Code of Conduct

Catholic Health's Corporate Compliance program is our first line of defense in preventing and detecting activities that may negatively impact our organization.

Compliance issues may violate Catholic Health, state or federal rules, laws or regulations, and have a potential for government audit or legal action.

Directors, officers, managers, associates, medical staff, house staff, contractors, volunteers, students and other agents are expected to comply with the following guidelines.

Standards of Conduct

PURPOSE: Catholic Health System (CHS) pledges to meet our mission in an atmosphere that recognizes its responsibility to conduct its business affairs with integrity based on sound ethical and moral standards. CHS recognizes our responsibility to treat the people we serve with the same standards of care, regardless of payor source and in accordance with applicable rules, regulations and laws. CHS is intolerant of fraud, waste and abuse throughout the organization and strives to always deliver medically necessary services in the most efficient and prudent manner. CHS also holds those with whom we conduct business to these same standards.

We intend to meet our mission through on-going, appropriate and timely education of all our constituents. We promote self-monitoring of our activities by providing oversight of our directors, officers, managers, associates, medical staff, house staff, contractors, volunteers, students (hereafter referred to as constituents) and others to assure compliance with these standards. We seek to provide an atmosphere that is safe, encourages open discussions on these matters with no fear of retribution, and promptly identifies and resolves issues.

This Corporate Compliance Statement is consistent with and supports the Mission Statement of the Catholic Health System

 “We are called to reveal the healing love of Jesus to those in need.”

APPLIES TO: All Catholic Health System entities and constituents, to include but not limited to: Associates, Physicians, Vendors, Contractors, Volunteers and Students.


A. Code of Conduct Statement

In keeping with the mission and goals of Catholic Health, directors, officers, managers, associates, medical staff, house staff, contractors, volunteers, students and other agents are expected to comply with the following guidelines. This Code of Conduct does not replace sound ethical and professional judgment.

Expectations of all work force members in Catholic Health are to:

1. Uphold Legal and Regulatory Compliance

  • Adhere to both the spirit and letter of applicable federal, state and local laws and regulations.
  • Refuse offers, solicitations and payments to induce referrals of the people we serve for an item or service reimbursable by a third party payor.
  • Protect and retain records and documents as required by professional standards, governmental regulations and organizational policies.

2. Promote Ethical Business Conduct

  • Deal openly and honestly with fellow associates, customers, contractors, government entities and others.
  • Maintain high standards of business and ethical conduct in accordance with the Catholic Health System Mission, directives of the Catholic Church and applicable federal, state and local laws and regulations
  • Document work related activities completely and accurately.
  • Conduct business dealings with the best interests of the Catholic Health System in view.
  • Ensure compliance requirements regarding billing are monitored and enforced.
  • Exercise discretion in the billing of services, incorporating payor guidance.

3. Disclose Potential Conflict of Interest

  • Disclose financial interests and/or affiliations or secondary employment with outside entities as required by the Conflict of Interest Statement Policy.
  • As requested, complete timely submission of the Conflict of Interest Disclosure Statement

4. Appropriately Use Resources

  • Use supplies and services in a manner that supports financial stability and positive environmental impact.

5. Preserve Confidentiality

  • Preserve patient confidentiality within the requirements of the law.
  • Maintain confidentiality of proprietary information.

6. Exhibit Catholic Health Behavioral Conduct

  • Act with integrity by exhibiting CH value based behaviors in work related activities.
  • If applicable, follow ethical standards of respective professional organizations.
  • Hold vendors to this same Code of Conduct as part of their dealings with the Catholic Health System.
  • Uphold the Non-Retaliation Policy for those who report concerns in good faith.

7. Act Responsibly & Be Accountable

  • Accept mission aligned challenges as opportunities for improvement.
  • Notify the appropriate person of instances of non-compliance and in a timely manner.
  • Ensure appropriate corrective action is taken in a timely manner.

All constituents and others affiliated with the Catholic Health System are informed of this Code of Conduct as much as practicable, and sign an Affirmation Statement indicating their adherence to the Code of Conduct.

B. Code of Ethics Statement

The Catholic Health System, through its constituents conducts patient care and other business operations in an ethical and non-discriminatory manner consistent with the mission, vision, values, strategic plan and Administrative policies.

The Catholic Health System has adopted a Code of Ethics as an expression of its identity as a Catholic Healthcare Organization and on behalf of the people it serves. A general framework for this code can be found in the Ethical and Religious Directives for Catholic Health Care Services, the codes of ethics of the various professional groups working within the Catholic Health System, applicable state and federal laws, as well as other documents. Specific guidelines for the code, which are summarized below, can be found in the above mentioned documents as well as in the following documents: quality of care, patient and associate rights policies, billing policies; marketing policies; admission, transfer, and discharge policies; conflict of interest and other policies. Also addressed in this code are procedures that should be followed in the event ethical conflicts or uncertainties arise.

1. Quality of Care

Policies support the commitment of the Catholic Health System to provide quality of care and services necessary to attain or maintain highest practicable physical, mental and psychosocial wellbeing. Appropriate and sufficient treatment and services will be provided to address the needs of the people served. Patients may only receive care that has been ordered by a Physician or qualified practitioner with established clinical privileges. The Catholic Health System establishes and implements policies and protocols related to the quality of care and perform ongoing evaluations of compliance to these policies and protocols.

2. Patient Rights and Responsibilities Policies

  • Policies support the rights of the people we serve to ask and be informed about the existence and nature of the business relationships between the health system, organizations, educational institutions, other healthcare providers, payors, or networks that may influence treatment and service.
  • To advance protections for all those we serve, Catholic Health prohibits discrimination of any kind, including but not limited to discrimination based on an individual’s race, color, national origin, religion, sex, gender identity and expression, sexual orientation, age, disability, pregnancy, childbirth and related medical conditions.
  • In addition, women are to be treated equally with men with respect to the healthcare they receive and individuals are to be treated consistent with their gender identity, including having access to facilities, and may not categorically be excluded or limited to healthcare services due to gender transition. Hard copies of Catholic Health’s Non-Discrimination Statement will be posted in public spaces at Catholic Health facilities or offices. Conspicuously posting the notice on the Catholic Health System Website is also required.
  • Every effort is made to help the people we serve and their families understand and exercise their rights and responsibilities. The people we serve are the primary decision makers in their own healthcare decisions and, to the extent possible, information regarding diagnosis, treatment, research options, and prognosis is to be provided in the patient’s preferred language. Language Service taglines with at minimum, the top 15 languages spoken outside of English in New York State, shall be posted at all Catholic Health locations where patients are seen. See policy CHS-CCP-121A Communication Assistance.
  • Should a patient believe that Catholic Health in any way has failed to provide services or discriminated in another way, a patient may file a grievance with:

    Kimberly E. Whistler, Esq., CHC
    Chief Compliance Officer
    144 Genesee Street, 6th Floor-West, Buffalo, NY 14203
    Office: 716.821.4471 Fax: 716.821.4460

    The Compliance Officer will have the right to delegate the grievance to a site representative.
  • Outpatient, rehabilitative and ancillary services for the people we serve also safeguard the patient’s respect, dignity, autonomy, positive self-esteem, and civil rights, and assure their involvement in all aspects of care. This safeguarding of the involvement of the people we serve includes taking account of their perceptions of their strengths, weaknesses, resources, and relevant demands of their environment(s) both within and without the healthcare setting.

3. Developing New Services or Acquiring New Technologies, and for Newly Constructed or Altered Facilities

The Catholic Health System provides those services that are compatible with its mission and values. New services and technologies are evaluated on the basis of criteria related to this mission and these values. The following criteria are also used to evaluate new services and technologies: safety, efficacy, efficiency, cost, experience, availability from other sources, number of individuals who benefit, and the effect on the Catholic Health System's ability to provide other needed services as well as the competence and qualifications of the staff required to provide those services or technologies in question.

For individuals with disabilities, Catholic Health System will make all programs and activities provided through electronic information technology accessible; ensure the physical accessibility of newly constructed or altered facilities; and provide auxiliary aids and services to individuals with disabilities.

4. Associate Rights Policies

It is the policy of the Catholic Health System to value associates, their wellbeing and their satisfaction; to respect the differences and diversity of its associates; and not to discriminate on the basis of race, color, religion, sex, pregnancy, gender identity and expression, national origin, age, veteran status or disability. The Catholic Health System fosters an organizational culture that encourages open communication, without fear of retaliation. Each associate has the right to work in an environment free of harassment and disruptive behavior.

5. Billing Policies

The Catholic Health System ensures that the people we serve and third party payors are billed only for medically necessary services actually provided and duly documented. Policies are established and mechanisms are implemented to help ensure that the people we serve are billed only for those services and care provided. It is also policy that the Catholic Health System will bill all payors in compliance with all federal and state rules and regulations.

6. Marketing and Public Relations Policies

The Catholic Health System fairly and accurately represents itself, its services, and its capabilities to the public. Marketing practices recognize the dignity of the person, freedom of speech and assembly, and the importance of freedom of the press. Marketing materials accurately reflect those services available, the level of licensure and accreditation in place, and comply with applicable laws and regulations governing truth in advertising and non-discrimination under the Public Health Service Act and the Rehabilitation Act of 1973, and other applicable state and federal laws and regulations. Marketing associates use their best efforts to adhere to the Code of Professional Standards as adopted by the Governing Assembly of the Public Relations Society of America. Marketing practices or benefits designs that discriminate on the basis of disability or other prohibited bases are not allowed.

7. Admission, Transfer, and Discharge Policies

Admission, transfer, and discharges are conducted in an ethical manner and in accordance with applicable local, state and federal regulations. Admission, transfer, and discharge policies are based on the need of the individual person and the ability of the Catholic Health System to meet that need. See Policy RSK-006 Patient Transfers (EMTALA/Cobra).

8. Procedures when Ethical Conflicts of Interest or other Issues Arise

It is recognized that ethical conflicts may arise when people who are trying to do right or realize good, either disagree or are uncertain about what constitutes the appropriate, right or good. The Catholic Health System’s Ethics Committee has processes to resolve such conflicts. Also see policy HR – 050 –Managing Associate Ethical Conflicts for additional guidance.

Contact Us

If you have questions or concerns about the Catholic Health Code of Conduct or Compliance policies contact:

Kimberly E. Whistler, Esq., CHC
Corporate Compliance & Privacy Officer
144 Genesee Street, 6th Floor-West, Buffalo, NY 14203