OUR VALUES AND ETHICS AT WORK - Catholic …

1 O U R VA L U E S A N D E T H I C S AT W O R KR e f e r e n c e G u i d eIntroduction1 Letter from the 2 President and CorporateResponsibility OfficerCatholic Health Initiatives4 FrameworkIntroduction to the 6 Corporate Responsibility ProgramHow to Use Our Values8and ETHICS at work Reference GuideStandards of Conduct10 Applications of the 11 Standards of ConductAnti-Kickback Statute and 12 Stark Self-Referral LawAnti-Kickback Statute12 Stark Self-Referral Law13 Antitrust Compliance14 Coding and Billing15 Confidential Information16 Patient/Resident 18 InformationEmployee Information19 Confidential Information19 About Our BusinessConflicts of Interest20 Contractor/Vendor 20 RelationsRequesting and 21 Accepting Gifts and GratuitiesOutside Interests 22and ActivitiesParticipation on Outside 24 Boards of Trustees/DirectorsCopyrighted, Trademarked 25or Licensed MaterialsDealing with Government 26and Regulatory AgenciesDocumentation Standards28 Business and Financial 29 RecordsMedical Records29 Emergency Medical 30 Treatment and Active Labor Act (EMTALA)

2 Environmental 31 ResponsibilityEthical and Religious 32 DirectivesEthical Behavior33 Excluded Providers33 False Claims Act Policies34 Marketing Practices36 Non-Retaliation36 Patient Care and Rights37 Political Activities38 Protecting Our Assets40 Record Retention41 Research 42 Grant Management42 Medical Research Compliance42 Institutional Review Boards and InformedConsent43 Scientific Integrity43 Research BillingCompliance44 Tax-Exempt Status46 Our VALUES at work 47 Credentialed Provider47 QualificationsExit Interviews47 Resources48 Getting Help48 Reporting Concerns48 Training and Education49 Consequences of 49 Failure to Comply With Our VALUES and ETHICS at work Reference GuideReferences50 Acknowledgment and 51 CertificationConclusion53 Contact Information53T A B L E O F C O N T E N T SO U R VA L U E S A N D E T H I C S AT W O R K1 Catholic Health Initiatives is people people caringfor people.

3 There are thousands of individuals acrossthe country working in our organizations and livingour mission with the highest standards and integrity,nurturing the healing ministry of the VALUES and ETHICS at WorkOur commitment to corporate responsibility is tied to the dis-tinctive culture of Catholic Health Initiatives. Each of us helps shapethat culture by acting in accor-dance with our core VALUES andstandards of conduct. We all havea personal responsibility to behaveethically and care is a complex of the laws and regulationsthat govern health care are diffi-cult to understand and to applyconsistently.

4 Catholic Health Initiatives has created this bookletto help you understand these lawsand regulations. This referenceguide describes our standards ofconduct and how to apply themto your daily work examples in this referenceguide will help you to understandthe importance of having honesty,directness and respect in all ofyour interactions with patients/residents and their family 2 WHERE WE work At Catholic Health Initiatives, we believethat corporate responsibility begins withpersonal responsibility and integrity onthe part of everyone who works for andwith our organizations. Michelle Cooper, Corporate Responsibility Officer Catholic Health InitiativesOur VALUES and ETHICS at wOrk3members, as well as co-workersand business partners.

5 We haveincluded questions posed by employees, medical staff andbusiness partners, and we haveprovided answers to the ques-tions to help you understand our standards of VALUES and ETHICS at WorkReference Guideis designed to help you make decisions atwork, however simple or difficultthey may be. Of course, it is not possible to cover every situationin this reference guide. If you are struggling to determine theright thing to do in a particularsituation, this booklet has infor-mation to help for ethical decision-making is available to you at all times. Please call on thatsupport to be confident in yourdecisions as you help shape and strengthen our health care ,Kevin E.

6 Lofton, FACHEP resident and Chief Executive OfficerA. Michelle CooperCorporate Responsibility OfficerWhy does Catholic Health Initiativestake corporate responsibility so seriously?Because it is an expression of our core VALUES of Reverence, Integrity, Compassionand Excellence. Kevin Lofton, President and Chief Executive Officer Catholic Health InitiativesMISSW here We Want to BeOur Vision is to live up to our name as oneCatholic Health Initiatives: Catholic : living our Mission and Core :Improving the health of the people and communities we : Pioneering models and systems of care to enhance care We Will Measure Our ProgressBalanced Scorecards, Dashboards, CulturalAttributes, Surveys and Evaluations4C AT H O L I C H E A LT H I N I T I AT I V E S F R A M E W O R KWhy We ExistMission.

7 The mission of CatholicHealth Initiatives is to nurture thehealing ministry of the Church bybringing it new life, energy and viability in the 21st century. Fidelityto the Gospel urges us to emphasizehuman dignity and social justice as we move toward the creation of healthier Are Our Guiding Principles?Nearly 700 employees, physicians, partici -pating congregation members and boardmembers from throughout Catholic Health Initiatives participated in the process of naming our core VALUES . The core VALUES define Catholic Health Initiatives and serve as our guiding principles. They are the roots,or anchors, from which all of our activities, decisions and behaviors respect and awe for all of creation,the foundation that shapes spirituality, our relationships with others and our journey to wholeness, soundness, fidelity, trust,truthfulness in all we with one another, capacity to enterinto another s joy and performance, becoming thebenchmark, putting forth our personal and professional We Will Get ThereOur VALUES and ETHICS at work Reference Guide,Employee Covenant,Employee Competencies, Leadership Development, Core VALUES Assessments.

8 Distinctive Culture, Strategic and Operational PlansHow We Live Our ValuesStandards of ConductOur VALUES and ETHICS at wOrk5 Catholic Health Initiatives is committed to continu-ing the healing ministry of the Church by creatinghealthy communities and defending the humandignity of each community member, especially the poor and underserved. Our Catholic identitycalls us to recognize God s presence in every man,woman and child. We serve God by caring for thosein need and for each other. Our core VALUES of Reverence, Integrity, Compassion and Excellenceprovide focus, direction and corporate responsibility program of CatholicHealth Initiatives and its organizations provides resources for making decisions based on ourCatholic identity.

9 These programs help us under-stand and comply with complex laws and regula-tions. They are founded on our core VALUES andstandards of reference guide provides a framework for ethical behavior based on the attributes that define our distinctive Catholic culture. Our cultural attributes call us to:6 Introduction to the Corporate Responsibility ProgramOur VALUES and ETHICS at wOrk7 Create a culture that supports open and honest communication. Exhibit high ethical standards of conduct that promote doing the right thing. Cultivate our human, financial and material resources as gifts entrusted to us.

10 Be accountable for our actions and performance. Commit to the common good. Share wisdom and knowledge, and develop individual and organizational potentials. Find ways to improve work processes, service and care delivery. Create a healing environment and a collaborative support you in making the right decisions andgetting answers to your questions or concerns, Catholic Health Initiatives has developed a simplereporting process, which is detailed on page are encouraged to use this process as neededto make the right decisions and to support othersin doing the same..an organizationshall promote an organizational culturethat encourages ethical conduct and a commitment to compliance with the law.