LEGAL

1. LEGAL

2. The Organizational Integrity Program “Supporting Right Relationships” New Associate Orientation

3. Many hospitals and organizations have compliance programs to avoid breaking the law. Our program is about integrity—doing the right thing. The only sustainable competitive advantage a company has is its reputation. Why Integrity

4. All associates are expected to know the seven standards of conduct and perform their work according to them. General legal matters. Conflict of interest. Confidentiality of information. Excellence in patient care. Cooperating with investigations. Gratuities to officials. False Claims Act. Standards of Conduct

5. We follow all federal, state and local laws. For example, associates: In the lab or environmental services, dispose hazardous material properly. In patient care areas, never take personal property of patients. Involved in billing, should never submit bills for services not provided. General Legal Matters

6. Associates should not represent any other organization other than SJRMC when providing care for patients For example, associates should not: Recommend a friend or family member to do home remodeling for a patient. Provide unfair advantage for your friend or family member’s business at SJRMC. Promote any business or product to patients or other employees that would benefit your personally. Conflict of Interest

7. To provide excellent care, patients must trust SJRMC with their most intimate medical and personal information. Associates should: Never access medical record systems for any reason other than treatment of a patient. Be careful to discuss patients’ conditions only in appropriate locations. Never disclose who they saw in the hospital. Use e-mail and internet only for business related purposes. Confidentiality of Information

8. Each of us is a part of an interdisciplinary team providing our patients with the best care possible Guided by our faith-based traditions,we will provide exceptional care to all we serve (SJRMC vision) Excellence in Clinical Care

9. Inspections routinely occur at the hospital. State and federal agencies and other accrediting organizations will conduct inspections. All employees and managers are expected to fully cooperate. Hiding or destroying information is a serious violation. If mistakes are made, we do not engage in a cover-up. Cooperating With Government Investigations

10. When any kind of inspection occurs, we will stand on the hard work of our associates. No one should ever provide a bribe or any undue influence to receive a more favorable rating. Gratuities to Officials

11. It is a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program, which includes any plan or program that provides health benefits, through insurance which is funded by US government of any state health care program. False Claims Act

12. Examples of potential false claims include: Knowingly billing Medicare for services that were not provided. Submitting inaccurate or misleading claims for actual services provided. Making false statements to obtain payment for services. False Claims Act

13. The Act protects anyone who brings forward a concern in good faith from: Being fired Demoted Threatened or harassed Similar protections are provided by Indiana state false claims acts law. False Claims Act

14. Your supervisor or manager Higher-level manager Human resources Mission/spiritual care/ethics resources Medical staff affairs Risk management and safety departments HIPAA Privacy Official (Lucinda Seider 472-6021) and HIPAA Security Official (Margaret Lynch 258-1201) Peers Local Integrity Officer – Rob Sink (237-7444) The SJRMC integrity line—1-866-472-4661 Where to Find Help

15. Rob Sink Organizational Integrity Officer. He is responsible for investigating any concerns about violations of our policies or standards. Rob can be reached at (574) 237-7444 Contact SJRMC Integrity Officer

16. The SJRMC Compliance Line Available 24/7/365. Answered by an outside service using trained professionals. Reports are sent to the Trinity Health Organizational Integrity Department within 1 business day or less. Calls are not recorded and Integrity Line does not use caller-ID. Callers may remain anonymous; Reports are treated confidentially. Callers can check back on status and resolution of their report. 1-866-477-4661

17. No one in SJRMC is allowed to retaliate in any form against an individual reporting an issue or concern in good faith. Retaliation is subject to discipline, up to and including dismissal. No Retaliation Policy

18. Trinity Health and Saint Joseph Regional Medical Center have made leadership in quality improvement and patient safety a strategic priority. Because we have an ethical obligation to do nothing less. Remaining trustworthy and dealing directly and honesty with a patient when an adverse outcome occurs is responsible patient care. Responding Justly to Adverse Outcomes

19. If you become aware of a physician, fellow associate, volunteer or other person who you suspect may be dealing with a problem that impairs his or her ability to provide safe, effective care, you should take immediate action to protect patients or the person. Talk to your manager, call the house supervisor, or call the Integrity Compliance Line to share your concern. Impaired Practitioners

20. If you have a question or concern, ask for assistance Keep asking until you get a satisfactory answer Thank-you for supporting “Right Relationships” in Trinity Health! Responsibilities of Associates