standards of conduct · 4 amita health compliance hotline: 855.477.8861 standards of conduct amita...

Standards of Conduct

AMITA Health Compliance Hotline: 855.477.8861

CEO Message

AMITA Health carries out its healthcare ministry consistent with the Adventist Health System and Ascension Health Missions, Visions and Values. Integrity is one of AMITA Health’s Core Values. The essence of integrity is a workplace in which we follow ethical and legal business practices.

The Standards of Conduct describe the behavior and conduct expected of AMITA Health employees; medical staff; Board and Board Committee members; and contractors. The Standards of Conduct are intended to help you respond to questions and situations you may encounter in your daily work. Please read it carefully and consider what it says.

No Standards of Conduct can anticipate every question or substitute for each individual’s sense of honesty and integrity. If you have questions about the Standards of Conduct or

come across any situation which you believe violates the Standards, you should consult your Supervisor, your Facility Compliance Officer or the Compliance Hotline at 855.477.8861 or AMITAhealth.ethicspoint.com. There will be no retaliation for asking questions or reporting possible compliance issues in good faith.

Our commitment to compliance begins and ends with each individual. Thank you for joining us in our shared commitment to the Standards of Conduct.

Mark Frey President & Chief Executive Officer

AMITAhealth.ethicspoint.com 1

Introduction

This booklet details the Mission, Vision and Values of AMITA Health, explains the Standards of Conduct we are responsible for practicing and describes ways for members of our workforce to find help and report ethical and legal issues.

Standard of Conduct DefinitionsThe following words and phrases have the following meanings as used in the Standards of Conduct.

Compliance Hotline is a confidential phone and internet web service for employees to report ethical and legal issues without providing their name.

Contractors are third party organizations with which we do business, such as vendors that provide supplies and services.

Nominal is an amount or value that is less than $10.

Retaliation is a harmful action against an associate in response to the associate asking questions or reporting a concern.

Responsibilities of Employees, Medical Staff, Leaders, Board and Board Committee Members and ContractorsThe Standards of Conduct apply to all employees, medical staff members, Board and Board Committee members, and contractors. You are expected to:

• Review and follow the Standards of Conduct, paying particular attention to those Standards of Conduct that apply to your everyday work responsibilities.

• Ask questions when you are uncertain what to do. See the Reference Guide – Where to Find Help section (on page 9) for additional information on getting your questions answered.

Responsibilities of LeadersLeaders have a role in receiving and responding to questions and concerns raised by employees and others you lead. How you respond to these questions and concerns is key to others having the trust and confidence to bring important matters to your attention.

You are expected to:

• Serve as a role model for our Mission, Vision and Values by carrying out your responsibilities with the highest degree of personal integrity.

• Clearly communicate to others your expectations for the highest standards of ethical behavior.

• Promote a culture of trust, open communication and respect.

• Hold those you lead accountable for behavior consistent with the Standards of Conduct.

• Encourage others to raise issues and concerns so they can be addressed.

• Respond timely and appropriately to issues and concerns brought to your attention and forward concerns expressed by your staff to the Compliance Officer, Human Resources or other appropriate leaders. See section entitled Reference Guide – Where to Find Help (on page 9) for additional information.

• Support our policy of non-retaliation for anyone who raises issues and concerns in good faith.

• Learn and follow applicable laws and regulations that affect your work.

• Ask for assistance when you are unsure how to respond to an issue or concern.

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Introduction

Responsibilities of the Board and Board CommitteesMembers of the Board and Board Committees have a responsibility to be informed and exercise appropriate judgment to:

• Ensure that legal and ethical business practices expressed in the Standards of Conduct guide the decisions you make on behalf of the Health Ministry.

• Disclose any potential Conflicts of Interest and take appropriate actions to address any situations that may appear to interfere with independent judgment or the duty to serve in the best interest of AMITA Health.

• Hold senior leadership accountable for effective policies, procedures and internal control systems that address compliance with laws and regulations and promotion of ethical business practices.

• Respond timely and appropriately to issues and concerns brought to your attention.

The following Standards of Conduct are a foundation for the behaviors that are expected from employees; the Medical Staff; Board and Board Committee Members and Contractors. Each AMITA Health facility may have additional policies and procedures related to specific expectations in the Standards of Conduct. Please consult your facility’s policies and procedures for additional information.


Mission, Vision and Values

MissionTo extend the healing ministry of Jesus

VisionAMITA Health will be a leader in faith-based healthcare in Chicago. We will:

• Be a system of outstanding quality with coordinated and comprehensive care

• Provide holistic care in a highly personal environment

• Partner with patients and families to achieve wellness for all those we are privileged to serve

ValuesGod Honoring• As a faith-based organization we show respect for

God by living justly and in right relationship with God, self, others, and creation.

Justice• We respect and protect the dignity of all people by

working to ensure that conditions in society allow people to reach their fulfillment, especially by providing healthcare to all, with special attention to the poor and vulnerable.

Compassion• Love is expressed in compassion, which includes the

willingness to enter into the suffering of another.

Integrity• Living authentically, our words and actions are

consistent with our identity and mission.

Dignity• We are created in God’s image and likeness as

relational beings. Every person is sacred and of immeasurable worth. Human dignity proclaims our equality and obligates us to respect all persons.

Our Mission, Vision, and Values provide a strong foundation and guidance for the work we do in transforming healthcare in the United States. They serve as a framework for our Standards of Conduct and they reflect our priorities in responding to the care of those in need.



AMITA Health, which includes all service lines, individuals, functions, etc., is committed to high standards of business ethics and integrity that reflect our heritage and values. Each of us has a duty to act in a manner consistent with AMITA Health’s mission and core values. The following six standards provide general guidance to assist you in complying with applicable laws and fostering an environment that promotes and encourages values-based business practices and high standards for ethical behavior.1. Foster an ethical culture 4. Avoid conflicts of interest2. Protect our assets 5. Protect confidential information3. Adhere to regulatory compliance 6. Provide quality of care

STANDARD #1: FOSTER AN ETHICAL CULTURE (Integrity, God Honoring, Justice)We promote a workplace climate that values the uniqueness of individuals. We believe employees, physicians, volunteers, vendors and other business sources (collectively called “you”) should feel valued, respected, listened to, responded to, satisfied and encouraged. We expect you to represent our organization accurately and honestly.

The Standards of Conduct ensure that our activities reflect high levels of integrity and ethical behavior, showing that AMITA Health values ethical decision-making as our normal business practice.

Honest Communication We expect you to communicate with honesty. This includes honesty with coworkers and those we serve. This also means that our marketing and advertising accurately explains our services, level of licensure and accreditation.

STANDARD #2: PROTECT OUR ASSETS (Integrity, Justice, Compassion)We are committed to providing an environment of stewardship conducive to wise and respectful decision making and encouraging the responsible utilization of resources as well as our name. You are responsible for protecting these assets by making careful decisions about how our human, material and monetary resources are used and ensuring that the use of our assets supports our healing ministry.

Internal ControlsAMITA Health is committed to providing accurate and truthful information in all transactions. This commitment is reinforced by internal control standards and procedures developed to ensure that assets are protected and used in accordance with their intended purpose. You are to act within the authority you are given to ensure that financial records and reports are accurate and reliable.


STANDARD #3: ADHERE TO REGULATORY COMPLIANCE (Justice, Dignity, Integrity)We are committed to protecting the integrity of AMITA Health within the marketplace. You are responsible for complying with all applicable regulations, statutes, laws and organizational policies that impact your work.

Compliance with Laws and RegulationsAnyone acting on behalf of AMITA Health is required to comply with all applicable regulations, statutes, laws and organizational policy (collectively referred to as “law”). If questions arise as to the existence or interpretation of any law, you should direct those questions to AMITA Health’s Compliance Department or Legal Department. You are responsible to report promptly to appropriate levels of management and/or your Facility Compliance Officer any suspected or actual violations of law so that timely appropriate action can be taken.

False Claims/Billing and Coding AccuracyFederal and state laws and regulations govern third party billing for our insured patients, clients and residents, and other individuals in our care. You and AMITA Health can be prosecuted for filing inaccurate or fraudulent claims or statements, a practice that carries extremely large civil fines and/or criminal penalties. AMITA Health does not condone and will not tolerate submission of false, fraudulent, inaccurate, incomplete or fictitious claims for payment or reimbursement.

The federal False Claims Act (31 USC 3729-33) imposes civil and/or criminal liability on any person or organization to who knowingly makes a false record or file a false claim with the government for payment.

A person who knows false claims were filed for payment should report it to the Compliance Department so the issue can be resolved. Federal law also permits

individuals to file a lawsuit in Federal Court on behalf of the government. The State of Illinois has a False Claims Act that allows a similar lawsuit in state court for false claims filed with commercial payers for payment. Federal law provides retaliation protections for persons who bring a False Claims Act Lawsuit.

STANDARD #4: AVOID CONFLICTS OF INTEREST (Compassion, Justice, Integrity)AMITA Health is committed to exercising responsible stewardship of natural, human and financial resources as well as its reputation and avoiding conflicts of interest and/or the appearance of conflicts. We expect you to use your position to exercise the best care, skill and judgment for the benefit of AMITA Health and not for personal benefit or to assist others in profiting at the expense of AMITA Health. You should avoid situations that could create an actual or apparent conflict of interest. Actions or relationships that have the potential to create a conflict of interest must be disclosed in advance and approved by the AMITA Health Compliance Department or Legal Department.

Gifts From And/Or To Business SourcesYou may not accept, directly or indirectly, anything of more than a nominal value from any physician, supplier, potential supplier or competitor (collectively referred to as “Business Sources”) of AMITA Health, or from any patient, resident or other individual in AMITA Health’s care. As a general rule, you must adhere to the nominal value limit and any exceptions must be approved by your Facility Compliance Officer. You must not accept anything of value in connection with your position with AMITA Health that would impair your business judgment. This includes but is not limited to gifts, transportation, education, lodging or entertainment provided or received in connection with your job.

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STANDARD #5: PROTECT CONFIDENTIAL INFORMATION (Compassion, Justice, integrity, Dignity)You may see a wide range of information that is confidential, sensitive or proprietary. That includes information that we create and own or that is owned by others and provided to us for limited use. This information may come in many forms, including paper or electronic records, voice mail or personal knowledge. We expect you to maintain a high level of confidentiality relative to this information.

Patient InformationWe expect you to keep patient information confidential and obey Patient Privacy laws and rules. You should prevent the release of any personal or confidential information about a patient unless it is needed for lawful business or patient care. Also, you should not seek personal or private information about any patient if you do not need it to complete your work duties. Access to patient information must be kept within the scope of your duties and responsibilities.

STANDARD #6: PROVIDE QUALITY OF CARE (God Honoring, Compassion, Integrity, Dignity)We are committed to maintaining an environment where we treat everyone with dignity and respect and our hallmark is high quality, holistic healthcare.

Quality of CareWe are committed to the consistent delivery of patient care. Persons will not be discriminated against for reasons of race, color, religion, gender, sexual orientation, national origin, age, disability, payer source or ability to pay. It is our goal to provide service to our patients, residents, and other individuals in our care with skill, concern and compassion. We expect you to be accountable for the quality of care or service we provide and for modeling the service and behavioral standards as set forth in these Standards of Conduct.


Compliance With the Standards of Conduct and Reporting ConcernsIn keeping with AMITA Health’s mission and core values, any person who is involved in or becomes aware of any events, which are, or appear to be, in violation of the standards, shall utilize the following process for reporting concerns:

• Contact your supervisor or a manager within your facility or department to discuss the matter.

• If you do not feel comfortable discussing the matter with your supervisor or in accordance with your normal chain of command or you do not feel the matter was adequately resolved, contact your Facility Compliance Officer.

• If you do not feel comfortable with speaking to an individual in your facility or department or you do not feel your matter has been adequately addressed by anyone you have spoken to, contact the AMITA Health Compliance Department and/or Legal Department. See the list of resources on the back cover.

• If you do not feel comfortable discussing the matter using one of the three alternatives above, call the confidential AMITA Health Compliance Hotline at 855.477.8861 or access the Hotline via the internet at AMITAhealth.ethicspoint.com. The Compliance Hotline is provided by an independent 3rd party and your identity will not be known unless you provide it.

Because some reports may be made as a result of misunderstandings of the facts and circumstances, it is the desire of AMITA Health to have timely knowledge of and investigate any suspected violation in order to avoid further misunderstandings, bad feelings and disrupted relationships when there is in fact no violation of the Standards.

All disclosures, interviews, reports, statements, memoranda or other data concerning a suspected violation shall be confidential except where disclosure is required by law. It is the policy of AMITA Health that an individual, who, in good faith, discloses activities of another that are or appear to be violations of the Standards of Conduct, shall not be subject to retaliation by AMITA Health, its employees and other relevant business sources. This does not imply, however, that disciplinary action will not be taken or considered if the individual reporting has personal involvement in the reported activity.

Alleged violations will be triaged and/or investigated by the AMITA Health Compliance Department. If a violation has occurred, the individual committing the violation will be subject to discipline according to established disciplinary policy, which may lead to suspension, termination or other disciplinary action.


Are My Actions Consistent With AMITA Health’s Mission and Values?

We recognize there are many regulations, statutes, laws, and organizational policy that govern healthcare and the healthcare facility or service line for which you work. Ethics and proper business conduct can sometimes be confusing. When you feel confused about an issue and are unsure of potential ethical implications, we recommend you ask yourself the following questions to lend clarity to the situation.

• Are my decisions based on sound judgment and common sense?

• Are my actions legal?

• Have I exercised good faith and honesty in all dealings and transactions?

• What would I tell my coworker to do?

• Is my decision in the best interest of my organization and AMITA Health?

• Will any part of my decision cause me anxiety?

• At some future date, will I look back and say, “I should have done it differently”?

If you are still unsure of the ethical implications in a situation, use the resources available to you. Talk with your immediate supervisor or contact your organization’s designated Facility Compliance Officer or your CEO (please see the contact details on the back cover). You can also use the AMITA Health Compliance Hotline (855.477.8861/AMITAhealth.ethicspoint.com).

A Process to Determine Whether Actions Are Ethical


AMITAhealth.ethicspoint.com

Reference Guide – Where to Find Help

To further guide you in directing your concerns to appropriate personnel, we are providing a list, which identifies the types of concerns to be handled by the departments/personnel as indicated below. If you have a concern you want to communicate which is not listed here and you are unsure who or what department should handle it, contact your Facility Compliance Officer or utilize one of the contacts listed under the Contacts/Resources portion on the back cover.

Issues handled by Facility Compliance Officer• Compliance Education and Training• Compliance Orientation• Billing-related issues• Improper or incorrect documentation supporting billing• Noncompliance with Standards of Conduct, policies

and procedures adopted as part of the AMITA Health Compliance Program

• Falsification of records• Fraudulent activities• Conflicts of interest issues• Contract-related issues• Disclosures of confidential information• Accountings for disclosures of confidential

information• Other patient privacy issues• Other information security issues• Misuse of assets• Compensation arrangements related to a contract• Contractual relationships potentially involving

referrals of patients/residents• Medically unnecessary services provided to

patient/residents

• Other activities violating any federal, state or local law, statute, regulations, guidelines or rules which govern the healthcare industry

Issues Handled by Safety Personnel/Department• OSHA issues

Issues Handled by Human Resource Personnel/Department• Employee Retirement Income Security Act of 1974

(ERISA) issues• Sexual harassment issues• Equal Employment Opportunity (EEO) and

discrimination issues• Americans with Disabilities Act issues• Illegal drug use issues• Labor relations/union issues• Workplace safety issues• Worker’s compensation issues• Weapons and violence in the workplace or on

workplace premises• Gambling in workplace or on workplace premises• Unexcused absences or repeated tardiness• Compensation arrangements unless related to

a contract• Employee benefits

Issues Handled by Mission Integration/Social Worker/Director of Nursing/Pastoral Care• Patient mishandling• End of Life issues• Organizational ethical issues

All issues identified above are supervised by or handled in conjunction with the CEO of your organization.

If you have any questions regarding the concepts identified within the Standards of Conduct or wish to review your organization’s policies, please contact your organization’s Facility Compliance Officer or the AMITA Health Compliance Department.

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© 2018 AMITA Health 180643

2601 Navistar Drive, Building 2-Compliance Lisle, IL 60532

AMITA Health Compliance Hotline: 855.477.8861 AMITAhealth.ethicspoint.com

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