Code Of Conduct - NewYork-Presbyterian Hospital
Code of ConductAugust 12, 2019
Table of ContentsA Message from our Chief Executive Officer . 3Our Commitment, Vision and Culture . 5Respect Credo. 6Overview and Introduction. 7Responsibility. 8Compliance with Rules, Regulations and Policies .8Reporting Expectations and Resources.10Excellence.12Training and Education. 12Billing, Coding and Reimbursement . 14Referrals of Care and Service. 15Quality of Care and Services.16Empathy.18Harassment and Workplace Violence. 18Diversity, Equal Opportunity and Inclusion. 20Environmental and Safety Considerations.22Teamwork. 24Business Ethics.24Conflict of Interest . 28Respect. 32Privacy, Security and Confidentiality.32Innovation. 34Communication, Marketing and Social Media.34Protection of NYP Assets and Proprietary Information . 36Research Compliance. 38Compliance Resources.40Compliance Policies.40Privacy Policies.41
Letter from theChief Executive OfficerA special message from Steven J. Corwin, M.D., Presidentand Chief Executive Officer, to the employees, medicalA Message from our Chief Execustaff, and others who work or do business with thetive OfficerNew York- Presbyterian community.Our goal is to be the preeminent academicintegrated delivery system in the country,providing the highest quality, safest, and mostcompassionate care to our patients and theirfamilies. To achieve our goal, we must be true toour commitment to “We Put Patients First” andoperate in a manner that satisfies regulatoryrequirements and social responsibility. Everyemployee, medical staff member, and all thosedoing business at or on behalf of New YorkPresbyterian are expected to embrace our Cultureand act with integrity, fairness, honesty, and in thebest interests of our Institution and those we serve.Steven J. Corwin, M.D.This is our Code of Conduct (Code). It reflectsPresident and Chief Executive Officercurrent requirements in an ever-changingregulatory environment. This Code was approvedby our Board of Trustees and articulates the principles that guide us. While each of us should take thetime to read and familiarize ourselves with the Code, I want to emphasize the following:1. Compliance is essential in every aspect of our business; we need to be aware ofand adhere to all laws and regulations.2. When issues or concerns are raised they will be addressed appropriately by ourmanagement team. It is management’s job to foster an environment that facilitatesproblem identification and resolution. So, do not be afraid to ask.3. Each of us has an affirmative duty to bring matters of concern to the attention of theappropriate personnel. You will be protected from retaliation or retribution for doing so ingood faith.4. The Code applies to all of us.Please read this booklet carefully, paying particular attention to those aspects of the Code which applyto your area of responsibility. Use the information to guide your work at NYP. Thank you for your ongoingsupport, and for your commitment to our patients and their families.Very truly yours,3
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Our Commitment, Vision and CultureOur Commitment“We Put Patients First”Our VisionTo Be the Top Academic Integrated DeliverySystem in the Nation in Patient Centered Care,Research and Education.Our CultureRespectEvery Person Counts, Every Role CountsTeamworkWorking TogetherExcellenceExceptional Quality and ServiceEmpathyListen, Understand and RespondInnovationCreative Ideas, Cutting Edge SolutionsResponsibilityHonoring Our Past, Ensuring Our Future5
Respect CredoOur CREDORESPECT at NewYork-PresbyterianAt NYP, every person and every role counts. We will treat everyone as a valued human being,considering everyone’s feelings, needs, ideas, and preferences. We will honor everyone’s contributionsto creating a healing environment for our patients, families, and colleagues.AS A MEMBER OF THE NYP COMMUNITY:I believeI willI will not Every individual who comes to us for care Treat others as they want to be treated, Speak or act disrespectfullyand who works here deserves my courtesyand respect. Every contact with a patient or co-workeris a chance to build a trusting relationship. It is my responsibility to honor ourcommitment to We Put Patients First. Teamwork and clear communicationare necessary for providing the highestquality care. NYP is enriched by embracing our diversity. Every team member contributes to NYP’ssuccess and to creating an environmentwhere everyone feels like they belong.with kindness, courtesy, and empathy. Show respect in my words, actions,communication, and body language. Listen to and respond to patients, families,and colleagues. Do my best to assist a patient or colleagueasking for help. Assume the best of others and give themthe benefit of the doubt. Be open to the ideas of others and handledifferences of opinion constructively. Hold myself, my colleagues, and my teamaccountable for our work. Help foster an environment of professionalism,openness, and high ethical standards. Uphold NYP’s commitment to diversity,inclusion and belonging.6WHERE AMAZING WORKStoward anyone. Engage in or tolerate abusive languageand behavior. Speak negatively about patients orcolleagues, especially in front of patientsand visitors. Create an environment in which peopleare afraid to bring forward concerns orissues of safety. Act irresponsibly with NYP resources.
Overview and IntroductionWhat is NewYorkPresbyterian’s (NYP)Code of Conduct?NYP’s Code of Conduct clearly and conciselyoutlines the types of behaviors expected inthe workplace. The Code of Conduct wasdeveloped to support NYP’s workforce incomplying with applicable laws, regulationsand NYP policies and assist with makingdecisions that are in the best interest of thehospital and our patients.Why is it important to have aCode of Conduct?NYP established a Code of Conductto reflect our culture and foster anenvironment that optimizes the deliveryof the highest quality and compassionate,patient-centered care. We share a commoncommitment, vision and values, and theCode of Conduct helps us to fulfill eachwith integrity, fairness and in the bestinterest of NYP and those we serve.Does the Code of Conductapply to me?Without exception, this Code appliesequally to everyone at all levels of theorganization across the NYP system and itis the responsibility of senior leadership,medical/professional staff, contract staff,volunteers, students, researchers andall employees of NYP to act in a mannerconsistent with the Code of Conduct.7
ResponsibilityCompliance with Rules, Regulations and PoliciesCompliance withRules, Regulationsand PoliciesNYP’s Commitment to You We work every day to achieve theorganization’s mission, vision andvalues. We apply the Code of Conduct andother organizational standards andpolicies fairly and consistently. If these important expectations arenot followed, we respondappropriately, according to theorganization’s discipline guidelinesand, if applicable, the terms of anycontracts and labor agreements.8
Your Commitment You understand and comply with applicable rules, regulations and laws that governNYP and its employees. You use the Code of Conduct and other resources from the organization to help youmake the right decisions. You familiarize yourself and comply with the contents of the Employee Handbookas well as with the policies and procedures applicable to your employment andresponsibilities at NYP. If you have questions about any of these requirements, youaddress them with management. You know that a violation of your responsibilities, as explained in the Code ofConduct, other organizational standards and policies and applicable laws can resultin corrective action, up to and including termination. Medical staff members,because they are employed by or appointed by the medical colleges, may haveadditional obligation.9
Reporting Expectations and ResourcesNYP’s Commitment to You We establish, maintain and makeavailable multiple mechanismsfor reporting compliance concerns,including a Compliance Helpline. Reports can be made through thetoll-free Compliance Helpline at1-888-308-4435 or web-basedsubmission at nyplalertline.com,which is available 24/7. TheCompliance Helpline is operated byan outside organization. Reports canbe made anonymously and in bothEnglish and Spanish.nyp.alertline.com1-888-308-4435 We ensure all reports receivedthrough the Helpline are thoroughlyinvestigated and addressed. We make every effort to maintainthe confidentiality of the informationprovided to the fullest extentpractical or allowed by law.10 We make sure that the informationwe create, maintain and report is fair,accurate, complete and timely.
Your Commitment You foster a culture of integrity and compliance, and model that behavior. You timely report any known or suspected Compliance violations. You understand that you cannot be retaliated against for reporting a complianceconcern. You will not intimidate or retaliate against others for reporting compliance concerns. You will report all known or suspected concerns in good faith. If there is a question or concern about a situation that you believe may be illegal orunethical, you may first seek guidance from your manager. If you are uncomfortableaddressing the issue with your manager or the manager has failed to address theissue in a timely or effective manner, you will inform one or more of the following:Senior Management, Office of Legal Affairs, Human Resources or Compliance. Whenmanagers are unsure of how to respond to an inquiry from an employee, you seekassistance through the chain of command, the Human Resources Department, theOffice of Legal Affairs or the Office of Corporate Compliance Reporting directly to the Office of Corporate Compliance should never be discouraged.11
ExcellenceTraining and EducationTraining andEducationNYP’s Commitment to You We maintain a comprehensive,formal program of generalcompliance and privacy training toensure that members of the NYPworkforce are aware of their legal,moral and ethical responsibilities. We will prepare and periodicallyupdate the compliance and privacytraining content and maintainrecords of training completion. Othercommunication and trainingmechanisms (e.g. specializedtraining and huddle messages), willbe implemented at the discretion ofthe Office of Corporate Compliance. We provide training and education tonew workforce members to ensureawareness of the NYP Complianceand Privacy Program expectations.12
Your Commitment You will attend general compliance and privacy training at new hire orientation andcomplete a general compliance and privacy training annually thereafter online. You complete required education and training on time. You ask your manager or reach out to the Office of Corporate Compliance for help ifyou do not understand something that is covered in a training or educationalmaterials. You reach out to the Office of Corporate Compliance if you recognize the need forspecialized department specific compliance training.13
Billing, Coding and ReimbursementNYP’s Commitment to You We continually evaluate our coding and billing activities to identify areas forimprovement. We will make special note of concerns identified by regulators to mitigate the riskof improper billing. We will properly train staff and provide them with coding and billing updates in atimely manner. We will ensure payers are notified of payment errors and process refunds promptlyand accurately.Your Commitment You will document, codeand bill only for servicesthat were actually rendered. You will maintain accurate,thorough and completedocumentation to supportcoding and billing for allservices. You will bill for servicesaccording to Federal PayerGuidelines where applicable. You will bill in compliancewith the Teaching Hospitals Guidelines where applicable. You will not routinely waive patients’ coinsurances and deductibles. If you notice a coding or billing error, you will report it to your manager or theappropriate NYP authority.14
Referrals of Care and ServiceNYP’s Commitment to You It is important that patients trust that when we suggest treatment and otherservices, our recommendations are based on their needs and that we are providingthe highest quality, safest and most compassionate care to our patients and theirfamilies. Therefore, we follow all laws, sound care, and referral practices by makingsure patients receive appropriate care and service.Your Commitment You follow all laws about referring patients to other providers, facilities, suppliersand plans. These laws, some of which are known as the Anti- kickback, Stark (orphysician self-referral) and Patient Freedom of Choice laws can be complicated;consult with the Office of Legal Affairs if you are considering an arrangement withan outside provider or supplier that might affect patient or member referralpatterns or choices. You do not directly or indirectly solicit, accept or offer anything of value in exchangefor patient or member referrals. You do not give, offer or promise anything of value to any government official,primary contractor, subcontractor or other entity for the purpose of improperlyobtaining or receiving favorable treatment for yourself or NYP. You do not accept, directly or indirectly, anything of value from any NYP vendor (orentity seeking to do business with NYP) in exchange for giving favorable treatmentto the vendor. If you are a physician, you do not refer patients to other providers or facilities withwhich you or your family have a financial relationship. You do not offer special benefits or incentives to patients unless thosearrangements meet very specific criteria approved in advance by the Office of LegalAffairs.15
Quality of Care and ServicesNYP’s Commitment to You We screen all prospectiveemployees, vendors and medicalstaff to assure that they have notbeen sanctioned by anyregulatory agency and are eligibleto provide services or performtheir designated responsibilities. We provide high quality careand skilled, compassionate,reliable service to our patientsand to our community in a safeand healing environment. We expect all employees andmedical staff to conform to thestandards of their professionsand exercise appropriatejudgment in the performance oftheir duties. We know that excellent patient experiences result when people are engaged andproud of their work.16
Your Commitment You act in accordance with the provisions of the Patient Bill of Rights, as well asadhere to the following principles as applicable: You honor the dignity and privacy of each of our patients and will treat them at all times withconsideration, courtesy and respect. You provide appropriate and timely care to all patients without regard to race, color, religion, age,gender, sex, national origin, sexual orientation, gender identity or expression, disability, militarystatus or source of payment. When a patient presents with an emergency medical condition, you provide that patient with ascreening examination and stabilization of any emergency condition in accordance withapplicable laws, rules and regulations, regardless of the patient’s ability to pay. Patients will onlybe transferred after they are medically stabilized and an appropriate transfer has been arranged. You ensure a qualified practitioner properly evaluates every patient before initiating a treatmentplan. You provide patient care that conforms to acceptable clinical and safety standards. You maintain complete and thorough records of patient information to fulfill the requirementsset forth in our policies, accreditation standards, and applicable laws and regulations. You support and promote the continuous quality and performance improvementprogram (s) throughout NYP. You continuously strive toward a culture of patient safety. You provide service to our patients and their families in a manner that embodies ourphilosophy of “We Put Patients First” and aligns with Commitment to Care serviceexpectations for all NYP employees or medical staff.17
EmpathyHarassment and Workplace ViolenceHarassmentand WorkplaceViolenceNYP’s Commitment to You We do not tolerate any form ofharassment, including verbal,physical, visual or sexual harassment,or the intent to create an offensive,hostile or int
Empathy Listen, Understand and Respond Respect Every Person Counts, Every Role Counts. Innovation Creative Ideas, Cutting Edge Solutions Teamwork. Working Together. 5. Respect Credo. RESPECT at NewYork-Presbyterian At NYP, every person and every role counts. We will treat everyone as a valued human being,
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