CODE OF ETHICS AND BUSINESS CONDUCT

HIGHLINE MEDICAL CENTER

The Code of Ethics and Business Conduct (hereinafter “Code”) expresses the commitment of the Board of Trustees, management, professional staff and employees of Highline Medical Center (hereinafter “Highline”) to the values, principles and standards drawn from its mission.

While our Code is designed to provide overall guidance, it does not address every situation.  More specific guidance is provided in Highline’s Policies and Procedures.  If there is no specific policy, our Code becomes the policy.  If a policy and our Code conflict, the Code takes precedence.  This Code shall be reviewed annually and changes will be distributed in a timely manner to all employees.

All employees and independent contractors of Highline are responsible to ensure that their behaviors and activities are consistent with the Code and with Highline’s Corporate Compliance Program.  Each employee has an affirmative duty to report compliance issues and that the failure to do so could result in termination.

QUALITY PATIENT CARE:

We work together to provide excellence as we provide safe, compassionate and accessible health care.

1. We are committed to providing safe patient care in a healing environment. We promote a culture of safety throughout the organization.
2. We will provide medical treatment and other healthcare services to patients based on patients’ medical needs, physical and emotional welfare and informed consent.
3. We will administer health care and related services with trust and sensitivity to our patients, physicians and the community. Patients will be treated with respect and professionalism at all times.
4. We are committed to be sensitive to family, cultural and spiritual differences and provide caring for the whole person.
5. We provide each patient with a written statement of patient rights and a notice of privacy practices.

LEGAL AND REGULATORY COMPLIANCE:

We strive to ensure that all activities conducted by, or on behalf of, the organization are in compliance with applicable laws, regulations, and industry standards.

1. We will provide health care services, planning and management support consistent with federal and state laws and regulations that apply to our business.
2. We take care to assure that all billings to the patient and to the government and private insurance payors reflect truth and accuracy and conform to all pertinent Federal and State laws and regulations.  We prohibit any employee or agent of the hospital from knowingly presenting or causing to be presented claims for payment or approval that are false, fictitious or fraudulent.
3. We comply with federal and state laws, regulations and guidelines relating to all cost reports.
4. We follow the Emergency Medical Treatment and Active Labor Act (EMTALA) in providing an emergency medical screening examination and necessary stabilization to all patients, regardless of ability to pay.
5. We deal with all survey or accreditation bodies in a direct, open and honest manner.  No action should ever be taken in relationships with survey or accrediting bodies that would mislead the members of the survey or accrediting team, either directly or indirectly.

BUSINESS INFORMATION AND INFORMATION TECHNOLOGY:

We are all responsible for the accuracy, integrity and security of our organization’s documents and records.

1. We may not alter or falsify information on any record or document.
2. Company books and records shall not contain false or misleading information.
3. Records must never be destroyed in an effort to deny governmental authorities access to that which may be relevant to a government investigation.
4. We will maintain medical and business documents and follow our record retention policy in accordance with the laws, HIPAA and other applicable guidelines.
5. We communicate honestly and candidly with Highline’s attorneys and auditors.
6. We are committed to maintaining the privacy and confidentiality of patient information entrusted to us in accordance with legal and ethical standards.
7. We will release medical, clinical or business information only when such release is supported by a legitimate clinical or business purpose and is in compliance with Highline’s Notice of Privacy Practices, other policies and procedures, applicable laws, rules and regulations.
8. We will respect the privacy of our patients, co-workers and customers and safeguard patient, employee and customer information from physical damage.
9. We will exercise care to ensure that confidential and proprietary employment related information (salary, benefits, payroll, personnel records) is carefully maintained and managed to protect its value and integrity.
10. We will maintain computer passwords and access codes in a confidential and responsible manner.
11. We maintain and monitor security systems, data back-up systems and storage capabilities to ensure that information is maintained safely and securely in accordance with our policies and procedures, state and federal requirements.

BUSINESS CONDUCT

To further Highline’s commitment to the highest standards of business ethics and integrity, employees will accurately and honestly represent Highline and conduct business in an honest and ethical manner.

1. We act in the best interest of Highline whenever we act as an agent of Highline in our dealings with suppliers, customers and government agencies.  This includes those acts formalized in written contracts as well as everyday business relationships.
2. We conduct business in a manner that avoids conflicts of interest and the appearance of conflicts of interest.  (Please see Conflict of Interest Policy and Conflict of Interest Disclosure Form.)
3. We do not give or receive any form of payment, kickback or bribe to induce the referral or the purchase of any service.
4. We do not offer any improper inducement or favors to patients, providers or others to encourage the referral of patients to our facilities or to use a particular product or service.
5. Business transactions with vendors, contractors and other third parties shall be transacted free from offers or solicitations of gifts and favors or other improper inducements in exchange for influence or assistance in a transaction.
6. Individual employees shall not solicit tips, personal gratuities or gifts from patients.  (Please see Accepting Gifts policy.)
7. We comply with the laws regarding intellectual properties, including patents, trademarks, marketing, copyrights and software.  All employees are responsible to ensure that they do not improperly copy for their own use, documents or computer programs in violation of applicable copyright laws or licensing agreements.
8. We will not contract with persons or entities that have been sanctioned by any regulatory agency or excluded from participation in any federally funded healthcare program.
9. We comply with applicable antitrust and similar laws that regulate competition.  We avoid inappropriate discussions with competitors regarding business practices.
10. We will not make false or misleading statements to any patient, physician, person or entity doing business with Highline.
11. We shall not use confidential business information obtained from competitors (customer lists, price lists, contracts or other information) in violation of any covenant not to compete, any prior employment agreements or in any other manner likely to provide an unfair competitive advantage to Highline.

WORKPLACE AND EMPLOYMENT PRACTICES

We strive to create and maintain a work environment in which employees are treated with respect, diversity is valued, and opportunities are provided for development.

1. We comply with all applicable workplace health, safety and environmental laws and regulations. All employees are expected to handle materials according to established control, storage and disposal policies and procedures.
2. We provide equal employment opportunities to prospective and current employees. Highline shows respect and does not discriminate in employment opportunities or practices on the basis of race, color, religion, gender, marital status, nationality, age, physical or mental ability, sexual orientation, veteran status or any other status protected by law.
3. We support and observe a workplace free of alcohol and drugs.
4. We will not employ persons who have been sanctioned by any regulatory agency or excluded from participation in any federally funded healthcare program.
5. We do not tolerate any act of retaliation or retribution against any employee who in good faith reports suspected violations of law, regulation, Highline policy or this Code.  We cultivate a management team that fosters an “open door policy” and creates a work environment in which ethical concerns will be addressed.
6. All Highline employees will receive appropriate training and orientation and have the proper experience and expertise to perform their duties and to meet the needs of our customers.

ADMINISTRATION AND APPLICATION OF THIS CODE

Highline expects each person to whom this Code applies to abide by the principles and standards set forth and to conduct the business and affairs of Highline in a manner consistent with the general statement of principles set forth.

Failure to abide by this Code or the guidelines for behavior that the Code represents may lead to disciplinary action, up to and including termination.  Failure to report a known violation of this Code may also lead to disciplinary action.