organizational guide to corporate integrity › images › codeofconduct.pdf · iii. workplace...

Code of Conduct & Ethical Behavior

Organizational Guide to Corporate Integrity

epson color

TABLE OF CONTENTS

Mission, Vision and Values............................................................................. 1

Letter from Cynthia Moore-Hardy, FACHE .................................................. 2

I. Purpose of this Code of Conduct and Ethical Behavior ......................... 3

II. Business Compliance and Ethics ..........................................................3-4

III. Workplace Compliance and Ethics .......................................................... 4

IV. Acceptable, Disruptive and Inappropriate Behaviors .........................4-5

V. Standards of Behavior .............................................................................5-6

VI. Reporting Concerns or Misconduct .....................................................6-7

Code of Conduct and Ethical Behavior Attestation ..................................... 8

Mi ssion

Our mission is to provide comprehensive health care services to the res-idents of Lake County and neighboring communities in partnership with those who share a commitment to local access, healing with compassion and superior quality.

V i sion

Lake Health, in partnership with its medical staff, will be the first choice for superior care close to home. Together, we will coordinate a lifetime of health which patients and families experience as warm, responsive and state of the art. Our organization and culture will produce the best oppor-tunities to practice and work.

Valu es

Respect: We believe in treating everyone in a dignified and caring manner.

Innovation: We believe that the pursuit of creative ideas leads to improvements that build a better future.

Teamwork: We believe that working together and communicating effectively help us achieve shared goals.

Stewardship: We believe that the wise use of our resources today assures our ability to continue our mission tomorrow.

Integrity: We believe that our words and actions need to be in harmony to build trusting relationships.

Lake Health Code of Conduct & Ethical Behavior 8/10 Page 1

Cynthia Moore-Hardy, FACHEPresident and Chief Executive Officer

Personal Commitment to Integrity

epson colorDear Colleague,

Lake Health is committed to delivering unsurpassed quality care to the Lake County Community and surrounding areas. We believe that the community, our patients and their families, Team Members, volunteers, vendors, medical staff members and other business partners have a right to expect that we will provide compassionate care with integrity and the highest ethical standards in support of our system, mission, vision and values.

This Code of Conduct is part of the Lake Health Corporate Compliance Program. The Code applies equally to everyone in the System and is intended to provide guidance to taking appropriate actions in the daily work of our Team Members, volunteers, physicians, vendors and other business partners. While we recognize that professional, legal, and regulatory guidelines are ever changing, we must be prepared to respond appropriately to these changes.

Each Team Member’s conduct is essential to building and support Lake Health’s commitment providing quality care, ensuring patient satisfaction, integrity and ethics. By your signature on the attestation accompanying this Code of Conduct, you are accepting the responsibility to do your part to achieve the values and principles of our system

Thank you for helping make Lake Health an organization of which we can all be proud.


I. Purpose of this Code of Conduct and Ethical Behavior This Code of Conduct and Ethical Behavior reflects Lake Health’s tradition of caring and provides guidance to ensure that our work is done in an ethical and legal manner. It sets forth principles to be upheld within day-to-day activities by all Team Members, Trustees, Medical Staff members, volunteers, vendors and other business partners.

The Code of Conduct and Ethical Behavior is an integral part of the operations of Lake Health and is provided to ensure that Lake Health will comply with ethical standards and applicable laws and regulations. It is intended to be comprehensive and easily understood. In addition to this Code of Conduct and Ethical Behavior, Lake Health has also developed a Corporate Compliance Plan which addresses areas of additional complexity and provides guidance and direction for actions in those areas. The Corporate Compliance Plan is incorporated by reference into this Code of Conduct and Ethical Behavior. A copy of the Corporate Compliance Plan can be found on the Lake Health’s net learning network and is also available through the Lake Health Corporate Compliance Officer. As appropriate, the Lake Health Corporate Compliance Officer will provide training on updates and changes to the Code of Conduct and Ethical Behavior, as well as any resulting expectations.

All Team Members, Trustees, Medical Staff members, volunteers, vendors, and other business partners should carefully review and understand this document and complete the attached attestation form. This form will certify in writing that you have read the Code of Conduct and Ethical Behavior, will act in compliance with it, and will report any known violations. Violation of the Code of Conduct and Ethical Behavior can result in disciplinary action, up to and including termination. Violation of the Code of Conduct and Ethical Behavior can also result in possible fines or criminal penalties from the federal, state or local government.

II. Business Compliance and Ethics A. Government Laws and RegulationsAll individuals doing business for, on behalf of, or af-filiated with Lake Health must comply with applicable federal, state and local laws and regulations.

B. Not-For-Profit Status Lake Health is a tax-exempt organization under federal, state and local law. Therefore, Lake Health must avoid engaging in activities that constitute “private inurement” or “private benefit.” An example of these prohibited activities is purchasing items for the personal use or benefit of any Team Member, Trustee, management, or Medical Staff member. All third parties must pay fair market value for the use of services and property of Lake Health.

C. Conflicts of Interest: A “conflict of interest” is a conflict between private interests and official responsibilities of a person. Examples of conflicts of interest include (1) promoting another business that affects your work at Lake Health, (2) using your position to influence the hiring of a family member or close friend, or (3) misusing confidential information for personal gain. Lake Health Team Members, and other Lake Health associates in a position to influence decision making at Lake Health, must perform duties in the best interests of the entire organization and not for personal gain. All individuals must also be alert to and avoid activities or situations involving a conflict of interest or the appearance of impropriety.

D. Improper Payments (Kickbacks) and ReferralsIt is illegal to solicit, pay, accept or offer any inducements (including gifts and entertainment) in exchange for conducting business or making referrals to Lake Health or its Medical Staff members. Lake Health’s medical staff and health care providers must make and receive patient referrals solely based on the patient’s clinical needs and symptoms as documented.

Lake Health Code of Conduct & Ethical Behavior


E. Credentials Only properly licensed, authorized and supervised individuals may provide patient care at Lake Health facilities. Each individual holds the responsibility of maintaining the necessary licenses and authorizations required for employment or maintaining privileges at Lake Health.

F. Emergency Medical Treatment and Labor Act (EMTALA) Lake Health will provide emergency service to any individual, regardless of their insurance status and ability to pay. Any person who comes to a Lake Health Emergency Department requesting examination or treatment for an emergency medical condition must be given an appropriate medical screening. All individuals with an emergency medical condition must be given the necessary treatment to stabilize the condition within the capabilities of the health care providers and facility. Transfers of patients from the emergency room must be solely based on the patient’s clinical and/or medical needs as identified by qualified health care providers.

G. Confidentiality: All Team Members, Trustees, Medical Staff members, volunteers, vendors and other business partners must keep all Lake Health information and patient health information confidential. These laws and regulations include but are not limited to the Health Insurance Portability and Accountability Act (HIPAA). As a general rule, only caregivers with a clinical “need to know” should have access to patient information, except as necessary to carry out billing and health care operation functions.

The privacy of our patients and colleagues is to be respected and includes not discussing patient information in public areas such as hallways and dining areas. Every reasonable measure should be taken to ensure the security and privacy of patient information, whether it is stored on paper or electronically.

The American Recovery and Reinvestment Act of 2009 expanded the HIPAA rules. As such, it is important that all individuals note the following:

•Patient information may not be disclosed for marketing purposes without the appropriate patient authorization. This includes disclosures for marketing by business associates (i.e. vendors and other outside business partners).

• In the event that patient information will be disclosed for fundraising purposes, each individual patient must be given the opportunity to opt-out of such disclosure. This also applies to Lake Health business associates.

•Lake Health and its business associates must comply with any patient request to restrict disclosure of their health information to a health plan for a health care item or service that is paid out of pocket by the patient.

•All individuals are responsible for making sure that all patient health information is secure and not inappropriately disclosed.

H. Patient Rights: Each patient is to be treated in an ethical, dignified and professional manner.

I. Documentation, Coding and Billing: All medical record documentation, coding and billing for services must be complete, accurate, legible, timely and in compliance with federal and state regulations. Documentation and coding of services should reflect actual services rendered to patients based on patient need and medical necessity. No claim or document may be submitted to any government entity or third party payer that is false, fraudulent, incomplete or fictitious. Fines and/or criminal penalties may be substantial if inappropriate documentation, coding or billing activities occur.


III. Workplace Compliance and EthicsA. Lake Health Compliance Plan – Policies & Procedures: All Team Members, Trustees, Medical Staff members, volunteers, vendors and other business partners must abide by the Lake Health Corporate Compliance Program and the Lake Health HIPAA Compliance Program, as well as all corresponding policies and procedures. These compliance programs, policies and procedures are designed to aid in the prevention and detection of fraud, waste and abuse in government and commercial health care programs, as well as the protection of patient health information. These documents also set forth the role of each individual in presenting and detecting compliance issues.

B. Fair and Equitable Treatment: Lake Health will provide equal employment opportunity to all persons, as required by law. All employment decisions will be made without regard to race, color, religion, sex, national origin, age, Vietnam-era veteran status, or any other classification prohibited by law. Reasonable accommodations will be made for individuals with physical handicaps or disabilities, as required by law.

C. Health, Safety and Environmental Practices: All individuals should accomplish all tasks in a manner that promotes the safety and health of themselves and others. The workplace will be free of recognized hazards that might cause physical harm. If you suspect a violation of an environmental or occupational safety or health law, immediately report the situation to your supervisor and/or Safety Officer.

D. Gifts and Entertainment: All Team Members, Trustees, Medical Staff members, volunteers, vendors and other business partners are responsible for helping Lake Health remain free from improper influence by individuals or organizations that have or seek business with Lake Health. As such, Lake Health has developed specific policies in its Corporate Compliance Program with regards to giving and receiving gifts,

entertainment and other business courtesies to and from potential referral sources and non-referral sources. Please consult these policies if you are faced with a situation involving the giving or receiving of gifts, entertainment or other business courtesies to or by any individual or organization. Additionally, please seek guidance from your supervisor or the Lake Health Corporate Compliance Officer prior to giving or accepting such gifts, entertainment or other business courtesies.

E. Harassment: All individuals must show proper respect and consideration for each other. Discriminatory treatment, harassment, abuse or intimidation will not be tolerated.

F. Use of Alcohol or Illegal Drugs: No individual may use, sell, possess, manufacture or purchase alcohol or illegal drugs while at work or while on Lake Health premises.

IV. Acceptable, Disruptive and Inappropriate BehaviorsMaintaining a positive and safe work environment is an integral part of enabling individuals to perform their assigned duties. Lake Health has adopted a zero tolerance policy for intimidating and/or disruptive behaviors, especially in cases



of disruptive behavior such as assault and other criminal acts. All intimidating and/or disruptive behavior should be reported and such reports will be investigated. If a medical staff member wishes to report inappropriate behavior, he or she should consult Medical Staff Policy MS-14-1 for appropriate procedures. All other individuals should notify their immediate department manager, the next level of administration, or a member of the operations management group. Additionally, anyone who reports inappropriate behavior will be protected from retaliation. Please refer to the Lake Health Administrative Policy Manual and its Policy No. C-80-2 (Code of Conduct: Acceptable Behavior) for further information.

A. Acceptable/Expected BehaviorAcceptable/expected behaviors include:

• Communication will take place in a timely fashion, involving the appropriate person(s), and an appropriate setting.

• Communications, including spoken remarks, written documents and emails will be honest and direct and conducted in a professional, constructive, respectful and efficient manner.

• Telephone communications will be respectful and professional.

• Cooperation and availability are expected of physicians, staff and volunteers. When individuals place a call or are paged, they will respond promptly and appropriately.

• Recognize that a variety of experience levels exist and that tolerance for those who are learning is expected.

B. Unacceptable, Disruptive and Inappropriate BehaviorUnacceptable, disruptive, inappropriate behaviors include:

•Yelling or shouting.•Threatening or violent behavior.•Disrespectful language.• Inappropriate arguments with patients, family,

staff or physicians.•Sexual comments or innuendo.• Inappropriate touching, sexual or otherwise.•Racial, ethnic or discriminatory jokes/slurs.•Retaliation against any person who reports or

addresses unacceptable behavior.

V. Standards of BehaviorAt Lake Health, we believe that if every Team Member lives our Values of Respect, Innovation, Stewardship, Teamwork and Integrity (RITSI Values) the result will be a superior, compassionate patient/family experience. At Lake Health, we define our customers to be our patients and their family, and anyone else whom we serve, including our internal customers. Our customer’s perception of Lake Health is our customer’s perception of you.

A. Service Service excellence is the cornerstone of healthcare. At Lake Health, we strive to provide service with respect, compassion and integrity.

Every Team Member will always:•Make eye contact, smile and project a “Can Do”

attitude.•Treat everyone with respect.•Anticipate and be attentive to the needs of those

we serve.•Acknowledge others, introduce him/her self, and say

“Thank you.”•Show compassion towards others.•Address service shortfalls with a sincere apology and activate the “Service Recovery” plan.

B. TeamworkWe are committed to a workplace that fosters healthy and supportive relationships. Through teamwork, respecting coworkers and recognizing personal contributions, we will meet this goal.

Every Team Member will always: •Be flexible and willing to help others.•Work together with all departments to achieve

success.•Be loyal to coworkers and not participate in gossip.•“Manage Up” by promoting and highlighting the

strengths of others.•Understand how his/her attitudes and actions affect

everyone with whom he/she comes in contact.

C. ProfessionalismWe express respect and pride in serving our patients and community through our personal appearance and professionalism. Our manner and expression convey our commitment to provide quality patient care.

Every Team Member will always:• Confidently apply his/her skills and knowledge.• Dress professionally and discreetly, adhering to the

hospital and department dress code policies.• Wear identification badge at all times clearly visible,

above the waist, with photo facing outward.• Pursue professional growth and development.• Remain respectful and sensitive in all situations

D. AccountabilityAccountability is taking ownership of one’s actions. We are dedicated to meeting and exceeding our professional responsibilities.

Every Team Member will always:•Take ownership of his/her actions and decisions.•Acknowledge mistakes and actively seek resolutions.•Not make excuses or blame others.•Be aware of his/her surroundings and report

misconduct.•Arrive on time and complete his/her assignments.•Not be wasteful of time or resources.

E. SafetySafety is everyone’s responsibility. We are committed to creating and maintaining a clean, safe environment for our patients, their families, and our Team Members.

Every Team Member will always:•Use equipment as intended and report any

malfunctions.•Know the meaning of and how to respond to all

safety codes.•Utilize security measures when appropriate.•Pick up trash rather than walk by it.•Understand and follow the National Patient Safety

Goals.

F. InnovationInnovation is the process of creating and managing new ideas and methods to improve our healthcare system and services.

Every Team Member will always:•Focus on creative solutions.•Seek a better way to improve organizational

performance.•Challenge the status quo.•Make “Excellence” the goal in everything done.•Submit at least one Bright Idea per year.

G. PrivacyWe will provide a secure and trusting environment. We will treat all information as confidential, recognizing its impact on patient care.

Every Team Member will always:• Respect the privacy of others and access only the

information needed to treat patients.• Not discuss personal information in public areas.Knock on the door before entering a patient’s room.• Address conflict with others in private.• Not impose personal beliefs upon others.• Treat others how he/she wants to be treated

(Golden Rule).

H. Communication We will demonstrate effective communication with our patients, families and co-workers to ensure a common understanding.

Every Team Member will always:•Actively listen and ask when in doubt.•Be mindful of his/her body language.•Put a smile in his/her voice.•Seek interpretive services when needed.•Make sure what he/she has said is clear and

understood.•Choose face-to-face communication or call if he/she

cannot meet face-to-face.•Ask if there is anything else he/she can do.

VI. Reporting Concerns or Misconduct

A. ReportingAll individuals should report any concern, perceived violation of this Code of Conduct or inappropriate and questionable behavior to their immediate supervisor, the Corporate Compliance Officer or the anonymous Compliance HELP Line. The Lake Health Corporate Compliance Officer is Joyce Taylor who can be reached at 440-354-1999. The confidential Lake Health Compliance HELP Line can be accessed at 440-354-1121. All reports are kept anonymous to the fullest extent possible, but it may be necessary from time to time for the Corporate Compliance Officer to reveal the identity of employees in order to effectively investigate compliance issues.


B. InvestigationsThe Corporate Compliance Officer or her designee will conduct a prompt and thorough investigation of all suspected violations in accordance with the policies and procedures set forth in the Corporate Compliance Program. Investigations will be conducted in a confidential and professional manner.

C. SanctionsAnyone who violates this Code of Conduct and Ethical Behavior, the Corporate Compliance Program, or the HIPAA Compliance Program is subject to disciplinary action, up to and including termination.

D. Whistleblower ProtectionNo one will be subject to retaliation or retribution for reporting in good faith a suspected or known violation of this Code of Conduct and Ethical Behavior.

Corporate Compliance Officer:Joyce Taylor(440) 354-1999

Confidential Lake Health Compliance HELP Line: (440) [email protected]


Code of Conduct and Ethical Behavior Attestation

I have received a copy of the Lake Health Code of Conduct and Ethical Behavior. I have read this document and understand that it applies to me and my conduct at Lake Health. I will comply with this Code of Conduct and Ethical Behavior and all applicable laws and regulations in the course of my personal and professional relationship with Lake Health or any of its affiliates. I also understand that this Code of Conduct and Ethical Behavior can change at any time without prior notice and that such change will be communicated to me as part of my personal and professional relationship with Lake Health.

Signature: ________________________________________________________________________________

Printed Name:_____________________________________________________________________________ Date: ____________________________________________________________________________________

Entity/Location: ___________________________________________________________________________


Lake Health Service Locations

lakehealth.org2324-8/10

epson color

West Medical Center36000 Euclid Avenue Willoughby, Ohio 44094440-953-9600Open 24 hours

TriPoint Medical Center7590 Auburn Road Concord, Ohio 44077440-375-8100Open 24 hours

Mentor Campus9485 Mentor Avenue Mentor, Ohio 44060440-974-6800Open six days

Madison Campus6270 North Ridge Road Madison, Ohio 44057440-428-6800Open seven days

Perry Walk-In Care CenterTwo Success Boulevard Perry, Ohio 44081440-375-8590Open five days

Painesville Quick Care Center74 South Park PlacePainesville, OH 44077440-354-3887Open seven days

Mentor Physical Therapy9170 Mentor Avenue Mentor, Ohio 44060440-352-1200Open five days; evening hours

Tyler Blvd.Urgent Care Center7956 Tyler Boulevard Mentor, Ohio 44060440-255-6400Open seven days

Willowick Campus29804 Lakeshore Boulevard Willowick, Ohio 44095440-585-3322Open seven days

Chardon Campus510 Fifth Avenue Chardon, Ohio 44024 440-286-8908Open seven days

Willoughby Hills Diagnostics*34600 Chardon RoadWilloughby Hills, OH 44094440-585-6163Open five days

Lyndhurst Diagnostics*5183 Mayfield RoadLyndhurst, OH 44124440-720-3000Open five days; evening hours

Mentor Diagnostics*8401 Mentor Avenue Mentor, Ohio 44060440-205-1730Open five days*An outpatient

hospital department

organizational guide to corporate integrity › images › codeofconduct.pdf · iii. workplace...

Documents