Hospital’s conduct code clarifies cloudy issues

Compliance one of several issues addressed

Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) is just one of the subjects addressed in UCSF Stanford Healthcare’s new "Code of Conduct and Principles of Compliance," says Cynthia A. Frizelle, RN, BS, assistant director of admissions/registration.

The code of conduct, aimed at helping employees fulfill the organization’s ethical and legal obligations to patients, was announced last August. It covers the following issues:

1. Employee compliance (general):

This section addresses conflicts of interest, arrangements with vendors and third parties, and compliance with copyrights, patents, and trademarks.

It also deals with confidentiality of proprietary information, compliance with sexual harassment laws, and occupational and environmental safety regulations.

2. Employee compliance (patient care):

EMTALA is addressed in this section, as are principles of patient care, patient information and confidentiality, medical records documentation, laboratory compliance, and home health agency compliance. Also discussed are billing regulations, including billing and coding compliance, patient co-payments and deductibles, and Medicare’s 72-hour rule compliance.

3. Business standards and compliance:

Compliance with equal employment opportunity laws, compliance with the Americans with Disabilities Act, tax compliance, and antitrust compliance are addressed in this section. Also discussed are the prohibitions against payments for referrals, physician ownership in ancillary ventures, and document retention.

Employees who learn about a violation of the code are required to inform their supervisor, manager, or the chief compliance officer as soon as possible, Frizelle explains. They also may report violations by calling the organization’s compliance hotline, in which case they may remain anonymous, she notes.