| Carbondale Area Physician Hospital
Organization (CAPHO) |
STANDARD OF CONDUCT
from the President and Chief Executive Officer
“I have come that all may have life”, the Mission of Jesus Christ,
is at the heart of the Mission of the Sisters, Servants of the
Immaculate Heart of Mary which inspires the Maxis Health System.
The Maxis Health System commits itself to this end by integrating
the resources of the entities for the total care of those we serve.
This Mission requires of us close and faithful attention to the
establishment and maintenance of right relationships within and among
all entities of the System as well as right relationship with clients,
patients, physicians, colleagues, volunteers, students, family members,
vendors, and payors.
understand that right relationships begin with a commitment on the part
of each individual working within our System to personal and
professional integrity. The
hallmark of our relationships with all those associated with Maxis
Health System is honesty, compassion, competence and a focus on service.
The relationships between members of the Maxis Health System are
those of support and challenge to further the System’s ability to
bring life to those we serve and to the members of the Maxis Health
Mission, Vision and Values of the Maxis Health System compel us to
foster and maintain an ethical culture, to engage in competent and
compassionate clinical practices, to adhere to appropriate and just
business practices. This
Standard of Conduct reflects the commitment of the Maxis Health System
to bring life to those we serve and with whom we serve within an ethical
culture that is consistent with our Catholic tradition and in compliance
with applicable laws, regulations, standards, policies and procedures.
These Standards apply to all who participate in the works of the Maxis
Health System - employees and Medical Staff from all entities, members
of the Maxis Health Board, the Health and Human Service Board and the
Foundation Board, and volunteers.
Mandated by the Maxis Health
System Board of Trustees, the Compliance Program has my full support.
In addition, this process to enhance the ethical culture of the
entities of the Maxis Health System has been endorsed by the Sponsor of
the System, the Sisters, Servants of the Immaculate Heart of Mary
Maxis Health System’s mission is to respond to the health and
human service needs of the community by integrating available resources of
each entity (Marian Community Hospital, Tri-County Human Services, Inc.,
Maxis Medical, Complete Pharmacy, Carbondale Area Physician Hospital
Organization, Maxis Foundation) into a network of care.
It is the intent of the System to create and support a network that
promotes the total health of the individuals and communities it serves. In order to achieve this mission and vision, we intentionally
commit ourselves to the Core Values of respect for human dignity,
compassion, hospitality, service, stewardship, competent care and a
special concern for the poor.
response to Maxis Health System Board of Trustee’s mandate to create a
program that provides guidelines and education aimed at helping us to
enhance and maintain our personal and corporate integrity, a Compliance
Program was developed. The
intent of this program is to provide broad based as well as
department-specific information to all employees through an education
program. In addition, the program details a process for employees to
report compliance-related concerns and questions through the use of a
Standard of Conduct manual reflects the work of the Compliance
Oversight, Anti-trust, Environment, General Laws, Labor, and
Oversight Committee provides direction and coordination of all compliance
efforts. Each of the other
committees have assessed our current status relative to the global risks
associated with their committees, evaluated current policies for relevance
and timeliness, and proposed the development of new policies as
appropriate. The untiring
work of these committees has added much to the development of our
Compliance Program and will continue to provide support and guidance in an
This Standard of Conduct for the System challenges each of
us and all of us together to engage in ethical business and clinical
practice. It is critical that we understand compliance as making
intentional decisions to do the right thing for the right reason. In
addition to keeping us focused on ethical behavior, the Compliance Program
is intended to facilitate a structure that helps to reduces the prospect
of criminal behavior. This
structure includes strategies that allow us to prevent infractions as well
as to detect and correct infractions if they occur.
Compliance is also about the
many types of relationships in which we engage.
It is critical for us to appreciate the relationship with those we
serve as a sacred trust which we take seriously.
Right relationships with our coworkers are key to fidelity to the
mission of each entity and the mission of the Maxis Health System. In
addition, honest and just relationships with payors and vendors are
essential to ethical business practice.
Dilemmas are part and parcel of
life. These challenging times
can become defining moments when we explore the dilemmas with an open mind
and focus on making the right choice for the right reason.
Included in this document is one suggested model for approaching
the decision-making process.
on-going ability to provide for the health and human service needs of our
community depends on our faithfulness to what is fair and true.
Acceptance of our duty to know and to comply with Federal, state,
and local rules and Church-related ethical standards is essential to
fidelity to our mission.
Standard articulates basic principles which apply to employees, medical
staff members, Board Members, volunteers, and students. The principles include the following:
We understand compliance as doing the “right thing for
the right reason” and therefore commit ourselves to:
conducting our business and clinical practice in a way
that respects the dignity of
each person and reduces the prospect of criminal behavior through
prevention, detection and correction of misconduct,
· adhering to the Ethical and Religious Directives for
Catholic Health Care Services
· complying with the rules, regulations, and
laws relevant to business and clinical practice.
2. Our relationships with the public and those we serve
(patients/ clients) are a sacred trust.
We are committed to serving those who entrust their care to us with
respect, compassion and competence.
3. Right relationships with our coworkers are key to fidelity
to the Mission of each entity and to the Mission of the Maxis Health
System. We are committed to
fostering environments in the workplace that foster trust, respect and
compliance with all relevant rules regulations, and laws.
4. Compliance is the responsibility of each employee, medical
staff member, Board Member, volunteer and student. We are committed to
knowing and adhering to prevailing rules, regulations and laws.
Compliance with these rules, regulations and laws is a condition of
Understanding of and adherence to sound business ethics is essential to compliance. We are committed to conduct ourselves with justice and honesty in our relationships with payors and vendors.
Notes Questions Comments
Understand Compliance as
As collaborators in Catholic
Health Care ministry our “right reason” is founded on the gospel
imperative to share in God’s life giving and healing work. The
Ethical and Religious Directives for Catholic Health Care Services guide
our decision-making processes. As
noted in these directives, it is the responsibility of all employees to
respect and uphold the religious mission of the Maxis Health System and
to promote the commitment to human dignity and the common good.
The internal and external
communication of the entities of Maxis Health System are governed by
honesty, accuracy, and respect for coworkers, patients, clients, and
those with whom we interact. Managers
and directors have a responsibility to ensure that staff is educated on
ethical behavioral practices as they apply to clinical work and business
dealings and to monitor their compliance.
It is the practice of the
entities of Maxis Health System to employ staff who are competent,
qualified, appropriately credentialed, and who are willing to share the
mission, vision, and values of the Maxis Health System.
We do not engage in business with nor do we hire persons who have
been convicted of health care-related crimes or are currently excluded
from participation in government-subsidized programs.
We expect all staff and
and comply with the requirements of the relevant rules, regulations,
laws, and policies that apply to their areas of responsibility. This includes maintaining copies of current licenses and
credentials in their Human Resources files;
their department director or the Corporate Compliance Officer regarding
issues that may be unclear, suggest inappropriate behavior, and/or have
the reporting policy and procedures when knowledgeable of
Notes Questions Comments
relationships with the Patients
Honesty, competence, and compassion are the hallmarks of our service and relationships with patients/clients and others with whom we come in contact. We are committed to treating patients/clients in a dignified manner, with courtesy, respect and professional competence, without regard to race, color, religion, ethnic origin, gender, marital status, public assistance, disability, age or any other category prohibited by law, with respect for confidentiality and privacy of the individual.
are informed of their rights. Employees
are aware of these rights and act in accord with them as outlined in the
“Patients’ Bill of Rights” (Marian Community Hospital) and the
“Client’s Rights and Responsibilities” and “Grievance
Procedure” (Tri-County Human Services Center, Inc.)
Patients/clients receive professional, clinically appropriate, and compassionate treatment and care. Confidentiality and privacy regarding patient and client information is maintained according to each entity’s standards.
In an on-going effort to foster and maintain an environment in which the
trust of patients/ clients are held sacred, we expect employees, medical
staff members, Board members, volunteers and students to take
appropriate action to:
|Notes Questions Comments|
Relationships with Our Coworkers Are Key
Each employee, medical staff member, Board member, volunteer, and
student must follow the Standard of Conduct as well as the regulations,
standards and expectations of their particular area. Compliance is required as a condition of continued association or
employment within Maxis Health System.
Together we enhance the integrity of our working environment,
conditions and the service we render to patients/clients and payors as
we commit ourselves to compliance in the following areas:
in Responsible and Respectful Personal Interactions
manner in which we treat each other has the potential to impact the way
we perform our work-related tasks.
It is the responsibility of all employees, medical staff members,
volunteers, and students to be aware of the ways their behavior affect
their patients/ clients, coworkers, and the ability of each entity to
convey a trustworthy image to those we serve.
Respectful and professional behavior is expected of all those who
participate in the Mission of each entity of the Maxis Health System.
Behavior reflecting discrimination of any form will not be tolerated and will be dealt with in an appropriate disciplinary manner after investigation.
|Creating a Safe Working Environment|
|All persons associated with Maxis Health System must obey all laws and regulations that apply to their area of work. These include environmental laws and rules in the operation of each entity, proper disposal of waste and protection from exposure. Accepted procedures will be followed for the safety of employees and staff members and the safety of all associates and patients/clients.|
|Maintaining Fair Working Conditions|
practices are in accord with the non-discrimination policies of each
entity. Qualified employees are sought to fulfill our mission.
Laws governing wages, employment, and employment termination are
followed. The workplace
fosters, supports and affirms excellence, professional development and
the health, safety, privacy and comfort of all associated with it.
As outlined in the Policy Against Sexual and Other Harassment,
harassment of any type is not tolerated.
References are sought for those who are hired. Upon employment all employees are expected to present appropriate licenses and credentials. In addition, employees will provide copies of updated licenses and credentials prior to expiration . This information will be maintained by the Human Resources department.
|Preserving the Confidentiality of Coworkers|
Confidential information (professional activity, peer review,
evaluations, appointments, etc.) regarding employees and the medical
staff is protected. Each
entity of the Maxis Health System is required to comply with the
security and safety policies that are detailed in the entity’s
Employees, medical staff members, Board members, volunteers and students are protected from retaliation when they, in good faith, report to their directors/supervisors or to the Compliance Officer any compliance-related infraction.
|Notes Questions Comments|
We Are Responsible for Promoting Corporate
Each employee, medical staff member, Board Member, volunteer, and
student has a duty to comply with all standards as well as to report
promptly and in good faith any procedures, regulations or the Standard
of Conduct. Employees are
required to use the existing systems or processes that are in place to
comply with policies and procedures.
If there is a question regarding compliance, employees,
medical staff members, Board Members, volunteers, and students are
encouraged to talk first with their supervisors or contact the Corporate
Compliance Officer. Reports
can be made anonymously, in a confidential manner and without fear of
|Hotline Policy - The Maxis Health System Reporting Process|
Hotline is one of the means available to report non-compliance with all
applicable standards. Reportable actions are those related to provider,
supplier, and practitioner practices that are inconsistent with our
Standard of Conduct, Federal, State, Local regulations, sound fiscal,
business, or medical practices. The
Hotline is not the vehicle for reporting Human Resource related
grievances, unless they are violations of the regulations with which we
are obliged to comply. Grievances
should be reported using the existing format as stated in the Personnel
All employees and Medical Staff throughout the Maxis Health
System have a duty to report suspected incidents of non-compliance to
the Corporate Compliance Officer. Open communication with the Compliance Officer is encouraged.
Concerns can be communicated in a number of ways: use of e-mail,
memo, hotline, and direct oral communication.
The Hotline can be reached by calling
This line is in the office of the Compliance Officer and is
available 24 hours a day, 365 days a year. This line is not equipped
with any type of caller identification devise.
The identification of the caller remains anonymous.
In addition, The Health and Human Services – Office of the
Inspector General Hotline is 1 – 800 – HHS – TIPS.
The duty to report is not limited to internal control in the
reimbursement and payment areas (regarding claims and billing
operations). It encompasses
each entity and all departments within the Maxis Health System, and is
incumbent upon corporate officers, managers, physicians, other health
care professionals, all employees as well as independent contractors to
facilitate ethical and legal conduct.
|Confidentiality of the Hotline|
ALL CALLS ARE CONFIDENTIAL. Reports and e-mail can be made on an anonymous basis.
Those calling to report using any format will not be required to
disclose their names. The
Hotline phone is not equipped with any form of Caller-ID technology.
Callers will be informed that their identity may need to be
revealed in the event of a governmental investigation or may become
known during the process of investigation.
Callers will be asked if they are willing to disclose their names
for the purpose of responding to their report but this will not be
required. Callers will be
given a code number and
a date to call the Compliance Officer back to receive a response.
The substance of the reports, not the names of the callers, will
be reported to the governing body of the System, the CEO, and the
Compliance Oversight Committee.
If a caller is involved in alleged misconduct, he/she needs to be aware, however, that not withstanding that fact, there may be legal implications for him or her. As a legal matter, voluntary disclosure can benefit the caller when prior misdeeds are taken into consideration.
|Truthful reporting of a concern in good faith is our duty and such reporting will not put the reporting employee’s job at risk. Retaliation or harassment violates Maxis Health System Mission and policies and it will not be tolerated. Incidents of any retaliation or harassment are to be reported immediately to the Compliance Officer. Each report will be investigated and the person(s) responsible will be subject to immediate discipline. In addition, frivolous or bad faith reporting can be the subject of disciplinary action.|
|Assessment and Investigation of Reports Made through the Hotline or Other Forms of Communication|
calls will be assessed and investigated for validity.
|Education and Training|
Managers, and Supervisors must ensure by training, teaching, leading and
monitoring that the people they direct or supervise follow the Standard
of Conduct, adhere to laws, standards, regulations, policies, and
procedures and do so in an ethical manner.
Members of the Boards of Trustees across the Maxis Health System will be apprised of their responsibilities through on-going Board Education. Each Board Member will sign a yearly Conflict of Interest statement.
Each employee of the Maxis Health System member, Medical Staff member, Board of Trustees member, and volunteer will acknowledge that the Standard of Conduct was received, reviewed, and complied with by signing a statement of acknowledgement upon initial affiliation with the organization. A copy of the signed statement will be kept on file.
|Notes Questions Comments|
Committed to Conduct Ourselves with Justice
employees, medical staff members, Boards members, volunteers, and
students within the Maxis Health System are obligated to comply with
Federal and State laws, regulations regarding the Medicare/ Medicaid
Programs, and Managed Care Plans, as well as regulations concerning
It is our responsibility to code and bill accurately for services and/or treatments rendered, and to maintain proper billing practices, which include following special billing requirements for government- sponsored programs and other payors. We will take appropriate and necessary measures to avoid instances of deliberately misleading any government agency or other payors. It is also our responsibility to ensure compliance with facility and operating standards for licensing and certification of the entities within the Maxis Health System.
Employees within each entity will attend appropriate mandatory education and training programs regarding Medicare/Medicaid and other payors as necessary.
|Notes Questions Comments|
Are Committed to Right Relationships with
Whom We Conduct Business
with Whom We Conduct Business
The vendors with whom we
conduct business are informed by the Director of Materials Management of
our Standard of Conduct and our expectation of them to comply with the
practices and policies of the entities with whom they engage.
All business transactions of Maxis Health System entities are conducted in compliance with applicable anti-trust laws. These complex laws are an effort to encourage competitive and fair operating practices between organizations. Price sharing is prohibited.
Providers of contracted services who are in violation of standards or who have been sanctioned or excluded from any governmental program that provides coverage for service rendered will have their contracts cancelled.
Health System has a policy regarding the reception of gifts from
vendors. Vendors will be apprized of this policy.
Employees and staff will be aware of and conform to this policy.
employees, medical staff members, Board members, volunteers, and
students are to avoid any behaviors that would engage in conflict of
interest. For example:
A Model for Decision Making
The following model can
be use to help us think through and make ethical and professional
We understand compliance as doing the “right thing for the
right reason” and therefore
Our relationships with the public and those we serve (patients/
Right relationships with our coworkers are key to fidelity to the
Compliance is the responsibility of each employee, medical staff
Understanding of and adherence to sound business ethics is
Employee Response to the Standard of Conduct
I have received and read
the Maxis Health System Standard of Conduct.
I will conduct myself according the principles set forth in this
document and according to the expectations that are included in the
relevant and appropriate accreditation bodies, professional organizations,
licensing bodies, regulations of payers with whom the entities of the
Maxis Health System are related. By
signing this document, I also agree to abide by the Ethical and Religious
Directives for Catholic Health Care Services, the Sexual and Other
Harassment Policy, the Patients’ Bill of Rights (MCH), the Client’s
Rights and Responsibilities and Grievance Procedure (Tri-County Human
Services), the Confidentiality and Security policy relevant to the entity
of which I am an employee.
I will attend the required educational programs regarding. Compliance as they are scheduled. I
understand that I have a duty to report any violations of this policy.
© 2001 Marian Community Hospital, Carbondale, PA. All
Comments/Suggestions to [email protected]