Code of Conduct TABLE OF CONTENTS

CEO Message ...... 2 Mission, Vision & Core Values ...... 3 Compliance Program ...... 4 Purpose of Code of Conduct ...... 6 Quality ...... 7 Quality of Care, Patient Safety, Patient Rights, EMTALA Service ...... 9 Communication, Privacy, Security, Wait Times, Etiquette Financial ...... 11 Coding, Billing, Reporting, Fraud & Abuse, Anti-Kickback, Stark People ...... 15 Behavior, Workplace Violence, Health & Safety, License & Certifi cation Renewal, Gift s, Use of Company Resources Reporting Improper Practices & Behavior ...... 20 Acknowledgement Process ...... 23 Workforce Members Acknowledgement Process ...... 24 Conditions of Medical Staff Appointment/Reappointment

—1— A Message from Alan Watson, CEO

Dear Colleague, Our commitment to providing compassionate, excellent service has earned us the respect and trust of our patients and the communities we serve. Patients and their families trust us to provide excellent care and treatment; physicians trust us to provide the tools and support they need to do their important work; and insurance and government payors trust us to provide accurate information. Maury Regional Health takes pride in maintaining this trust by acting with integrity, fairness and honesty in everything we do. Our success is determined by how we earn that trust every day and with every decision. Th at’s why this code of conduct may be the most impor tant piece of company communication you receive. Guided by our values and our mission, this code of conduct sets forth the ethical principles that guide our delivery of patient care and services, as well as the way we conduct business and behave in the workplace. Each and every workforce member of Maury Regional Health plays an important role in maintaining these values and in ensuring the quality of the care we provide to our patients. You must lead by example when it comes to ethics. Make sure the people you work with understand this code of conduct and follow it. We have a responsibility to follow these guidelines every day and in every decision we make. Ask questions about information you do not understand. Report inappropriate or unethical actions and encourage your co-workers to do the same. We will not tolerate any retaliation for reporting unethical behavior. Our mission is clear: “To serve our region with clinical excellence and compassionate care.” We ask that you assist us in achieving our mission by supporting the values and principles set forth in this code of conduct. Sincerely,

Alan Watson, CEO

—2— QUALITY SERVICESERVICE

FINANCIALFINANCIAL

PEOPLEPEOPLE

Mission: To serve our region with clinical excellence and compassionate care.

Vision: Maury Regional Health will be southern Middle Tennessee’s essential, independent health care leader among patients and insurers by 2030. Core Values:

P Patient-centered ...... Provide care with empathy, understanding and compassion R Respect ...... Treat everyone as they wish to be treated I Integrity ...... Do the right thing for the right reason D Dedication ...... Be committed to achieving excellence E Enthusiasm ...... Be positive and friendly

—3— COMPLIANCE PROGRAM

MRH Compliance Committee Th e MRH Compliance Committee is comprised of hospital leaders from various areas who have an Maury Regional Health (MRH) has expressed interest in the success of our compliance a comprehensive compliance program initiative and whose backgrounds, experiences and that promotes ethics and compliance among areas of expertise are relevant to the compliance workforce members at all levels. MRH, when program’s activities. Th e Compliance Committee referenced throughout this document, includes all is primarily responsible for advising and assisting departments, clinics and locations affi liated with the the Director of Compliance in the fulfi llment of following entities: responsibilities and in facilitating the implementation • Maury Regional Hospital of MRH’s compliance program. d/b/a Maury Regional Medical Center • Maury Regional Hospital d/b/a Marshall Medical Center Compliance Department • Maury Regional Hospital Th e Compliance Department’s section on the MRH d/b/a Wayne Medical Center intranet includes additional information regarding • Maury Regional Hospital the Compliance Department and the compliance d/b/a Lewis Health Center program as well as educational materials that can • Maury Regional Medical Group, Inc. be viewed or downloaded at any time, and links to numerous other compliance resources. Th e Compliance Department is available to assist you Program Structure with any questions or concerns that you may have Th e compliance program at MRH is intended to about the numerous laws, rules and regulations that demonstrate the absolute commitment of MRH apply to Maury Regional Health. to the highest standards of ethics and compliance. To promote this commitment, we have established systems, processes and committees to ensure Written Guidelines compliance with governmental laws, rules and regulations as well as to support the system’s ethical MRH policies and procedures, along with this code standards, code of conduct and zero tolerance for of conduct, provide guidance on how to perform fraud and abuse. job responsibilities ethically and legally. As a workforce member of MRH, it is your responsibility to become familiar with and abide by the policies Board of Trustees and procedures that govern your workplace. All While the board of trustees oversees the compliance MRH workforce members are encouraged to review program, the Director of Compliance is responsible all applicable policies and procedures on a periodic for day-to-day administration and management of basis in order to remain up-to-date with our written the compliance program. guidelines.

—4— Ethics is the Foundation of an Effective Compliance Program Many ethical situations are black and white. For Training example, if the law is at issue, we follow the law. But not every situation is clear cut, nor is every situation MRH has established training programs to provide addressed by this code of conduct. When things are detailed information about our compliance pro gram, not clear, here are some things to think about: federal and state false claims acts, fraud and abuse, patient privacy protections and numerous other • Evaluate your facts for accuracy. topics that relate to operating an eff ective compliance • Th ink about the impact of your decision. program. • Handle your decision as if it was going to be reported in the news. Monitoring • Identify the potential consequences of your decision before you take action. Internal and external monitoring systems make • Consider if your decision is setting a it possible for MRH to make certain that written precedent. guidelines and training programs are working to • Stop if you are in doubt and ask for address compliance concerns. Th ese monitoring assistance. systems also provide valuable information on how to improve operations.

—5— THE PURPOSE OF THE CODE OF CONDUCT

Honesty and integrity are core values of our As a workforce member, it is your responsi bility to organization. Th e need to make sound, ethical immediately notify your supervisor and Human decisions has never been greater as we interact with Resources if you are arrested or if you are convicted patients, other health care providers and colleagues. of a crime. In addition, if you become ineligible from It’s not only the right thing to do, it’s necessary for participating in the federal health care programs success now and in the future. Our code of conduct by the Department of Health and Human Services provides guidance to all MRH workforce members or the U.S. General Services Administration, or are and assists us in carrying out our daily activities convicted of a crime that could lead to becoming within appropriate ethical and legal standards. ineligible (such as one related to the provision of health care), you must inform the Human Resources Although the code of conduct is not meant to cover Department or the Compliance Depart ment. every situation you’ll encounter or every detail of our policies, the guidelines on these pages are mandatory. Behavior which interferes with patient care and the Th ey apply to every workforce member, regardless course of business is disruptive. Unaccept able and of classifi cation. Th ey also apply to all of those who disruptive behavior will be addressed according to work on behalf of MRH — physicians, contractors, the appropriate policy and procedure (employee vendors and other health care professionals affi liated and volunteer related), or through the appropriate with us or doing busi ness in our facilities. medical staff committee (physician related). Personal Accountability Leadership Responsibilities All of us are personally accountable for our decisions While all MRH workforce members must follow and actions. We each must follow a course of conduct these guidelines, each MRH leader must be an that preserves and enhances our reputation for example for others in the organization. Our leaders honesty and integrity. To do so, it is critical that are expected to be open to employee concerns about we understand the laws, company policies and ethics and compliance. Th ey need to create a work contractual obligations that apply to MRH. environment in which concerns can be raised and openly discussed. If criticisms or uncomfortable MRH defi nes “acceptable behavior” as that which questions are raised, supervisors and managers must is ethical, legal, conforms to established policies/ welcome the communication, always remembering procedures/code of conduct and demonstrates a that openness is essential to a healthy work commitment to internal/external customers by environment. pro viding excellent service. Behavior that is unethical, illegal, does not conform to policies/ procedures/code of conduct is not acceptable.

—6— QUALITY A Commitment to Providing the Best Possible Patient Care

Th e mission of MRH is to serve our region with mission statement: “To serve our region with clinical excellence and compassionate care. Th e clinical excellence and compassionate care.” Our following standards help us in our goal to achieve commitment is to ensure the continued growth of a “best practices” clinical outcomes and to aid us in our culture of patient safety. Th is can only occur through commitment to provide the best possible patient care. the strong involvement and dedication of our entire workforce. Quality of Care and Patient Safety Our vision and mission identify patient safety as a We provide high quality, cost-eff ective health care to high priority. All workforce members are empowered all of our patients. We treat all patients with warmth, to take whatever action necessary and appro priate to respect and dignity and we provide care that is both make certain that excellent clinical care and service necessary and appropriate. MRH dedicates itself are provided to patients at all times. to continuous quality improvement and patient centered care. MRH focuses on training as well as policies and procedures to achieve quality care and Patient Rights quality outcomes, while at the same time recognizing Upon admission to any facility, our patients have the that the road to quality is full of opportunities for right to expect: improvement. • Equal access to quality care regardless of age, gender, gender identity, sexual orientation, Th e commitment to excellent service and patient disability, race, color, religion or national safety is an obligation of every MRH workforce origin. member. To help us meet our quality and safety • Patient care that is considerate and respectful goals, we establish processes that refl ect the best of his/her personal beliefs and values. practices required or implied by the Conditions • To be informed about and participate in of Participation of the Centers for Medicare and decisions regarding his/her care. Medicaid Services (CMS), the standards and surveys • To participate in ethical questions that arise of Th e Joint Commission, and the ongoing Planetree in the course of his/her care. initiative focusing on patient centered care. In • To designate a decision maker in case one addition, we strive to achieve and maintain magnet is unable to communicate one’s wishes status for various service lines. regarding care. • Personal privacy and confi dentiality of Patient Safety protected health information. Th e vision of Maury Regional Health is to provide • Compliance with a request to transfer innovative care to improve community health to another health care facility. In such by combining value with access and world-class circumstances, the patient is also provided outcomes. Th is is strongly supported by MRH’s with an explanation of the associated risks, benefi ts and alternatives.

—7— Emergency Medical Treatment and Active Labor Act (EMTALA)

In accordance with federal law, MRH is committed If medically necessary, the emergent patient will be to ensuring that patients have access to emer gency admitted to our facility. A patient will be trans ferred medical treatment without regard to their fi nancial only if we do not have the capacity and capability to resources. Any patient who comes to one of our treat him/her or if the patient requests a transfer. In facilities seeking treatment will be given a medical such circumstances, the patient will be transferred to screening examination. If an emergency medical a facility which can provide the required level of care. condition exists, the patient will be given stabilizing A patient is not transferred until he/she is stabilized treatment within the capacity and capability of as much as possible and has been formally accepted the facility. We do not delay a medical screening as a patient by the other facility. examination or necessary stabilizing treatment in order to collect fi nancial and demographic information. Th e immediate needs of the patient always come fi rst.

—8— SERVICE A Commitment to Our Patients and to Each Other

Service Excellence In accordance with HIPAA (Health Insurance Portability At MRH, we continuously strive to improve the services and Accountability Act) standards, MRH will only that we provide to our customers. We are committed to disclose patient-specifi c information to others as we are providing excellent care and service to our patients each allowed to do so by law for patient treatment, billing and every day. We are also committed to treating each purposes or in the course of hospital operations. No other with respect and dignity and we demonstrate these MRH workforce member or other health care partner commitments when we abide by the following standards. has a right to any patient information other than what is necessary to perform his or her job responsibilities. Care and Compassion Care is at the heart of what we do. We must treat our Guiding Principles of Information patients equally and with compassion, understanding Privacy and Security and respect. We never distinguish among them based on race, ethnicity, religion, gender, gender identity, sexual • We comply with all MRH policies and procedures orientation, national origin, age, disability or veteran relating to patient privacy and security. status. We involve them in decisions aff ecting their care. • We safeguard confi dential information from misuse, We obtain their consent for treatment or participation theft or unauthorized access. in research and we explain available options. We never • We use reasonable steps to ensure unauthorized conduct medical procedures unless doing so is in persons do not overhear or see confi dential accordance with good medical practices. information. We do not discuss confi dential information in public areas, (i.e., elevators, stairwells, hallways, coff ee shop or cafeteria.) Patient Communication • We do not access or use confi dential information • Our patients have the right to know the without a work-related need. All patient identity and qualifi cations of all workforce information is confi dential; not only the medical members who provide services for them. information – ALL information. • We provide a variety of resources to our • We do not access our own records or information. patients and their families to educate them Employees are encouraged to use the patient portal about their illnesses and treatment plan. to access information regarding his/her health • We encourage patients to share any records or offi cially request records through the concerns they may have with us. We use this Health Information Management Department. information to improve patient care and • We do not access records or information belonging customer satisfaction. to family members, friends, neighbors, co-workers, high profi le people or celebrities without a work- Privacy and Security related need. We respect our patients by protecting their privacy and • We access, disclose or use only the minimum securing their personal information. We recognize that amount of information necessary to complete the we hold private and sensitive information about our task at hand. patients, and that patients expect this information to • We do not take photographs or videos of patients be kept confi dential. For this reason, we have physical or patient information, nor do we post hospital or and procedural safeguards in place to ensure their patient information on social media. information is protected. Upon registration, we provide • We promptly report any theft , loss or breach of patients with a Notice of Privacy Practices. Th is notice confi dential information to our supervisor or details a patient’s rights and responsibilities regarding his/ Privacy Offi cer. her medical information.

—9— • We interview patients as privately as possible. We Elevator Etiquette knock before entering a room, and close doors or curtains whenever possible. Elevator etiquette can create a favorable impression • We communicate with our patients, their families for our patients, visitors and co-workers. Good and signifi cant others in a private and respectful elevator manners contribute to patient satisfaction. manner. • Pause briefl y before attempting to board an elevator • We respect the privacy of our co-workers by so that you don’t block the way for anyone wishing refraining from gossip. to exit. • We ensure our patients’ dignity by providing • Use the elevator as an opportunity to make a appropriate gowns, sheets or blankets. favorable impression. Smile and speak to fellow • We keep passwords secure and do not share passengers. accounts. Authorized users are responsible for the • Do not discuss patients, their care or MRH business security of their passwords and accounts. on elevators. • We log off all PCs, laptops and workstations when • Use service elevators when transporting patients they are unattended. and equipment. • We always encrypt emails containing patient • When transporting patients in wheelchairs, always information when they are transmitted outside the face them toward the elevator door. MRH network. • Always make sure the way is clear when exiting an • We ensure the appropriate disposal of patient elevator with a patient in a wheelchair or on a bed information. or stretcher. • We take extreme care to ensure that patient • Do not allow the patient to be surrounded by other information is not mailed, emailed or faxed to visitors or employees. Politely ask the others to wait wrong parties. for another elevator. • We do not leave patient information in any format • Be considerate of a patient’s condition prior to unattended in public areas. entering the elevator. Th e presence or aroma • Only the minimum necessary information needed of food, perfume, etc., may be unpleasant to a to complete the task at hand is used, accessed or patient and have an adverse aff ect on the patient’s disclosed regardless of the extent of user access condition. provided. • Once on an elevator, if suffi cient room is available for others, hold the door or “door open” button for Patient Waiting them. We recognize that our patients’ time is valuable. We strive to provide our patients with prompt service, always keeping them informed of delays and making them comfortable while they wait. • If there is a delay in service, thank the patient for waiting, apologize for their inconvenience and determine the best way to meet their needs. In such situations, patients should be updated frequently. • Educate patients and families about the process. Th ey need to know that procedures generally do not begin as soon as patients enter the area. • Our patients’ families are as important to us as our patients. Update family members periodically while a patient is undergoing a procedure. • Provide a comfortable atmosphere for waiting patients and family members.

REMEMBER: “If our patients wait, we update!”

—10— FINANCIAL FINANCIAL A Commitment to Conduct Business in an Ethical and Financially Responsible Manner

In order to provide the best possible any billing discrepancies. Staff assigned to work in quality care to our patients, we must billing and coding areas are expected to understand produce the fi nancial re sources required to and comply with all billing-related policies and support our mission. Th erefore, we are committed procedures established by Medicare, Medicaid, and to conducting business in an ethical and fi nancially other payors to which claims are submitted. responsible manner. Any subcontractors engaged to perform billing or Documents and Records coding services on behalf of MRH are expected to have the necessary skills, quality control processes, Each MRH workforce member is responsible for systems and appropriate procedures to ensure all the integrity and accuracy of our organization’s billings for government and commercial insurance documents and records, not only to comply with programs are accurate and complete. regulatory and legal requirements, but also to ensure records are available to support our business practices and actions. No one may alter or falsify information Relationships with Payors on any record or document. Records must never be We must provide government agencies and other altered or destroyed in an eff ort to deny authorities payors with truthful and accurate information information that may be relevant to an investigation. in all written and oral statements. Anyone who documents in the medical records in our facility Medical and business documents and records are must provide complete and accurate information retained in accordance with the law and our record in a timely manner. Inaccurate or false statements retention policy. Medical and business documents to a government agency or other payor will not be include paper documents (letters and memos, etc.), tolerated. computer-based information (email, computer fi les, etc.), or any other medium that contains information Proprietary Information about the organization or its business activities. It is important to retain and destroy records only in ac- Th e term “proprietary information” refers to cordance with MRH policy. We are not to use patient, information about our organization’s strategies employee or other information to derive personal and opera tions as well as patient information and benefi t (identity theft ). third party information. Proprietary information is anything related to MRH’s operations that are not publicly known, to include personnel data, patient Coding and Billing fi nancial information, passwords, pricing and cost MRH is committed to making sure that the bills data, fi nancial data, strategic plans and marketing we submit for payment are complete and accurate. strategies and techniques. Improper use or disclosure We will only bill for services which have been of proprietary information could violate our legal properly documented as medically necessary, which and ethical obligations. Workforce members may have been provided and which support the level of use proprietary information only as necessary to services billed. Services will not be misrepre sented perform their job responsibilities and will not share to circumvent coverage limitations or to maximize such information with others unless the individuals reimbursement from third party payors. MRH takes and/or entities have a legitimate need to know the reasonable steps to ensure that billing and coding information in order to perform their specifi c job are accurate and timely, and we will investigate duties or carry out a contractual business relationship.

—11— Financial Reporting hospital administration or immediate supervisor). Any individual who reports known or suspected MRH is committed to ensuring that all of its fi nancial wrongdoing shall be protected from retaliation as reports and records are accurate and complete and discussed below. Furthermore, it is our policy that in conform to generally accepted accounting principles. instances where credible evidence of misconduct is MRH maintains a system of internal controls and obtained, we shall take appropriate corrective action procedures to provide reasonable assurances that immediately. all transactions are executed in accor dance with management’s authorization and are recorded in a Defi nitions: proper manner so as to maintain ac countability of the organization’s assets. Fraud – A deception deliberately practiced in order to secure unfair or unlawful gain. As it relates to Relationships with Vendors and the False Claims Act, fraud is defi ned as knowingly or intentionally making false statements in order Subcontractors to receive some benefi t or payment for which no If you deal with suppliers, you should do so in entitlement would otherwise exist. a reputable, professional and legal manner. We promote competitive purchasing to the maximum Abuse – Excessive and wrongful misuse of anything. extent possible. We select products or services based As it relates to the False Claims Act, abuse would solely on business criteria, including quality, price, include providing services that are inconsistent with delivery, technical excellence, availability, service established, sound medical practices, or practices and maintenance of adequate sources of supply. that result in unnecessary costs to the Medicare or Purchasing decisions should not be based upon per- Medicaid programs. sonal relationships or compensation paid to the individual making the selection. In accordance with Whistleblower – One who reveals wrongdoing our no gift policy, you should not accept anything of within an organization to the public or to those in a value from suppliers or potential suppliers. position of authority. An employee who has inside knowledge of illegal activities occurring within his/ We also expect the people and companies that work her organization and reports the wrongdoing to the on our behalf to maintain our high standards. If you public. Th e False Claims Act provides protection work with contractors, it is your responsibility to from retaliation for whistleblowers as detailed below. make these companies and their employees aware of our compliance program. All vendors are provided Federal False Claims Act – Th e Federal False with information regarding our com pliance plan via Claims Act (FCA) was established to punish persons the check-in kiosk in the main lobby. or entities that fi le false or fraudulent claims for payment with federal government agencies. Th ese When faced with a diffi cult situation, it may help to laws apply to all kinds of claims for payment from ask yourself these questions: the federal government, not just health care claims. • Are my actions legal? Generally, the FCA is violated when a service • Am I being fair and honest? provider, either knowingly or recklessly, allows the • Will my actions stand the test of time? fi ling of false or fraudulent claims for payment to government programs such as Medicare and/or Medicaid. Billing errors are not false claims so long STATEMENT ON FRAUD as they are promptly corrected when found and AND ABUSE refunds are processed appropriately. Violations of the False Claims Act may result in treble damages plus It is the policy of MRH to encourage and require mandatory fi nancial penalties ranging from $11,000 all workforce members to report known or to over $21,563 per claim and exclusion from the suspected wrongdoing (more specifi cally fraud, Medicare and/or Medicaid programs as detailed waste, or abuse) to the Director of Compliance or below. through other appropriate means (for example: the Compliance Reporting Hotline, the intranet,

—12— Tਅ਎਎ਅਓਓਅਅ Fਁ਌ਓਅ C਌ਁਉ਍ਓ Aਃਔ – Tennessee’s False • Claiming payment from federal programs Claims Act established liability for presenting false for services that are not medically necessary claims and is very similar to the Federal False Claims or not authorized by the physician or Act. Under the act, Tennessee may impose penalties practitioner who is treating the patient. of up to three times the amount of damages sustained • Failing to have in place reasonable business by the government if there is a fi nding of a violation practices to process and fi le accurate claims of the Tennessee False Claims Act. Th e state may also for payment, resulting in the fi ling of impose a civil penalty between $5,000 and $25,000 inaccurate or misleading claims. for the submission of false claims. • Billing Medicare or Medicaid substantially in excess of usual and customary charges. Our code of conduct requires that all workforce • Filing false or erroneous cost reports. members report known or suspected wrongdoing. Reports can be made to the compliance offi cer, Violations by a health care provider of other laws, hospital Administration, or the workforce member’s such as the Anti-Kickback Statute and the Stark Law, immediate supervisor. Reports can also be made may form the basis for an FCA action. anonymously to the Compliance Reporting Hotline at 800.905.5190; or through the intranet. Failure Another important feature of the FCA is the qui to report known or suspected wrongdoing is a tam provision, or whistleblower statute. Under violation of our code of conduct and may result in this provision, individuals are allowed to fi le suit disciplinary action up to and including termination on behalf of the federal government if they have of employment. independent knowledge of illegal activity including fraud and/or abuse. With regards to fraud, waste and abuse: Th e Defi cit Reduction Act requires that any provider that receives Whistleblower actions are fi led under seal (“in more than $5 million annually from the Medicaid camera”) and remain secret for at least 60 days while program must implement policies and procedures the government decides if it wishes to intervene. If for detecting and preventing fraud and abuse. Th ese the government decides to intervene, it will take over eff orts must include workforce education which has the case and prosecute the wrongdoing or settle the been incorporated into our compliance program, new charges. If the government refuses to intervene, the hire orientation and annual compliance training. qui tam relator (whistleblower) may go forward with the prosecution at his/her own expense as long as the In addition, Medicare Part C (Medicare Advantage/ government does not object. Medicare Managed Care) and Medicare Part D (Medicare Prescription Drug Benefi t) both require In cases where the government intervenes, the that health care providers implement policies and whistleblower is entitled to between 15% and 25% procedures that are designed to detect and prevent of the recoveries as a reward for coming forward. In fraud, waste and abuse. Our compliance program cases where the government refuses to intervene and contains all of the necessary elements for an eff ective the whistleblower moves forward on his/her own, the fraud, waste and abuse prevention program as whistleblower is entitled to between 25% and 30% outlined in the Medicare Prescription Drug Benefi t of the recoveries. Of course, if an action is brought Manual Chapter 9. by an individual who participated in the illegal activity, then the court may reduce the award to the Examples of FCA violations can include: extent that it feels is appropriate. If the individual is convicted of an off ense resulting from his/her Filing or contributing to the fi ling of a false • involvement in the activity, then the individual shall claim for payment. not receive any share of the recoveries. • Intentionally making or using false records or statements to support a claim. Whistleblowers are protected from retaliation • Seeking reimbursement at a higher code under the FCA which states,“any employee who or level than is appropriate for the service is discharged, demoted, suspended, threatened, provided or “unbundling” claims for services harassed, or in any other manner discriminated that are required to be billed on a bundled against by his/her employer because of lawful basis. whistleblower actions shall be entitled to all relief

—13— necessary to make the employee whole…” Remedies Stark may include two times back pay plus interest, reinstatement at the same level with the same Th e Stark Law is a federal law that prohibits seniority, plus legal fees and any other costs incurred physicians from referring Medicare patients for by the employee as a result of the discrimination. certain types of services, known as “designated health services”, to an entity if the physician or an immediate Any individual making a good-faith report of family member of the physician has a direct or wrongdoing at MRH shall be protected from all forms indirect fi nancial interest in the entity providing of retaliation. Intentionally making false allegations such services unless the requirements of a specifi c of misconduct will not be tolerated and may result exception under the Stark Law is met. in disciplinary action including termination of employment. To ensure compliance with this law, MRH requires that all compensation agreements with physi cians In an eff ort to prevent and detect fraud and abuse, we be put in writing. Contracts must be submitted for have implemented a compliance program containing legal review before the agreements are fi nalized. Any all of the essential elements of an eff ective compliance questions or concerns about whether a particular program as outlined in the Federal Sentencing arrangement is permissible under these laws should Guidelines and the Prescription Drug Benefi t Manual be directed to the Compliance Department. Chapter 9. In addition, we have implemented billing edits and routine monitoring activities designed to Physician Recruitment detect claim errors and/or fraudulent activities. Th e recruitment of physicians and acquisition of All workforce members are required to complete physician practices requires special care to comply annual compliance training to obtain updated with fraud and abuse laws, the Stark Law and Internal information regarding the compliance program, Revenue Services rules governing MRH’s tax-exempt regulatory changes, and updates regarding the status. Each recruitment package or acquisition prevention of fraud, waste and abuse. should be in writing and consistent with policies established by MRH. All workforce members are reminded of their obligation to report any and all known or suspected Physicians are not required to refer patients to MRH, wrongdoing. Failure to report known or suspected and physician compensation or support is not related wrongdoing is a violation of our code of conduct and to the volume or value of referrals. Since physician may result in disciplinary action up to and including recruitment and practice acquisitions present special termination of employment. issues, all such activities need to be reviewed by legal counsel. Anti-Kickback Th is federal law prohibits providers from knowingly or willfully soliciting or accepting anything of value directly or indirectly for referrals of Medicare or Medicaid patients. A violation of this prohibition can result in imprisonment, civil fi nes and exclusion from the Medicare and Medicaid programs.

We should never give or off er anyone something of value with the hope or intent to induce referrals or as a reward for referrals. Th e “something of value” doesn’t have to just be money. It can also be services, gift s, entertainment or anything else that would be attractive to a recipient.

—14— PEOPLE A Commitment to Ethical Conduct

MRH strives to create an environment that draws and nurtures the best people possible to provide the Inappropriate best care possible to our patients. Workforce members Disruptive Behavior are expected to read and familiarize themselves with Inappropriate behavior means conduct that is unwarranted applicable policies, procedures and bylaws, as they contain and is reasonably interpreted to be demeaning or off ensive. more specifi c information. Persistent, repeated inappropriate behavior can become a form of harassment and thereby become disruptive and Positive Work Environment subject to treatment as disruptive behavior. Examples of inappropriate or disruptive behavior include, but are not Each MRH workforce member has the right to work limited to, the following: in a positive environment. We do not tolerate conduct that disrupts our work environment, including behavior • Belittling or berating statements; that is disrespectful, hostile, intimidating, threatening • Name calling; or unprofessional. Professional behavior creates an • Profane or disrespectful language; environment that promotes safe and high quality patient • Outbursts of anger; care and engenders a constructive learning environment. • Racial or ethnic jokes; For this reason, it is the policy of MRH that all workforce • Criticizing other caregivers in front of patients or members conduct them selves in a professional manner; other staff ; refrain from engaging in inappropriate or disruptive • Comments that undermine a patient’s trust in behavior and resolve confl icts in an appropriate manner at other caregivers or the facility; all times. • Comments that undermine a caregiver’s self- confi dence in caring for patients; • Inappropriate comments written in the medical Examples of Professional record; Behavior • Blatant failure to respond to patient care needs or staff requests; • Clearly identifi es one’s self to patient • Deliberate lack of cooperation without good cause; and staff ; • Deliberate refusal to return phone calls, pages, or • Maintains a clean, neat appearance; other messages concerning patient care or safety; • Maintains composure; • Intentionally degrading or demeaning comments • Treats co-workers and patients with dignity and regarding patients and their families, nurses, respect; physicians, volunteers, facility personnel/and or • Collaborates with other members of the health the facility; care team and treats them with respect; • Intimidating behavior that has the eff ect of • Answers questions and explains the patient’s suppressing input by patients or other members of plan of care to patient, family (with patient’s the organization; permission) and health care team members; • Physical or verbal intimidation or challenge, • Respects cultural and religious diff erences including disseminating threats or pushing, of others; grabbing or striking another person involved in • Is truthful in verbal and written communications; the facility; • Communicates diff erences in opinion and good faith criticism respectfully in the appropriate forum; • Is on time for meetings and appointments.

—15— • Physically threatening language directed at anyone in the facility including physicians, nurses, Alcohol and Drugs other staff members or any facility employee, in the Workplace administration or member of the board of trustees; MRH is committed to providing and fostering a safe • Physical contact with another individual that is work environment and the well-being and health of its threatening or intimidating; workforce members and patients. Th is commitment is • Th rowing instruments, charts, or other things; jeopardized when anyone uses drugs and alcohol on or off • Th reats of violence or retribution; the job, comes to work under their infl uence, possesses, • Sexual or other forms of harassment including, but distributes or sells drugs in the workplace, uses alcohol in not limited to, persistent inappropriate behavior the workplace, or allows the use of alcohol to aff ect them and repeated threats of litigation; while at work. • Retaliation against patient, visitor, or other member of the organization team who has You are prohibited, while on duty or on facility property, reported an instance of violation of the code from being under the infl uence of alcohol and/or of conduct or who has participated in the illegal drugs or from being impaired by excessive use of investigation of such an incident, regardless of the prescription or over-the-counter drugs. Moreover, you perceived veracity of the report. may not possess, sell, solicit, or receive alcohol or illegal drugs while on duty or on hospital property. Th e violation If you experience or observe any form of inappropriate of this policy will result in immediate action. or disruptive behavior, you should immediately report the incident to a supervisor, the Human Resources MRH reserves the right to require employees, physicians Department, the Compliance Department or call the and volunteers, while on duty or while on hospital Compliance Reporting Hotline at 800.905.5190. property (including parking lots), to agree to inspections of their persons, lockers and personal property. If any employee, physician or volunteer withholds consent to Workplace Violence such an inspec tion, the hospital may take appropriate We are committed to maintaining a violence-free work action. environment. Workplace violence includes criminal acts, robbery, violence (actual or threatened) directed at Controlled Substances anyone, intimidation, stalking, terror ism and hate crimes. No fi rearms or other weapons, including explosive devices Prescription and controlled medications and supplies must or dangerous mate rials, are allowed on the premises, be handled properly and only by authorized individuals except when possessed by law enforcement offi cers on to minimize risks to workforce members and to patients. duty. If you be come aware of inadequate security of drugs or controlled substances or the diversion of drugs from the Health, Safety and organization, it must be reported immediately. Environmental Laws License and Certifi cation MRH is committed to complying with all federal, state Renewals and local health, safety and environmental laws. MRH workforce members are responsible for ensuring that we MRH workforce members are required to maintain all comply with these laws, including laws regarding: credentials, licenses and certifi cations that are necessary • Handling and disposal of infectious materials to perform their job. MRH does not hire, contract with or • Use of medical equipment bill for services rendered by persons or entities excluded • Use of personal protective equipment to prevent from participating in the federal health care programs the spread of infectious diseases by the Depart ment of Health and Human Services or • Storage, security, handling and disposal of the U.S. General Services Administration. If you become hazardous materials ineligible for participation in federal health care programs or are convicted of a crime that could lead to becoming Please notify your supervisor immediately if you become ineligible (such as one related to the provision of health aware of a condition or situation that pre sents a danger or care), you must inform the Human Resources Department may be in violation of health and safety standards. or the Compliance Department. You must also inform the Human Resources Department or the Compliance Department of any lapse in credentials, licenses or certifi cation re quired to perform your job.

—16— • Th ere are laws and regulations governing political Confl icts of Interest contributions and gift s to elected offi cials and MRH wants to make certain that business decisions gov ernment employees. Th erefore, we will not are made objectively and free from improper or undue commit to any political contribution or gift on infl uence. All potential confl icts of interest must be behalf of MRH before fi rst consulting with the disclosed. A confl ict of interest may occur if a workforce Compliance Department. member’s outside activities, outside employment, personal fi nancial interests, or other personal interests Receiving Gift s infl uence or appear to infl uence his or her ability to make objective decisions in the course of the employee’s job • MRH has adopted a “no-gift ” policy. To avoid a responsibilities. A confl ict of interest also may exist if the confl ict of interest, the appearance of a confl ict demand of any outside activities hinder or distract an of interest, or the need for our employees to employee from the performance of his or her job or cause examine the ethics of acceptance, our company the individual to use MRH resources for other than MRH and its workforce members do not accept gift s purposes. from vendors, suppliers, customers, potential employees, potential vendors or suppliers, Examples of possible confl icts of interest include: patients, or any other individual or organization, under any circumstances, unless an exception • Being employed by a competitor or potential com- applies as outlined in the MRH policy “Gift s, petitor while employed by MRH. Gratuities and Business Courtesies to Employees.” • Requesting or accepting anything of substantive Gift s and business courtesies mean any item of value in exchange for, or as a result of, services value, including but not limited to: cash of any performed in the course of employment. amount, gift certifi cates, loans, or promotional • Conducting business on behalf of the hospital with items (e.g., pens, hats, t-shirts, key chains, any company in which you or a member of your calculators, notepads, coff ee mugs, etc.) given family has a fi nancial or personal interest. out on campus or at any MRH location, fl owers, food and beverage (e.g., lunch, box of chocolate, If you have any questions about whether an activity might wine) discounts or other favorable terms other constitute a confl ict of interest, you must obtain the than those generally available to the public, written approval of your supervisor before pursuing the entertainment tickets, golf-related items, stocks or activity or immediately upon identifi cation of the possible other securities, or other tangible items of value. confl ict of interest. Gifts and Entertainment Computer, Email and Internet All communication systems in our facilities, including MRH workforce members must remember that the phone systems, voice mail, internet access and federal Stark law governs all business relationships with email are company property and are to be used for physicians and that the federal anti-kickback statute and business purposes. You should assume your personal other laws restrict the giving or receiving of anything communications on company owned or maintained of value to induce the referral or recommendation of systems are not private. Confi dential patient or federal health care program business. In order to promote organization information should never be sent outside compliance with these laws, MRH policies and procedures the MRH network via email or other unencrypted mobile provide guidelines on the giving and acceptance of gift s. device. We never off er, give or accept bribes or kickbacks. If in doubt, ask fi rst! Employees must refrain from sending confi dential patient or organization information through email. Providing Gift s and Entertainment Information Technology provides encrypted email service • We never provide gift s or entertainment if a law for employees who need to send sensitive information or the policy of the recipient prohibits it. Nor through email. Confi dential patient or organization do we provide gift s or entertainment in order to information should not be included in the subject line of induce referrals or as a reward for referrals. Gift s an email. Designating an email for encryption can be done to potential referral sources must be reasonable, in one of two ways: occasional and in accordance with the MRH 1. Put either Marked for Secure Delivery or Mark policy on “Extending Business Courtesies to for Secured Delivery in the subject line. Th is Potential Referral Sources.” If the recipient is not a will work using Outlook or the Outlook Web potential referral source, any gift or entertainment Application (Webmail). Th is is the preferred must be small enough in value so that the method. recipient will not be improperly infl uenced.

—17— 2. When using Outlook – in the email message, select Options and then click the small square Giving Directions and Information with the arrow pointing down to the right near Observe customers and visitors. If someone appears to Tracking. Th e Message Options dialog box need directions, off er to help. Let customers know that you will appear. Select the dropdown list next to will help them to their destinations. If you are unable to Sensitivity. Select Confi dential. Click Close. personally escort a customer, take him or her to someone Note: When using Webmail, in the email who can. message, click the 3 dots (…) to the right of Insert. Next click Show Message Options…Click Communication the dropdown list below Sensitivity and select Confi dential. Click OK. Th e goal of communication is understanding. We must be committed to listening attentively to our internal and We should not use any communication system to post, external customers in order to fully understand their store, download or transmit any illegal, threatening or needs. We must pay close attention to both verbal and obscene material. We should not use MRH resources to nonverbal messages. distribute false materials. Do not use communication systems to send or solicit chain letters or spam and do not Our messages should be delivered with courtesy, clarity violate copyrights. MRH reserves the right to periodically and care. Speak in terms that the customer can easily access and monitor company communication systems. understand. We must avoid communicating negatively (i.e. Anyone who abuses our information systems or uses them gossip, malicious and/or vi cious statements, etc.) excessively for non-business purposes will be subject to corrective action. Greetings and Introductions • Introduce yourself promptly with a warm and Personal Use of Company friendly smile. Resources • Use “please” and “thank you”, “sir” and “ma’am” in all conversations when appropriate. Other terms We are all responsible for using company resources of endearment such as “honey”, “sweetie”, etc., are and assets wisely, including time, materials, equipment, inappropriate in the work place. supplies and information. Th ese resources are to be • Listen to your customers’ concerns attentively, maintained and used for business purposes only. Th e showing them you care. use of company assets for personal fi nancial gain is not allowed. Written approval must be obtained from your supervisor prior to the use of company assets for Telephone Etiquette charitable reasons. • Answer all telephone calls promptly, (within three rings whenever possible), in a courteous, Attitude professional manner. At MRH, we believe that we are here to serve our • In answering calls, identify your department and customers. We are committed to providing excellent yourself and off er assistance to the caller. Speak service in meeting our customers’ needs with the utmost clearly. courtesy and care. • When transferring a call, fi rst provide the caller with the correct number in case the call is lost. Th is commitment must be refl ected in our behavior. • Get the caller’s permission before putting him or • Promptly welcome customers in a friendly her on hold. Th ank the caller for holding when manner, smiling warmly and introducing yourself. you return to that line. • Listen carefully to what our customers have to say. • If you answer or place a call on speakerphone, Avoid interrupting people. inform the other person on the line that you have • Rudeness is never acceptable. them on speakerphone and if anyone else is in the • Meet the customer’s immediate need or gladly room with you listening to the conversation. take him or her to someone who will. • Acknowledge callers on hold periodically, report • Apologize for problems and inconveniences. the status of their calls and ask if they want to • Th ank our customers for choosing MRH. continue to hold. • Exceed our customers’ expectations. • Place phones on voice mail only when necessary. • Recognize that our customers have a sense of Keep recorded voice mail messages short and to urgency and show them we value their time. the point. Avoid leaving complex messages. • Return calls promptly. • End calls in a courteous manner by saying, “thank you”, “goodbye”, etc.

—18— Email Etiquette Commitment to Our Colleagues Electronic email is a convenient and effi cient means MRH workforce members are linked to one another of communication. However, there are some special by a common purpose—serv ing our patients and our considerations to keep in mind when utilizing email. community. As workforce members, we have obligations Email is not private. Email is considered company to one another. Without everyone’s contributions, we property and can be retrieved, examined and used in a could not perform our responsibilities to the fullest. court of law. A rule of thumb: compose email as if it will show up on the front page of the daily paper. Make new employees feel welcome to MRH by being supportive and off ering help. • Limit the length of the email. • Avoid using ALL CAPITAL LETTERS. Th e reader MRH workforce members are encouraged to address may feel that you are SHOUTING at them. problems by speaking with the appropriate supervisor, • Treat email as confi dential. Do not forward the or by contacting Human Resources or the Compliance messages without the knowledge of the author. Department. • Th ink before you send. If a message generated emotion, read it again and re-assess the message. • When necessary, break the cycle of SEND and RESPOND. Pick up the phone. • Do not manage by email. While email is a useful tool, it is not meant to replace face-to- face communication between supervisor and employee. • Be diplomatic. Criticism is always harsher when written. • Be calm. You may have misunderstood what was meant. Don’t reply while you are still angry. • Be brief. When replying to a message, you don’t have to include the entire text of the original message. Include just enough to give the context of your response. • Watch out for viruses in attached fi les. Attached fi les are a common way to spread computer viruses. • Be professional. Only send/reply email to a person or group who have a “need to know” relating to email content. • Use correct spelling and grammar. Use a dictionary or spell checker. Pay attention to rules of grammar. • Don’t forward chain mail or unsolicited “junk mail” or “spam.” It slows down the network and is a waste of valuable time and is a policy violation.

—19— REPORTING IMPROPER PRACTICES AND BEHAVIOR A COMMITMENT TO INTEGRITY

While ethics and compliance can be complex and You should also report incidents that could confusing, our commitment to doing the right thing potentially harm patients or co-workers. is not. We do the right thing - ALWAYS! Examples would include: • On-the-job substance abuse Personal Obligation to Report • Stealing or accepting bribes or kickbacks We are committed to ethical and legal conduct • Using company resources for personal use or that is compliant with all relevant laws and gain Accepting entertainment, gift s and gratuities regulations and to correcting wrongdoing • Violating internal accounting controls whenever and wherever it may occur in the • Being asked to lie to cover another employee’s organization. Each MRH workforce member has • mistake an individual responsibility for reporting any Using a company computer to send activity that appears to violate applicable laws, • inappropriate email rules, regulations, and accreditation standards of Improperly retaining or disposing of medical practice, Federal Healthcare Conditions • company records of Participation, or this code of conduct. • “Covering up” any violation of this code of conduct You should report actions that confl ict or appear to confl ict with this code of conduct, MRH Report suspicious or questionable behavior even policies or our commitment to provide high if you’re not sure there is a problem. Sometimes quality health care in an ethical manner. Some a small detail of a situation is discovered to be examples would include: part of a much larger problem. It’s important to • Admitting or keeping a patient in the facility remember that even the appearance of a confl ict for reasons other than medical need. of interest or a violation can be serious. If you • Paying professionals to refer or admit doubt the issue/concern has been given suffi cient patients. or appropriate attention, you should report the • “Upcoding” or billing for services not matter to a higher level of management or the provided. Compliance Department until you are satisfi ed • Providing services in violation of federal or the full importance of the matter has been state regulations. recognized. • Using accounting practices in violation of MRH policies and/or laws. Leadership Responsibilities • Allowing a vendor’s gift to infl uence a While we are all obligated to follow our code business decision. of conduct, we expect our leaders to set the • Disclosing confi dential information. example. We expect everyone in the organization • Harassing or discriminating against others. with supervisory responsibility to exercise that • Engaging in any activity that involves a responsibility in a manner that is kind, sensitive, confl ict of interest. thoughtful and respectful. We expect each

—20— supervisor to create an environment where all Non-Retaliation for Reporting team members feel free to raise concerns or propose ideas. Retaliating against someone for raising a good faith concern, for calling the Compliance We also expect that supervisors and managers Reporting Hotline or for cooperating with an will ensure those on their team have suffi cient investigation is strictly prohibited. Retaliation is information to comply with laws, regulations and defi ned as an action taken in return for an injury policies, as well as the resources to resolve ethical or off ense. Claims of retaliation are taken very dilemmas. Th ey must help to create a culture within seriously and if proven, will result in corrective MRH that promotes the highest standards of ethics action. and compliance. Th is culture must encourage everyone in the organization to share concerns when Internal Investigations of Reports they arise. We must never sacrifi ce ethical behavior in the pursuit of business objectives. We are committed to investigating all reported concerns promptly and confi dentially to the fullest extent possible. If MRH initiates an Compliance Reporting Hotline investigation to determine whether there has been 800.905.5190 illegal or unethical conduct, you must cooperate with the investigation and disclose all information Th e Compliance Reporting Hotline is a and records of which you are aware that are confi dential telephone line to report ethics and relevant to or will assist in the investigation. compliance concerns or to ask questions about Failure to cooperate with an internal investigation compliance issues. Th e Compliance Reporting violates the principals outlined in this code of Hotline is answered by communications conduct and can lead to corrective action. specialists who work for a company that is not a part of MRH. You can call the Compliance Governmental Investigations Reporting Hotline at any time of the day or night, from any location – even your home. It’s a free It is our policy to comply fully with all state and call and completely confi dential. You do not have federal laws and regulations. We will cooperate to give your name. with any reasonable request for information from any governmental entity. It is important to re- When you dial 800.905.5190, a specialist will spond to government requests for information answer the phone and listen to the details of in an accurate, complete and timely manner. You your concern. Th e specialist may ask follow-up must notify your supervisor, department director questions to make sure he or she understands the or the Compliance Department immediately if situa tion. At the end of the call, the specialist will you receive a subpoena, search warrant or other give you a confi dential case number, a security legal document from a government agency re- code and a date to call back if you want an update garding MRH business. on the situation. We encourage you to cooperate with Aft er each call, the specialist will report the governmental authorities conducting an information to the Compliance Department investigation and no adverse action will be taken for investigation. Aft er the investigation, the against you by MRH for any lawful cooperation. Compliance Reporting Hotline will be updated so You should be aware that the law guarantees that you can check back and get the results of the each person the right to be represented by legal investigation should you wish to do so. counsel during any investigation or inquiry by any government agency.

—21— Corrective Action Key Contacts and References When an internal investigation substantiates a reported violation, it is the policy of MRH to Due to the fast pace and many demands of our initiate corrective action, including, as appropriate, environment, the best course of action in any given making prompt restitution of any overpayment situation may sometimes not be obvious. MRH off ers amounts; notifying the appropriate governmental many options to help you discuss issues or report agency; instituting whatever disciplinary action is concerns. necessary; and implementing appropriate changes Compliance Department...... Ext. 4338 or 7060 and/or education to prevent a similar violation from Your contact for advice on compliance, ethical, legal occurring in the future. or privacy issues or to report suspected violations of the code of conduct and/or policies. Resources for Guidance and Compliance Reporting Hotline ...... 800.905.5190 Reporting Concerns Available 24 hours a day, 7 days a week. To obtain guidance on an ethical or compliance Supervisor or Manager issue or to report a concern, individuals may choose Your best contact for workplace issues (i.e., staffi ng, from several options. We encourage the resolution of co-worker relationships, etc.) issues, including human resource-related issues (e.g., fair treatment, disciplinary issues), at a department Human Resources Department ...... Ext. 1095 level. It is an expected good prac tice to raise Your contact for employment concerns, policy concerns fi rst with one’s supervisor or manager. If guidance and interpretation. this is uncomfortable or inappropriate, the individual Performance Improvement ...... Ext. 1152 may discuss the situation with the Human Resources Your contact for reporting concerns regarding a Department or Compliance De partment. Individuals physician. are always free to contact the Compliance Reporting Safety Offi cer ...... Ext. 1235 Hotline at 800.905.5190. Your contact to report unsafe conditions and workplace hazards. For concerns regarding a physician, the appropriate avenue for reporting is to notify the Performance Risk Manager ...... Ext. 2264 Improvement Department in writing, by email Your contact for patient care issues and concerns. or voice mail. Email may be sent to Performance Patient Experience Coordinator ...... Ext. 4456 Improvement or voice mail may be left at extension 1152. Intranet Your resource for compliance-related policies, the We have an obligation to report concerns that Compliance Plan and other compliance information. would prevent us from pursuing our mission Th e Compliance Reporting Hotline is a toll-free to serve our region with clinical excellence and number for use by employees who SEEK GUID ANCE on compassionate care. ethical, legal or corporate compliance issues or who want to REPORT CONCERNS regarding business-related conduct. MRH makes every eff ort to maintain, within the Reports may be made ANONYMOUSLY and without fear of reprisal. limits of the law, the confi dentiality of the identity of any individual who reports concerns or possible Compliance Reporting Hotline 800.905.5190 misconduct. Th ere will be no retribution, discipline or retaliation for anyone who reports a concern in good faith; however, any colleague who deliberately makes a false accusation against another colleague is subject to corrective action.

—22— ACKNOWLEDGEMENT OF RECEIPT AND RECOGNITION OF MAURY REGIONAL HEALTH’S CODE OF CONDUCT I acknowledge my receipt of a copy of Maury Regional Health’s (MRH’s) Code of Conduct. I understand that the content contains important information on MRH’s Compliance Program; Confi dentiality Policies and Procedures; the Fraud, Waste and Abuse Program, and the Confl ict of Interest Policy. I recognize the Code of Conduct explains my obligations as a workforce member or business entity contracted with MRH.

I acknowledge that I am expected to read, understand and adhere to the Code of Conduct and MRH policies and procedures and will familiarize myself with their contents.

I understand that accessing my own information or the information of my family members, friends or others without a work-related need is a violation of this Code of Conduct and will be subject to employee accountability action.

I understand I have a legal, moral and ethical obligation to report potential privacy breaches as well as potential fraud, waste and abuse in compliance with state and federal laws, contractual requirements and MRH Policies and Procedures.

I understand that violation and/or non-compliance with the Code of Conduct requirements is grounds for disciplinary action, up to and including termination of employment or contract.

______Workforce Member Name (Print) MRH Entity Name (Print)

______Workforce Member Signature Date

______Workforce Member Relationship (Employee, Volunteer, Medical Staff , Student, Contract Worker, Vendor, etc.)

—23— ACKNOWLEDGEMENT PROCESS Conditions of Medical Staff Appointment/Reappointment

Collaboration, communication and collegiality are essential for the provision of safe and competent patient care. As such, all Medical Staff Members and Specifi ed Professional Personnel practicing in MRH must treat others with respect, courtesy and dignity and conduct themselves in a professional and cooperative manner. In dealing with all incidents of inappropriate conduct, the protection of patients, employees, physicians, volunteers and visitors and the orderly operation of the Medical Staff and MRH are paramount concerns. Complying with state and federal law and providing an environment free from sexual or any other type of harassment is also critical.

In this respect, I understand that any and all acts considered unprofessional or disruptive to medical or hospital staff , patients or visitors potentially impact the care and safety of patients and will not be tolerated. Such acts will be investigated and evaluated by MRH and the Medical Staff .

Signature ______

Date ______

Please print name ______

—24— 1224 Trotwood Avenue Columbia, Tennessee38401

MauryRegional.com

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