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OurCodeofEthicalBehavior
DearTannerHealthSystemColleague,
Tannerstrivestoprovidehigh-qualityhealthcareserviceswithinourresourcecapabilities.Wealsostrivetodeliverhealthcarecompassionatelyandtoactwithabsoluteintegrityinthewaywedoourworkandthewayweliveourlives.Therefore,wedevelopedacomprehensivevaluesbasedcomplianceprogram.
OurCodeofEthicalBehaviorreflectsthevaluesthatguideouractions.NoCodeofEthicalBehaviorcansubstituteforeachperson'sinternalsenseoffairness,honestyandintegrity.Therefore,ifyouhaveanyquestionsregardingthiscodeorbelievethatasituationviolatestheprovisionsofthiscode,pleasedonothesitatetoconsultyoursupervisor,amemberofthemanagementteam,theComplianceofficeortheCompliancehotline.
Weaskyoutoassistusinourcontinuedjourneyfrom"goodtogreat."
LoyHowardPresidentandCEO,TannerMedicalCenter,Inc.,andTannerMedicalCenterAlabama,Inc.
INTEGRITYshallneverbeII
OurCodeofEthicalBehavior
MISSION Toprovidequalityhealthcareserviceswithinourresourcecapabilities;toserveasaleaderinacollaborativeeffortwiththecommunityinprovidinghealtheducation,supportservices,andcareforallcitizens.
Everyplan,decisionandactionshallbeguidedbythesevalues:
1.RecognizethatourCUSTOMERScomefirst.
2.EDUCATIONwillbeencouraged,supportedandmadeavailable.Ifwearetofulfillourdreamsandreachourpotential,wemustallbelifetimelearners.
3.TEAMWORKisthebasisofourorganizationalstructure.
4.IndividualandcorporateINTEGRITYshallneverbecompromised.
5.ImprovingQUALITYmustalwaysbeourfocus.
6.OurrelationshipswithoneanothershallbefoundedonmutualRESPECT.
7.ThefoundationofeverythingwedoisCARINGforpeople.
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TABLEOFCONTENTS
IntroductionandPurpose....................................................2Everyone’sResponsibilities...................................................2Leadership’sResponsibilities.................................................3Physician’sResponsibilities.................................................4BusinessAssociates’Responsibilities.........................................4Hotline....................................................................5
CONTENTSPatientRights.....................................................................................................................6ProtectionofClinicalDecisionMaking...............................................................................6PatientReferrals/PhysicianArrangements........................................................................7ConfidentialInformation....................................................................................................8Billing..................................................................................................................................9FinancialRecords.............................................................................................................10PersonalUseofTannerHealthSystemProperty.............................................................10AdvertisingandMarketing ..............................................................................................11ConflictofInterest...........................................................................................................12GiftsandGratuities..........................................................................................................12Anti-trustLaws.................................................................................................................13EnvironmentalLaws.........................................................................................................13SafetyandHealth.............................................................................................................14EqualEmploymentOpportunity......................................................................................14PaymentstoGovernmentOfficials..................................................................................15GovernmentRequests.....................................................................................................15ComplianceAcknowledgement.......................................................................................16
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IndividualandcorporateINTEGRITYshallneverbecompromised.TheTannerMedicalCenter,Inc.,BoardofDirectorsandTannerMedicalCenterAlabama,Inc.,BoardofDirectorspublishthisCodeofEthicalBehavior(Code)toprovideguidancetoallofourTannerHealthSystemcolleaguesandaffiliatestoensurethatwemeetourethicalstandardsandcomplywithapplicablelawsandregulations.Wehaveconfidenceintheloyaltyandintegrityofourhealthcareteam.Weexpectourdirectors,managers,employees,affiliatedphysicians,contractors,consultantsandvendorstousetheseguidelinestocarryouttheirdailyactivities.
Thisbookletisdesignedtobecomprehensiveyeteasytounderstand.Itisoneofseveraltoolsavailabletohelpyouperformyourjob—professionallyandethically.OurCodeassistseveryonein:
§ Avoidingboththefactandtheappearanceofimproperactivities§ Assuringthatallapplicableregulationsandlawsarefollowedappropriately
Often,asubjectmayneedadditionalguidance.WedevelopedacomprehensiveComplianceResourceCenterlocatedonourinternalwebsite,tanner@work.ThebelowpoliciesexpandontheprinciplesexpressedinourCodeofEthicalBehavior.§ HIPAApolicies§ Patientrightsandresponsibilitiespolicies§ Determiningeligibilityforindigentcharitycare§ Freedomofchoice§ Billing, charging andcollectionpolicies§ Identificationofnon-allowableexpensesforcostreports
Everyone’sResponsibilityTeamworkisthebasisofourorganizationalstructure.
Everyonewilldisplaygoodjudgementandhighethicalstandardsintheirbusinessdealings.TheTannerHealthSystemCodeofEthicalBehaviorisdesignedtoeducateanddeterwrongdoing. AllTanner HealthSystemoperationsmustbeconductedwithhonesty, fairnessandintegrity. Pleaserememberthatthe foundationofeverythingwedoiscaringforpeople.
AllTannerHealthSystemcolleaguesandaffiliatesareobligatedtoperformtheirdutieswithintheprescribedlimitsoftheTannerHealthSystemEthicsandComplianceProgram. Itiseveryone’sresponsibilitytoreportanyconcernsorviolationsofthesepoliciestoany oneofthefollowing:
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§ Immediatesupervisor§ ComplianceOfficerValorieComley(770.812.8159)§ ComplianceHotline(1.800.648.1507) § PrivacyOfficerTerriLee(770.812.9602)§ MECchair
Failuretocomplywiththeseprovisionsmayresultin:§ Disciplinaryaction§ Terminationofemployment§ Revocationofprivileges§ Civilpenalties§ Criminalcharges§ Monetaryfines§ LossofconfidenceinTannerHealthSystem'sintegrity
Ourrelationshipwithoneanothershallbefoundedonmutualrespect.
TannerHealthSystem’sleadershipisexpectedtocreateanenvironmentwhereallcolleaguesfeelfreetoraiseconcernsandaskquestions.Managementensuresthatthepersonneltheysuperviseunderstandsandcomplieswiththehighstandardsofbusinessconductestablishedbythesepolicies.TheComplianceOfficeandallmanagementpersonnelareresponsibleformaintainingprogramstofamiliarizeemployeesandotherpersonnelwithmattersrelatingtoethicalbehavior.Disciplinaryactionsarenecessaryforcomplianceviolationswheninvolvinganyoneofthefollowing:§ Employee§ Employee’ssupervisor§ Anyonedirectingorapprovingimproperactions§ Anyoneawareofimproperactionsbutdoesnotactappropriatelytocorrectthem§ Anyonewhootherwisefailstoexerciseappropriatesupervision
ManagementisresponsibleforpromptlyadvisingtheComplianceOfficerofanyreportedorsuspectedviolationthatneedsinvestigationorresolution.ManagementthroughoutthehealthsystemshoulduseourCodetoincorporateethicsandcomplianceintoallaspectsofourorganization.
TheactionsofeachTannercolleagueoraffiliatearesignificantindicationsofjudgementandcompetence.Accordingly,thoseactionsconstituteimportantelementsintheannualevaluationoftheemployeeorcontractualarrangementaswellasforpositionassignmentsandpromotions.
Leadership’sResponsibility
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Physician’sResponsibility ThefoundationforeverythingwedoisCARINGforpeople.
MedicalStaffMissionStatementToprovidepatientswiththehighestqualityofcarethatensuresthehealthandsafetyofthecommunityitservesbymaintainingindividualcompetenceandsupportingTannerHealthSystem.
TannerHealthSystemiscommittedtoprovidingaworkenvironmentwithexcellentfacilities,modernequipmentandoutstandingprofessionalsupport.Accordingly,wewillnotallowanyphysiciantoworkwithoutavalidmedicallicenseorpropercredentials.
§ Anybusinessrelationshipwithaphysicianwillbeinwriting.§ TannerHealthSystemwillnotpayoroffertopayforreferrals.§ TannerHealthSystemacceptsandreferspatientsbasedontheirclinicalneedsandourability
renderneededservices.§ TannerHealth Systemwill not contractwith, employ or bill for services rendered by any
individualorentitythatisexcludedorineligibletoparticipateinfederalhealthprograms,orhas been convicted of a criminal offense related to the provision of healthcare items orservices.
§ TannerHealthSystemrequirescolleaguestoreporttousiftheybecomeexcluded,debarred,orineligible.
§ Toparticipateinfederalhealthprogramsorhavebeenconvictedofacriminaloffense.§ Tanner Health System collects information about the patient’s medical history,
condition,medicationandfamilyhistoryinordertoprovidequalityhealthcare.NoTanner Health System-affiliated physician has a right to access any patientinformationotherthanthatnecessarytoperformhisorherjob.
Vendor,Consultant,ContractorandBusinessAssociateResponsibilities OurrelationshipswithoneanothershallbefoundedonmutualRESPECT.
TannerHealthSystempromotesacompetitiveenvironmentandiscommittedtofaircompetition.OurbusinessdecisionsarebasedonourabilitytomeettheSystemneedsandnotonindividualpersonalrelationships.
§ Wewillnotcommunicateconfidentialinformationtothirdparties(i.e.,bids,pricing,financialinformation).
§ Patientinformationaccesswillbelimitedtoonlywhatisnecessarytoperformhisorherjob.
§ TannerHealthSystemwillnotdobusinesswithanyindividualorbusinessthatisexcludedfromparticipatingintheMedicare/Medicaidprogram.
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§ TannerHealthSystemwillnotcontractwith,employorbillforservicesrenderedbyanyindividualorentitythatisexcludedorineligibletoparticipateinfederalhealthcareprogramsorhasbeenconvictedofacriminaloffenserelatedtotheprovisionofhealthcareitemsorservices.
§ TannerHealthSystemrequirescolleaguestoreporttousiftheybecomeexcluded,debarred,orineligibletoparticipateinfederalhealthprogramsorhavebeenconvictedofacriminaloffense.
HOTLINEIndividualandcorporateINTEGRITYshallneverbecompromised.AnintegralpartofourcomplianceeffortsistheestablishmentofaconfidentialandanonymousComplianceHotline,throughwhichourTannerHealthSystemcolleaguesmayanonymouslyreportviolationsofanylawsorregulations.Everyoneisresponsibletopromptlyreportpossibleviolationstotheirsupervisor,theComplianceofficeortheComplianceHotline.
Callstothehotlinearetreatedconfidentially.Noretaliationorharassmentwillbetakenagainstanyoneforusingthehotlineorreportingconcernsofimproperconduct.HotlinecallswillbereportedtotheTMC,Inc.BoardofDirectorsortheTMCA,Inc.BoardofDirectors.
TheComplianceHotlinephonenumberis:1.800.648.1507Complianceconcernsare:§ Suspectedwrongdoing§ Illegalorunethicalacts§ BreachesoftheTannerHealthSystemLegalComplianceProgram§ BreachesofTannerHealthSystemCodeofEthicalBehavior§ LossesrelatedtoTannerHealthSystemoperations,propertiesoremployeesPatientcarerelatedconcernsmustalwaysbehandledimmediatelybytheappropriatestaff,patientrepresentativeordirectorofRiskManagement.OurTannerHealthSystemGrievancePolicywillbefollowed.
Examplesofhotlinecallsareasfollows:§ Breachesofconfidentiality(HIPAA
violations)§ EMTALAviolations(anti-dumping)§ Fraudandabuse(billingissues)§ Upcoding(codingforhigher
reimbursement)
§ Billingforservicesnotrendered§ Costreportfraud§ Anti-kickbackviolations§ Insurance
§ Fraud
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PatientRightsRecognitionthatourCUSTOMERScomefirst.
TheTannerHealthSystemhealthcareteamtreatsallpatientswithdignity,respectandcourtesy.Ourmissionistoprovidequalityhealthcareserviceswithinourresourcecapabilities.Wealsostrivetoserveasaleaderinacollaborativeeffortwiththecommunitytoprovidehealtheducation,supportservicesandcareforallourcitizens.
Each patient is provided with their rights andresponsibilitiesandaNoticeofPrivacyPracticesinvarious written formats as well as postedthroughoutthesystem.
Wearecommittedtoensuringahealthcareethicthatrespectstheroleofpatientsindecision-makingaboutcare,treatmentandserviceswithinourcapabilitiesandmissionandincompliancewithlawsandregulations.Also,wearesensitivetorespectcultural,psychosocial,spiritual,personalvalues,personalbeliefs,personalpreferences,racial,linguistic,religious,age,genderandotherdifferencesaswellastheneedsofpersonswithdisabilities.
ProtectionofClinicalDecisionMakingThefoundationforeverythingwedoisCARINGforpeople.TannerHealthSystemprotectstheintegrityofclinicaldecisionmakingregardlessofcompensationorsharedfinancialriskswithitsleaders,managersandclinicalstaffandlicensedindependentpractitioners.
InaccordancewiththeEmergencyTreatmentandActiveLaborAct(EMTALA),thehospitalprovidesamedicalscreeningexaminationandnecessarystabilizationtoallpatientswhopresenttotheemergencydepartmentwithanemergencymedicalcondition,includingwomeninlabor,suicidalpatientsandpatientsundertheinfluenceofcontrolledsubstances,regardlessoftheirabilitytopay.Therefore,treatmentwillbebasedonourcapacityandcapabilityandwewillnotdelaythemedicalscreeningexaminationordelaytheadmission,dischargeortransferofpatientssimplybasedonthepatients’abilityorinabilitytopay.
TannerHealthSystemdoesnotmakeadistinctiononadmission,transferanddischargepoliciesbasedonapatient’sage,gender,disability,race,color,religion,veteranstatusornationalorigin.
§ Patientswhosespecificconditionordiseasecannotbesafelytreatedaredivertedortransferredtoanacceptingorganizationonlywhenthetransferassuresthepatientofcontinuousappropriatecare.Therisks,benefitsandalternativeofthetransferareexplainedtothepatient.
§ Patientsaredischargedwhenacceptableguidelinesaremet.
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PatientReferrals/PhysicianArrangementsIndividualandcorporateINTEGRITYshallneverbecompromised.
TannerHealthSystemwillcomplywithfraudandabuselaws, StarkII, privateinurementIRSlawsandanti-kickbackstatute.
TannerHealthSystemprotectstheintegrityofclinicaldecisionmakingregardlessofcompensationorsharedfinancialriskswithitsleaders,managersandclinicalstaffandlicensedindependentpractitioners.
Thehealthsystemprohibitsthepaymentsofremunerationinreturnforthereferralofpatientsortoinducethepurchaseofgoodsorservicestobepaidfororbyanyfederallyfundedprogram—MedicareorMedicaid.TanneralsoprohibitssubmittingfalseclaimsinordertoobtainMedicareorMedicaidreimbursement.
§ Noemployeeshallsolicitorreceivepaymentofanytypeinexchangeforreferringanypersontoanotherforthepurchaseofgoodsorservices.
§ Noemployeeshallofferorgrantanybenefittoareferringphysicianorotherreferralsourceontheconditionthatsuchphysicianorreferralsourcereferoragreetoreferanypatientstothesystem.
§ EverytypeofarrangementthatinvolvescompensationorcrossreferralswithaphysicianorotherreferralsourcewillbereviewedbytheComplianceOfficerorlegalcounselpriortoitsexecution.
§ Alltransactionswithphysiciansmustbeinwriting.
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ConfidentialInformationOurrelationshipswithoneanothershallbefoundedonmutualRESPECT.
Informationregardingprotectedhealthinformation, bids, employmentrecordsandotherbusinessinformationwillnotbesharedwithotheremployeesoroutsideindividuals.
ConfidentialinformationdevelopedoracquiredbyTannerHealthSystemisnotgenerallyavailabletoothers.ItisavaluableassetofTannerandiskeptconfidentialandprotectedagainsttheft,lossorimproperdisclosure.
TannerHealthSystemcolleaguesmustneveruseordiscloseconfidentialinformationthatviolatestheprivacyrightsofourpatients.
§ Privilegedinformationisallinformationthatresultsfromphysician/patientrelationships.§ Protectedhealthinformation(PHI)isanyinformationthatisindividuallyidentifiableand
relatestothepast,presentorfuturephysicalormentalhealthorconditionofapatient.§ Confidentialinformationincludespricingandcostdata,financialdata,strategicplans,
supplierinformation,patientlistsandclinicalinformation.
Confidentialityisatrustvitaltothefreeandcandidcommunicationnecessaryforeffectivepatientcare.Nooneshalldiscuss,discloseorpermitthedisclosureofinformationwhichhasbeendeemedconfidentialunlessitdirectlypertainstotheirjob.§ Verbal,writtenandelectroniccommunicationsmustbeprotected.§ Conversationsregardingpatientsarediscouragedinpublicareasandarenotallowed
outsidethehospital.§ Informationgainedinthetreatmentofapatientisonlysharedwithothersona“needto
know”basis(directlypertainstoone’sjob).Examplesofindividuallyidentifiableinformation:§ Patientname§ Address§ Accountnumber§ Dispositionlocation§ Medicalrecordnumber§ Clinicaldata/diagnosis§ Financialinformation
§ Treatmentinformation§ Demographicinformation§ Picture/imageofpatient§ SocialSecurityNumber§ Dateofbirth/death§ Dateofadmission/discharge§ Telephone/faxnumbers
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Specialcareisgiventomaintaintheconfidentialityofpsychiatric/behaviorhealthtreatment,chemicaldependencetreatment,sexuallytreateddiseasesandHIV/AIDStesting/treatment—allofwhichareprivilegedinformation.AllrequestsforthereleaseofmedicalrecordinformationwillbesenttotheHealthInformationManagement(HIM)Departmentwhereanauthorizationmustbeproperlyexecuted.
§ Confidentialpatienthealthinformationwillbeshredded.§ Passwordswillnotbeshared.§ Confidentialinformationwillnotbeleftunattended.§ Nopatientinformationwillbesentthroughtheinternetwithoutencryption.
Confidentialityconcernsarereportedtoyoursupervisor,thePrivacyOfficerTerriLee,ortheComplianceOfficerValorieComley.
BillingIndividualandcorporateINTEGRITYshallneverbecompromised.
Alwaysbillcorrectlyforservicesrendered.TannerHealthSystembillsthird-partypayersforservicesrendered,andallbillsmustcomplywithbillingrequirementsforgovernment-sponsoredprogramsaswellasotherpayors.
§ Employeeswillexercisecareinassuringtheaccuracyofanyinformation,whetherwrittenororal,providedtoanygovernmentagencyorotherpayer.TannerHealthSystemprohibitsandwillnottoleratefalseinformationbyanyemployeetoagovernmentagencyoranyotherpayer.
§ Allindividualsthatcontributetothemedicalrecordmustprovidecomplete, accurateandtimely information.
§ Deliberatelyprovidingfalseorinaccurateinformationtogovernmentagenciesorotherpayerswill exposeanemployeetocivilandcriminalpenalties, aswellasterminationofemploymentandlossof benefits.
§ Allindividualsinvolvedinpatientcare,billingorcodingmustabidebyourCodeofEthicalBehavior.
TannerHealthSystemwillnotroutinelywaiveco-paymentsordeductibles.Waiversareonlygranteduponanalysisofthefinancialstatusofthepatient.Aspartofourmission,TannerHealthSystemmayprovidefreeorreducedchargecaretouninsuredorunderinsuredpatientswhoareunabletopayfortheseservicesbaseduponsetguidelines.
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FinancialRecordsIndividualandcorporateINTEGRITYshallneverbecompromised.
Keephonestandaccuratefinancialrecords.TannerHealthSystemisresponsiblefortheintegrityandaccuracyofourorganization’sdocuments.Associatesmustensurethatanyfinancialrecordforwhichtheyareresponsibleaccuratelyreflectsalltransactions.TannerHealthSystemhaswrittenpoliciestoensurethatourfinancialactivitiesreflectactualtransactions,areproperlyauthorized,fairlystatedandrecordedinaccordancewithgenerallyacceptedaccountingprincipals.
Documentsmustberetainedinaccordancetothelawandourrecordretentionpolicy.Noonemayremoveordestroyrecordspriortothespecifieddatewithoutfirstobtainingpermission.
Allexpensesdefinedas“non-allowable”costsforMedicare/MedicaidpurposesareexcludedfromreimbursablecostsontheMedicareCostReport.
Marketing, alcoholicbeverages, charitabledonations, civicsponsorshipsandnon-patient carerelatedflowersareexamplesof"non-allowable"Medicare/Medicaidcost.
PersonalUseofTannerHealthSystemPropertyIndividualandcorporateINTEGRITYshallneverbecompromised.
TannerHealthSystempropertyisforbusinessuseonly.TannerHealthSystemisanonprofitorganizationandnoneofitsearningsmayinuretothebenefitofprivateindividuals.Ourresourcesmustbeusedforourmissionofprovidingqualityhealthcareservicesandinacollaborativeeffortwiththecommunitytoprovidehealtheducation,supportservicesandcareforpatients.
Accordingly,propertywillnotbeusedforpersonalreasonsduringbusinesshoursorremovedfromthepremisesforpersonaluse.
§ ImproperuseofTannerpropertywouldinclude,butarenotlimitedto,personaluseofcomputersaswellaspersonaluseofclinical,dietaryorengineeringequipment.
§ Theelectronicandvoicemailsystemmaynotbeusedtosendchainlettersornon-organizationrelatedcommunications.o LimitedandreasonableuseofTannerHealthSystemcommunicationsystemsis
permitted,butusersshouldassumethesecommunicationsarenotprivate.
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o Foul,inappropriate,offensive,abusive,threateningorharassingemailorvoicemailmessages—includingbutnotlimitedtothoseofaracial,religiousorsexualnature—areprohibited.
MarketingandAdvertisingIndividualandcorporateINTEGRITYshallneverbecompromised.
TannerHealthSystem’sservicesandproductswillbeportrayedfairlyandhonestly,stressingtheirvalueandmerits.TannerHealthSystemwillmarketandadvertiseservicesinanon-deceptivemanner,stressingitsvalueandmeritstoeducatethepublic,provideinformationtothecommunityandincreaseawarenessofourservices.
§ Allmarketingmaterialsmustbefactual, easyforthereadertointerpret, andincludenolanguagethatintentionally misleadsthereader.
§ AllcostsassociatedwithmarketingTannerHealthSystem servicesareexcludedfromtheMedicareCostReport.
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ConflictofInterest
IndividualandcorporateINTEGRITYshallneverbecompromised.
EachemployeehasadutyofloyaltytoTannerHealthSystem.Tanner Health System associateswill avoid any actions that involve, or appear to involve, aconflictofinterestwiththeirobligationstotheorganization.
§ AnemployeewillnotrealizeanyprofitorgainasaresultoftheirpositionwithTannerHealthSystemapartfromTannercompensation/benefitprograms.
§ Associateswill notbecome involved innon-TannerHealth System related interestduringworkinghours.
Aconflictofinterestoccurswhenyouractivitiesorpersonalinterests:§ Appeartoinfluenceone’sbusinessdecisions§ AredetrimentaltothebusinessofTannerHealthSystem§ Resultinanimproperorillegalgainforyouorathirdparty
o Non-employedmedicalstaffphysiciansmaycontinuetohavecompetitivebusinesstransactionswithTannerHealthSystem.Thesesituationsareconsideredapartofanormal,healthycompetitiveenvironment.
TannerHealthSystemassociateswhodealwithsupplierswilldosoinareputable,professionalandlegalmanner.§ Donotdisclosepricing, finances, systems ordatatocompetitors/vendors.§ Donotacceptgiftsintendedtoinfluencedecisions.
Behavioral Health Department employees are restricted from conducting intimate, personaland/orfinancialrelationshipsofanykindwiththeirpatientsandtheirfamilieswhohavebeentreatedwithinthreeyearsofthepatient’sdischarge.
GiftsandGratuitiesIndividualandcorporateINTEGRITYshallneverbecompromised.
Usegoodjudgementwhengivingorreceivinggiftsthatareto/fromcustomers,vendors orphysicians.Employeesoftenreceiveacceptablegiftsfromotheremployeesorcolleaguesforappreciationorholidays.TannerHealthSystememployeesmayacceptnon-cashgiftsupto$50fromanyonewithacurrentorpotentialbusinessrelationship.Furthermore,entertainmentmaybeaccepteduptoa$100limitandshallnotincludetravelcosts.§ Cashorgiftcertificates(redeemableforcash)areconsideredinfluencesandarenever
acceptable.
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Employeeswillnotdirectlyorindirectlygive,acceptorsolicitanygifts,gratuities,favors,mealsorentertainmentto/fromanindividual/businesswhomtheassociateknowsorshouldknowbecauseofthenatureoftheassociate’sworkthatcan:
§ Inducereferrals§ Alterorappeartoalterbusinessoutcomesorrelationships§ Influenceorappeartoinfluenceassociate’s/recipient’sjudgementorconduct
onthejob
Acceptablegiftsincludeperishablegoods,promotionalitemsoranoccasionalbusinessmeal.
§ TannerHealthSystemgiftcertificatestoemployeesareacceptable.Theaccountingdepartmentshouldbecontactedpriortoinitiatingadepartmentalgiftinordertodeterminethetaxconsequences(i.e.,employertoemployeeholidaygiftcertificates).
§ Doorprizesareacceptable.
Anti-trustLawsIndividualandcorporateINTEGRITYshallneverbecompromised.
TannerHealthSystemwillnotshareinformationwithcompetitorsaboutmattersthatreducecompetition.TannerHealthSystemrecognizesthatroutinecommunicationswithcompetitorsareappropriateandreasonableinmanyinstances.Communicationwithcompetitorsaboutmattersthatcouldbeperceivedashavingtheeffectofreducingcompetitionwilltakeplaceonlyafterconsultationwithlegalcounsel.Onlylegalandethicalmeanswillbeusedtogatherinformationaboutexistingorpotentialcompetitors.
Associatesmay:§ Notrespondtoanyinquiryorrequestanyinformationfromacompetitorthatdealswith
informationonprices,wages,marketingactivity,acquisitionordevelopmentplansoranyothercompetitiveinformation.
§ Onlycollectcompetitiveinformationfromgenerallyavailableindustrysourcesandfrominformationwithinthepublicdomain.
§ ProvideinformationtothirdpartiessuchasTheJointCommission,agovernmententityorhospitalassociationaslongasitisgatheredconfidentially.
EnvironmentalLawsImprovingQUALITYwillalwaysbeourfocus.
TannerHealthSystemwillprotecttheenvironment.TannerHealthSystemiscommittedtopromotingsoundenvironmentalpracticesthat:§ Preventdamagetotheenvironment§ Enhancehumanandcommunityresources§ Reduceoravoidexposuretoenvironmentalliabilities
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Therearestandardsforthestorage,handling,transportationanddisposalofhazardousandinfectiouswaste.TannerHealthSystemanditsassociateswillcomplywithallfederal,stateandlocalhealthandsafetylawsandregulations,includingtheOccupationalSafetyandHealthAdministration(OSHA).Itisimportantthateachcolleagueimmediatelyadvisehisorhersupervisorofanyseriousworkplaceinjuryoranysituationpresentingadangersocorrectiveactionmaybetaken.
SafetyandHealthImprovingQUALITYwillalwaysbeourfocus.
TannerHealthSystemwillmaintainasafeandhealthfulworkplaceTannerHealthSystemanditscolleaguesareresponsibleformaintainingasafeandhealthfulworkenvironment.Wehaveanongoing,proactivepatientsafetyprogramfortheidentificationofrisktopatientsafetyandtheprevention,reportingandreductionofhealthcareerrors.
§ TannerHealthSystemisanon-smokingfacility.
EqualEmploymentOpportunityOurrelationshipswithoneanothershallbefoundedonmutualRESPECT
TannerHealthSystemwillnotdiscriminateinitsemploymentpractices. Employeeswillbetreatedwithrespect, trustandcompassion.Nopersonwillbediscriminatedagainstbecauseofsuchperson’srace,color,creed,religion,age,handicap,sex,nationalorigin,ancestry,disability,maritalstatus,statusasaVietnamveteranoranyotherfactorprohibitedbyfederal,stateorlocallaw.Thispertainstothefollowingsituations:recruitment,employment,promotion,terminationoranyothertermorconditionofemployment.
Wedonottolerateanyformofharassmentoforbyemployees,patients,membersofthemedicalstafforothers.
§ Harassmentincludesbutisnotlimitedtoslurs,jokesandotherverbal,graphicorphysicalconductrelatingtoanindividualsrace,color,sex,religion,nationalorigin,citizenship,ageorhandicap.
§ Italsoincludessexualadvances,requestsforsexualfavors,unwelcomeoroffensivetouchingandotherverbal,graphicorphysicalconductofasexualnature.
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PaymentstoGovernmentOfficialsIndividualandcorporateINTEGRITYshallneverbecompromised
TannerHealthSystemfundswillnotbeusedforimproperorillegalactivities.EmployeeswillnotmakepaymentsonbehalfofTannerHealthSystemtogovernmentofficialsinordertosecurecontractsorobtainfavorabletreatment.
§ Gifts,favorsorentertainmenttogovernmentofficialsareprohibitedbecausetheymaybeconstruedasattemptstoinfluenceadecision.
EmployeesareprohibitedfromusingTannerHealthSystemfundstocontributetoapoliticalparty,committee,organizationorcandidate.
§ Youmaymakepersonalpoliticalcontributionsofyourownchoice,butsuchcontributionsaremadeonavoluntaryandpersonalbasisandnotsubjecttoreimbursementbyTannerHealthSystem.
GovernmentRequestTEAMWORKisthebasisofourorganizationalstructure.
TannerHealthSystemcomplieswithalllegitimategovernmentrequests.EmployeeswillcooperatewithreasonablerequestsfromanygovernmentagencyconcerningTannerHealthSystem’soperations.TannerrequeststhatyouadvisethedirectorofRiskManagement,ComplianceOfficerorTannerHealthSystem’slegalcounselbeforerespondingtoanyrequeststhatareout-sidetheordinaryscopeofroutineinquiriesmadebygovernmentalauthorities.Ifalawenforcementagentseekstocontactyoudirectly,youareadvisedthat:
§ Youhavetherighttospeakordeclinetospeak,asallsuchconversationsareentirelyvoluntary.
§ Youhavetherighttospeaktoanattorneybeforedecidingtobeinterviewed.§ Youcaninsistthatanattorneybepresent,ifyouagreetobe
interviewed.§ Ifyouagreetobeinterviewed,youwillbetruthfulinallofyouranswers.
DirectorofRiskManagement•patientcarerelatedsituations
ComplianceOfficer•federal,stateandlocallawsandregulations
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ComplianceAcknowledgementIherebyacknowledgeandaffirmthatIreceived,read,understoodandwillabidebytheprovisionsincludedinTannerHealthSystem’s“CodeofEthicalBehavior”booklet.IunderstandtheprovisionsincludedintheCodeofEthicalBehaviorandrealizethatImayasktheComplianceOfficer,PrivacyOfficer,mysupervisororadministrativecontactanyquestionIhaveregardingtherequirements.InconsiderationofmyemploymentorassociationwithTannerHealthSystem,andasanintegralpartofthetermsandconditionsofmyemploymentorassociation,IherebyagreethatIwillnotat any time during my employment or association with Tanner Health System or after myemploymentorassociationends,accessoruseprotectedhealthinformationorrevealordisclosetoanypersonswithinoroutsidetheTannerHealthSystem,anyprotectedhealthinformationexceptasmayberequired in thecourseofmydutiesandresponsibilities inaccordancewithapplicable regulations and Tanner Health System policies governing proper release ofinformation. Furthermore, I understand that it is my responsibility to comply with therequirementsoftheCodeofEthicalBehavior.IalsorealizethatIamrequiredtoreportviolationstomysupervisor,theComplianceOfficer,thePrivacyOfficerortheHotline.IunderstandthatincludesthoseviolationsthatIwitnessmyselforaminformedofbyothers.IamfamiliarwithboththeHotlinetelephonenumber(1.800.648.1507)andthelocationoftheComplianceOfficer(ProfessionalParkBuilding,Suite305).IunderstandthatIwillnotbepunishedforreportingmisconductofanymagnitudeormisconductthatinvolvesanylevelofsystempersonnel.IhavebeeninformedthatImaybedisciplinedforfailingtoreportsuchviolations.Ialsounderstandthatunauthorizeduseordisclosureofsuchinformationwillresultindisciplinaryactionuptoandincludingterminationofemployment/contract/association/appointment,theimpositionoffinespursuantandareporttomyprofessionalregulatorybody.IfurtherunderstandthatmyobligationsconcerningtheprotectionoftheconfidentialityofpersonalhealthinformationrelatetoallprotectedhealthinformationwhetherIacquiredtheinformationthroughmyemployment/contract/association/appointmentwithTannerHealthSystemorwithinanyofthehealthcarefacilitieswithintheTannerHealthSystem.Iunderstandthatmyobligationoutlinedabovewillcontinueaftermyemployment/contract/association/appointmentwithTannerHealthSystemends.
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IcertifythatIhavenotbeenexcludedfromparticipationinanyfederalorstatehealthcareprogram.Ihavenotbeencriminallyconvictedofanycrimeregardingfederalorstatehealthcareprogramsoranyoffenseinvolvingfinancialmisconduct(suchasfraudorembezzlement).
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