referral sources. Referral sources include physicians or other entities that are in a position to refer patients to our facility. Any arrangement with a referral source must be structured to ensure compliance with the legal requirements, our policies and procedures, and with any applicable guidelines. Most arrangements must be in writing and approved by the proper approval process. We do not pay or offer items or services of value in order to induce referrals or as a reward for referrals. Any entertainment, gifts or tokens of appreciation involving a referral source must be undertaken in accordance with Federal laws, regulations, and rules regarding these practices.
We may provide gifts, entertainment and meals of nominal value to non-referral sources, such as Hospital customers, current or prospective business associates and other persons, when such activities have a legitimate business purpose and are reasonable and consistent with applicable laws. It is imperative to avoid the appearance of impropriety when giving gifts to individuals who have a relationship with the facility. An effort will be made to ensure that any gift we extend meets the business conduct standards of the recipient’s organization. If there is any concern whether a gift, entertainment or meal should be provided, consult the Compliance Officer, Administration or Legal Services.
A Pledge to Our Community
Our Mission Statement declares: “Choctaw Memorial Hospital is here to improve the physical, emotional and spiritual well-being of those we serve by providing quality, compassionate healthcare”. We are committed to this endeavor and work to understand the particular needs of our community. We serve our community by providing quality cost-effective healthcare and recognize our specific responsibility to help those in need. We encourage volunteerism for charitable activities, but do not pressure others to do so. We sponsor activities that benefit the community and aim to fulfill our ultimate purpose.
As an Oklahoma municipal hospital authority, Choctaw Memorial Hospital will not provide funds or resources directly to an individual’s political campaign, political party or other organization, which intends to use the funds or resources primarily for political campaign objectives. This includes the use of the Hospital’s facilities as an open forum for making political speeches. On limited occasions, the Hospital may engage in public policy debates where it has special expertise that can inform the public policy formation process. During these events, the Hospital may provide relevant factual information about the impact of decisions on the health care sector. An employee may personally participate in and contribute to political organizations or campaigns, but they must do so as an individual, not as representatives of the Hospital and they must use their own funds and time. Use of the facility’s resources, such as telephone, fax, copiers or email, is not appropriate for personal engagement in political activities. Any activity that relates to political campaigns, such as ticket sales for political fund-raising or advertising for political candidates, is not allowed on the Hospital’s campus.
We will strive to comply with the laws and regulations relating to our environment. We utilize all resources appropriately and efficiently and dispose of all waste in accordance with applicable law. The Hospital will assist appropriate authorities to remedy any environmental contamination for which the Hospital may be held responsible.
A Pledge to Our Fellow Employees
Diversity and Equal Employment Opportunity
We ensure that all employment decisions are made on a non-discriminating basis, and without regard to an employee’s or applicant’s race, ethnicity, religion, gender, national origin, veteran status, age, sexual orientation or disability. We will make reasonable accommodations to the known physical and mental limitations of qualified individuals with disabilities. Employee information is confidential and will only be accessed as part of our job and when necessary to complete our work.
Positive Work Environment
We strive to create an environment that supports working in teams and respecting other people, regardless of their position in the organization. We will make ourselves accountable to one another for the manner in which we treat one another and for the manner in which people around us are treated. Undesirable and disruptive behaviors that intimidate coworkers, patients and/or visitors, decrease morale or increase staff turnover may threaten the safety and quality of services provided and will not be tolerated. These undesirable and disruptive behaviors may be verbal, non-verbal or written and may include, but not be limited to, the following:
1. rude, abusive language - in person, on the phone or via email;
2. making fun of or mocking someone - alone or around others;
3. public embarrassment;
4. threatening mannerisms/intimidating body language - clenched fists, a raised voice, obscene gestures, snapping fingers, pointing, staring;
5. physical abuse;
6. blaming others for your actions, reactions, problems; and
7. gossiping, spreading rumors.
No form of harassment or discrimination on the basis of sex, race, color, disability, age, religion/ethnic origin, in addition to sexual harassment or any other protected classification prohibited by law will be permitted. Each allegation of harassment or discrimination will be promptly investigated in accordance with applicable Human Resources Department policies.
Health and Safety
We promote a safe and healthy workplace by complying with the governmental health and safety rules and regulations. We follow policies and procedures when handling hazardous materials or dangerous instruments and are informed of their properties. When a situation arises that may cause an injury or accident, we immediately report it to our Director or Manager, Administration or the Safety Officer.
We are committed to a safe drug-free workplace. Reporting to work under the influence of any illegal drug or alcohol; having an illegal drug in your system; or using, possessing, or selling illegal drugs while on work time or property may result in termination. Prescription and controlled substances must be handled properly and by authorized individuals to minimize risks. Any appearance of mental impairment or drug diversion will be reported to Management, Compliance or Human Resources for follow-up actions.
We endeavor to provide the highest quality care and service to our patrons. We maintain all professional credentials, licenses, and certifications that are necessary to perform our jobs. At all times, we comply with Federal and state requirements applicable to our respective disciplines. We do not knowingly contract with, employee, or bill for services rendered by an individual or entity that is: excluded or ineligible to participate in Federal healthcare programs; suspended or debarred from Federal government contracts; or has been convicted of a criminal offense related to the provision of healthcare items or services and has not been reinstated in a Federal healthcare program after a period of exclusion, suspension, debarment, or ineligibility. A thorough search of the Department of Health and Human Services’ Office of Inspector General and the U.S General Services Administration’s exclusion list is conducted to ensure compliance with this standard. If we become aware of an ineligibility action, we will report the issue to the Compliance Officer.
A Pledge to Be Professionally Responsible
We strive to make prudent effective use of the Hospital’s resources including time, materials, supplies, equipment, capital, space and information. As a general rule, the personal use of Hospital resources is prohibited without prior Management approval. Everyone is responsible to ensure that we do not improperly and unreasonably use documents, telephones, computers, copiers, equipment, or Hospital licensed computer programs (e.g., access to inappropriate websites) for personal purposes. We do not use supplies or equipment for personal purposes or remove them from the premises, even just to “borrow” them. Occasional use of facilities and telephones, where the cost is insignificant, is permissible, but limited. To ensure compliance with our duties regarding the use of Hospital assets, periodic audits will be conducted, sometimes without notice, and may result in disciplinary action, up to and including termination.
We strive to protect the organization’s assets from loss, damage, carelessness, misuse and theft. Our computers and sensitive documents are password protected and/or protected behind physical barriers. We do not discuss sensitive, confidential matters over cellular phones or in public areas. We screen files and downloads to ensure that they are free from viruses and hackers’ intentions. We secure assets when they are not in use to prevent any misappropriation.
Travel and entertainment expenses should be consistent with the employee’s job responsibilities and the Hospital’s needs and resources. We may not have an interest in or speculate in products or real estate. We may not divulge the Hospital’s confidential information such as financial data, payer information, computer programs, and patient information for our own personal or business purposes.
Accuracy, Retention and Disposal of Documents and Records
We are responsible for the accuracy and keep complete, clear documents and records. We maintain and comply with internal controls, regulatory and legal requirements, and our policies and procedures. All financial reports, accounting records, research reports, expense accounts, time-sheets and other documents must accurately and clearly represent the facts or the true nature of the transaction. According to Choctaw Memorial Hospital Policies we will maintain for inspection all documents and records relating to reimbursement from Federal health programs or compliance with the policies for a period of six years or longer if required by law. All other information will be retained according to the law and our records retention policy. Information should not be destroyed in an effort to hide the information from governmental authorities.
Coding and Billing for Services
We will prepare and submit accurate claims for payment from government payers, commercial insurance payers and patients. We will comply with all Federal and state laws and regulations concerning proper billing and reimbursement of medical claims. We make every attempt to present claims for payment or approval that are not false, fictitious, exaggerated or fraudulent. We make every effort to ensure that entries in patient records are clear, complete and accurately reflect the item or service that was provided to the patient. No one may alter or falsify information on any record or document. We strive to ensure that our records do not include guesswork, exaggerations or miscoding. If we change a record, per physician documentation, we note the change as required by our internal policies. If we discover a claim, bill or code that contains a possible error, we have an obligation to investigate the potential error and if possible, correct the error prior to the bill or claim being submitted. If the issue cannot be resolved, we will report the issue to the proper authority, including Management, Administration or Compliance.
Financial Reporting and Records
All financial information must reflect actual transactions and conform too generally- accepted accounting principles (“GAAP”). We do not hide expenditures, funds, assets or liabilities. All funds and assets must be properly recorded in the books and records of the Hospital. If we ever become aware of or suspect any potential improprieties regarding accounting, internal controls, or auditing, we will report it immediately.
Fraud and Abuse
We must refrain from conduct that may violate the fraud and abuse laws. Abuse is defined as payment for items or services when there is no legal entitlement to that payment and the Hospital, physician or supplier has not knowingly and/or intentionally misrepresented facts to obtain the payment. Fraud is defined as intentional deception or misrepresentation, which an individual or entity makes, knowing to be false and the deception could result in some, unauthorized benefit.
The Federal False Claims law protects Government programs including Medicare, Medicaid and Tri-Care from fraud and abuse. These laws prohibit: 1) direct, indirect or disguised payments in exchange for referral of patients; 2) submission of false, fraudulent or misleading claims to any government entity or third party payer, including claims for services not rendered or claims which do not otherwise comply with applicable program or contractual requirements; and 3) making false representations to any person or entity in order to gain or retain participation in a program or to obtain payment for any service. The Federal Deficit Reduction Act of 2005 (“DRA”) provides states with financial incentives for enacting State False Claims laws to protect the individual states’ Medicaid Program from fraud and abuse. Provisions in the DRA specifically provide protection from retaliation to employees who initiate lawful actions under the False Claims and DRA laws. If any possible fraud or abuse situations arise, we will report the issue to Management, Administration or Compliance.
The term “confidential information” refers to proprietary information about the Hospital’s strategies and operations as well as patient information and third party information. Improper use or disclosure of confidential information could violate legal and ethical obligations. We may use confidential information only as required to perform our job duties and shall not share this information with others unless they have a legitimate need to know the information. We must protect the organization’s confidential information, even if we leave the organization. We shall not use confidential business information obtained from competitors, including customer lists, price lists, contracts or other information in violation of a covenant not to compete, prior employment agreements, or in any other manner likely to provide an unfair advantage to the Hospital. Salary, benefits and other personal information relating to employees shall be treated as confidential.
We will not disclose non-public material information about the organization or any other company or buy, sell, transfer, trade or gift based upon information that has not been publicly disclosed. In general, it is illegal for any person, either personally or on behalf of others, to buy or sell securities, bonds or investments while in possession of material non-public information, or to communicate material non-public information to another person who trades in the bonds on the basis of the information or in turn passes the information on to someone who trades. Some examples of insider information are: financial results, earnings projections, changes in senior management, information about acquisitions, etc. Within the organization, we will discuss this information on a strict “need to know” basis only with other associates who require this information to perform their jobs.
Conflict of Interest
A conflict of interest is a situation when outside activities, personal financial interests, or other personal interests hinder, distract, influence or appear to influence the ability to make objective decisions in the course of employment. We have a duty of loyalty to the Hospital and must avoid conflicts of interest. We will act to protect the Hospital and its interests by acting in a way that positively represents our endeavors. When a conflict of interest or the appearance of a conflict of interest develops, we will disclose the conflict to Management immediately. Written approval by Management or Administration must be acquired before pursuing the activity or obtaining or retaining the interest. Types of activities that might cause conflicts of interest include, but are not limited to: ownership in or employment by an outside concern that does business with or competes with the Hospital; conduct of any business, not on behalf of the Hospital, with any vendor, supplier, contractor or agency or any of their officers or employees; disclosure or use of confidential, special or inside information of or about the Hospital, particularly for personal profit or advantage.
A Pledge to be Honorable in All That We Do
Choctaw Memorial Hospital is committed to the highest standards of business ethics and integrity and to providing services in compliance with all state and federal laws governing our operations. We will accurately and honestly represent the Hospital and will not engage in any activity or scheme intended to defraud anyone of money, property or honest services. We shall not make false or misleading statements to any patient, person or entity doing business with the Hospital about other patients, persons, entities doing business or competing with the Hospital, or about products or services of the Hospital or its competitors.
We all have the obligation to follow the code of conduct, but the leaders of the Hospital are held to a higher standard and have a special responsibility to set the right tone. We must not sacrifice ethical and compliant behavior for business objectives. We expect everyone with supervisory responsibility to exercise authority in a manner that is kind, sensitive, thoughtful, and respectful. We expect every supervisor to create an environment where all staff feels free to raise concerns and propose ideas, without any fear of retaliation. This includes situations where employees give criticism or raise an uncomfortable question. Management must remember that openness is essential to maintaining a healthy work environment.
Retaliation is considered a serious violation and will not be tolerated. When an individual raises a good faith concern, calls the Compliance Hotline or fully cooperates with an investigation, retaliation against that person is strictly prohibited. Appropriate steps will be taken to protect those who report retaliation. Allegations of retaliation will be promptly investigated and if supported, will result in disciplinary action, up to and including, termination of employment of the individual responsible for the retaliation.
The Compliance Program is charged with the responsibility of reviewing our compliance policies and acting to resolve/investigate specific compliance situations that may arise. The Hospital’s Compliance Program is led by the Compliance Officer and is supported by the Compliance Committee. Even though these individuals operate the Compliance Program, each one of us is part of the Compliance Program and has individual duties and responsibilities. The key elements of the Program include: setting written standards (the Code of Conduct and policies and procedures); conducting education and training to further the knowledge base of the organization; monitoring, auditing, investigating and resolution of compliance issues; providing a mechanism for reporting potential exceptions; ensuring the eligibility of employees and business associates; and maintaining an organizational structure that supports the furtherance of the Program.
Reporting Compliance Issues
When we become aware of an issue that does appears inconsistent with the ethics and values of the Hospital, we are encouraged to call the Compliance Hotline. Calls to the Compliance Hotline allow individuals to confidentially disclose information to someone who is not part of the reporting structure of the Hospital. Global Compliance answers the Hotline and completes the initial complaint. Any call to the Compliance Hotline has the option to remain anonymous. However, sometimes the only way for an investigation to proceed is if the caller provides details specific to the incident, such as department, location and in limited circumstances, the caller’s name. When requested, strict confidentiality of the caller’s identity will be maintained to the extent allowed by law. Access to the Compliance Hotline is available 24 hours a day, 7 days a week by calling the following numbers:
Toll Free Number: 1-800-273-8452
When the Compliance Hotline is not utilized, but you wish to contact the Compliance Officer, please contact her as follows:
Tawnya Gee, Compliance Officer
Choctaw Memorial Hospital
1405 E Kirk
Hugo, OK 74743
Via Telephone: 1-580-317-9530
Via FAX: 1-580-317-9604
Any time we do not understand something or have a concern, we need to question others for accurate answers. Often the best person to contact when questions arise concerning appropriate actions is your department Director or Manager. If the Director or Manager is unavailable or is inappropriate to question, then turn to the other resources of the Hospital, such as Administration, the Compliance Officer, the Compliance Hotline, members of the Compliance Committee or Human Resources. The important thing is not so much where you obtain help; the important thing is to seek help.
As misconduct or perceived misconduct is observed, it is our responsibility to report the issues to the proper members of the Hospital. Any violations of laws, regulations or our policies and procedures will be disciplined in the proper manner with appropriate authorities. Discipline may also result for those who knew about the issue, but failed to report it. The Hospital will use increasing levels of discipline, up to termination, depending on the severity of the violation. All reports of potential violations must be made in good faith. It is unacceptable to falsify facts or spread rumors to get someone else in trouble. This is a form of retaliation and will not be tolerated.
The Compliance Officer, the Compliance Committee, or proper designee, shall investigate all reported allegations. As part of the investigation, we will ensure that each situation shall be given a good faith inquiry into the allegations set forth and that all of the information necessary to determine the scope of incident has been determined. For alleged improper practices, we will adopt corrective actions to prevent further misconduct. As necessary, the Compliance Officer shall confer with legal counsel and administration to determine if credible evidence of misconduct exists. On-going and specific-to-risk evaluations will be conducted on a regular and/or “as needed” basis in order to determine that corrective actions are effective and to uncover potential areas of non-compliance.
Reviewed and revised: May 3, 2010