live our mission know our standards · promedica is a mission-driven, community-based, non-profit...
TRANSCRIPT
6
v
LIVE
OUR
MISSION
KNOW
OUR
STANDARDS PROMEDICA’S STANDARDS OF CONDUCT
LETTER FROM THE
PRESIDENT ProMedica is a mission-driven, community-based, non-profit organization with a vision to create communities where all individuals reach their highest potential for health. At ProMedica, we hold each other and ourselves accountable for meeting expectations to ensure we live up to our Mission and Values. Our Mission – to improve your health and well-being – is our driving force. Our commitment to our values guide us in the way we pursue our goals, tackle challenges, and find answers to the difficult questions that arise for a company doing business in the dynamic and complex healthcare field. As a health care organization, we have an obligation to our patients to enable ethical decision-making and create an environment of respect. Each day we make an effort to conduct ourselves in an ethical fashion; we are all accountable for the decisions we make and actions we take.
The Standards of Conduct is a declaration of our expectations regarding ethics and integrity in the workplace. The policies provide clear, practical guidance on how we can live our core values — compassion, innovation, teamwork, and excellence. We are all expected to know and comply with the Standards and any policies related to our specific job function. We ask that you be informed, accountable, and actively engaged as one of our caregivers, whether you provide direct bedside care or indirectly support those who do. Our Standards of Conduct serve as a guide for everyone at ProMedica, and establishes our legal and ethical standards of behavior and business practices. We encourage you to read these Standards and use the numerous resources provided throughout this document anytime you are unsure about the right thing to do.
Should you have any questions regarding the Standards of Conduct, or ethical concerns regarding any situation at ProMedica, please contact your supervisor, your Regional Compliance Officer, or the Compliance Department. If you wish to remain anonymous, you may call the Compliance Hotline at 419-824-1815 in the metro-Toledo area or 1-800-807-2693.
Randy Oostra
Chief Executive Officer President
2
OUR MISSION To improve your health and well-being
When we live by our Mission and Values,
we create an environment centered on our patients.
Realizing our patients and members come first,
we are humbly committed to serving the calling
of our collective professions.
If we do not directly serve patients,
our job is to serve those who do;
in this sense, we are all caregivers.
3
GUIDING
PRINCIPLES CLINICAL EXCELLENCE We strive to build and maintain a culture of safety, clinical excellence, and exceptional patient experiences
SOCIAL DETERMINANTS We have an obligation not only to advance the clinical care we provide, but also to focus on those societal factors that influence our health and well-being, like hunger and mental health
ECONOMIC DEVELOPMENT We will ensure the health of our communities, create jobs, and safeguard a sustainable future for ProMedica
HEALTHCARE INNOVATION We invest in new technologies and start-ups that enhance care for future generations while creating jobs and revenue
EDUCATION We seek academic partners to help the next generation
of care givers learn how to succeed in our future
healthcare environment
VALUES COMPASSION We act with respect integrity, and dignity; each of us is a caregiver, our actions, words, and tone let other know we truly care
INNOVATION We continually search to find a better way forward. Changes enable us to deliver high-quality care and best possible outcomes
TEAMWORK We are an inclusive team of diverse and unique individuals who collaborate to meet the ongoing needs of our patients and communities. We are better together than apart
EXCELLENCE We strive to be the best in all we do; we value lifelong learning, practice continuous improvement and provide exceptional service in living our Mission to improve your health and well-being
4
HOW WE GUIDE
OUR ACTIONS
PURPOSE
At ProMedica, we are proud of the
values that drive our success.
These values shape an
environment and culture that
nurtures the highest standards in
business ethics and personal
integrity. These same ethics and
values are displayed in our
commitment to excellence in the
services we provide. We have
reached an exemplary level of
corporate citizenship that is
benchmark within health care. It is
imperative as individuals we
understand and adhere to these
principles and values to protect
ProMedica’s integrity and welfare.
If you are unsure what to do in a
situation, you have support. Please
speak with your manager or
Regional Compliance Officer about
your concerns.
5
POLICY
Exactly what constitutes an unethical
business practice is both a moral and legal
question. ProMedica recognizes and respects
the right of each person covered by this
policy to engage in activities that are private
in nature and do not in any way conflict with
or reflect poorly on ProMedica. ProMedica
reserves the right, however, to determine
when any activity represents a conflict with
ProMedica’s interest and to take whatever
action is necessary to resolve the situation.
SCOPE
The Standards of Conduct (SOC) is designed
to address all business activities,
relationships, and affiliations within
ProMedica. They are in no way intended to
interfere with the provider/patient
relationship. Providers are expected to act in
the best interest of their patients in
providing medical care.
PROCEDURE
In order to achieve the above objectives,
ProMedica has developed SOC. These
standards apply to all ProMedica board
members, associated physicians, and
employees. These standards are described in
the four SOC and certification statements for
board members, physician (employed and
non-employed), and employees. Members of
each of these categories are expected to
certify their compliance with the accepted
standards.
Responsibility for administration of this
policy is shared by the Governance Office,
Human Resources, (“H/R”), the Chief
Medical Officer (“CMO”), the Office of the
General Counsel, the Audit and Compliance
department, and all of ProMedica
leadership. Specific responsibilities are
defined by certifying groups below:
CERTIFICATION
All employees (other than physician
employees) must sign the Employee
Certification Statement prior to beginning
their employment with ProMedica. Annually,
at a minimum, all salaried employees (other
than physician employees) must sign an
Employee Certification Statement.
All physicians employed by ProMedica will
be given a copy of the appropriate Physician
SOC and the Certification Statement for
completion/signature upon initiation of
his/her association with ProMedica.
Annually thereafter all employed physicians
will re-certify by completing the Certification
Statement within the timeframe specified.
Each non-employed physician associated
with ProMedica will be given a copy of the
Physician SOC and the Certification
Statement upon initiation of his/her
association/contract with ProMedica. Each
physician must sign a Physician Certification
Statement upon initiation and renewal of
his/her association/contract with
ProMedica.
6
STANDARDS
All persons covered by this policy must also promptly
report a violation or suspected violation of law or the
Compliance Program. Any form of retaliation against
any employee who reports a perceived problem or
concern in good faith is strictly prohibited. All
Physicians are required to disclose any activities,
associations, or interests that may conflict with this
policy in an effort to resolve the situation(s) in an
effective, timely manner that is in the best interest of
ProMedica.
While it is not possible to define all the various
circumstances and relationships that would be
“unethical”, the following guidelines should provide a
good understanding.
Compliance with Laws and Regulations
The compliance with all federal, state, and local laws is
of the utmost importance to ProMedica’s continued
success. ProMedica is committed to complying with all
applicable laws.
While it is not practical to attempt to list all laws to
which ProMedica is subject, it is obvious that neither
ProMedica nor any Employee should participate in any
fraudulent or deceptive activities toward:
ProMedica
Patients
Insureds
Suppliers
Contractors
Anyone else with whom ProMedica has
business associations
To that end, ProMedica has implemented a Corporate
Compliance Program, with which all Employees must
comply. Any Employee who becomes aware, directly
or indirectly, of any instance violating the Compliance
Program, must promptly report the situation to his or
her department Director or Manager, the ProMedica
Compliance Department, or call the Compliance
Hotline at 419-824-1815 or 800-807-2693. Detailed
requests for information regarding the Corporate
Compliance Program may be referred to the
Compliance Department.
7
Patient Privacy
We respect our patients’ right to privacy. Any
Employee/Physician/Board Member who has
knowledge of or access to any patient’s protected
health information must take necessary steps to
ensure information is not released or disclosed in a
manner that would violate the patient’s rights
under the Health Insurance Portability and
Accountability Act (HIPAA) or under any other
federal or state law. Privacy can be contacted at
419-291-1211.
Improper Influence
Employees/Physician/Board Members shall not
influence, or seek to influence, any person, firm,
customer, or supplier who has, or is likely to have,
business dealings with ProMedica through the
exchange or offer to exchange of cash, gifts,
services, promises or other remuneration in an
attempt to influence their actions related to
ProMedica.
Board Members shall not accept, or seek, any cash
or significant gifts (i.e., with a value in excess of
$75), services, or personal favors from anyone who
has, or is likely to have, business dealings with
ProMedica.
Confidential Information and Trade Secrets
At no time during or after the employee, physician,
or Board Member’s association with ProMedica
may he/she use, disseminate, or disclose to any
person, firm, corporation or other business entity,
any confidential information or trade secret
belonging to any ProMedica organization. A
Physician may use confidential information and
trade secrets of a ProMedica organization only in
the furtherance of and to the extent required to
perform his/her duties to that organization. All
documents, communications and things containing
confidential information or trade secrets belonging
to a ProMedica organization are the property of
that organization.
Campaign and Election Guidelines
ProMedica’s policy with respect to the
nomination or election of candidates to public
office is one of non-partisanship. ProMedica
does not support or take positions as to political
parties or as to the nomination or election of
individual candidates to political office.
ProMedica funds, properties or services shall not
be contributed or used directly or indirectly for
the purposes of influencing the nomination or
election of individual candidates to political
office.
Gifts and Other Benefits
Employees may not accept cash, gifts, products,
services, or loans (monetary, equipment,
supplies, material, etc.) other than those of
nominal value, or have any travel, living, or
entertainment expenses paid for themselves or
members of their households, by any supplier or
any person, firm, or company doing business or
seeking to do business with ProMedica. Such
gifts, if received, must be returned to the
provider/supplier. Infrequent exceptions may be
made for activities such as supplier-sponsored
seminars upon advance written approval by the
Senior Vice-President, the Business Unit Head,
or higher-level management not participating in
the activity.
Speeches, Presentations, and Publications
Honoraria and publication opportunities for
ProMedica employees must be conducted on an
individual’s own time and must not conflict with
his/her job responsibilities. Each opportunity will
be considered on an individual basis and must
have the documented, advance approval of a
business unit president or corporate vice-
president. Under no circumstances may any
information derived from any ProMedica source
be used without advance approval. The
employee is responsible for following each of
the following steps depending on the type of
presentation or publication: See policy SP 1.03
for more details.
8
Conflicts of Interest
Employees, physicians, and Board Members are expected to avoid conflicts of interest and/or the appearance
of conflicts of interest, which may arise from their activities related to business decisions of ProMedica. All
conflicts of interest must be disclosed on the appropriate Certification Statement and, if not previously
disclosed, reported immediately to the appropriate personnel.
Employees
o Use Employee Certification Statement
o Report to Business Unit Vice President of Human Resources
Physician
o Use Physician Certification Statement
o Report to Chief Medical Officer of PPG or CMO for ProMedica Health System
Board Member
o Use Board Member Certification Statement
o Report to board chairperson, the CEO, or the General Counsel
While it is not possible to describe, or anticipate, all the circumstances and situations that might involve or
appear to involve a conflict of interest, see policy SP 1.03 for more details. The conduct of Immediate Family
Members shall be considered conduct by the employee, physician, or Board Member.
9
KEEP IN MIND AS YOU VIEW THE SCENARIOS
BELOW:
Every case is examined on its own merit.
As you are promoted or change roles at ProMedica, you will have to reexamine your relations
with outside organizations.
SCENARIO 1: EMPLOYED AT MULTIPLE ORGANIZATIONS
A nurse with ProMedica recently accepted a per diem position with another hospital system in the Toledo
area. She will be doing the same job at both locations, but she is worried about the impact working for
the other organization may might have on her ProMedica career.
SCENARIO 2: VENDOR PAID EDUCATION
A vendor is offering to pay an employed physician to attend a continuing education activity at a hotel
conference center. Since this event is off-campus, does the situation qualify as a conflict of interest?
SCENARIO 3: PAID POSITION ON AN ADVISORY BOARD
An employee accepted a paid position on the advisory board for another organization. The employee will
keep both positions. If this does not create a schedule issue is it still a conflict of interest?
KEEP IN MIND
This scenario could constitute a conflict of interest
o Employees may not have any travel, living, or entertainment expense paid for themselves
(or their family) by any supplier or any person, firm, or company doing business or
seeking to do business with ProMedica.
o Infrequent exceptions may be permitted for activities such as this upon advance written
approval by the Senior Vice-President, the Business Unit Head, or higher level of
management not participating in the activity.
KEEP IN MIND
If the nurse is not in a position of influence at either organization, it is likely there is no conflict of
interest.
KEEP IN MIND
Being a member of an advisory board for another organization may conflict with the interests of
ProMedica.
An Employee must obtain approval from the President/CEO of ProMedica prior to serving as a
member of the governing board of any organization whose interest may conflict with the
interests of ProMedica.
A conflict of interest is any relationship that may sway opinion. Act in the
best interest of ProMedica if you are privy to business decisions.
10
Q: What is ProMedica Compliance? A: ProMedica Compliance is a department that supports Our ProMedica Mission and helps protect our culture and our reputation by providing resources that help employees make ethical decisions at work. Q: What are ProMedica’s Standards of Conduct? A: The Standards of Conduct is a resource distributed to all employees to help make appropriate decisions at work. The Standards are a brief statement of some of the company’s expectations of how we are all to conduct business. Q: What am I expected to do with the Standards of Conduct? A: Read the Standards carefully and make sure you understand them. If you have any questions or concerns, ask your supervisor, Regional Compliance Officer, or contact Compliance via the Compliance Hotline. Q: Where can I find the Standards of Conduct? A: The Standards of Conduct can be located in the Compliance Resources on myProMedica. Select Our System > Departments > Compliance and Privacy > Resources. Q: What is ProMedica’s Compliance Hotline? A: The Compliance Hotline is a free phone number for reporting issues or raising concerns that involve ethics, legal issues or potential violations of ProMedica’s Compliance Plan, including the Standards of Conduct and our core values. 419-824-1815 or 800-807-2693. Q: May I call the Hotline anonymously? A: Yes. Calls to the Hotline are not traced and are handled in a confidential manner. We encourage callers to provide their names and contact numbers because calls in which the caller does not provide those details can be more difficult to investigate. ProMedica cannot guarantee your anonymity if you identify yourself or give information from which you can be identified, but the Compliance department will take every reasonable precaution to assure the identity of a caller remains as confidential as possible. Q: Can I be retaliated against or victimized for using the Hotline? A: ProMedica does not tolerate retaliation against or the victimization of any employee who raises concerns or questions regarding a potential violation of ProMedica policy that he or she reasonably believes to have occurred. Q: Who is my contact for more information or to obtain policies? A: Contact your supervisor, your Regional Compliance Officer, or the Compliance department via the Compliance Hotline. Q: What is a privacy breach? A: In general, the term ‘breach’ refers to an incident in which unsecured, protected health information (PHI), either electronic or hard copy, has potentially been accessed, stolen, or used by an individual unauthorized to do so, or disposed of in a manner that allows unauthorized access.
FREQUENTLY
ASKED
QUESTIONS
11
Q: What are some examples of incidents I should report? A: Reportable instances may include, but are not limited to:
A workforce member that snoops into the electronic records of fellow employee.
A stolen or lost laptop computer or thumb drive containing unencrypted PHI.
Posting patient information on Facebook even in general terms could be a privacy violation. For example, “We had a fifty-year-old male in the ER last night with alcohol-induced liver disease.” It only takes a few clues for someone to identify a patient. Information as little as time and place coupled with a diagnosis could be enough to constitute a privacy violation.
A workforce member who take a cell phone picture of a patient in the ER and transmits the photo to a friend.
A misdirected fax containing PHI sent to a grocery store fax instead of the intended requesting provider’s fax.
Intentional and non-work related access by a workforce member to a family member’s medical record.
Misdirected or unsecured emails Q: How do I report a suspected breach? A: Workforce members are required to report a breach immediately, and not later than 24 hours after discovery of a breach. Reports should be made via the RL6and must include the date and time of the discovery and as much information about the suspected breach as is available. The reporting person is required to cooperate in providing any requested follow-up information whether in writing or orally. Privacy can be reached at 419-824-1211.
12
ProMedica associates have a responsibility
to report suspected violations of the
Standards of Conduct. ProMedica is
committed to ensuring that an individual
does not face retaliation for reporting such
concerns. Here is how to report suspected
violations to get help on these issues:
THE PROMEDICA COMPLIANCE
HOTLINE
Reports of suspected violations or concerns
may be made anonymously, where local
laws allow.
However, you are encouraged to identify
yourself when making a report, so that
additional information can be obtained if
needed. Whenever possible and permitted
by law, your identity will be kept strictly
confidential.
PROHIBITING RETALIATION FOR
REPORTING
It takes courage to raise concerns about
actions that may violate or be inconsistent
with our Standards or the law, and
ProMedica recognizes the critical aspect of
its compliance program to ensure an
individual does not face retaliation for
reporting concerns. Prohibited acts of
retaliation include discharge, demotion,
suspension, harassment, threats, or any
other action that discriminates against an
individual who submits a report of suspected
non-compliance. Any employee who
commits or condones any form of retaliation
will be subject to discipline up to, and
including, termination. If you know or
suspect that you or someone you know has
been retaliated against, you should contact
your Regional Compliance Officer, the
System Compliance Officer, or the
Compliance Hotline immediately.
For more information about our prohibition
on retaliation for reporting, please see
policy SP 1.13 regarding Problem Reporting
and Non-Retaliation.
To report a real or suspected
violation of the Standards of
Conduct, the following
individuals and resources are
available:
Your supervisor
Your designated Regional Compliance
Officer
AVP, Compliance
Our Chief Compliance Officer (CCO)
/VP, Audit & Compliance
Our ProMedica Compliance Hotline
ACCESSING THE
COMPLIANCE HOTLINE
To report by telephone, please
dial:
419-824-1815
800-807-2693
OR
REPORTING A
POSSIBLE VIOLATION
13
Rachel Burkin
Senior Regional Compliance Officer
567-585-0650
Kris Crandall
Regional Compliance Officer
567-585-6703
Ryan Dolan
Regional Compliance Officer
567-585-0653
Karl Strauss
Regional Compliance Officer
567-585-1795
Stella Wohlgamuth
AVP, Compliance
567-585-6706
Vivien Townsend
VP, Audit & Compliance/CCO
567-585-6707
COMPLIANCE
CONTACTS
14 14