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CHI Saint Joseph HealthNew Employee Orientation

Corporate Responsibility Program

Catholic Health Initiatives /

What is a Corporate Responsibility Program?

Helps us understand and comply with complex laws and regulations

Promotes a culture of honest and ethical behavior

Provides resources for making decisions based on our Catholic identity

Founded on our core values and standards of conduct

The primary goals of the CRP are threefold:

1. Prevent wrongdoings including failure to follow laws, regulations, policies, and the standards of conduct.

2. Detect wrongdoings so they can be corrected immediately.3. Correct wrongdoings while taking steps to ensure they do not occur again.

New Employee Orientation 2019 2


Core Elements of a Corporate Responsibility Program

Edward Davis, MSHA, MBA, CHCDivision Compliance Lead,

Southeast(501) 552-3941

Charnise Moore, DrPH, MPH, CHC, CHRC

CRO(859) 313-2012

Jared Sommers, MPH, CHCAssistant Regional CRO, CHI Saint Joseph Health

(859) 313-4718

Heather Lovelace, MBA, CHCCRO

(606) 330-6771


Written standards of conduct Designated corporate responsibility

officer Compliance committees Education and training programs Issue reporting and response process System to respond to allegations of

wrongdoing Investigation and corrective action Audit and monitoring systems Measurement of program

effectiveness

Corporate Responsibility Officers


Reference Guide


Our Values and Ethics at Work Reference Guide is a policy document.

It is designed to help you do what is right and to ensure that your behavior demonstrates CHI’s values.

Our Values and Ethics at Work Reference Guide is one of many tools that can help you work in a responsible, professional and ethical way.

By understanding and using this reference guide, we demonstrate our commitment to CHI’s core values.

VIDEO LINK

http://collab.catholichealth.net/gm/folder-1.11.593577?


Getting Help


As an organization and as individuals, we are responsible for promptly reporting potential violations of law, regulation, policy or procedure.

You are protected from retaliation if you make a good-faith report, complaint or inquiry.

If you are unsure about how to respond to a particular situation, you can use the Catholic Health Initiatives reporting process.

CHI Reporting Process

• Speak with your supervisor or another manager.

• If the supervisor/manager is not available, or you are not comfortable speaking with him/her, or you believe the matter has not been adequately resolved, contact your human resources representative.

• Contact the Corporate Responsibility Officer

• Call the Ethics at Work Lineo 1-800-261-5607o File your report at

www.ethicspoint.com


Gifts

• Do not accept cash or cash equivalents (which includes gift cards).

• Do not accept any gift of more than $100.

• Gifts of entertainment, such as tickets to a sporting event or concert, are not allowed under our policy.

• Each Business Source may provide lunch/gifts two to three times per year.



Gifts

QuestionMay I receive a free meal from a Business Source?

AnswerYes, if: 1. A representative of the Business Source is on site, 2. The representative is providing education, and 3. You have a need for that education.



Gifts

QuestionWhat types of gifts may I accept from a Business Source?

AnswerGifts of minimal value are acceptable, such as T-shirts, promotional pens or office supplies, and small perishable gifts, such as flowers, fruit, or candy.

Gifts that primarily benefit patients may be acceptable if they are not of substantial value. • Example: a stethoscope for use in an examination room.



Conflicts of Interest

A conflict of interest exists when the personal interests of a Person, a Person’s family member, or a Person’s business may affect the ability of that Person to act in the best interest of, and with good faith and loyalty to CHI, its mission, patients, residents, clients, or research participants.

A Person is defined in this policy to include Board members, employees, employed physicians, employed advance practice clinicians (APC), or research personnel.



Conflicts of Interest

Each Person is required to promptly and fully disclose to his/her direct manager, supervisor, medical staff office, board or board committee chair any situation or circumstance that may create a conflict of interest.

On an annual basis, the following individuals are required to complete a new conflict of interest form:• Board and board committee members;• Employees at the level of vice president and above;• Researchers, as defined within the policy;• Supply Chain Employees at the level of vice president and above and

those employees involved in contracting regardless of employment level;

• Other Employees as deemed applicable by CHI Leadership.



EMTALA

• The Emergency Medical Treatment and Labor Act (EMTALA) is intended to prevent hospitals from:

• Turning away or refusing to treat patients based on their ability to pay, and

• Transferring patients to “charity hospitals”.

• Requires medical screening examination (MSE) and stabilization before a patient is transferred or discharged.

• Applies to anyone, patients and visitors alike, located anywhere in one of our facilities or on campus (i.e., main campus, parking lots/structures, sidewalks).



Common EMTALA Traps

• “We don’t treat or delivery babies.”

• “We don’t treat psychiatric patients.”

• “We are on diversion.”

• “You’ll be treated quicker if…”



What is HIPAA?


Health Insurance Portability and Accountability Act of 1996 (HIPAA)• Federal law passed by Congress• Applies to all healthcare organizations• Composed of the Privacy Rule, Security Rule, Transactions and Code Standards

Purpose• Protect the confidentiality and security of health information as it is used, disclosed and electronically

transmitted• Create a framework, using standardized formats, for transmitting electronic health information more

efficiently

Key components• Outlines acceptable uses and disclosure of health information• Enumerates several rights to individuals about their health information• Requires specific training and sanctions for all healthcare employees and partners• Designates a Privacy Officer and a Security Officer to oversee the program and manage privacy complaints

or security breach events

You will learn more about HIPAA in a separate required module that you must also complete as part of your new employee orientation.


Information Security is a Shared Responsibility


Everyone plays a part in keeping patient and other Confidential information private and secure. It doesn’t matter what position you hold at CHI—the information you have and the systems you can access are of interest to a cybercriminal.

Gaining unauthorized access to healthcare information has become big business as health records contain a multitude of information. In addition to medical history, health records may include:

• social security numbers,

• credit card data,

• email addresses, and

• employment information.

This type of information is sold to the highest bidder on the Internet and provides opportunities to

conduct illegal activities like stealing medical identities to file fraudulent insurance claims or obtain

prescription medications, in addition to using the information in more traditional identity theft scams.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiRvby32vbPAhVkyoMKHTv2DmkQjRwIBw&url=http://gbsense.com/2013/06/25/how-to-lose-your-credibility-let-pew-show-you-in-3-easy-steps/&psig=AFQjCNFkd5-NIbFpaZ49q53n14CFHqIzrA&ust=1477510677659087



You Are Accountable


Everyone who works directly for or on behalf of CHI has legal and ethical obligations to protect patient information, apply a security and privacy mindset to every task, and recognize that individual behaviors directly affect the security of CHI systems and information.

YOU ARERESPONSIBLE:

For all activities performed using your logon credentials (user names, passwords, etc.)

To protect your passwords and prevent someone from performing activities using your identity

For immediately changing your password(s) if you think it may have been compromised

No Expectation of PrivacyThe equipment you use and the information you access on your job belong to CHI:• It is important to understand that everything you do online is regularly monitored and tracked.• Do not expect your email, web usage, or other system actions to be private.




Know Who To Call: Report Security or Privacy Incidents


Contact the ITS Service Desk to report:• loss or damage to any device,• compromised passwords,• suspected virus or other malicious software activity, and• suspicious calls or email.

Call 866-236-044124 Hours a Day – Every Day of the Year

CHI also has Regional Information Security Officers and Privacy Officers available to answer any information security or privacy questions or discuss concerns. Find contact information on Inside CHI:

Security Officer: Inside CHI > About CHI > CHI Secure > ITS Security Resources Privacy Officer: Inside CHI > National Groups > Privacy

It is better to report a potential problem and discover there is no issue than to realize later that you should have done so.


HIPAA Contacts for CHI Saint Joseph Health

Privacy

Marian HughlettRegional Privacy OfficerCHI Saint Joseph Health(502) 560-8347

Information Security

Douglas AshbaughRegional Information Security OfficerACO/CIN/CHI Living Communities/SE Division(515) 643-2684



Questions/Discussion


The time is always right to do what is right.”

Rev. Dr. Martin Luther King Jr.

Thank you for supporting the Corporate Responsibility Program!



chi saint joseph health new employee orientation resources... · chi saint joseph health (859)...

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