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