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Our Values and Ethics at Work OUR VALUES AND ETHICS AT WORK Reference Guide TABLE OF CONTENTS Introduction 1 Requesting and 21 Record Retention 41 Letter from the 2 Accepting Gifts Research 42 and Gratuities President and Corporate Grant Management 42 Responsibility Officer Outside Interests 22 and Activities Medical Research Catholic Health Initiatives 4 Compliance 42 Framework Participation on Outside 24 Boards of Trustees/Directors Institutional Review Introduction to the 6 Boards and Informed Corporate Responsibility Copyrighted, Trademarked 25 Consent 43 Program or Licensed Materials Scientific Integrity 43 How to Use Our Values 8 and Ethics at Work Dealing with Government 26 Research Billing Reference Guide and Regulatory Agencies Compliance 44 Standards of Conduct 10 Documentation Standards 28 Tax-Exempt Status 46 Business and Financial 29 Our Values at Work 47 Applications of the 11 Records Standards of Conduct Credentialed Provider 47 Medical Records 29 Qualifications Anti-Kickback Statute and 12 Stark Self-Referral Law Emergency Medical 30 Exit Interviews 47 Anti-Kickback Statute 12 Treatment and Active Labor Act (EMTALA) Resources 48 Stark Self-Referral Law 13 Environmental 31 Getting Help 48 Antitrust Compliance 14 Responsibility Reporting Concerns 48 Coding and Billing 15 Ethical and Religious 32 Training and Education 49 Directives Confidential Information 16 Consequences of 49 Ethical Behavior 33 Failure to Comply With Patient/Resident 18 Excluded Providers 33 Our Values and Ethics at Information Work Reference Guide Employee Information 19 False Claims Act Policies 34 References 50 Confidential Information 19 Marketing Practices 36 About Our Business Non-Retaliation 36 Acknowledgment and 51 Certification Conflicts of Interest 20 Patient Care and Rights 37 Conclusion 53 Contractor/Vendor 20 Political Activities 38 Contact Information 53 Relations Protecting Our Assets 40 Catholic Health Initiatives is peopl e— people caring for people. There are thousands of individuals across the country working in our organizations and living our mission with the highest standards and integrity, nurturing the healing ministry of the Church. Our Values and Ethics at Work OUR VALUES AND ETHICS AT WORK 1 WHERE WE WORK Our commitment to corporate consistently. Catholic Health responsibility is tied to the dis - Initiatives has created this booklet tinctive culture of Catholic Health to help you understand these laws Initiatives. Each of us helps shape and regulations. This reference that culture by acting in accor - guide describes our standards of dance with our core values and conduct and how to apply them standards of conduct. We all have to your daily work situations. a personal responsibility to behave The examples in this reference ethically and appropriately. guide will help you to understand Health care is a complex industry. the importance of having honesty, Many of the laws and regulations directness and respect in all of that govern health care are diffi - your interactions with patients/ cult to understand and to apply residents and their family 2 Why does Catholic Health Initiatives take corporate responsibility so seriously? Because it is an expression of our core values of Reverence, Integrity, Compassion and Excellence.” “Kevin Lofton, President and Chief Executive Officer Catholic Health Initiatives “At Catholic Health Initiatives, we believe that corporate responsibility begins with personal responsibility and integrity on the part of everyone who works for and with our organizations.” Michelle Cooper, Corporate Responsibility Officer Catholic Health Initiatives members, as well as co-workers possible to cover every situation Sincerely, and business partners. We have in this reference guide. If you included questions posed by are struggling to determine the employees, medical staff and right thing to do in a particular business partners, and we have situation, this booklet has infor - Kevin E. Lofton, FACHE President and Chief Executive Officer provided answers to the ques - mation to help you. tions to help you understand Support for ethical decision- our standards of conduct. making is available to you at A. Michelle Cooper Our Values and Ethics at Work all times. Please call on that Corporate Responsibility Officer Reference Guide is designed support to be confident in your to help you make decisions at decisions as you help shape work, however simple or difficult and strengthen our health they may be. Of course, it is not care ministry. Our Values and etHics at wOrk 3 CATHOLIC HEALTH INITIATIVES FRAMEWORK Where We Want to Be Our Vision is to live up to our name as one Catholic Health Initiatives: Catholic: Living our Mission and Core Values. Health: Improving the health of the people and communities we serve. Initiatives: Pioneering models and systems of care to enhance care delivery. Why We Exist Mission: The mission of Catholic MISS Health Initiatives is to nurture the healing ministry of the Church by bringing it new life, energy and viability in the 21st century. Fidelity to the Gospel urges us to emphasize human dignity and social justice as we move toward the creation of healthier communities. How We Will Measure Our Progress Balanced Scorecards, Dashboards, Cultural Attributes, Surveys and Evaluations 4 What Are Our Guiding Principles? Nearly 700 employees, physicians, partici - pating congregation members and board members 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 follow. Reverence Profound respect and awe for all of creation, the foundation that shapes spirituality, our relationships with others and our journey to God. Integrity Moral wholeness, soundness, fidelity, trust, truthfulness in all we do. ION Compassion Solidarity with one another, capacity to enter into another’s joy and sorrow. Excellence Preeminent performance, becoming the benchmark, putting forth our personal and professional best. How We Live Our Values Standards of Conduct How We Will Get There Our Values and Ethics at Work Reference Guide, Employee Covenant, Employee Competencies, Leadership Development, Core Values Assessments, Distinctive Culture, Strategic and Operational Plans Our Values and etHics at wOrk 5 Introduction to the Corporate Responsibility Program Catholic Health Initiatives is committed to continu - The corporate responsibility program of Catholic ing the healing ministry of the Church by creating Health Initiatives and its organizations provides healthy communities and defending the human resources for making decisions based on our dignity of each community member, especially Catholic identity. These programs help us under - the poor and underserved. Our Catholic identity stand and comply with complex laws and regula - calls us to recognize God’s presence in every man, tions. They are founded on our core values and woman and child. We serve God by caring for those standards of conduct. in need and for each other. Our core values of This reference guide provides a framework for Reverence, Integrity, Compassion and Excellence ethical behavior based on the attributes that provide focus, direction and accountability. define our distinctive Catholic culture. Our cultural attributes call us to: 6 .. .an organization shall promote an organizational culture “that encourages ethical conduct and a commitment to compliance with the law.” 2010 Federal Sentencing Guidelines Manual Ⅲ Create a culture that supports open and Ⅲ Find ways to improve work processes, honest communication. service and care delivery. Ⅲ Exhibit high ethical standards of conduct Ⅲ Create a healing environment that promote doing the right thing. and a collaborative spirit. Ⅲ Cultivate our human, financial and material To support you in making the right decisions and resources as gifts entrusted to us. getting answers to your questions or concerns, Ⅲ Be accountable for our actions and performance. Catholic Health Initiatives has developed a simple Ⅲ Commit to the common good. reporting process, which is detailed on page 48. Ⅲ Share wisdom and knowledge, and develop You are encouraged to use this process as needed individual and organizational potentials. to make the right decisions and to support others in doing the same. Our Values and etHics at wOrk 7 How to Use Our Values and Ethics at Work Reference Guide is Our Values and Ethics at designed to help you do what is right and to ensure that Work Reference Guide your behavior demonstrates our values. At a minimum, this means obeying the law and avoiding improper activities. This reference guide includes examples of how the stan - dards of Catholic Health Initiatives apply to your daily work. These applications are arranged alphabetically by topic for ease of reference. Our Values and Ethics at Work Reference Guide is one of many tools that can help you work in a responsible, professional and ethical way. Other tools and resources include: Ⅲ Local and national policies and procedures, including those specific to corporate responsibility. Ⅲ Compliance reference and guidance documents. Ⅲ Educational offerings, including training in complicated or high-risk areas. Ⅲ Consultation from local and national corporate responsibility officers. Ⅲ Federal and state laws and regulations. Ⅲ Consultation from Catholic Health Initiatives Legal Services Group attorney. Our Values and Ethics at Work Reference Guide
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