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CHILDREN’S HOSPITAL & MEDICAL CENTER CORPORATE COMPLIANCE PLAN - page 10 / 15

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For further guidance for leaders in managing conflict that has the potential to impact quality and patient safety, see Conflict Management policy.

Positive Attitudes and Behaviors

Hospital Staff will display positive attitudes and behaviors, enthusiastically approach their role and display pride in the organization. Hospital Staff is expected to take pride in and care of their personal appearance, choose to have a positive attitude each day, let go of past resentments, speak positively about the Hospital in the presence of coworkers, customers and the community, use tone, body language and facial expressions that project a positive attitude and actively participate in organizational change.

LEGAL PRINCIPLES

Legal Compliance

Hospital Staff is expected to be sufficiently knowledgeable of the legal aspects of their responsibilities and activities in order to reduce the risk of unintended legal violations. Hospital Staff whose positions may impact the Hospital’s compliance with laws and regulations will attend training and educational opportunities offered by the Hospital and pursue a reasonable amount of continuing self-education. It is the responsibility of all Hospital Staff members to notify their supervisor when they have a question regarding the legal aspects of their job and when additional information is needed. If questions arise regarding the existence, applicability or interpretation of any law, the Compliance Office should be contacted.

Hospital Staff is required to comply with applicable laws and regulations related to their job responsibilities and to refrain from knowingly participating in illegal activities or failing to meet affirmative legal duties whether or not specifically addressed in this Code of Conduct.

Hospital Staff is expected to refrain from conduct that may violate fraud and abuse statutes with respect to all federally funded health care programs including Medicare, Medicaid and Tricare. Fraud and abuse statutes, including the False Claims Act, prohibit: (1) payments made to a referral source in exchange for a patient referral; (2) the submission of false, fraudulent, or misleading claims; and (3) making false representations to gain or retain participation in or to obtain payment from a federally funded health care

program.

The False Claims Act protects

whistleblower

protection.

The

Hospital

those who report misconduct has adopted a Whistleblower

under the “qui Policy which

tam” or explains

whistleblower protections (see Whistleblower Policy). The Hospital against employees who raise concerns honestly and forthrightly, and not be tolerated.

strictly prohibits retaliation retribution in any form will

Hospital Staff is expected to comply with applicable antitrust and similar laws that regulate competition. Examples of prohibited conduct include: (1) agreements with competitors to fix prices; (2) organized boycotts of governmental of other payors; and (3) unfair trade practices.

In order to maintain its nonprofit status, the Hospital must ensure that resources are used in a manner that furthers the public good rather than the private interests of any individual. In order to assure compliance with applicable tax laws, the Hospital will not enter into compensation arrangements in excess of fair market value, will only pay for services actually provided, will accurately report payments to the appropriate taxing authority and will file all required tax returns in a timely manner.

CORPORATE COMPLIANCE PLAN 5/6/10

Page 10 of 15

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