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CODE
OF CONDUCT
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 | Patient Rights |
| Professional Standards of Practice |
| Medicare Fraud/Abuse |
| Professional and Business Ethics |
| Bribes |
| Kickbacks |
| Confidentiality |
| Conflicts of Interest |
I. Introduction
This Code of Conduct has been created in order to express how GFH follows its own policies and procedures and state and federal laws. Today, a large number of complicated laws affect all of our jobs. Helping us to understand those laws is also an important reason why we created this Code of Conduct. GFH is committed to do all things ethically and legally and for everyone with whom we come in contact: fellow employees, patients, families, guests, physicians and volunteers. This promise is consistent with our values of Respect, Responsiveness, Responsibility and Service to All.
II. Standards of Conduct
1. Confidentiality and Patient Relations
GFH is committed to providing excellent care to our patients and their families. We treat emergency patients whether or not they can pay. We do not share confidential patient information with anyone who does not have a legal need to know it. We will not tolerate poor care or service. Examples of poor care are:
| Bad manners to a patient or their family. |
| Something that places a patient in danger. |
| Failure to provide the standard of care.* |
| Stealing patient property. |
| Not reporting a problem with medical equipment. |
| Not providing a proper examination. |
All of us should report poor care or service if we observe it or become aware of it.
*Standards for patient care are in various policies in the manuals of specific departments. You should be aware of the policies and laws that apply to your job.
2. Open and Honest CommunicationsGFH tries to create a workplace where you feel free to discuss concerns about any issue in a professional atmosphere. We should respect, support and respond to each other and be honest in our work with one another. If you need help regarding communication with your manager, please talk with the Human Resources Department at (518) 926-1800.
3. Dignity and Respect in the Workplace
GFH is an "equal opportunity employer." We do not allow discrimination based on race, creed, color, religion, gender, national origin, age, disability, marital status or any other legal classification. GFH prohibits sexual harassment. Sexual harassment is:
- Offensive comments, jokes, indirect suggestions and other sexually oriented statements.
- Unwanted sexual advances, requests for sexual favors and all other
verbal or physical conduct or a sexual nature, especially where it
| Becomes a term or condition of employment. |
| Is used to make decisions affecting someone's job. |
| Creates an intimidating, hostile or offensive work environment. |
Q: I know an employee who is occasionally offended by the language and inappropriate humor their supervisor uses when speaking with employees. What should I advise the employee to do?
A: Advise the employee to tell his or her supervisor that he or she finds the language and humor offensive. If the employee is not satisfied with the results or is uncomfortable speaking directly with the supervisor, then the employee should discuss the situation with the supervisor's manager or the Human Resources Department at (518) 926-1800.
GFH is dedicated to preventing discrimination and harassment of any kind. You are responsible for respecting the rights of your co-workers and reporting discrimination to your supervisor, to Human Resources, the Confidential Message Line at 1-800-975-9427 or the Compliance Officer at (518) 926-1981. The Compliance Officer is located on 2 East.
4. Record KeepingGFH maintains many types of records (i.e., Unit-Specific Manuals, Administrative Policies and Procedure Manual, etc.). It is not possible to list all the rules that apply to them. Learn the rules that specifically apply to documents with which you work. The general rules are:
| Do not falsify facts or make false records. |
| Create only those records that are necessary to the performance of your function or job and those required by law. |
| Provide records only to those who have a legal "need to know." |
| Preserve patient confidentiality. |
| Maintain records as long as the law requires. |
| Follow policies on court orders, subpoenas and search warrants. |
Q: I am a Registered Nurse at Glens Falls Hospital. A fellow RN called me from home after she completed her shift. She told me that she forgot to enter an order for a change in medication for a patient that had been phoned in at 9:00 a.m. by the patient's physician. The nurse asked me to log the change into the patient's record at the appropriate time - 9:00 a.m., and to use her initials. She said records are often updated in this way. No harm is done. Is this okay?
A: While the nurse did the right thing by calling to note the record error, the error should be promptly reported to your supervisor. You should never record an order you did not hear and never sign someone else's signature or initials. Even if no harm occurred in this case, the error needs to be reported. If you fear retribution, GFH does not tolerate retaliation against employees who promptly report errors of omission or commission.
5. Use of GFH ResourcesNaturally, we all protect GFH's property and may not borrow. GFH's property without permission. Work time, facilities or equipment cannot be used for unapproved purposes. Any member of management should be able to help you if you have questions concerning the appropriate use of property.
6. Workplace Safety and Health
We follow all health, safety and environmental laws and regulations. If you are unsure of the correct procedure to follow or you observe unsafe conditions, check with your manager or contact the GFH Safety Director at (518) 926-5904.
7. "Intellectual Property"
"Intellectual property" means copyrights, trademarks, patents and trade secrets. Some examples of potential problems in this area include:
| Installing computer software without the proper license. |
| Copying printed materials for reasons other than limited internal distribution or education. |
| Selling or giving away a new process or device developed by GFH. (Sharing of protocols, policies and procedures, etc., with other healthcare organizations is acceptable.) |
If you have questions about this subject, contact your supervisor or the Compliance Officer at (518) 926-1981.
8. Drug-Free WorkplaceGFH maintains a drug-free workplace. The illegal or unauthorized use of drugs and/or the consumption of alcohol creates safety hazards and hinders our ability to function well and provide high quality care and services. For these reasons, you may not illegally have, distribute, sell or use drugs or alcohol at work.
Each of us must maintain awareness that certain prescription drugs can also interfere with our ability to perform our duties and responsibilities appropriately and safely.
9. Relationships with Competitors, Vendors, etc.
We choose vendors using objective measurements. We give all vendors who meet these standards an equal chance to present their products and services. We choose the product or service that best meets the needs of GFH and the GFH community.
Information about GFH business such as strategy, prices, costs, finances and similar matters is private and should not be discussed with those who do not have a "need to know" to perform their jobs or those it does not concern. All contracts and contract discussions must be consistent with law.
10. Illegal or Questionable Gifts
We exercise good judgment and discretion in accepting gifts. We never accept gifts, favors, services, entertainment or other things of value to the extent that acceptance influences decision-making. We may accept gifts of nominal value from vendors. At a vendor's invitation, we may accept meals or refreshments at the vendor's expense. Occasional attendance at an entertainment event may also be accepted. To the extent possible, we should share gifts with our colleagues. We cannot accept expensive gifts other than those for charitable fund-raising activities. Vendor-sponsored trips may be acceptable with prior approval from the appropriate divisional vice-president.
11. Conflicts of Interest
GFH follows standards regarding conflicts of interest. A "conflict of interest" happens when any outside work you perform or any outside financial interest you have influences your ability to put the interests of GFH first. The following examples might be conflicts of interest:
| Accepting gifts or entertainment from another organization. |
| Competing either directly or indirectly with the services, product or plans offered by GFH. |
| Holding a financial interest in a company with which GFH does business. |
Possible conflicts of interest should be reported to your supervisor. Management can help determine if a conflict of interest exists and can help take whatever action is necessary to solve the problem.
Q: I have an outside business selling products. Can I use the
company bulletin boards or interoffice mail to advertise these products to
other GFH employees?
A: No. Products or services not offered by GFH should not be promoted
during working hours or on GFH property. Neither should you use GFH's
name, its facilities, or resources (i.e., telephones or your work time) to
sell these products or services (except in designated areas approved
through Human Resources). However, you are free to engage in an outside
business that does not pose a conflict of interest with GFH on your own
time and off GFH premises.
Note: This policy is not intended to prohibit support of activities
(civic, community, school, etc.) such as girl scouts, little league,
school classroom fund-raising events to support field trips, bake sales in
support of charitable or worthwhile causes, etc., as long as there is no
direct or indirect pressure to coerce participation and the activity is
conducted in a manner that does not interfere in carrying out individual
job responsibilities. This would also apply to certain entrepreneurial
activities such as making available Avon products.
12. Fraud and Abuse
The law is strict in prohibiting healthcare fraud and abuse. For
example, filing false or misleading claims for reimbursement, using
wrong billing codes, providing unnecessary services or paying for
patient referrals may be fraud or abuse. GFH is committed to taking all
necessary steps to avoid activities like these. Therefore, we try to see
that all services are necessary, that they are documented properly, and
that billing and coding are accurate. We arrange all financial and
business relationships properly. We involve legal counsel when
necessary.
GFH is exempt from paying taxes because of our community service, purpose and mission. This means we cannot give GFH money, property or services (including employee work time) to political parties or individuals running for public office. You may, of course, give your own money to political candidates and participate in political campaign activity on your own time as a private individual.
14. General Laws
We must all comply with all laws and rules affecting our jobs, not just the laws and rules mentioned here. When in doubt, ask for clarification from your supervisor or the Compliance Officer at (518) 926-1981.
15. A Condition of Employment
Abiding by the Code of Conduct is a condition of your employment with Glens Falls Hospital. Failure to meet the standards and principles defined in this code will be subject to discipline, up to and including terminations, based on the nature of severity and frequency of the violation. The disciplinary process is described in current Human Resources policies and procedures.
III. Conclusion
It is expected that each one of us will follow GFH policies and the Code of Conduct and report violations when they occur.
If you know about conduct that may be illegal or unethical, you should
report it to your supervisor, to the Confidential Message Line or the Compliance Officer. The Confidential
Message Line is free and operates 24 hours a day. You do not have
to give your name and you can remain anonymous. You will not be criticized
or disciplined for calling the Confidential Message Line.
The Confidential Message Line number is 1-800-975-9427.
Revised 7/00