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ETHICAL CONDUCT GUIDELINES

INSTITUTIONAL MANUAL OF

ETHICAL CONDUCT GUIDELINES

INSTITUTIONAL MANUAL OF

# 7 Edition, October 2019

There is a growing concern in relation to ethics in general and

in health care, which justifies the existence of the institutional

manual of ethical conduct guidelines.

The ethical work practiced in health care must take into account the

multiple types of relationship between the involved parties and the

service providers, their diverse interests, the dynamics and the economic

values related to service and the rate of change, which are a part of the

current scenario.

In addition to addressing the challenges of sustainability, competition

and the expectations of society in relation to how social responsibility

is carried out, health care institutions are responsible for offering an

operating model in which the various aspects of its activities, such as

the purchasing process, payment models, cost reduction initiatives,

management of access to health care, protection of patient privacy

and security, management of relationships with physicians, the industry,

government and health insurance operators, among others, meet the

highest ethical standards.

A Manual of Ethical Conduct Guidelines, drafted with the participation

of the institution’s leaders, reaffirms the commitment to appropriate

attitudes in the conduction of activities, especially its relation to people.

This position is built upon the need to protect the reputation built

over the past 60 years, which must always be recognized and also

systematically reinforced by management that is attentive and knows

how to respond to the ethical dilemmas prevalent in the sector.

Dr. Sidney KlajnerPresident Sociedade BeneficenteIsraelita Brasileira Albert Einstein

Dr. Claudio Luiz LottenbergAdvisory Board ChairmanSociedade Beneficente Israelita Brasileira Albert Einstein

MESSAGE FROM SENIOR MANAGEMENT

1. GOAL ....................................................................................................8

2. JEWISH PRECEPTS ..................................................................................8

3. MISSION, VISION AND VALUES ..............................................................9

4. WORK PLACE ENVIRONMENT ...............................................................10

5. RELATIONSHIP WITH SOCIETY AND THE ENVIRONMENT ......................11

6. ASSETS, RESOURCES AND INSTITUTIONAL INFORMATION ....................12

Use and Protection of Assets ................................................................................. 12

Confidential Information –

Privacy and Information Security ......................................................................... 12

Internal Controls and Accounting Procedures .............................................. 13

Communication with Stakeholders and

Statements to the Press .............................................................................................. 14

Internet, E-Mail and Social Media ........................................................................... 14

Trademark and Intellectual Property Protection .......................................... 15

7. RELATIONSHIP WITH PARTNERS AND THIRD PARTIES ...........................16

Conflict of Interest ........................................................................................................ 16

Fraud and Corruption ................................................................................................. 18

Gifts and Gratuities ....................................................................................................... 19

Donations and Sponsorships .................................................................................. 19

TABLE OF CONTENTS

Relationship with Political Parties and Candidates

for Public Office .............................................................................................................. 19

Relationships with Manufacturers and Distributors of

Medical Supplies, Equipment and Medications .............................................20

8. SUPPLIERS AND SERVICE PROVIDERS .................................................... 21

Integrity in the Procurement Processes ............................................................. 21

Competition .......................................................................................................................22

Billing .....................................................................................................................................22

9. RESEARCH ........................................................................................... 22

10. EDUCATION AND KNOWLEDGE MANAGEMENT .................................. 24

Relationship between Teaching Staff and Students ................................... 26

11. MANAGEMENT OF THE ETHICS MANUAL ............................................ 27

12. REPORTING VIOLATIONS .................................................................... 28

13. RESPONSIBILITIES ............................................................................... 29

2. JEWISH PRECEPTS

1. GOAL

The institution follows universal ethical and moral principles,

derived from Judaism.

Means health, healing or the return to health changed by disease.

REFUAH

Means education. Carries within itself the concept of human enhancement by means of knowledge and study.

CHINUCH

Means human solidarity. Covers both the ideas of philanthropy and social justice, practiced as guiding principles for life.

TZEDAKAH

Means the duty to practice good deeds.

MITZVAH

Present the institutional ethical conduct guidelines of Sociedade

Beneficente Israelita Brasileira Albert Einstein.

ETHICAL CONDUCT GUIDELINESINSTITUTIONAL MANUAL OF 8

3. MISSION, VISION AND VALUES

To provide excellent quality in health care, in the generation of knowledge and in social responsibility, as a way to highlight the contribution of the Jewish community to Brazilian society.

MISSIONTo be a leader and innovator in medical and hospital care, a reference in knowledge management, recognized for our commitment to social responsibility.

VISION

Honesty: deal with reality as it is, and honor our commitments.

Truth: match what is said to the reality of what is.

Integrity: consistency between values and actions.

Diligence: effort and care in all the tasks that are performed.

Justice: no discrimination against people in any form, whether due to race or ethnicity, age, gender, religion, philosophy, physical or intellectual ability, socio-economic background, sexual orientation, physical or mental health, genetic attributes, behavior, attractiveness, place of birth, cultural values or political position.

Altruism: concern for the well being of others, without expecting reciprocity.

Autonomy: ability to make choices and carry out one’s own actions.

Professionalism: if it’s worth being done, it should be done well.

Team work: cooperation to achieve goals and objectives

VALUES

The mission, vision and organizational values of the institution are its

foundation and serve as guiding principles for the conduct of all the

professionals who work representing it. The respect for the institutional

values and the austerity in the performance of their duties underlies

and strengthens the commitment to ethics. More than mere ideals, the

following principles define the way one must act and care for patients,

employees and partners:


The Institution seeks to be a safe working environment

and takes steps to protect its employees and professionals,

to prevent any risks associated with the work. It is expected

that all employees and professionals report any concern

and/or violations of the safety rules.

All employees, staff and students must be treated with

respect and dignity and have the opportunity for personal

and professional growth.

No form of forced, child or compulsory labor, discrimination,

threat, coercion, abuse or harassment will be tolerated in

the work environment.

Laws that guarantee the freedom of association, collective

agreements, working hours, privacy of employees and

professionals and compensation must be respected.

Employees, professionals and students may take part in the

democratic political process, as long as it is done outside

of working and study hours. It is, however, forbidden to

campaign or solicit contributions for political ends in the

institution’s facilities, as well as use its assets or resources

for these purposes.

4. WORK PLACE ENVIRONMENT


5. RELATIONSHIP WITH SOCIETY AND THE ENVIRONMENT

The Institution is committed to sustainable development and

adopts the following behaviors:

• Act in a preventive manner in relation to potential risks to

the environment and to the health and safety of people,

avoiding waste and adverse events.

• Give preference to the use and consumption of products

and services that are socially responsible, taking into

account the entire life cycle of the products and the working

conditions of the supply chain.

• Reduce consumption, reuse and recycle materials and

products and, when this is not possible, properly dispose of

the waste.

• Promote social inclusion, valuing diversity and encouraging

education for human and community development.


.6. ASSETS, RESOURCES AND INSTITUTIONAL INFORMATION

USE AND PROTECTION OF ASSETSThe assets of the Institution – financial and physical – must be

used exclusively for its purposes. The assets are entrusted to

the employees and professionals, who are responsible for its

safeguarding and proper use in the execution of their tasks.

Safeguarding involves protecting against waste, loss, damage,

misuse, theft or abuse.

CONFIDENTIAL INFORMATION – PRIVACY AND INFORMATION SECURITY

Confidential information that only a specific group of people can

have access to, due to the need of maintaining confidentiality for

the protection of strategic information about the institution and

whose disclosure is likely to frustrate its purposes or jeopardize

its safety and/or image. The following can be considered as

confidential information, among others, any information relating

to patients, students, suppliers, partners, business plans, data or

specifications, technical documentation, practices and procedures,

contracts, presentations, know-how, lesson plans and information

about markets, competitive analysis, databases, applications, and

inventions. The breach of confidentiality or misuse of confidential

information is unacceptable. The use and/or disclosure of

information about the activities and affairs of the Institution

in favor of one’s self or a third-party is forbidden. Based on

the general data protection law, law # 13.709/18, the personal

information of patients, employees and students must also be

protected, and the use of such information is forbidden without

previous consent.


Access passwords are tools for the protection of information

and, therefore, their use should always be personal and non-

transferable. The sharing of passwords to access information

systems is considered a violation of the guidelines of this Manual.

INTERNAL CONTROLS AND ACCOUNTING PROCEDURESThe Institution maintains appropriate internal controls to evaluate

and manage the corporate risks that may impact its activities,

employees, professionals and its reputation. The records of

activities, financial transactions and accounting will be carried out

in an accurate, complete and true manner, and the related controls

should ensure the timely preparation and reliability of reports and

financial statements. The Institution and the employees shall co-

operate, without restriction, with internal and external audits.

The destruction of records or documents related to employees,

occupational health and safety, the environment, taxes, contracts,

finance, social responsibility projects and patients, among others,

can only be carried out after the required legal term has expired.

No payment shall be approved or made with the intention or

knowledge that, in whole or in part, it will be used for any purpose

that is not described in the document justifying the payment.


COMMUNICATION WITH STAKEHOLDERS AND STATEMENTS TO THE PRESSExclusively authorized representatives will make statements to the

press, with prior approval of the Presidency or General Management

and with the involvement of the Press Office.

The Institution maintains an open and frequent dialogue with its

stakeholders and commits to convey the necessary information

with transparency and truthfulness.

Information about the products and services provided must be true,

complete, updated and, where applicable and necessary, supported

by scientific evidence, promoting an ethical and reliable dialogue

with its stakeholders.

INTERNET, E-MAIL AND SOCIAL MEDIA

With the objective of setting guidelines for the responsible and

ethical use of the internet, e-mail and social media, all employees and

professionals that have a relationship with the Institution should follow

the following guidelines:

• Do not express opinions that would lead to an understanding that

they are the Institution’s official position.

• Do not disclose or share images, videos, or internal information

about the Institution that has not been disclosed through the official

channels of the Institution.

• Do not expose information about patients, users, partners, students

and suppliers.

Computers and computer servers, including sent and received emails,

are property of the Institution, and their contents are not considered

private, except when required by specific legislation.


TRADEMARK AND INTELLECTUAL PROPERTY PROTECTIONThe Institution’s trademark and the knowledge produced internally in

the development of its activities or in partnership are institutional assets

and should always be protected by all those to whom this Manual applies.

The intellectual property of the Institution is related to its right to

protect the ideas and creations developed internally or in partnership

and include its trademark, patents, copyright, software registration,

etc. The Institution must have its trademark and intellectual property

protected from misuse, diversion or use for personal benefit. The same

care and respect should be shown in with respect to the intellectual

property of third parties.

It is strictly forbidden for students and teaching staff to falsify information

contained in publications, use any data, information and knowledge

without making reference to the author or without obtaining previous

authorization to do so, as well present any idea, discovery or illustrations

given in class as being original.


7. RELATIONSHIP WITH PARTNERS AND THIRD PARTIES

CONFLICT OF INTEREST

A conflict of interest is any situation in which an employee or

professional, spouse, child or parents have professional or personal

interests that will hinder in any way an employee’s impartial

fulfillment of their obligations to the Institution, even if no unethical

or inappropriate act is caused by the situation.

Although it is not possible to list all situations or relationships that

may pose a potential conflict of interest, some examples are:

• Use the premises, equipment or any other resources or rights

belonging to the Institution to benefit themselves or third parties.

• Use of privileged information, obtained as a part of their professional

role in the Institution, for personal or indirect gain.

• Use of the time that, according to the contract, should be dedicated

to the Institution for private purposes, even though it may be scientific

or academic.

• Establish or maintain any formal or informal partnership relationship

with suppliers or competitors.

• Hire or influence the hiring of goods or services from businesses

owned by or in which the people described above work. To influence

the hiring or hiring an employee that is a family member.


• A relationship of subordination between the persons described above

is not allowed. When there are family ties between employees that

are part of the same team, without a subordination relationship, the

fact must be declared to HR and to the direct manager, so they can

recommend preventive actions.

• Carry out teaching and student evaluation activities with the

interference of personal or ideological interests.

Whenever there is no clarity or certainty as to the existence or not

of a Conflict of Interest, the issue should be declared for analysis by

the Compliance area and the direct manager.

All the Institution’s employees and professionals must annually fill

out the Annual Declaration of Potential Conflict of Interests, in which

they should declare any connection to companies, in the health care

field or another, in the public sector or the award of educational

scholarships, among others. This declaration is for informative

purposes and the responses will be reviewed by the Compliance

area, in conjunction with the manager of the employee/professional.

Actions for mitigation of possible conflicts may be taken.


FRAUD AND CORRUPTIONAny acts that harm the public, national or foreign administration

or any other entity or individual with which the Institution has any

connection will not be tolerated.

Harmful acts are any participation in, encouragement or

acceptance of any act involving fraud, corruption, bribery or tax

evasion. The Institution, its employees and professionals will not

promise, offer or give, directly or indirectly, an undue advantage

to a public agent, or third party related to said agent. They

will also not finance, defray, sponsor or in any way subsidize

the practice of unlawful acts provided for in the law, nor the

use of an intermediary person or entity to conceal or disguise

its real interests or the identity of the beneficiaries of the acts

committed. Any possible act of active or passive corruption of

which there is knowledge should be reported immediately, so

that it can be investigated.


GIFTS AND GRATUITIESThe receipt or payment of gifts and gratuities should always be

avoided.

Gifts distributed as a courtesy, propaganda, regular or occasional

promotion, such as on the occasion of special events or

commemorative days can be received, provided they do not exceed

the nominal value of R$ 100.00 (one hundred Reais) per gift. Any

amount, offered as a gratuity, may not be accepted.

The acceptance of invitations to sporting or entertainment events

is forbidden.

DONATIONS AND SPONSORSHIPS

The donations made to or by the Institution, whether for the

purposes of research, health care, education, philanthropy, or for

any other purpose, must not generate any type of advantage, or

material compensation.

Donations must always be received and managed by the Institution,

which will retain the records of the amounts in an appropriate manner

and with all the information necessary for accountability purposes.

Sponsorships, in the same way, should always be received or paid

as per the guidelines documented and the compensations must

be detailed and explicit in a contract formally signed between the

parties. Any benefit to the sponsor that is not properly expressed in

the sponsorship contract is forbidden.

RELATIONSHIP WITH POLITICAL PARTIES AND CANDIDATES FOR PUBLIC OFFICE The Institution has absolute political neutrality and does not

make contributions, in any form, to political parties or political

organizations or candidates for elected offices.


RELATIONSHIPS WITH MANUFACTURERS AND DISTRIBUTORS OF MEDICAL SUPPLIES, EQUIPMENT AND MEDICATIONS

The relationship of Institution employees and professionals

with medical supplies, equipment and medications companies

should be based on the exchange of information that supports

the development of medical and pharmaceutical care, helping

patients have access to therapies that are safe and efficient,

through the sharing of knowledge of the benefits and risks of

products and solutions.

Any promotion of medical and pharmaceutical materials in the

Institution’s is forbidden in the facilities as well as to the doctors,

staff and researchers whenever they are on duty for the Institution.

Medical students may not be approached for the purpose of

advertising medications and products.


8. SUPPLIERS AND SERVICE PROVIDERS

As a way to promote a fair environment and in keeping with our

commitment to sustainable development, the Institution expects its

suppliers and service providers to be aligned with the ethical values

explained in this Manual.

The relationship between the Institution and its vendors must

always happen at the institutional level, and contacts aimed at

private or personal interests or that are not foreseen in the contract

formally signed by the parties should be avoided.

All contractual conditions must be explicit, documented, and complied

with in keeping with current legislation and fair market practices.

INTEGRITY IN THE PROCUREMENT PROCESSES

The process for purchasing and supply fulfillment is guided by

fair market practices and by the compliance of the laws that

regulate competition. Transparent and equitable opportunities are

guaranteed to suppliers and service providers.

The choice and hiring of suppliers and service providers are made

based on technical and ethical criteria. The purchasing processes

are the objects of policies and procedures in order to ensure the

level of service provided at a fair cost.

The Institution’s suppliers and service providers must be

committed to its policies and procedures, acting in accordance

to the norms that regulate the health care sector, safety and the

work environment, respecting privacy and treating confidential

information properly.


COMPETITIONThe Institution defends the freedom of the market and competes

fairly and ethically, as established by current laws. Decisions on

pricing policy, participating or not in activities and competing or

not are not made exclusively by the Institution and in accordance

with technical and legal criteria.

BILLINGThe billing process is carried out with transparency, based on the

current legislation and in the contracts signed between the Institution

and the health insurance companies or with their clients. The

Institution maintains all the records required for accountability.

9. RESEARCH

The development of scientific research is a process that is central

to the progress of science and to the advances of medicine and

human health. As new knowledge may define the future of humans

and their living conditions, it is essential that scientific studies are

developed with consistency, ethics and technical and professional

accuracy, meeting all the legal requirements.

Research involving humans, animals, genetic manipulation and

stem cells have specific regulations that must be observed and

complied with, in order to safeguard the integrity and rights of

research subjects.

Among the ethical guidelines regarding the conduct of scientific

research, are:

• Review and approval of the research project in advance, by the

appropriate Committees.


• Act with ethical and professional rigor in the publication /

dissemination of results, with any form of fraud, plagiarism,

falsification of data, fabrication of results, use of third-party

data, information or knowledge etc. without appropriate credit

to the author being inadmissible.

• To ensure the accountability of the researcher in obtaining

informed consent in research involving human subjects, that the

subjects of the research to understand clearly the scope of their

participation, the risks involved, how your information will be

used and what the responsibility of the Institution will be.

• Protect the privacy of research participants, so that all the

information obtained during the study development process is

safeguarded.

• Make sure the researcher provides a statement of their potential

conflicts of interest at the submission stage for approval of the

research project.

• Perform the management of financial resources with total

accuracy, whether they come from the Institution or from third

parties, ensuring proper application and avoiding waste.


10. EDUCATION AND KNOWLEDGE MANAGEMENT

The teaching and learning relationships established in the

Institution or in name of the Institution should be motivated by

the diffusion of knowledge and be guided always by respect,

politeness and ethics.

The Institution’s education programs are sometimes carried out

in partnership with the medical and pharmaceutical industry

in order to disseminate academic knowledge that will result in

the improvement of the patient’s health as well as that of the

population.

The relationships between the Institution, its employees and

professionals, and the medical equipment and pharmaceutical

industry should be guided by the highest ethical standards.

Conflicts of interest must be avoided or properly declared.

Among the ethical guidelines for the carrying out of education

programs, are:

• Ensure that the Teaching activities will always be the

responsibility of the Institution and should not suffer technical or

academic interference from the industry.

• Require the teacher to declare formally, in classes or lectures,

any connection between him/herself and the industry.

• Carry out the choice of materials and medical textbooks used

for communicating the content of the lessons based on technical

and scientific knowledge criteria.

• To not condition support and sponsorship from industry to

interference in the programming, goals, location, or selection of

speakers and instructors.


• Limit the reimbursement of expenses arising from the participation

of professionals in events and courses, to the sums expended

with transportation, food, lodging, and registration unless it is

strictly necessary to facilitate the attendance of the speaker at

the event.

• Ensure the prior approval of the Director whenever the industry

offers financial support for the participation of employees in

external events. All employees that receive financial support from

third parties should formalize this fact in the Annual Declaration

of Potential Conflicts of Interest.

• Continual monitoring to ensure that employees and professionals

who are invited to deliver lectures and external events to

communicate, through their direct manager, for review and approval.

• Define which professionals will receive scholarships that may be

awarded by the industry to the Institution.


RELATIONSHIP BETWEEN TEACHING STAFF AND STUDENTS The relationship between teaching staff and students must be

underpinned by a respect for autonomy and human dignity, with

no tolerance for acts or manifestations of arrogance or violence

that may pose a risk to the physical and moral integrity of others.

The following actions will not be tolerated:

• Any type of inappropriate relationship between a member of the

teaching staff and a student, which is not related to the teaching

and learning process.

• Perform medical consultations or any other type of consulting

activity in the academic environment.

• Self-promotion or promotion of parallel professional activities in

the academic environment, whether during a class or by directly

approaching students.

The member of the teaching staff is expected to act in a manner that

is compatible with academic morality and integrity. The teaching and

evaluation of a student must not suffer interference from personal

and/or ideological interests, and the teacher must always behave in

keeping with the Institution’s principles.


11. MANAGEMENT OF THE ETHICS MANUAL

The Governance Audit Committee is responsible for the following:

• Permanently evaluate the topicality and relevance of this Manual,

as well as determine the actions necessary for disclosure and

dissemination of the standards of ethical conduct within the

Institution.

• Evaluate the cases of violations of the Ethics Manual and

deliberate regarding any doubts of its interpretation.

• Recommend effective and timely solutions for ethical conflicts

that arise.


12. REPORTING VIOLATIONS

Anyone having a relationship with the Institution should report

violations or possible violations of the guidelines contained in this

Manual through the Complaints Channel, (Canal de Denúncias),

which can be accessed at www.einstein.br/compliance or by

telephone at: 0800 741 0004.

The reports may be made anonymously, if the complainant chooses

not to identify him/herself.

The Institution is committed to treating reports with confidentiality,

fairness, depth, respect, and reasonableness. The Institution does not

tolerate any retaliation against anyone who, in good faith, reports

such violations or possible violations.

Reports of violations will be determined and/or monitored by the

Compliance area, which will always is identified, a transgression, an

opinion containing the description of the facts, the analyses carried

out with the respective evidences, the conclusions, recommendations

and action plans. Such recommendations or action plans may

determine the review and possible change of processes or procedures,

as well as impose educational or disciplinary measures, such as

resignation, without prejudice of civil and criminal actions that may

be applicable.

If the violation is strictly related with the professional activity of

doctors or nurses, without causing harm to the Institution, or issues

related to research, the process will be forwarded, respectively, to

the appropriate ethics commissions at Hospital Israelita Albert Einstein

and Instituto Israelita de Ensino e Pesquisa.


13. RESPONSIBILITIES

The guidelines contained in this Manual must be observed by all

employees in the performance of their duties at the Institution. The

associates are: board members, directors, employees, teachers,

researchers, interns and volunteers. All the professionals who, in some

way maintain a relationship with the Institution, that is, doctors on the

open clinical staff and other professionals from various health care

fields that work on the medical teams, service providers, suppliers,

freelancers, scholarship recipients and monitors involved in the

provision of services to the Institution or in its name.


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