Code of Conduct

The Health System operates in a very complex business and social environment. It is the Health System's mission to continually improve the health and wellbeing of the people it serves. Our philosophy and policy is to operate legally and ethically within this environment while treating all patients, families, doctors, employees, and the public with dignity and respect. The Health System tries, with help and expertise of all its employees, to know, distribute, and obey all laws and regulations to which it is subject. This Code is not intended to, nor can it, contain everything an employee must know and comply with. However, all employees are expected to be mindful of the areas covered in this document while performing their daily tasks and duties. Any questions regarding the interpretation of this Code or application of any law should be directed to the employee's supervisor or the Compliance Officer.


The Health System operates in a competitive business environment, but does not involve itself in any practices that inhibit competition such as price fixing, collusion, boycotts, price discrimination agreements, deception, intimidation, misappropriation of trade secrets, or bribery.

As a not-for-profit corporation, all resources are used in a manner which furthers the public good rather than the private or personal interests of any individual. We accurately file all tax returns and make all payments in accordance with applicable tax laws.

Political Activity
All employees shall refrain from any activity which may jeopardize the tax exempt status of the organization such as political lobbying or entering into agreements to pay money, property, or services for any political activities that are not on their own time and using their own funds. All governmental contracts and transactions will be done in an honest and ethical manner. No one will attempt to improperly influence any government representative.

Fraud and Abuse
The Health System, its management, and its employees will refrain from all behavior that may be construed as Fraud (intentional) or Abuse (unintentional), understanding that ignorance of the law is not a suitable defense. This includes, but is not limited to, payments in exchange for referrals; filing false, misleading, or fraudulent claims; or making false representations to gain or maintain it self in programs to get payments.  The Federal False Claims Act establishes liability for, among other things:

  • knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval;
  • knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim; 
  • conspiring to commit a violation of the Federal False Claims Act; and 
  • knowingly making, using, or causing to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government, or knowingly concealing and improperly avoiding or decreasing an obligation to pay or transmit money or property to the Government.

The Health System respects the environment and will strive to use its resources appropriately and efficiently, dispose of all materials in a safe and appropriate manner, and will cooperate with any governmental agency to remedy any contamination.

The Health System treats all of its employees, patients, and other persons fairly and equitably without regard to the race, color, religion, sex, ethnic origin, age, veteran status, or disability of such person, or any other classification prohibited by law. Please refer to the Equal Employment Opportunity Statement in this handbook. Additionally, no harassment or discrimination of any type will be permitted.

Business Ethics

The Health System's management and employees will accurately and honestly represent the Health System in all matters and will not defraud anyone of their time, money, property, or services. All employees will be candid and honest in all communications and will not intentionally make false or misleading statements.


All requests for information shall be directed to the appropriate department.

Patient Information and Medical Records 
Medical records are property of the Health System and shall be maintained to serve the patient, the health care providers, and the Health System in accordance with legal, accrediting, and regulatory agency requirements. All patient information including medical treatment shall be regarded as confidential and available only to authorized users.

Employee Information
Salary, benefits, and other personal information relating to employees shall be treated as confidential. Personnel files, payroll information, disciplinary matters, and similar information shall be maintained in a manner designed to ensure confidentiality in accordance with applicable laws. All requests for information pertaining to Health System employees, former employees, and job applicants should be forwarded to the Human Resource Department.

Proprietary Information
Information, ideas, and intellectual property assets of the Health System are important to its success and are considered confidential and proprietary information belonging to the Health System. Employees shall preserve the confidentiality of all confidential and proprietary information. Employees will not, either during or after their employment, disclose to others, use for their own benefit, copy or make notes of any confidential and/or proprietary information, trade secrets, or any other knowledge or information relating to the business activities, or facilities of the Health System which may come to the employee's knowledge during his/her employment with the Health System.

Upon separation of employment with the Health System for whatever reason and regardless of whether this separation is voluntary on the employee's part or not, the employee will deliver to the Health System all records, notes, data, memoranda, and equipment of any nature which are in the possession and/or control of the employee that are the property of the Health System and/or relate to the employment or the business, activities or facilities of the Health System. No employee shall disclose any confidential and/or proprietary information to the news media, general public or other outside third parties without the advance written approval of the appropriate Vice President or the President of the Health System.

Conflicts of Interest

The Health System's employees and management owe a duty of unqualified loyalty to the Health System. No employee or a member of any employee's family may use the employee's position to profit personally or assist others in profiting in any way at the expense of the Health System.


Business Relationships

Gifts and Gratuities 
The Health System will conduct all business transactions free from offers or solicitations of gifts and favors. Employees are prohibited from soliciting tips, personal gratuities or gifts from patients or family members and from accepting monetary tips or gifts exceeding a modest value. Gifts (at Christmas, Birthdays, or other Special Occasions) may be exchanged between physicians or vendors and staff personnel or between employees as expressions of friendship, however, such gifts shall not be more than a modest value and shall not influence or affect decision-making or actions of the Health System. No employee shall offer or give money, property or services with the expectation of influencing the judgment or decision making process of any purchaser, supplier, person or government official.

Workshops and Seminars
Workshops and seminars given by vendors or agencies may be attended with Administrative approval. Any travel must be approved and all policies must be followed.

Employees may accept rebates, discounts, or allowances that are approved by Administration and that are properly documented.

All business with contractors must be conducted openly with the Health System's needs being the primary factor in all contract negotiations. Employees may not utilize "insider" information for any business activity conducted by or on behalf of the Health System.

Protection of Assets

Internal Control and Reporting
The Health System will strive to use its resources effectively and to accurately report its financial condition. Internal controls and standards have been established to protect assets and financial records. Employees will maintain and comply with those standards and controls that apply to them. All financial activity is to be classified and reported accurately in a timely manner.

Personal Use of Assets
Employees are prohibited from utilizing any of the Health System's assets for personal gain.

Travel, Education and Entertainment
Travel, education and entertainment expenses must be consistent with the employee's job responsibility and the Health System's needs and resources as well as approved and properly documented.

Implementation of this Code

Departmental Rules, Compliance Officer and Compliance Committee
Each department has individual rules and regulations that it must follow. The Health System has a Compliance Officer to make certain that policies and procedures are in place to ensure that the regulations are followed and that they are periodically reviewed to make certain that they conform to the most current guidelines. To assist the Compliance Officer, a compliance committee has been named. This committee is comprised of representatives of each of the departments most affected by the governmental rules and regulations. The Compliance Officer together with the Compliance Committee have developed detailed departmental and Health System policies and procedures to detect and prevent fraud, waste and abuse in federal health care programs.

Reporting of Violations
If you know of a violation or possible violation of this Code including any violations of state or federal laws regarding compliance, you must immediately report such information to your supervisor, appropriate department head or the Compliance Officer. All supervisors and department heads must report potential violations to the Compliance Officer. If for any reason the employee cannot report a violation or possible violation to the employee's supervisor or appropriate department head, or if the employee feels that the complaint has not been appropriately addressed, the employee should report to the Compliance Officer either personally or through the use of the Health System Compliance Hotline (888-884-2499). All matters will be kept confidential except when the nature of the complaint requires disclosure and then will be disclosed only to the extent necessary to resolve the complaint. An investigation will be conducted anytime there is a possible violation of the regulations or policies and procedures.

Disciplinary Actions
All employees will be assessed on their compliance with these guidelines as well as their assigned tasks and duties. The failure of an employee to comply with the provisions of this Code of Conduct can have serious consequences. The Health System will impose appropriate disciplinary action for violations of this Code of Conduct, up to and including dismissal. Disciplinary actions will be taken against employees who authorize or participate directly or indirectly in any action which constitutes a violation of law, this Code of Conduct or any related policies or procedures and, when appropriate, will be reported to the proper authorities.

Any employee who makes a knowingly false report or utilizes this Code of Conduct or other reporting mechanism for personal gain will be subject to appropriate disciplinary action, up to and including dismissal.

No Retaliation for Good Faith Reporting of Violations
The Health System's policy, as well as federal and state law, prohibits retaliation against any employee who reports, in good faith, an actual or suspected violation of the law. No employee shall take retaliatory action against any individual for reporting, or causing to be reported, suspected wrongdoing, or for assisting in the authorized investigation of alleged wrongdoing. Retaliation, if confirmed, will result in appropriate disciplinary action. Persons who believe they have been subjected to retaliation in violation of this policy should notify the Compliance Officer.

Nothing in this Code of Conduct is intended to, nor shall be construed as, providing any additional employment or contract rights to employees or other persons. While the Health System will generally attempt to communicate changes with, or prior to, the implementation of such changes, the Health System reserves the right to modify, amend or alter the Code of Conduct without notice to any person or employee.