Ashe Memorial Hospital/
AMH Segraves Care Center
Code of Conduct
CODE OF CONDUCT
Introduction and Purpose
Our community has entrusted Ashe Memorial Hospital/AMH Segraves Care Center (AMH/SCC) to provide quality health care to our patients and residents, and to conduct our activities with integrity, dignity, and professionalism. Our code of conduct is a written standard of behavior based on our organization's mission and values and provides guidance to our employees to ensure our work is done in an ethical and legal manner.
It is important that each employee become familiar with each of the standards listed in
this Code of Conduct.
Refer to this Code of Conduct often. Difficult situations and decisions may arise in your
daily work where you may have to apply these standards. The sole purpose of the Code of Conduct is to ensure that no matter what decision we make, either on an organizational or personal level, that it meets our value standards.
Mission Statement
Investment in the development of people
Commitment to continuous improvement
Accountability to those we serve
Responsiveness to the health care needs of the community
Excellence in primary health care
Vision and Value Statement
Ashe Memorial Hospital/AMH Segraves Care Center, in recognition of its mission, will
strive:
To provide the quality primary hospital and nursing facility services needed by the
community
To develop a system of health care services in partnership with the hospital's
medical/dental staff, and the community, in order to provide the most appropriate
care to the greatest number of people in need
To maintain an environment which promotes safety, satisfaction and opportunity
for the patients/residents, the employees, the physicians, and the community.
To maintain the hospital's financial ability to support quality health care at
reasonable cost, in accordance with community need and regulatory authority
To demonstrate by actions and results the commitment to continuous improvement
Ashe Memorial Hospital/AMH Segraves Care Center's vision is to uphold our mission. We will accomplish this through the joint efforts of the hospital leadership, staff, volunteers, medical staff, other health care agencies and the community. To achieve our vision we will promote these values:
People- We value all people: those we serve and those with whom we work. We encourage people to express ideas and consider suggestions from others. We work together as a team and treat each other with respect, and as customers of each other.
Service-We value listening, caring and being sensitive to the needs of others. We respond to patients, family members, community members, each member of the hospital team, and whomever else we may serve in a manner that clearly indicates our desire not only to meet their needs, but also to exceed their expectations.
Communications- We value continuously improving communications within the organization and with all the publics served by members of our team.
Continuous Improvement-We value continuously improving upon everything we do to achieve excellence in performance. This continuous improvement applies to people as well, and we encourage personal growth and learning for all members of our team.
Resource Use- We value our resources and recognize that we will fulfill our mission only if we successfully manage our financial and other resources. Therefore, we actively create innovative, collaborative, cost-effective systems throughout the organization to continuously improve the management of all resources used.
Ethical Conduct-We value the trust placed in our institution by others and ourselves, therefore we should strive to use the best judgment and highest ethical standards in all our business and personal dealings. We will conduct ourselves with honesty, fairness and integrity, treating others, as we would wish to be treated.
Patient Care
Ashe Memorial Hospital/AMH Segraves Care Center is committed to delivering quality care to patients and residents in a compassionate and respectful manner. It is important to remember the rights of each patient/resident and to apply those rights in every situation.
Patients and residents have the right to:
Considerate and respectful care
Personal privacy and security
Be well informed about their illness, treatment, and prospects for recovery in terms
he/she understands
Actively participate in all decisions regarding his/her medical care and be fully
informed of all resources available
Confidential treatment of all communications and medical records
Review his/her own medical record
Consent to or refuse treatment
Expect the hospital to provide necessary care to the best of its ability without regard to
sex, cultural, economic, educational, or religious factors
Examine and receive an explanation of his/her bill regardless of source of payment
Have an advance directive such as a Living Will or Health Care Power of Attorney
Participate in the management of their pain
Freedom from restraints that are not medically necessary or are used as a means of
coercion, discipline, convenience, or retaliation by the staff
Spiritual care
A clearly explained procedure for the submission of a written or verbal grievance to
the hospital
Equal Employment Opportunity
Ashe Memorial Hospital/AMH Segraves Care Center is committed to a work environment that promotes fairness and mutual respect. No person may be discriminated against concerning hiring, performance evaluation, career development, compensation, discipline, and termination or any other term or condition of employment because of such person's age, race, religion, sex, disability, national origin, or marital status. No employee shall engage in any type of conduct that could be construed as sexual harassment or other illegal harassment. We strive to create a culture that is based on equality and the awareness of the rights of individuals.
Safety and Environmental Law
Ashe Memorial Hospital is committed to providing a safe and healthy work environment. Our policies have been developed to protect you from potential workplace hazards and are in accordance with governmental rules and regulations. You should become familiar with and understand how these policies apply to your specific job responsibilities. Seek advice from your department manager/supervisor or the hospital Safety Officer whenever you have a question or concern.
It is important that you advise your supervisor or department manager of any workplace
injury or any situation presenting a danger of injury so that timely corrective action may
be taken to resolve the issue.
It is our policy to comply with all environmental law and regulations that relate to our
hospital/long term care facility operations.
Follow all requirements for the proper handling of hazardous material and immediately
alert your supervisor, department manager, or Safety Officer of any situation regarding
the discharge of a hazardous substance, improper disposal of medical waste, or any
situation which may be potentially damaging to our environment.
Drug Free Workplace
Ashe Memorial Hospital recognizes that unlawful use of drugs and alcohol in the workplace impairs safety and health, lowers productivity and quality of care, and undermines public confidence in our work. Accordingly, it is the hospital's policy to maintain a workplace that is free from the effects of drug and alcohol abuse. Refer to the hospital personnel policies for more detail on this and other issues concerning personal conduct.
Conflict of Interest
A conflict of interest may occur if your outside activities or personal interests influence or appear to influence your ability to make objective decisions in the course or your job responsibilities. A conflict of interest may also exist if the demands of any outside activity hinder or distract you from the performance of your job or cause you to use Ashe Memorial Hospital/AMH Segraves Care Center's resources for other than AMH/SCC purposes. If you find yourself in a situation of uncertainty in how to meet your obligations to AMH/SCC consult your supervisor or department manager.
Ashe Memorial Hospital/AMH Segraves Care Center employees may not receive gifts or discounts with cash value from suppliers that are not available to all hospital employees. Gifts may be intended to influence purchase decisions based on factors other than quality, price, suitability and timing. This practice is illegal. To avoid even the appearance of impropriety, decline gifts. (This policy is not intended to forbid the giving or receiving of common, non-cash courtesies of small value that are not intended to influence a business transaction: for example, key chains or mugs with company logos, small non-cash gifts of gratitude from patient families).
Use of Ashe Memorial Hospital/AMH Segraves Care Center Resources
It is the responsibility of each employee to preserve our hospital and long term care facility resources including time, materials, supplies, equipment, and information. AMH/SCC resources are to be used for AMH/SCC related purposes.
Ashe Memorial Hospital/AMH Segraves Care Center intends to comply with all copyright and software licensing laws. An employee may not make copies of computer software programs for any purpose or load unauthorized programs on AMH/SCC computers without permission from the Information Services Department Manager. As a general rule, the personal use of any hospital resources without prior approval from your supervisor or department head is prohibited. The occasional use of items such as the telephone where the cost to the hospital is insignificant, is in accordance with other personnel policies. Any community or charitable use of hospital resources must be approved in advance by your supervisor or department manager. Any use of AMH/SCC resources for personal financial gain unrelated to Ashe Memorial Hospital is prohibited.
Confidentiality-Patient/Resident
Any patient information obtained by Ashe Memorial Hospital/AMH Segraves Care Center is confidential. Information concerning patients must not be shared with any individual without written consent of the patient/resident or legal guardian except for purposes of treatment, payment or operations. Each patient receives a copy of our Patient Privacy Notice that explains their right to privacy of their protected health information. Within the hospital, information sharing concerning patients or residents should only be with those providers or hospital employees that have a legitimate medical or business
reason to know.
Confidentiality-Employee
Ashe Memorial Hospital/AMH Segraves Care Center is committed to strive to protect the confidentiality of our employees. Information in an employee's personnel file is not released without written consent of the employee. Employees may ask to view their employee personnel file. Employee health records are confidential and are kept by the Employee Health nurse. Copies of these may be obtained by the employee or by written permission of the employee. Requests for references for employment for former or present employees should be directed to Human Resources in order to assure all information supplied is within the boundaries of the law.
Reporting Laws
There are some instances when a health care worker must break the "confidential' relationship with the patient/resident because of reporting laws. When the welfare or safety of one or more persons is jeopardized or when required by the government to provide such information, extreme caution must be taken to assure the proper procedures are followed and the proper authorities notified. Your department manager or supervisor should be notified of any suspected reportable incident. Policies and procedures for reporting criminal actions are found in the Emergency Room Policy and Procedure Manual. Communicable disease concerns should be addressed through the Infection Control Nurse.
Types of cases that must be reported for individual safety purposes are:
Suspected abuse of the mentally and/or physically incapacitated
Suspected child abuse
Deaths of an uncertain nature
Poisonings
Criminal wounds
Reportable communicable diseases as required by the NC Department of
Environment, Health, and Natural Resources
Work related injuries deemed reportable by OSHA
Admissions, Emergency Treatment, Transfers and Discharges
Ashe Memorial Hospital will only admit/accept for care those patients who need or will
benefit from the services we provide. Standard clinical admission criteria that include
medical necessity guidelines are used to determine whether or not an individual is
admitted.
We comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) in providing emergency medical treatment to all patients, regardless of ability to pay. Anyone with an emergency medical condition is treated and admitted based on medical necessity. In an emergency situation, financial and demographic information will be obtained only after the immediate needs of the patient are met. We do not admit or discharge a patient based on their ability to pay.
Patients will be transferred to another facility if the patient's medical needs cannot bemet by our facility and the appropriate care is knowingly available at another facility. Patients may only be transferred after they have been stabilized and are formally accepted at the alternate facility.
Referrals
Physicians and other health professionals are free to refer patients to any person or entity they deem appropriate. Ashe Memorial Hospital will not enter into any contracts or other arrangements that entice or encourage admissions or referral. Recruitment of physicians will be based on the needs of the service and will not be used for any other
purpose. Any financial assistance to new physicians will be in the form of a loan and in no way will be used to encourage unnecessary admissions, referrals, or utilization of services.
Proper Accounting Methods
Ashe Memorial Hospital/AMH Segraves Care Center will abide by all federal, state, and local regulations that govern accounting methods. Annual audits of our accounting procedures will be conducted by an outside agency to ensure accuracy and compliance with third parties (not limited to but including Medicare and Medicaid). No undisclosed or unrecorded funds or assets may be established. All financial information must reflect actual transactions. Any effort to alter or fabricate Ashe Memorial Hospital/AMH Segraves Care Center's accounting records for personal or organizational benefit will not be tolerated.
Record Retention
Ashe Memorial Hospital/AMH Segraves Care Center will abide by all federal and state statues that address the retention of patient and accounting records. Each employee should be familiar with the policies regarding the maintenance and destruction of records in their department.
Billing and Coding
Ashe Memorial Hospital/AMH Segraves Care Center will only bill for services actually rendered which are properly authorized and based on the patient's current and documented medical condition. We will use accepted standards in coding medical records to ensure that the level of coding accurately matches the associated documentation.
AMH/SCC will not tolerate anyone misrepresenting the services, supplies and equipment furnished in order to meet insurance coverage limitation or to increase payments from third parties. We will operate oversight systems designed to verify that claims are submitted only for services actually provided and that services are billed as provided. We will take every reasonable precaution to ensure our billing practices are in compliance with our policies, federal and state laws and regulations.
Employees working in a billing or coding area are expected to understand and comply with all billing-related policies and procedures established by Ashe Memorial Hospital/AMH Segraves Care Center as well all third-party carriers to which claims are submitted.
Marketing and Media Inquires
We may use marketing and advertising activities to educate the public, provide information to the community, increase awareness of our services, and to recruit health care professionals. Every effort is made to insure we present only truthful, informative, and non-deceptive information in these materials and announcements. All contacts by representatives of the media should be referred to the office of Foundation and Public Relations or to the Administrator on call. Contact the hospital communication center to obtain information on how to reach the appropriate person. Ashe Memorial Hospital uses the media guide of the American Hospital Association for release of information on a patient's conditions and presence in the facility. Press releases are reviewed and issued though the Public Relations office. This office should be made aware of requests for interviews and special articles.
Personal Obligation to Report
Ashe Memorial Hospital/AMH Segraves Care Center is committed to ethical and legal conduct that is compliant with all relevant law and regulations and to correcting wrong doing wherever it may occur in the organization. Greater details on these issues discussed in this Code can be found in the Hospital Compliance Plan. A copy is located in each department. As an employee or an associate of this hospital you have a responsibility as a condition of your employment to report any activity by any colleague, physician, subcontractor, or vendor that appears to violate applicable laws, regulations, or this Code. AMH/SCC has a responsibility by law to protect you from retaliation by anyone associated with AMH/SCC for reporting any violations of hospital policy, state or federal law. If you suspect a violation, your first step is to contact your supervisor or to search for the specific policy or manual that may address the situation.
Healthcare ValuesLine
Anyone wishing to report concerns regarding any of the issues discussed in this Code of Conduct or the Compliance Plan, personnel issues, or those relating to patient safety and wish to remain anonymous, my call the AMH Healthcare ValuesLine or “hot line”. A “live” person is available to take your calls 24 hours a day,7 days a week. The caller will be given an identification number and prompted to provide pertinent information relating to the reason for the call. That information is emailed to the Compliance Officer who is responsible to the Board of Trustees to investigate each call from the Healthcare Values Line. The caller will be instructed to call back to the Alertline to obtain information and updates on the progress of the Compliance Officer’s investigation.
REPORTING AND INVESTIGATING VIOLATIONS
To report a suspected violation, contact any of the following:
Your supervisor or department manager
Administrator............................................................................................................846-0790
Compliance Officer...................................................................................................846-0709
Healthcare ValuesLine.....................................................................................(800) 273-8452
JCAHO……………………………………………………………………..(800) 994-6610
Reviewed and update: 04/30/2007 JD |