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Hope. Care. Cure.™
Corporate Compliance Program
and Code of Conduct
We are all responsible.
M/S S-232
PO Box 50020
Seattle, WA 98145-5020
www.seattlechildrens.org
Pub. 8/01
Rev. 11/04
10/06
4/09
6/12
About Seattle Children’s
Hope. Care. Cure.
These three simple words capture what we are
here to do. They speak to what inspires us now,
and to our aspirations for the future. We are a
compassionate community where skilled
physician-researchers, nurses and staff partner
with patients and families to help each child live
their best life.
We are united by a compelling mission: to
prevent, treat and eliminate pediatric disease.
Seattle Children’s consists of:
Seattle Children’s Hospital
Seattle Children’s Research Institute
Seattle Children’s Hospital Foundation
Seattle Children’s Hospital Guild Association
The statements contained in the following pages are guidelines only and
do not constitute an express or implied contract for employment nor
promise of any speciﬁc beneﬁt, procedure, or treatment in any particular
situation. Children’s is an at-will employer, which means that you may
resign at any time, with or without a reason or notice, and Children’s
may terminate you at any time, with or without cause or notice.
Nothing in the following pages and nothing in the work environment
at Children’s can modify the at-will status of employment. No one at
Children’s except for the Board of Trustees, and then only in writing, is
authorized to alter the at-will status of employment.
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Together, we deliver superior patient care,
advance new discoveries and treatments through
pediatric research and serve as the pediatric and
adolescent academic medical referral center for
Washington, Alaska, Montana and Idaho - the
largest region of any children’s hospital in the
country.
For more information visit www.seattlechildrens.org.
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Table of Contents
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Introduction
About Seattle Children’s
Table of Contents
Letter From Tom Hansen, M.D., C.E.O.
Mission and Vision
Seattle Children’s Code of Conduct
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| Corporate Compliance Program
Laws and Regulations
Responsible Conduct of Research
Reporting Compliance Concerns
Auditing and Monitoring
Disciplinary Process/Corrective Action
12 | Protecting Conﬁdential Information
Protected Health Information
Other Conﬁdential Information
Information Systems and Data Security
Dear Fellow Children’s Staff and Faculty:
Enclosed is your copy of Seattle Children’s Compliance Code of
Conduct. These materials, developed with input from our employees,
senior management and the Board of Trustees, strive to: tell you
about the basic laws that govern our daily work and the standards of
behavior expected at Children’s; communicate our commitment to
follow laws, regulations, standards of care and ethical business practices;
and help you understand how you can help assure that Children’s
remains compliant with all the laws and regulations that govern our
organization and support our mission.
These materials serve as a reference point for compliance standards.
We outline a process to follow if you should ever have any questions
or concerns. Children’s will continue to provide detailed communications
and training regarding the laws and regulations that apply to your
speciﬁc job functions. It is your responsibility to understand, learn and
obey these rules. If you ever feel uncertain about the right thing to do, I
encourage you to ASK. You will not be penalized for asking a question
about your legal or ethical responsibilities.
The importance of following the standards in these materials cannot be
overestimated. A violation of law or unethical conduct in delivering
health care services could reduce the quality of patient care and even
harm patients. It could also cause Children’s to have to pay ﬁnes.
More Information
14 | Business Standards
Billing Practices
Conﬂict of Interest
Gifts
Antitrust
Government Investigations and Legal Actions
Copyrights, Intellectual Property and Inventions
Children’s provides excellent, safe, quality care to children and families
throughout the Washington, Alaska, Montana and Idaho (WAMI) region.
Since Children’s founding in 1907, our ethical and professional conduct
has earned us an unsurpassed reputation. Thank you for your continued
support of Children’s mission and dedication to excellence.
Sincerely yours,
17 | Patient Care Standards
Admission, Transfer and Discharge
Patient’s Right to Protective Services
Patient Care Decision Dilemmas
Integrity of Clinical Decision Making
Staff Request to Not Participate
Staff Right to Notify The Joint Commission
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Tom Hansen, MD
Chief Executive Officer
| Acknowledgement Form
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD, click on I want to... Report a Compliance Issue
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Mission and Vision
Seattle Children’s Code of Conduct
The Code of Conduct is applicable to the entire Children’s workforce,
including employees, non-employees, medical staff, volunteers, vendors
and others.
Seattle Children’s has adopted these standards
as our Code of Conduct:
We strive to deliver excellent quality care to our patients.
Integrity, both personal and professional, is and always has been
our most important asset.
We demand ethical conduct in all our activities.
We care not only for the end result, but also how we achieve
that result.
Our Mission:
We believe all children have unique needs and should grow up without
illness or injury. With the support of the community and through our
spirit of inquiry, we will prevent, treat and eliminate pediatric disease.
Our relationships with our patients, other professionals and
vendors are essential to our business. They must be built
upon credibility and mutual respect.
When confronted with a choice, we do the right thing.
Our Vision:
Our founding promise is to care for each child in our region, regardless
of their family’s ability to pay. Over the next ﬁve years we aspire to:
When in doubt about the rules, we ask.
We are committed to an environment that fosters communication
and partnerships among patients, families and staff.
• Provide the safest, most effective care possible.
• Control and reduce the cost of providing care.
• Find cures and educate clinicians and researchers.
• Grow responsibly and provide access to every child who needs us.
We strive for excellence in family-centered care, quality,
responsible research, cultural competency and workplace
engagement.
We act in accordance with Children’s Community Standards of
Accountability, Respect and Teamwork (ART).
The Code of Conduct applies to the entire Children’s workforce
and supports Children’s mission, policies and procedures.
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Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
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Corporate Compliance Program
•
Establish methods for employees to provide feedback and convey
concerns or complaints without fear of retaliation:
Pru Arnquist
Corporate Compliance Officer
206-987-5220
[email protected]
• How to report (see page 8).
Respond to questions about improper or unethical activities and
take appropriate disciplinary action when violations occur:
• Disciplinary process (see page 9).
Monitor compliance efforts and help solve problems:
• Auditing and Monitoring (see page 9).
Corporate Compliance is a program designed to ensure that the
organization’s workforce follow the laws and regulations that govern
healthcare. The term “workforce” includes, but is not limited to the
entire Children’s workforce. Children’s commitment to ethical behavior is
reﬂected in our Compliance Code of Conduct and our business practices.
Making sure we understand how to apply the laws and regulations that
guide our activities is what the Compliance Code of Conduct and the
Corporate Compliance Program are about. Children’s Corporate
Compliance Program affirms our dedication to excellence.
The Corporate Compliance Program encourages and enhances the
efforts of everyone to use the highest level of integrity. Ethical behavior
will help shield Children’s from potential liability under the complex laws
and regulations that govern the activities of the healthcare industry.
To do this, we will:
Provide written standards such as:
• The Code of Conduct (see page 2).
• Policies and procedures located on CHILD, Seattle
Children’s intranet.
Conduct education and training programs for employees,
volunteers, certain vendors and nonemployees:
• All new employees are required to take the Corporate
Compliance web-based training module.
• All employees are required to take the web-based training
module annually prior to performance evaluations.
Laws and Regulations
The ultimate goals of the Corporate Compliance Program are ﬁrst and
foremost to prevent actions that may violate laws and regulations and
to prevent fraud and abuse of healthcare dollars wherever possible.
The False Claims Act
A false or fraudulent claim is a request for payment for a medical
service or item that is not reasonable or necessary for the diagnosis or
treatment of a patient.
What do you need to know about the False Claims Act?
• The submission to a federal governmental health care program of
a false or fraudulent claim for a medical service or item is
prohibited by the federal False Claims Act (FCA) (3729 - 3733 of
Title 31 U.S.C.) and also prohibited by Washington state law (see
page 6).
• Employees who report the submission of false or fraudulent
claims are protected as “whistleblowers” and may not be
retaliated against in their employment. Private citizens may share
in the money recovered by the government if a prosecution is
successful.
• Children’s Corporate Compliance Program policies and
procedures have been developed to further deﬁne our plan to
prevent and detect fraud, waste and abuse. Go to CHILD to read
the Compliance Program policies and procedures.
Submitting false or fraudulent claims may result in enforcement action
by a government agency.
• Volunteers and other non-employees also receive compliance
training. Ask your supervisor or sponsor to learn more.
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Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
It is important for everyone to understand how
serious it is to submit a false claim!
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
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The penalties can be very high, such as:
Conditions of Participation (CoP) or Conditions for Coverage (CfC)
•
A provider may be ﬁned up to $11,000 for each false claim for
certain kinds of fraud in addition to three times the amount of the
loss.
•
Providers may be excluded from participating in any federal
healthcare program.
These laws are mandated by the Centers for Medicare and Medicaid
Services and are focused on minimum standards expected to maintain
quality of patient care. Hospitals and other providers must comply with
these standards to maintain their Medicare and Medicaid provider
status.
•
Providers may face jail time.
Applicable State Law
The Program Fraud and Civil Remedies Act
Under the Program Fraud and Civil Remedies Act (PFCRA, 31 U.S.C §
3801-3812), the person submitting the claim may be subject to a penalty
of up to $5,000 per claim or statement, plus up to double the amount of
each claim falsely made. The Office of Inspector General (OIG) of the
Department of Health and Human Services (HHS) is repsonsible for
investigating allegations of false claims and statements to HHS.
Anti-kickback
The primary purpose of this federal law is to protect patients from
providers making healthcare decisions based on the inﬂuence of
anything of value from interested parties. Anyone who knowingly
receives or pays anything of value to inﬂuence the referral of federal
healthcare program business, including Medicare and Medicaid, can be
prosecuted for a felony. Washington State also has anti-kickback laws.
Patient Protection and Affordable Care Act
(also known as healthcare reform)
This law makes compliance programs mandatory. Many changes to laws
occurred under this statute, including anti-kickback violations can now
be prosecuted as false claims. Additionally, if an overpayment is
received from a government payer, it must be returned in a speciﬁed
time or it can be considered a false claim and prosecuted as such.
Emergency Medical and Active Labor Act (EMTALA)
This law, also known as the “anti-dumpting” law,, states that anyone
presenting to an emergency department asking for treatment for an
emergency condition must be provided an emergency medical
screening and necessary stabilization measures. This exam and
treatment cannot be delayed to inquire about payment status.
5 Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Under Washington State Law, it is a felony for any person or institution
to knowingly make or cause to be made any false statement or
representation of material fact:
• In application for payment under any state medical care program; or
• For use in determining rights to such payment.
It is also a felony to conceal, cover up or fail to disclose:
• Any material fact to a state medical care program or any right to
payment greater than is due or for which no payment is due.
• The occurence of any event affecting either the initial or continued
right to any payment with the intent to secure payments fraudently
either in a greater amount than what is due or when no such payment
is authorized.
The above crimes may be punishable by up to 5 years in prison and/or a
ﬁne not to exceed $25,000.
In addition to criminal sanctions and other penalties, a person or
institution who obtains or attempts to obtain payment from a state
health care beneﬁt program in an amount greater than that to which the
person or institution is entitled by means of:
• Willful false statements;
• Willful misrepresentation or concealment of any material facts; or
• Any fraudulent scheme (including billing for items or services not
provided, misrepresenting the items billed, or billing for purportedly
covered items, which were in fact not covered)
Must repay the amounts wrongfully obtained plus interest and
subjected to a civil penalty in an amount up to 3 times the amount of the
excess payments received.
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
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Did you ever wonder who Children’s reports to? See the image
below for the federal, state, local and miscellaneous agencies
the govern Seattle Children’s activities.
COMPLIANCE IS NOT ONLY IMPORTANT FOR
SEATTLE CHILDREN’S, IT’S MANDATORY!
Responsible Conduct of Research
Nicole Jacobs
Research Integrity Officer
206-884-4054
[email protected]
Seattle Children’s Research Institute strives for excellence in the
responsible conduct of research. This involves:
• Protection of human research participants
• Ethical treatment of animal research subjects
• Assurance of environmental health and workplace safety for
researchers
• Administration and management of research awards
• Identiﬁcation and management of ﬁnancial conﬂicts of interest
• Fostering a culture of research compliance and responsible ﬁnancial
stewardship.
As a result, all employees and agents of Children’s who are engaged in
research activities are expected to conduct research in compliance with
federal, state and local laws, as well as institutional policies and
procedures.
The Office of Research Compliance works with the Corporate
Compliance Program to encourage and enhance the efforts of employees and agents to achieve the highest level of integrity. It does so by
performing compliance research risk assessments, auditing and monitoring research activities, conducting effective education and training
programs on responsible conduct of research, developing research
policies and procedures, and promptly investigating all reported
research compliance concerns (See page 9 “How do I report an issue”).
For more information on the research compliance program, go to the
Research tab on CHILD and click Forms and Policies. Research policies
and procedures can be found by clicking on the Policies & Procedures
tab and choosing Research in the left hand column.
You may direct research compliance questions to the Office of Research
Compliance at [email protected]
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Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
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You have a duty to report potential compliance
concerns -- we can’t ﬁx it if we don’t know about it.
Reporting
What do I report?
Compliance issues can be complex and knowing when to report a
potential issue is not always easy. Ask yourself these questions when
you see a possible violation:
•
Does the action seem illegal?
•
Is it inconsistent with Children’s policies and procedures?
•
Does it violate your standard of ethical behavior?
If you are still unsure after considering these questions, contact your
supervisor, the Corporate Compliance Department, the Compliance
Helpline or you can report online through CHILD using Ethics Point.
How do I report an issue?
•\
If an issue arises that you feel may violate the Compliance Code of
Conduct or any of the laws described in these materials, please do
the following:
1.
Start with the chain of command by talking to your immediate
supervisor or manager.
2.
If that does not seem appropriate, go to the department
director or another trusted manager or leader at Children’s.
3.
You can also call the Compliance Helpline, report using Ethics
Point through the CHILD, or contact the Corporate Compliance
Officer directly at 1-206-987-5220.
Potential violations and other compliance concerns can be reported
anonymously if you desire. Ethics Point is a company completely
external to Children’s. Those who wish to report a violation can call
and talk to a live person or type in their concern through a webbased program.
Reporting a Potential Violation Using the Compliance Helpline
When you call the Helpline, you can identify yourself or, if you prefer,
just let them know that you would like to provide information
anonymously. The representative will create a report based on the
information that you provide and send the report to the Children’s
Corporate Compliance Office.
Compliance Helpline: (877) 483-3049
When should I use the Compliance Helpline or submit questions
online?
Anytime. The Compliance Helpline and Ethics Point (the online source
from CHILD) are additional resources available for you to report
potential violations or ask questions.
Reporting Potential Violation on the Web
Ethics Point not only services the Compliance Helpline, but it also
provides a Web-based option for reporting compliance concerns.
The process is described as follows:
1.
You can report online by going to the CHILD homepage or
Corporate Compliance Program site.
2.
Click on the Compliance Reporting link.
3.
This will take you to an external website. This website is not
part of the Children’s system and cannot be tracked by
Children’s, so reporters may remain anonymous if desired.
4.
You will be directed to set up a password so that those
investigating can communicate with you while maintaining
your anonymity if so desired.
Children’s takes seriously the importance of conﬁdentiality in matters
involving potential compliance violations.
All calls placed to the Compliance Helpline or Ethics Point will be
kept conﬁdential as provided by law.
When you call the Helpline, you will speak directly with a compliance
professional who will ask questions about the issue. This line is staffed
on a 24/7 basis.
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Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
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Protecting Conﬁdential Information
You will never be required to provide your name if you do not want to. If
you wish to know what follow-up has occurred, you can set up an
appointment to call back and ask the Compliance Helpline or use the
“follow-up” function in Ethics Point.
What happens after I report a violation?
Children’s will promptly investigate all reports. Investigations will be as
conﬁdential as possible. The Compliance Officer will coordinate ﬁndings
and, if necessary, recommend changes that need to be made to ﬁx
identiﬁed problems.
Will I get in trouble for reporting a violation?
No. Children’s policy, as well as federal and state laws, described in these
materials, prohibit any retaliation or harm to a person who reports in
good faith. In fact, Children’s wants to know of all potential violations.
Auditing and Monitoring
Auditing and monitoring is an important component of an effective
compliance program. To help assure Children’s compliance with all
applicable laws and regulations, we will perform periodic compliance
audits. Audits in identiﬁed risk areas will be more frequent and detailed.
The Compliance Officer and a group of internal staff members, as well as
external auditors (as needed), will conduct the audits. When complete,
the audit results will be presented to the Compliance Committee and the
affected department.
Disciplinary Process/Corrective Action
Children’s will not tolerate behavior that violates the Compliance Code of
Conduct. This includes failure to comply with laws, regulations, policies
and procedures. Failure to comply is a serious matter and may lead to
corrective action, up to and including immediate suspension and even
termination. In addition, employees who violate certain laws may be
subject to legal prosecution.
Management staff may be held accountable for failure to comply with
Children’s Corporate Compliance Program or for the failure of their
reporting staffs to comply. Managers will be evaluated on how well they
educate about and enforce the standards of the Corporate Compliance
Program.
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Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Cris Ewell, Chief Information
Security Officer
206-987-5077
[email protected]
Sue Stubbs, Director, Health
Information and Privacy
206-987-3869
[email protected]
Protected Health Information (PHI)
Federal and state laws impose speciﬁc requirements and restrictions
on the use of protected health information (PHI). Children’s requires that
all members of its workforce take privacy and security training in order
to more clearly understand their responsibilities. Remember, all who
work at Children’s are responsible for maintaining the privacy and
security of PHI in all forms; oral, written and electronic.
Other Conﬁdential Information
Children’s also creates and uses many other kinds of conﬁdential
information to conduct business. Examples include strategic plans,
contracts, budgets, salaries and personal information about employees.
These types of information are to be viewed and used only by the
individuals who need them to do their jobs.
Information Systems and Data Security
Much of Children’s PHI is stored in electronic form. Many of Children’s
large computer applications contain information that is used for patient
care and related activities (treatment, payment and hospital operations).
Just as with paper or oral communications, you are responsible for
making sure that electronic information about patients and research
participants is protected from unauthorized access, modiﬁcation or
theft.
It is also your responsibility to keep Children’s business information
conﬁdential. Any attempt to inappropriately access or share conﬁdential
information, including PHI, may be subject to disciplinary action, up to
and including termination.
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
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It is a violation of policy to:
Business Standards
• Share your user ID (login) or password for any Children’s system;
• Seek or share conﬁdential information that is outside the scope
of your job responsibilities;
• Access information for others who are not authorized to obtain
that information;
• Breach or attempt to breach the security of any Children’s information
system or conﬁdential data; or
• Leave computers or media containing patient or other conﬁdential
information unsecured.
All workforce members sign a conﬁdentiality agreement before they
receive access to Children’s network and information systems. Your
access to electronic information may be monitored to assure compliance with Children’s privacy and security policies.
We Are All Responsible
Protecting the privacy and security of PHI and other conﬁdential
information is:
• Everyone’s responsibility.
• The right thing to do!
• The law.
Never access or disclose PHI or any other type of conﬁdential
information except as needed to perform your job; share
conﬁdential information only with authorized individuals.
More Information
To ﬁnd more information about Children’s Privacy and Security
programs, from the CHILD home page, select the People and Places tab;
select Programs, and then select the Privacy and Security Program.
Privacy and Security policies can be easily found by selecting the
Policies and Standards tab at the top of the CHILD home page; then
select Policies and Procedures. From this page you may search all
policies using key words or select Privacy and Security or Information
Services from the categories displayed on the left-hand side of the
page.
You may direct speciﬁc privacy questions to the Privacy Help Line,
206-987-1200, or via email: [email protected]. You
may direct information systems security questions to the IS Service
Desk, 206-987-1111.
Compliance Helpline: 1-877-483-3049
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EthicsPoint: From CHILD Applications, click on Compliance Reporting
Billing Practices
Accurate billing and submission of claims are top priorities for
Children’s. We must follow billing laws and regulations to be appropriately paid for our services. Clinical records must contain complete and
accurate documentation necessary to support all claims. Failure to
follow proper procedures can result in improper billing, which may lead
to civil and criminal liability for Children’s as well as individual employees.
We want to know when errors are found, and we encourage you to
report them so corrections and education can occur. The deliberate
submission of charges or claims for reimbursement that are false,
inaccurate, incomplete or duplicate is strictly prohibited.
If you discover a billing error, you should notify your supervisor or
Business Services immediately. It is important for Children’s to learn of
billing errors and ﬁx them as well as any system problems that may have
caused the error.
If we do not do so, the government may consider ongoing errors to be
false claims. The government may then sue Children’s under the False
Claims Act (see page 5).
If you have concerns about any charges submitted from your
department you should contact your supervisor, the Revenue Cycle
Director or call the Compliance Helpline at 1-877-483-3049.
You will not get into trouble for reporting your good faith concerns. You
are protected by law and also by Children’s non-retaliation policy. See
page 9 for how to report.
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
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Patient Billing and Resolution of Conﬂicts
Government Investigations and Legal Actions
Children’s requires that charges for services shall be standard for all
patients and payers. Claims are submitted in accordance with
government program regulations, payer contract requirements, and
industry standards. Questions from patients or payers are reviewed and
responded to .
If you are approached by any person who identiﬁes himself or
herself as a government investigator, you should contact the
General Counsel’s office immediately at 206-987-2044. Notify the
person taking the call that you are reporting a potential government investigation.
Billing complaints are handled through established procedures.
Children’s general credit and collection procedures comply with the Fair
Debt Collection Practices Act. We prohibit harrassmentin our debt debt
collection efforts.
If you receive a subpoena or other written request for information
related to a government investigation contact the General Counsel’s
office immediately. Do not respond directly to such requests or
subpoenas.
Conﬂict of Interest
Copyrights, Intellectual Property, Patents and
Inventions
As an employee of Children’s, you are expected to avoid situations that
might cause your personal interests to conﬂict with Children’s or to
compromise Children’s reputation for integrity.
A conﬂict of interest or the appearance of one, occurs when you or your
immediate family could use your position for personal beneﬁt.
We care not only for the end result, but also how we achieve that result.
If you have a question about whether an activity or involvement might
create a conﬂict of interest, contact your supervisor, the General
Counsel at 206-987-2044 or call the Compliance Helpline.at
1-877-483-3049.
Children’s retains the right to all copyrights, intellectual property,
discoveries, patents and inventions developed by staff that involve
Children’s facilities, services, conditions of employment or
assignment of duties.
The rights to inventions developed by employees of Children’s will
be assigned by agreement to Children’s.
You are required to report any inventions conceived or developed in
connection with your work or that involve Children’s facilities or
services to your department director. Your director will work with
you to make the appropriate invention disclosure.
Gifts
You are not allowed to receive gifts that may be viewed as a bribe or
a kickback. These include gifts with more than a small value, excessive
entertainment or anything of any value given to employees, physicians
or any other party in a position to inﬂuence patient referrals, patient
care or Children’s business.
Antitrust
Children’s is committed to competing fairly and in compliance with all
applicable laws. Antitrust laws prohibit agreements or attempted
agreements that limit or restrict competition. This includes sharing
information on prices or costs, products or services, dividing geographic
markets, boycotting or leading patients or customers to certain facilities.
While most business agreements are in the form of a written contract,
unwritten or informal agreements also fall under the guidance of antitrust laws. Children’s complies with all antitrust laws.
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Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
16
Patient Care Standards
Admission, Transfer and Discharge
Staff Request to Not Participate in Aspect of Care
At Children’s, a pediatric patient in need of medical care is admitted
without discrimination on the basis of race, gender, creed, ethnicity
or disability. Patients who enter our system are carefully assessed at
the time of entry and placed in a patient care area that best meets
their clinical needs.
Children’s respects a staff member’s request not to participate
in an aspect of patient care that infringes on his or her cultural
values, ethics or religious beliefs. The medical needs of patients and
their overall well-being take precedence, however, so that care,
treatment and services are not negatively affected.
Transfer to another unit or service is determined by the patient’s
clinical condition, matched to the admission and discharge criteria
of the speciﬁc units. Diversion to another health care facility occurs
only after a child’s condition has been assessed, and we are unable
to match their needs based on bed availability, adequate and
trained staff, technology or necessary equipment.
Staff Right to Notify the Joint Commission
Patient’s Right to Protective Services
Under Washington state law, all professional staff are obligated to
make a report to the proper authorities if they have reasonable
cause to believe that a child has suffered abuse or neglect. Seattle
Children’s provides resources to help determine the need for these
services and, if requested, a list of advocacy groups.
Employees have the right to report to The Joint Commission
concerns about the safety or quality of clinical/medical care
provided at Children’s.
Concerns may be reported to The Joint Commission via any of
the following:
• •
Telephone: 800-994-6610
• •
Fax : 630-792-5636
• •
Email: [email protected]
• •
Mail: One Renaissance Boulevard, Oak Terrace, IL 60181
Patient Care Decision Dilemmas
Individuals with knowledge and training in medical ethics are
available for consultation on a 24-hour, 7-day-a-week basis to
patients, family, staff or health care providers through the paging
operator at 206-987-2000.
Integrity of Clinical Decision Making
Clinical decisions are based on identiﬁed patient health care needs.
The integrity of clinical decision making is maintained, regardless of
how leaders, managers, clinical staff or licensed independent
practitioners are compensated and/or share ﬁnancial risk.
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Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Children’s will take no disciplinary action against
the person for good faith reporting.
Remember, for further information, see the Corporate
Compliance Web page on CHILD:
http://child/People_and_Places/Programs_and_
Services/Corporate_Compliance_Program/
Compliance Helpline: 1-877-483-3049
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EthicsPoint: From CHILD Applications, click on Compliance Reporting
Seattle Children’s Corporate Compliance
Program and Code of Conduct
Acknowledgement Form
My signature on this form acknowledges that I have received, read
and understand Seattle Children’s Corporate Compliance Program and
Code of Conduct.
Signature
Printed Name
Employee Number
Department
Date
Please return the completed form to the Corporate Compliance
Office.
Fax:
Mailstop:
Scan and email to:
206-987-5237
RC-402
[email protected]
If you need any help understanding these standards, please talk with
your supervisor.
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Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
Compliance Helpline: 1-877-483-3049
EthicsPoint: From CHILD Applications, click on Compliance Reporting
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