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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.
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.
POLICY:
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
2. Promote Ethical Business Conduct
3. Disclose Potential Conflict of Interest
4. Appropriately Use Resources
5. Preserve Confidentiality
6. Exhibit Catholic Health Behavioral Conduct
7. Act Responsibly & Be Accountable
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
The Compliance Officer will have the right to delegate the grievance to a site representative.
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.
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
1-888-200-5380
