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  • Q.

    My supervisor directed me to do something that I believe is against Hospital policy and, perhaps, the law. I don’t want to do something improper, but I’m afraid if I don’t do as I am told, I may lose my job. What should I do?

    • A.

      Do not risk your job or the organization’s future by taking part in improper or illegal activity. Discuss the situation with your supervisor to be sure you understand the facts and that she is aware of your concern. If you are uncomfortable discussing the situation with your supervisor or you are not satisfied with her response, contact the Compliance Officer. The effectiveness of the Compliance Plan depends on Hospital Staff taking appropriate action if they suspect non- compliant conduct is occurring. The Hospital strictly prohibits retaliation against employees who raise concerns honestly and forthrightly, and retribution in any form will not be tolerated.

  • Q.

    What should I do if a physician asks me to provide payment or compensation in exchange for referrals to our facility?

    • A.

      Such a request is against our Code of Conduct and may be illegal. Discuss the situation with your supervisor or the Compliance Officer. Any supervisor receiving this type of information should immediately notify the Compliance Officer.

Confidentiality of Information

Hospital Staff shall at all times maintain the confidentiality of patient and other information in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and all other legal and prevailing ethical standards.

Hospital Staff will have access to confidential and sensitive patient and family information whose use

should be limited only to individuals directly involved in the care information will be released only upon obtaining a valid authorization otherwise authorized by law (See HIPAA policies).

of for

that patient. Confidential release of information or as

Hospital Staff will have access to information, ideas and other intellectual property important to the success of the Hospital. Hospital Staff should take care to assure that such proprietary information is carefully managed and maintained and is shared with other Hospital Staff on an as needs to know basis.

Hospital Staff will have access to confidential information regarding other information should be protected and released only by designated personnel if the to know in order to perform his assigned duties or has valid written consent.

Hospital Staff. party requesting

This needs

Q. I overheard that the 15-year-old son of a local government official has been admitted to the Hospital and that it was due to a self-inflicted gunshot wound. Is it appropriate to access the medical record to see if the rumor is true?

    • A.

      No, access to patient information is limited to individuals directly involved in the care of the patient under HIPAA and other state law. Unauthorized or inappropriate access or attempts to access patient information will subject the employee to disciplinary action up to and including termination.

  • Q.

    A man came to our clinic and showed me his FBI badge and asked to see specific patient files. Should I give him the information he requested?


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