code of business ethics - texas health resources

Code of Business Ethics

I N T E G R I T Y

I PROMISE to earn your trust.

• I will earn your trust by:

° Being honest.

° Keeping my word.

° Working to resolve any issues with you

before going up the chain of command

or involving others.

° Owning responsibility for my behavior.

• I will project a professional image by:

° Following clothing and grooming

standards.

° Wearing my badge above the waist, facing

outward so it can be seen clearly.

° Communicating with confidence and

concern.

I PROMISE that, before acting, I will first ask, “Does this positively

reflect THR’s Mission, Vision, Values and Promise?”

• I will demonstrate this by:

° Keeping patient information confidential.

° Being aware of conversations and what can be heard by others.

° Not discussing my problems with patients or visitors or blaming others.

Revised January 2007

Table of ContentsA Commitment from the President..............................................................................................................1Corner Stones:

THR Business Ethics and Compliance Program.............................................................................2Addressing Business Ethics or Compliance Concerns................................................................4Business Conduct .............................................................................................................................................5Conflicts of Interest.........................................................................................................................................7Corrective Action for Violation of THR’s Code of Business Ethics ..................................10Federal and State False Claims Acts...................................................................................................11Non-Retaliation...............................................................................................................................................14

Regulatory:Admission, Emergency Treatment,Transfer and Discharge Practices ..............................15Antitrust and Restraint of Trade ...........................................................................................................16Corporate Image ...........................................................................................................................................17Disclosure of Affiliations with Other Healthcare Providers .................................................18Environmental Compliance......................................................................................................................19Legislative Activities ......................................................................................................................................20Relationships with Joint Ventures and Other Business Affiliations ....................................22Tax-Exempt Status ........................................................................................................................................23

Internal Activities:Billing, Coding and Cost Report Practices......................................................................................24Books, Records and Accounts................................................................................................................26Business Courtesies: Gifts .........................................................................................................................28Confidential Information............................................................................................................................31Electronic Communications and Data ..............................................................................................35Fraudulent Activities.....................................................................................................................................38Inside Activities................................................................................................................................................39Solicitation..........................................................................................................................................................41Use of Licensed Property or Copyrighted Materials ...............................................................44Use of Resources ..........................................................................................................................................46

External Activites:Donations, Grants and Other Charitable Gifts............................................................................48Fair and Accurate Representation of Products and Services ..............................................51Gifts to Physicians or Practitioners .....................................................................................................52Honoraria...........................................................................................................................................................54Outside Activities...........................................................................................................................................55Relationships with Suppliers and Representatives .....................................................................57Product Samples, Demonstration Equipment and Acceptance of Vendor Products......................................................................................................................................59Request for Quote Process ....................................................................................................................62Vendor Endorsements, Demonstrations and Education ........................................................65

Left Blank Intentionally

A Commitment from the PresidentTO ALL EMPLOYEES, CONTRACTORS AND AGENTS:

“Doing the Right Thing”. This is the simple imperative that stands behindeverything we do at Texas Health Resources (THR). We pursue our missionand business objectives with integrity and a commitment to full compliancewith laws. This is the right thing to do and it also makes good business sense.By acting with integrity, we earn the trust of our patients, business partners,co-workers, suppliers and the communities we serve.

This Code of Business Ethics (Code) is a component of the THR Business Ethicsand Compliance Program that includes standards of conduct designed toguide and explain, in a practical and understandable way, basic rules that applyto our healthcare business activities. The Texas Health Resources’ ChiefCompliance Officer is responsible for overseeing the THR Business Ethics andCompliance Program and related processes.

Today’s healthcare laws and standards can seem complex. This bookletexplains the personal responsibilities we bear as THR employees, contractorsand agents, such as speaking up if something doesn’t seem right. Review theCode carefully. This will help you make sure your actions never fall short ofour commitment to doing the right thing.

Nothing is more important than our commitment to integrity—not meeting abusiness goal, achieving a budget objective or pleasing a boss. Ourcommitment to all four THR values—Respect, Integrity, Compassion andExcellence--helps us live the THR Promise (see inside front cover).

Together, by following the letter and spirit of this Code, we will ensure thetrust of all stakeholders and maintain the pride that comes along withworking at THR.

Sincerely,

Douglas D. Hawthorne, FACHEPresident and CEOTexas Health Resources

THR Business Ethics and Compliance Program

THR’s Business Ethics and Compliance Program (Program) represents a commitmentto doing what is right. As a THR employee, you are agreeing to uphold thiscommitment, understand the standards that apply to your job and follow thosestandards.

You should carefully examine your conscience when you think or hear…

“It can’t hurt just this once.” “We can bury it and no one will know.”“No one will ever find out.” “Everyone does it.”“You never heard this conversation.” “Don’t tell anyone about this.”

AAllwwaayyss ddoo tthhee rriigghhtt tthhiinngg.. The biggest mistake anyone can make is attempting tocover something up, not telling the truth or failing to speak up when somethingdoesn’t seem right.

THR’s Business Ethics and Compliance Program addresses the essential elementsnecessary for an effective compliance program and builds upon the practices ofchecks and balances, ethics, common sense, trust and best practices. The Program isvital in assisting THR with achieving its healthcare mission in full compliance withapplicable laws and consistent with the highest ethical standards.

SEE ALSOIn This Book: Non-Retaliation; Addressing Business Ethics or Compliance Concerns.

THR Policy: Non-Retaliation – Good Faith Reports of Suspected Misconduct; Record Retention Periods;Record Retention Schedule; Business Ethics and Compliance – Education and Training;THR Business Ethics and System Compliance Program.

Q U E S T I O N S A N D A N S W E R SCOMMON EMPLOYEE QUESTIONS

I spoke to my supervisor on an issue andhe is not taking action. If I call theHotline, will my name be told to mysupervisor?

You may remain anonymous, if desired.However, there may be a point whereyour identity may become known shoulda governmental agency become involvedor due to specific facts. Your concernwill be reviewed and a decision madeabout follow-up and/or corrective action.Even though you may not always beaware of the investigation outcome, beassured your concern was investigatedand appropriate actions taken. Therewill be no retaliation or retribution to areporting employee for asking a questionor raising a concern in good faith.

Page 2 Inquiries may be made through the THR Compliance Hotline at 11--880000--338811--44772288. Callers may remain anonymous, if desired.


Pointing You in the Right Direction

What training is available to help meknow the laws and regulations for my jobduties?

Our office has many boxes of oldrecords. How long must I keep records?

Where can I find more information onTHR’s Business Ethics and ComplianceProgram and policies?

THR is aware of the need forappropriate and on-going compliancetraining. General and specificcompliance training for identified riskareas is available. Let your supervisorknow if you need specific training ortools to do your job and feel confidentabout compliance with laws andregulations.

THR has a record retention policy andschedule listing common documentsand the length of time thesedocuments must be kept. Yoursupervisor can clarify record retentionquestions.

Program information can be found onthe “System Compliance” Intranetwebsite. The website containsProgram details, information onsupport structures, contactinformation, training and awarenessmaterials, policies, other guidance andlinks to outside tools.

Page 3Inquiries may be made through the THR Compliance Hotline at 11--880000--338811--44772288. Callers may remain anonymous, if desired.

Addressing Business Ethics or Compliance Concerns

Employees are expected to ask questions and express concerns about actual orsuspected misconduct. Managers should promote open and honest communication.THR does not allow retaliation or retribution against an employee for asking aquestion or concern in good faith. Good faith means you believe the informationreported is true.

Use the Chain of Command

1. Ask and keep asking until you get an answer that makes sense.

2. Discuss your question or concern with your supervisor or another member ofmanagement. Give your supervisor a chance to resolve the problem.

3. If your supervisor is unable to find an answer, or you are uncomfortablediscussing the issue with your supervisor, call the THR Chief Compliance Officerdirectly, or

4. Call the THR Compliance Hotline at 1-800-381-4728. You may remainanonymous, if desired.

After considering the options above, if an employee has an unresolved concern aboutsafety or quality of care, the employee may contact the Joint Commission onAccreditation of Healthcare Organizations (JCAHO) at 1-800-994-6610.

Be sure to contact your entity Human Resources Department for human resourcerelated topics and concerns.

SEE ALSOIn This Book: Business Conduct; Federal and State False Claims Acts; THR Business Ethics and

Compliance Program.

THR Policy: THR Business Ethics and System Compliance Program; Federal and State False ClaimsActs and Protections.


Business ConductYou should conduct your business affairs with honesty, fairness, integrity and respect.These qualities are evidenced by being truthful and never misrepresenting facts orinformation. All activities should be conducted in the spirit of “transparency”.Employees must not engage (directly or indirectly) in conduct that is disloyal,disruptive or damaging to THR. You should strive to treat your customers withrespect and dignity. THR is judged by your actions, the attention and care you give,the courtesies you extend, the problems you solve and the quality of service youdeliver. If you have questions or concerns about THR policies, laws, regulations,patient safety or quality of care issues, you must inform your supervisor, a seniormanager, or, if you prefer, the THR Chief Compliance Officer. Failure to report knownor suspected misconduct may result in disciplinary action.

SEE ALSOIn This Book: Non-Retaliation; Addressing Business Ethics or Compliance Concerns; Corrective Action for

Violation of THR’s Code of Business Ethics.

THR Policy: Non-Retaliation – Good Faith Reports of Suspected Misconduct; Progressive CorrectiveAction; Personal Conduct.


What should I do if I know a THRemployee is violating the Code ofBusiness Ethics?

If you think you know of an illegal orunethical activity, voice your concernto your supervisor. If your supervisoris unable to answer your question, callthe THR Compliance Hotline at 1-800-381-4728. You may remainanonymous, if desired. Not reportingsuspected misconduct could result indisciplinary action. Employees or otherpersons who, in good faith, reportsuspected misconduct will not sufferharassment, retaliation or adverseemployment consequences. Goodfaith means you believe the issue isbased on true facts. A report is notmade in good faith if it disregards orignores facts that disprove theallegation.



Report Actual or Suspected Violations of the Code

What should I do if I am asked to dosomething I think is wrong?

As I walked by a patient’s room, I noticeda situation I believe is unsafe for thepatient. What should I do?

It is THR’s policy that no one shouldbe expected or permitted to act in away that violates his or her personalintegrity based on personal ethicalvalues, religious beliefs or culturaltradition. If you think you have beenasked to not follow THR’s Code ofBusiness Ethics, system values or toperform illegal activities, you mustspeak up. Take time to gather thefacts. After reviewing the known facts,speak to your supervisor if you stillhave concerns. If your supervisor isunable to answer your question, callthe THR Compliance Hotline.

Employees are expected to askquestions and express concerns if theywitness a safety or quality of careissue. Voice your concern to yoursupervisor. If your supervisor is unableto answer your question, contact theTHR Compliance Hotline. You shouldalso complete the on-line THR SafetyAction Learning Tool (SALT) andsubmit the incident for review andfollow-up through THR’s patient safetyprocesses. If after using all options youhave an unresolved patient safetyconcern, you may call the JointCommission on Accreditation ofHealthcare Organization (JCAHO) at1-800-994-6610.


Conflicts of InterestYou should not be a part of any undisclosed and unapproved activities that actuallydo or have the appearance of a conflict with your THR duties. All activities should beconducted in the spirit of “transparency”. A conflict of interest occurs if youractivities or personal interests appear to or may influence objective decisions requiredto perform your THR duties. You or any family member should not receive specialfavors from anyone that, to the best of your knowledge, does or seeks to do businesswith THR or is a competitor of THR. Employees whose families work for or consultwith THR suppliers or competitors must disclose that relationship to theirsupervisors. Investments in competitor’s or supplier’s businesses must not involveconflicts of interest that are not disclosed and approved by management in a fair andopen manner.

If you have or may have a conflict of interest, do not take part in any decision-makingactivity related to the conflict. Contact the THR Chief Compliance Officer with anyquestions about activities that may cause a future conflict of interest.

Annually, specific THR employees, board members, officers, hospital committeemembers and certain others must complete a THR Annual Conflict of InterestDisclosure Form. This process allows transparency so THR and our Boards ofTrustees know about and can manage any potential conflicts of interest. All personsasked to complete the THR Annual Conflict of Interest Disclosure Form must do sopromptly and either submit or return the form as directed.

SEE ALSOIn This Book: Outside Activities; Honoraria; Request for Quote Process; Relationships with Suppliers and

Representatives; Inside Activities; Business Courtesies: Gifts; Solicitation.

THR Policy: Dualities and Conflicts of Interest Policy and Forms.


My wife is a nursing/allied healthrecruiter for a local firm. She plans tosend people to THR for work. Will thiscause me to have a conflict of interest?

You must tell your supervisor aboutyour wife’s work as a recruiter. Youmust not be a part of the hiringprocess for any person sent to THR byyour wife’s firm. If you are asked tocomplete an Annual Conflict ofInterest Disclosure Form, you must listthe relationship on your form.



I own a part of a private supply companyfrom which THR buys supplies. I am aTHR manager and make buying decisionsfor my department. What should I do?

As a department head, I have workedwith a THR vendor for several years. Thevendor asked to remodel my house at agreatly reduced price because I give himso much THR business. Can I agree tothis price?

I have been asked to serve on the TexasNurses’ Association Board. Will myacceptance cause a conflict of interest?

Our area decided to buy a product. Thevendor allows buyers to attend aneducational session to learn proper use,patient safety and efficacy of the product.Is it OK for me to attend at the vendor’sexpense?

I have been asked to be a speaker/facultymember at an industry conference. Theconference is partially paid by one ormore THR vendors and is not promotionalin nature. The conference is devoted toobjective scientific educational topics. Is itOK for the industry conference sponsor topay my travel and lodging, and also payme an honorarium?

Even if you own a small part of thesupply company and your benefit fromthe sales are small, your fairness couldbe questioned. You should tell yoursupervisor about your ownership in thecompany and refrain from participatingin any buying decisions that involve thesupply company.

Accepting a greatly reduced price forremodeling work from the THR vendorwould directly violate the Code. Thevendor would be giving you a specialfavor due to his relationship with THR.

Serving on the board of a professionalorganization is acceptable. You should,however, discuss the position with yoursupervisor to be sure yourresponsibilities will not interfere withyour job duties and schedule.

You may attend the educational sessionat the vendor’s expense since thesession is not for sales or promotionalpurposes. In addition, the session isneeded to provide informationregarding the safe and effective use ofthe product.

Since the conference is for objectiveeducational purposes (rather than topromote vendor products) and sinceyou are serving as a bona fide facultymember, it is OK for the industryconference sponsor to pay for yourtravel and lodging. Further, if youprepared the presentation on your owntime and, if you are taking PTO toattend the conference, you may keepthe honorarium. Please refer to theHonoraria section of this booklet formore information.



Display Prudent Judgment and Avoid Undisclosed and Unapproved Conflicts

A marketing firm asked me to completea product survey and participate in agroup discussion about specific productsthat I know about because of myhealthcare background and experience.The firm does not share specific vendornames as a part of the activity and I willnot know which vendors are involved.The event will not take place on THRproperty. Is it OK for me to participateand keep any fee for this activity?

A pharmaceutical company has offeredto provide financial support for educationof medical staff members. Is this OK?

A vendor has offered to give me ascholarship to attend an outsidehealthcare educational event. May Iaccept the scholarship?

I’ve been asked to complete an AnnualConflict of Interest Disclosure Form.What is the purpose of this form andwhy must I complete it?

You may keep the fee if youparticipate outside of normal workinghours and you are not acting as anagent of THR regarding the survey.The activity should not be inconnection with a known THR vendor.If the activity is merely an opportunityfor a specific vendor to promoteproducts through a third partymarketing firm, you should notparticipate or keep the fee. You mustavoid even the perception that futurebuying decisions might be affected.

You should contact the THR ChiefCompliance Officer to discuss theproposal. There are many laws thatapply to hospital – physicianrelationships including the provision ofeducation to medical staff members.

A vendor’s scholarship, grant or awardmay be accepted only if recipients arechosen based upon objective criteriaduring an independent review process.The process should not involve salesagents or others involved in businesswith THR. The scholarship should notbe linked in any way to THR’s vendorrelationship.

Specific THR employees, boardmembers, officers, hospital committeemembers and certain others mustcomplete an Annual Conflict ofInterest Disclosure Form. This formassists THR and its Boards of Trusteesin knowing and managing any potentialconflicts of interest. You shouldcomplete the form and return orsubmit it promptly.


Corrective Action for Violation of THR’s Code of Business Ethics

Any employee who violates the THR Code of Business Ethics is subject to correctiveaction in accordance with Human Resources’ policies. This can include verbal orwritten corrective action up to and including involuntary separation of employment.

You should be aware that certain actions prohibited by THR policies might alsoviolate criminal laws, thus resulting in personal criminal prosecution and, uponconviction, fines or imprisonment.

Ethical behavior depends on self discipline and maintaining respect for customers, co-workers and the working environment. The guidelines published in this booklet areestablished to assist you in making appropriate decisions in situations that may arise inyour daily activities. Good judgment should be used at all times, maintaining integrityin all that you do. Inappropriate conduct is cause for corrective action, up to andincluding involuntary separation of employment. An employee may not excuse his orher conduct because this booklet or other THR policy does not specifically prohibitthe behavior preceding the corrective action. THR encourages you to act in anethical manner reflecting the faith-based values and mission upon which ourorganization is based. Additionally,THR expects that employees recognize thatprofessional, responsible and courteous conduct fosters a positive and productiveworking environment.

SEE ALSOIn This Book: Business Conduct; Non-Retaliation; Fraudulent Activities; Federal and State False Claims

Acts; Relationships with Suppliers and Representatives; Use of Licensed Property orCopyrighted Materials.

THR Policy: Progressive Corrective Action; Personal Conduct; Non-Retaliation-Good Faith Reports ofSuspected Misconduct.

Ethical Behavior is Essential to Good Business


Federal and State False Claims ActsTHR is committed to compliance with Federal and State False Claims Acts and theprevention and detection of fraud, waste and abuse. The False Claims Acts (Act)provide a mechanism for investigating and prosecuting healthcare fraud. Healthcareclaims sent to government programs are subject to detailed reviews and may start agovernment investigation if the reviewer believes the claim may be false or fraudulent.

The government defines a false claim as knowingly making, using or causing to bemade or used, a false statement or record to get a claim paid or approved. Thiscould include anything from documenting false items in a medical record to incorrectcoding or submitting an inaccurate cost report. THR has internal and external audits,consultants, continuing education and subscriptions to many publications to help usdetect and prevent any problems with claims submitted to federal or stategovernment healthcare programs.

Employees, contractors and agents should be aware that they may call thegovernment, if they believe a company does not respond appropriately when told ofa potential violation. Under certain facts, individuals are allowed to enter into a suitagainst those sending false or fraudulent claims and share in part of any recoveredfunds.

Violations of the Act can subject companies or individuals to fines between $5,000and $10,000 plus up to three times the actual damage. Other penalties could includeprobation, prison, suspension or revoking a provider’s agreement to participate ingovernment programs.

Employees must never knowingly send, cause to be sent or plan to send false orfraudulent claims for payment or approval. Employees involved in false or fraudulentclaims will be subject to disciplinary action including involuntary termination. Allknown or suspected concerns of fraud, waste or abuse should be communicated toyour supervisor, a member of management, Human Resources or the THRCompliance Hotline at 1-800-381-4728. You may remain anonymous, if desired.

SEE ALSOIn This Book: Non-Retaliation; Fraudulent Activities; Corrective Action for Violation of THR’s Code of

Business Ethics; Billing, Coding and Cost Report Practices; Addressing Business Ethics orCompliance Concerns; Books, Records and Accounts.

THR Policy: Federal and State False Claims Acts and Protections; Prohibition Against Doing BusinessWith Any Ineligible Person; Cooperation with Search Warrants, Subpoenas andGovernmental Investigations; Business Ethics and Compliance-Education and Training; THRBusiness Ethics and Compliance Program Auditing and Monitoring; THR Business Ethicsand System Compliance Program; Non-Retaliation – Good Faith Reports of SuspectedMisconduct; Progressive Corrective Action.



I heard a person can violate the FalseClaims Act if he or she “knew or shouldhave known” about a rule, but did notfollow it. Laws and regulations changeoften, how can I stay up-to-date?

I recently read an article where both theemployer and several employees wereconvicted of violating the Federal FalseClaims Act. As an employee, can I beheld personally liable for false claims?

I work in a clinical area. Would I have toworry about the False Claims Act orbeing part of a government investigation?

Understanding and obeying laws andregulations is everyone’s job. Thegovernment publishes laws, regulationsand rules and expects healthcareproviders to know those rules. Youand your supervisor have a duty tomake sure you have the knowledgeand tools to do your job duties incompliance with laws and regulations.Voice any concerns you have aboutneeded education to your supervisor.If you still believe you do not have theneeded tools or education, call theTHR Chief Compliance Officer or theTHR Compliance Hotline at 1-800-381-4728 for assistance.

In significant cases, both companies andindividuals can be prosecuted underthe Federal or State False Claims Acts,if the government concludes violationstook place. Usually, companies signsettlement agreements and agree toimprove processes and education toavoid prosecution. However, all partiescan be impacted by the False ClaimsActs. Never be part of an activity youbelieve may violate laws andregulations.

While false claims investigations usuallybegin with data and systems reviews, itis possible that medical record data,medical necessity for services given oreven patient care quality may bequestioned. Be sure to accurately andthoroughly document all clinicalservices provided and follow all THRpolicies. Never intentionally enterwrong data in a medical record.



Never Disregard Laws and Regulations

What should I do if a government agentarrives unannounced for a non-routinebusiness matter?

Be cooperative and ask foridentification. Contact THR LegalServices at 817-462-7141 prior tospeaking with the agent. If after hours,call 214-345-8480 or 817-250-2000and ask for the “on-call” attorney. Donot interfere with or delay theinvestigation. Do not alter, remove ordestroy data. Do not guess if asked aquestion you do not know. Be awarethat making statements to an agentwithout the advice of an attorneycould leave you at risk. Yourcomments might be misunderstoodand used against you later.


Non-RetaliationNo employee or other person who, in good faith, reports suspected misconductinvolving the Code,THR policies, laws or regulations, patient safety or quality of careissues will suffer retaliation. Retaliation includes harassment or adverse employmentaction. A question or concern raised in good faith means the employee believes theconcern is based on true facts. A concern is not made in good faith if the concern ismade with disregard for or ignores facts that disprove the concern.

Any employee who retaliates against a person reporting a concern in good faith issubject to disciplinary action up to and including employment termination based onthe THR Progressive Corrective Action policy.

SEE ALSOIn This Book: Corrective Action for Violation of THR’s Code of Business Ethics; Business Conduct;

Fraudulent Activities; Federal and State False Claims Acts; Books, Records and Accounts;Billing, Coding and Cost Report Practices.

THR Policy: Non-Retaliation – Good Faith Reports of Suspected Misconduct; Progressive CorrectiveAction.


No Retaliation for Reports Made in Good Faith

I called the THR Compliance Hotline toreport a concern in good faith. Mysupervisor called me into her office andwas angry that I called the Hotline.I believe my supervisor is retaliatingagainst me for calling the Hotline.What should I do?

I reported a patient safety issue toJCAHO. Will I get in trouble for callingJCAHO?

Report the retaliation concern to yourentity Human Resources Departmentor call the THR Compliance Hotline.

You will not be in trouble forreporting a patient safety issue.Employees are encouraged to followthe Chain of Command steps toreport any issue or concern. Afterconsidering all options, if an employeehas an unresolved concern aboutsafety or quality of care, the employeemay contact JCAHO at 1-800-994-6610 without fear of retaliation.


Admission, Emergency Treatment,Transfer and Discharge Practices

THR is committed to fair and ethical processes for the admission, emergencytreatment, transfer and discharge of all patients. These processes will be free fromdiscriminatory bias in accordance with applicable federal and state laws andregulations including the Emergency Medical Treatment and Active Labor Act(EMTALA).

Treatments Are Conducted in a Fair and Ethical Manner


Antitrust and Restraint of TradeYou must not engage in formal or informal, oral or written, expressed or impliedcollaboration with competitors or their representatives about establishing ormaintaining prices on competing goods or services, or restraining competition byallocation of product markets or customers (for example, price fixing, agreements notto compete, boycotts). However, it is possible to discuss prices to accomplish a lawfuland ethical objective when dealing with competitors as suppliers or customers, or aspartners in legally permitted organizational agreements. Call THR Legal Servicesabout restraint of trade questions.


Avoid Circumstances of Unlawful Collaboration with Competitors and Restraint of Trade

A strategic planner from a competitorhealth system starts an exploratoryconversation about mutually agreed uponstrategies for “protection” of respectivemarket shares or service areas. Am I inviolation of the Code if I participate?

The THR employee must refuse toparticipate. If such discussion is notstopped, the THR employee mustleave the meeting. Strict federal andstate antitrust laws protect the freeenterprise system. This conversationwould be seen as collaboration withcompetitors for the purpose ofdividing the market and “restrainingtrade.”


Corporate ImageOur mission as a non-profit, faith-based organization is to improve the health of thepeople in the communities that we serve. As an employee, you are expected toobserve the highest standards of personal and professional conduct. Personalbehavior is particularly important to remember when you are wearing a THR uniformor identification badge or are representing THR.


Observe Professional Conduct when Representing THR

I am attending a conference as arepresentative of THR. During theconference there is an after hours socialevent. Would attending this event causeme to be in violation of the Code?

An employee has a right to privacyoutside the work environment.However, you should be aware of thepossibility that inappropriate behaviorof any kind could jeopardize thepublic’s trust of THR particularly if youare wearing a THR uniform,identification badge or are otherwiseassociated with the health careprofession, such as wearing a lab coat.


Disclosure of Affiliations with OtherHealthcare Providers

THR has various financial contracts and affiliation arrangements with other healthcareproviders including physicians, physician groups, other hospitals or hospital systemsand vendors. In each of these relationships,THR activities will support its Mission,Vision,Values and non-profit, faith-based heritage. These affiliations and financialarrangements are governed by applicable legal and accreditation requirements.Clinical decisions (including decisions about tests, treatments and other interventions)are based solely on identified patient healthcare needs. Disclosure about THR’sarrangements and affiliations with another healthcare provider is available uponrequest.

Clinical Decisions Are Based Solely on Identified Patient Healthcare Needs


Environmental ComplianceIt is the policy of THR to strictly adhere to federal, state and local laws andregulations relating to environmental protection, especially for disposal of medicalwaste and hazardous materials.


Help THR Protect the Environment

I have been asked to store hazardousmaterials in a supply closet. I amworried about the safety of this practice.What should I do?

If you have a question regarding safetyor the appropriateness of the task,speak to your supervisor. If yoursupervisor is unable to answer yourquestion or if you remainuncomfortable after the discussion, callyour entity’s Safety Officer or the THRChief Compliance Officer.


Legislative ActivitiesTHR and its employees participate in local, state and national legislative activities andgive information to elected officials on issues important to the healthcare industryand THR’s healthcare mission. THR legislative activities should be coordinatedthrough the THR Government and Community Affairs Department and must followTHR’s Legislative Activities policy.

THR does not directly or indirectly support or oppose any candidate for electiveoffice. Payments are not made to political campaigns or its activities. THR employeesmay not use THR letterhead or other resources for personal political correspondenceor to engage in any political campaign activity. Further, any personal political activitiesmust be conducted outside of working hours and off THR property. In no case willTHR reimburse employees for expenses related to political candidates or causes.

If you have questions regarding permitted legislative activities, contact the THRGovernment and Community Affairs Department.

SEE ALSOTHR Policy: Legislative Activities.


I received a personal letter from mysupervisor at work through interofficemail requesting that I give money to aspecific political action committee (PAC).Do I have to give and, if I do, will I violatethe Code?

You do not have to give money to thePAC nor should you be asked by yoursupervisor to give money to a specificPAC in the workplace and duringregular business hours. THRencourages employees to maintain aninterest in governmental issues relatedto the healthcare industry. However,participation in the political process ispersonal and should be free frompressure. If you are asked to givemoney to a PAC or other politicalactivity during regular business hoursand in any THR work areas report theissue to either THR Government andCommunity Affairs Department or theTHR Chief Compliance Officer.



Employees Should Adhere to the THR Policy on Legislative Activities

My supervisor asked me to write a letterto my congressman supporting proposedhealthcare legislation that THR favors. Isit OK for me to do so?

I would like to run for city council? Is itOK for me to do so?

It is OK for your supervisor to makeyou aware of the proposed legislationand encourage you to write a letter toyour congressman. However, you areunder no duty to write such a letter tokeep your job. It is your personaldecision to support or oppose anyproposed legislation.

THR encourages employees to beactive in their communities. A decisionto serve in public office is personal.However, discuss your plans with yoursupervisor to determine if the dutiesof that public office, meetings, etc.(should you be elected) will keep youfrom fulfilling your THR job duties. It ispossible that the duties of the publicoffice may interfere with your THR jobduties. These factors should bediscussed and considered prior tomaking a decision to run for a publicoffice.


Relationships with Joint Ventures and Other Business Affiliations

THR sometimes enters into joint ventures or other business affiliations with unrelatedthird parties such as physicians or other hospital systems to share ownership and/orgovernance control over an entity or business activity. Some of these affiliations mayinclude permission to use a THR trade name. In other cases, the activity may beoperated under a name that is not associated with any THR trade names. In all cases,joint ventures and business affiliations are carefully evaluated, designed and operatedto be compliant with all regulatory requirements.

Most THR joint ventures do not function as tax-exempt entities. THR’s relationshipswith these joint ventures must be conducted on an arms-length basis and incompliance with specific laws and regulations. For example, fair market value feesmust be charged for any services provided to a joint venture by THR employees,equipment should not be loaned and confidential information should not be sharedwithout prior approval from THR Legal Services. Any questions regarding THR jointventure or permissible relationships should be directed to THR Legal Services.

SEE ALSOIn This Book: Confidential Information; Conflicts of Interest; AntiTrust and Restraint of Trade; Business

Courtesies: Gifts; Gifts to Physicians and Practitioners.

Contact THR Legal Services for Questions Concerning THR Joint Ventures


Tax-Exempt StatusMost THR operations are conducted within tax-exempt corporations. Exemption isaccomplished through the exercise of the THR Mission Statement and compliancewith existing regulations issued by the Internal Revenue Service and other regulatoryagencies. You must understand and protect THR’s tax-exempt status and make sureassets in your area are dedicated to THR’s charitable healthcare mission. Further, takeno action that you feel may be inconsistent with THR’s tax-exempt status. Specificquestions and concerns should be directed to your supervisor,THR Legal Services orthe THR Tax Management Department.


Help Protect THR Tax-Exempt Status

I am thinking of buying a homecomputer from a THR vendor. The salesperson knows I work at THR. Could Iorder my computer through THR to get abreak on the price and avoid payingsales tax?

Use of THR tax-exempt status andpurchasing power for a personalpurchase violates the Code andInternal Revenue Service laws.


Billing, Coding and Cost Report PracticesAs a major provider of healthcare services,THR takes part in several private andfederally funded health benefit programs such as Medicare and Medicaid. Theseprograms are subject to specific rules and requirements. THR is committed to billing,coding and cost report integrity. Please refer to the various billing, compliance andfinance policies for more information.

THR follows guiding principles consistent with recommendations by the AmericanHospital Association:

• THR will serve the emergency health needs of all regardless of the patient’sability to pay;

• Charity care notices will be prominently posted in appropriate languages;

• Financial counseling will be available to financially and medically indigentpatients to provide full or partial financial help and to identify other fundingsources if available; and

• THR will offer a discount to underinsured patients who do not qualify forfull or partial financial help.

Additional THR standards:

• Employees aware of a billing, coding, cost report or other violation mustreport the problem using the Chain of Command process;

• Employees must not knowingly violate any payer rules and must followbilling, coding, charging and cost report rules;

• Employees should assist persons asking about actual or estimated charges,patient bills, health benefit coverage or services;

• Employees must not submit a claim or charge for payment known to befalse, fraudulent, fictitious or a duplicate of another claim or charge;

• Billing errors causing an overpayment must be promptly corrected andreturned to the payer and/or patient;

• Collection processes must be done with fairness and must comply with theFair Debt Collection Practices Act;

• Coding activities must follow THR coding compliance policies and officialcoding guidelines. Upcoding, unbundling or any other means of receivingincorrect payment is unlawful and strictly prohibited; and

• All cost reports must be prepared based upon accurate information and inaccordance with laws and regulations.

SEE ALSOIn This Book: Fraudulent Activities; Non-Retaliation; Federal and State False Claims Acts; Addressing

Business Ethics or Compliance Concerns.



THR is Committed to Accurate Billing Practices

I believe a process in my departmentleads to incorrect patient and payer bills.What should I do?

I am not sure what billing code shouldbe used for a specific medical service. Isit OK for me to use a general billingcode that I know will be accepted by thepayer?

I know my manager is not following aTHR billing compliance standard forcharging my department’s services.What should I do?

First, discuss this concern with yoursupervisor. If you believe your concernis not being addressed, contact theTHR Chief Compliance Officer or callthe THR Compliance Hotline. Youmay remain anonymous, if desired.

Coding for medical services is oftencomplex. It is critical that correctcodes be used. Never “guess” what acode should be and do not choose ageneral code just because you knowthe general code will be paid by thepayer. Speak with your supervisor orseek advice to confirm which code iscorrect.

You and your manager are heldaccountable for following THR’s billingcompliance standards. Use the Chainof Command process to resolve yourconcern or call the THR ComplianceHotline.


Inquiries may be made through the THR Compliance Hotline at 11--880000--338811--44772288. Callers may remain anonymous, if desired.

Books, Records and AccountsAll records, whether medical, operational or financial, should be recorded andmaintained in accordance with all applicable laws and approved THR policy.

THR’s financial books, records and accounts must be maintained in accordance withgenerally accepted accounting principles. All business transactions must be accuratelyshown in THR’s books and records. No false or misleading entries will be made forany reason. All records must be maintained in accordance with THR’s RecordRetention policy.

THR will follow a quarterly certification process to affirm the accuracy of its financialstatements. Certifications will be made by finance officers or directors responsible forthe entity’s financial statements, the THR Chief Executive Officer and THR ChiefFinancial Officer.

SEE ALSOIn This Book: Fraudulent Activities; Non-Retaliation; Use of Resources; Billing, Coding and Cost Report

Practices.

THR Policy: Asset Transfer, Disposal and Sale; Business Travel, Entertainment and ExpenseReimbursements; Record Retention Schedule; Record Retention Periods.


As a unit secretary, I am responsible forsummarizing and taking time sheets tothe Payroll Department. After I completemy initial summary, I give the time sheetto my supervisor for approval.Occasionally, I notice my supervisoradded hours on an employee’s time thatI know he did not work. I am afraid I willlose my job if I tell anyone. What shouldI do?

Our department sold a piece of oldequipment for $200 cash. Thedepartment frequently needs to pay forsmall expenses. Can the departmentstart a petty cash fund?

First, consider discussing this matterwith your supervisor. If you still believetime is being altered, call your entityHuman Resources Department or callthe THR Compliance Hotline at 1-800-381-4728. You may remainanonymous, if desired.

All money from the sale of a THRasset must be given to your entityFinance Department along with adescription of the sale. Employees ordepartments may not keep moneyfrom the sale of THR assets in thedepartment. Any petty cash fund mustbe opened through Finance. Assetsales must follow the Asset Transfer,Disposal and Sale policy.


Maintain Accurate and Complete Records

I am a secretary and was asked tocomplete an expense report for mysupervisor. I know her husband wentalong on the trip and she added herhusband’s costs in the report. Whatshould I do?

First, if you are comfortable, ask yoursupervisor if she meant to add herhusband’s costs in the report. If so,remind her of the THR policy. If youknow the expense report is false, youshould call your entity HumanResources Department. If you prefer,call the THR Chief Compliance Officeror the THR Compliance Hotline.Further guidelines regarding travelexpense reimbursement are part ofthe Business Travel, Entertainment andExpense Reimbursements policyposted on the THR Intranet.


Business Courtesies: GiftsYou should not solicit, accept or offer a substantial gift or courtesy. In most cases, agift worth more than $100 may be considered substantial unless the item is widelyrecognized as a routine business courtesy. Business gifts and courtesies should beinfrequent, low in value and must not influence your judgment or fairness. Thereceipt or offer of cash or cash equivalents is prohibited in any amount. Cashequivalents include checks, gift certificates, gift cards or any other item redeemable ata store for products or cash. For purposes of this standard, gifts include itemsreceived from or offered to a patient, physician, supplier, or their employees or agents,or any person with whom, to the best of your knowledge,THR does business.

Employees must use good judgment in deciding when a gift or courtesy might beperceived as creating a conflict or influencing objectivity. Routine business courtesiesinclude such things as one or two tickets to a local sporting event, play or concert,tickets to charity events, flowers, candy, fruit baskets or an occasional round of golf ata local golf course. Special rules apply to non-monetary gifts or courtesies offered tophysicians. Please refer to the “Gifts to Physicians or Practitioners” section of thisbooklet for specific information and guidance on gifts to physicians.

Federally funded healthcare programs have strict requirements that prohibit givingitems of value to influence patient choice of a specific hospital or other healthcareprovider. If you have questions about business gifts or courtesies, ask your supervisoror call the THR Compliance Hotline at 1-800-381-4728.

SEE ALSOIn This Book: Gifts to Physicians or Practitioners; Conflicts of Interest.

THR Policy: Business Travel, Entertainment and Expense Reimbursements.


I manage the relationship between THRand a pharmaceutical company. Duringthe holidays, the sales representativesent me two tickets to a local sportingevent. May I accept?

This gift must not affect your fairnessor objectivity. In most cases, $100 is agood rule of thumb in decidingwhether the gift has a significant value.However, giving tickets to a localsporting event is a widely acceptedroutine business courtesy. Therefore,you may accept the two tickets eventhough the value may exceed $100 invalue. On the other hand, a gift to aplay-off game or a season pass wouldnot be acceptable since these gifts arenot routine business courtesies.




A vendor has offered to pay for myattendance at an industry educationalconference in Chicago. The program isrelated to my job duties. Should I acceptthe offer?

Due to my position and expertise, I havebeen asked to serve as a keynotespeaker at a conference in Los Angelessponsored by a healthcare tradeassociation. Can the trade associationpay all my expenses?

The vendor should not pay yourexpenses. You may attend the event, ifyour supervisor agrees that theprogram is related to your job dutiesand will be beneficial. However,THRshould pay for registration fees, hoteland airfare in accordance with theTHR Business Travel, Entertainmentand Expense Reimbursements policy.Vendor payment for these items couldbe perceived as affecting your fairnessand objectivity. Acceptance of foodand non-lavish entertainment at theconference is OK.

The trade association may pay for yourexpenses, if your supervisor agreesthat your participation is acceptableduring work hours. The tradeassociation may pay these expensesbecause THR has no purchasingrelationship with the trade associationand because it is customary andappropriate for professionalorganizations to pay for speakers’expenses.


Use Good Judgment when Receiving or Offering Gifts

A supplier wants to routinely pay for mymonthly departmental lunches and themeeting room. Is it OK for me toaccept?

A supplier has offered to provide lunch tomy staff as an expression ofappreciation. Is it OK to accept?

You must avoid the appearance thatsuch a courtesy might influence yourobjectivity and decisions. If there is abusiness need to have routinedepartmental meetings and servelunch, the cost of the lunches andother out-of-pocket expenses shouldbe paid through the department’sbudget. This is true whether themeeting is held in the department orat an off-site location. On the otherhand,THR does not prohibit a supplierfrom providing a modest appreciationlunch on a one-time or infrequentbasis, if there is no disruption to theworkplace.

If the offer is a one-time or infrequentoccurrence, it is OK for the supplier toprovide a modest lunch as a token ofappreciation. As a supervisor, youmust use good judgment indetermining whether the lunch mightbe perceived as affecting you or yourstaff ’s fairness and objectivity.


Confidential InformationConfidential information, whether medical, technical, business, financial or personal,and whether or not specifically identified “confidential”, must not be divulged exceptas authorized and required by law and THR policy. When in doubt, ask yoursupervisor, Human Resources,THR Legal Services,THR Finance, SystemCommunications or the THR Chief Compliance Officer. Your duty to protect suchinformation exists both during and after your employment with THR.

Confidential information should be accessed and used only by persons authorized toreview and act upon such information. You must not (for personal gain or curiosity)use or direct confidential information to any other person or entity. Thisconfidentiality requirement applies regardless of the nature of the information,whether financial, patient-related, medical staff-related or personnel-related andregardless of how you acquired the information.

Further, it is THR’s policy to respect and protect confidential information of otherpersons or companies. You must not use or share another company’s proprietaryinformation or trade secrets unless the submitting party agrees in writing that theinformation is not confidential. The approved written non-disclosure agreement willindicate the rights and obligations of all parties. In addition, no THR employee shoulddisclose information to THR that might be reasonably considered confidentialinformation of a former employer.

Protected health information must be handled in strict accordance with the HealthInsurance Portability and Accountability Act (HIPAA). Please refer to THR privacy andinformation security policies for full information on handling and security of protectedhealth information.

SEE ALSOIn This Book: Use of Licensed Property or Copyrighted Materials; Outside Activities; Honoraria; Vendor

Endorsements, Demonstrations and Education; Solicitation; Use of Resources; ElectronicCommunications and Data.

THR Policy: Patient Access to Health Information.


What is considered THR confidentialinformation?

Any information which has thepotential to jeopardize THR’smarketplace competitiveness or causedamage or harm to THR is consideredconfidential. If you have a questionabout whether something isconfidential, ask your supervisor. Inmost cases, the following examples areconsidered confidential information:

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[Question is on previous page.] [Answer continued from previous page.]

• Patient information;

• Information on participants in THRbenefit plans and programs;

• Compensation, wages or salaryinformation;

• Marketplace strategies and strategicplans;

• Financial data that is not madeavailable to the public or otherwisesent to audiences outside THR;

• Quality and patient safety dataintended for internal use only;

• THR and/or hospital policies withoutprior approval of the policyoriginator or the person withresponsibility for the policystatement;

• Contracts and other legal documentsand data contained in suchdocuments;

• Information referenced or marked as“confidential” in documents, meetingrecords or other THR materials;

• Other documents or data generallyknown to be confidential to THR andnot generally available for discussionor distribution outside THR;

• Confidential data or trade secretsbelonging or submitted to THR byothers in the course of doingbusiness; and

• Pricing for products, equipment,supplies or services.



As part of an industry survey, aprofessional association is requestingsalary data for certain job categories inmy department. The information will becompiled by the association as part oftheir annual salary survey for publicationin the professional association’snewsletter. There will be no reference inthe publication to any of the surveyrespondents. Is it OK for me to providethis information since it is a “generic”part of an industry survey?

I have a friend who works in the financedepartment at a nearby hospital. Heoccasionally calls me to compare pricesfor certain THR outpatient services.What should I tell him?

While filing medical records, I discoveredmy next door neighbor has HIV. I amconcerned not only for my own family,but also for my neighbor’s wife who maynot know of her husband’s diagnosis.What can I do?

You should not release salary data toanyone outside THR. Compensationand salary data is consideredconfidential. Call your THRCompensation Department forapproval prior to releasing any salarydata to an outside agency. This is trueeven in cases where the request isthrough an industry survey. In mostcases, your THR CompensationDepartment will take ownership tosend the data, if participation in thesurvey is deemed appropriate.

You should politely tell him you cannotdiscuss confidential matters and reportthe inquiry to your supervisor. Even ifthe inquiry is only pertaining topublished charges, you should remindyour friend to seek this data throughpublic sources.

Your discovery of this diagnosisinformation may place you in a moraland ethical dilemma, but the Code, theTHR Personal Conduct policy and thelaw, clearly prohibit you from divulgingany protected health information. Youmust not discuss protected healthinformation or other confidential datawith family, friends or associates.



Do Not Disclose Confidential Data or Protected Health Information

I have been approached by Medicareauditors seeking to review an agreementbetween THR and a physician group. Ibelieve the document constitutesconfidential information. Should Iwithhold the information from theMedicare auditors?

I often receive questions from companieswanting references on former THRemployees. May I respond withoutviolating the Code?

As an employee, I have access to theelectronic health record for my job role.May I use my access to look at my ownpersonal health information?

You are correct in that the agreementwould be considered confidentialinformation. However, since Medicareis permitted by law to audit ourrecords, a review of confidentialinformation is allowed under theCode. In this case, before releasing theagreement to the auditors, you shouldfirst check with your supervisor andTHR Finance to verify the auditor’scredentials and reasons to access theinformation.

Employee’s performance evaluationsrepresent confidential data. Direct thecaller to your entity Human ResourcesDepartment.

Employees, like any other patient, mayrequest access to their own healthinformation by submitting a request inwriting using the form entitledAuthorization for Release of PatientInformation. This form is located onMyTHR Connection. The request willbe reviewed by Health InformationServices. Review the THR PatientAccess to Health Information policyfor more information.


Electronic Communications and DataTHR maintains electronic communication systems (such as electronic mail, Internet,Intranet, voice mail and other such automated information) to assist in conductingTHR business. These systems, the equipment and the data stored in the systems, arethe property of THR whether they are located in the employee’s home, at a remotelocation or in the office. THR retains the right to access and review THR’s electroniccommunication systems at any time for any reason without user notice.

THR data is the property of THR and should be used for THR business only. You donot have a personal privacy right in any matter created, received or sent from theelectronic mail system. Threats to data include accidental or deliberate destruction,changes or misuse. THR policy states access to data will be granted on a “need-to-know” basis. You are accountable for the changes or use of data that is obtainedunder your individual log-on ID. You must protect and guard the data andinformation you have access to.

THR’s electronic mail system should not be used as a means to communicate orforward “chain letters” or other messages that are not directly related to your jobduties. Use of the THR electronic mail system for such messages may result indisciplinary action. Email messages should not contain content that may reasonablybe considered offensive or disruptive to any employee. Communication such assexual comments or images, racial slurs, gender-specific comments or any words orphrases which may reasonably be considered offensive, harassing, vulgar, obscene orthreatening is strictly prohibited.

THR’s Electronic Communications Acceptable Use policy provides detailed guidanceon protecting patient and THR confidential data when using voice mail, the Internetand electronic mail. Protected health information (PHI) may be sent by email ifcertain requirements are met such as limiting the patient data to those who need-to-know and to the minimum necessary amount, confirming email addresses beforesending, using encryption and using the confidentiality statement.

THR workforce members using or accessing PHI from non-THR locations mustreceive prior written authorization to use and access data remotely. PHI must besecured and protected from unauthorized access at all times using reasonable physicaland technical safeguards. Follow THR policy guidelines when authorizing, accessing,storing or printing PHI remotely. PHI must not be stored on personal computers orother non-THR owned hardware devices, except by written approval.

SEE ALSOIn This Book: Solitation; Use of Resources; Confidential Information.

THR Policy: Safeguarding Health Information and Sensitive Personal Information; ElectronicCommunications Acceptable Use.



My computer is linked to the Internet. Isit a violation of the Code tocommunicate daily with my sister in NewYork about the health of our parentswho live with me in Texas?

I have been granted special securityclearance for a category of highlysensitive information. While on abusiness trip, I phoned my office and toldmy security password to the receptionistso she could access a file and give medata. Is this action in violation of THRpolicy?A friend has forwarded an emailmessage to me concerning a goodcause. I would like to forward this emailto my friends. Is it OK for me to forwardit to other THR employees?

Is it legal for THR or my supervisor toread my email?

What type of information requiresadditional protections when usingTHR’s electronic systems?

Frequent use of a THR resource, likeelectronic mail, for personal reasons isa Code violation. Routinecommunication with relatives shouldnormally be done at home using yourpersonal computer and Internetaccess.

Providing your security accessinformation to the receptionistcompromises the security of the data.The receptionist was not approved forthis access.

The electronic email system is forbusiness use only. Notify your friendthat non-business messages should besent to you at your home. Do notforward the message to other THRemployees.

It is legal for your supervisor to readyour email. According to the FederalElectronic Communications PrivacyAct, an employer-provided computersystem is the property of theemployer. The company has everyright to monitor all email traffic andInternet surfing that occurs on thecompany’s system.

Under the HIPAA Privacy and SecurityRules, reasonable administrative,physical and technical safeguards mustbe used to protect electronic patienthealth information. Review theElectronic Communications AcceptableUse policy for guidance on using thedifferent types of electroniccommunication systems.



Protect the Appropriate Use and Integrity of Electronic Data and Communications

Are there other types of informationwhich require additional protections?

Are there any measures to take whenworking with protected healthinformation or sensitive personalinformation (SPI) from a remote location?

Electronic systems and confidentialinformation (for example, names, socialsecurity numbers and financialinformation) require additionaladministrative, physical and technicalsafeguards. Review the appropriateTHR information privacy and securitypolicies for further information.

THR workforce members mustreceive prior written authorization touse and access PHI or SPI remotely.Reasonable physical and technicalsafeguards must be taken inaccordance with THR policies.


Fraudulent ActivitiesNo employee is authorized by anyone associated with THR to commit fraudulentactivities. Any employee who commits fraud or assists another person in hiding afraudulent act will be terminated from THR employment and may be subject toprosecution by law enforcement agencies. Employees should not ignore orintentionally prevent the detection of a fraudulent activity. If an employee is uncertainif an activity is fraudulent, call the THR Chief Compliance Officer.SEE ALSOIn This Book: Billing, Coding and Cost Report Practices; Books, Records and Accounts; Corrective Action for

Violation of THR’s Code of Business Ethics; Federal and State False Claims Acts; Non-Retaliation.


Help Detect and Prevent Fraudulent Activities

What are considered fraudulentactivities?

Fraudulent activities include, but arenot limited to:

• Forgery or alteration of patientbilling-related items such assubmitting false claims andassignments of accounts;

• Forgery or alteration of checks,drafts, promissory notes andsecurities;

• Any misappropriation of funds,securities or any other similar assets;

• Any irregularity in handling orreporting of money transactions;

• Any irregularities of payments withbusiness transactions and giving orobtaining contracts with the intentto misrepresent;

• Falsifying or altering any record orreport that misrepresents facts ordata, such as employmentapplication, payroll or time record,production record, expense account,email or correspondence, shippingand receiving record or scientificresearch/data collection record;

• Misappropriation, theft, unauthorizeduse of furniture, fixtures, equipment,supplies, software and/or any otherTHR property, property of patients,guests, physicians or vendors.


Inside ActivitiesTHR prohibits any employee from accepting a position as an independent contractorto THR when the contracted work will be personally performed and falls within theemployee’s current THR job duties. All work performed for THR must generally beshown as wages on your W-2 Form provided at the end of each calendar year.

If an employee has a bona fide outside business activity that is not related to theemployee’s current job duties, it may be OK for the employee’s outside business tocontract with THR for services at an entity where the employee does not work. Anysuch arrangement must be free from conflicts of interest and approved by HumanResources. In addition, the THR Chief Compliance Officer must approve theestablishment of a vendor file prior to making independent contractor payments toan employee through the accounts payable system.

SEE ALSOIn This Book: Conflicts of Interest.

THR Policy: Dualities and Conflicts of Interest Policy and Forms.


I work at a THR entity as a full-timeemployee and at another THR entity ona part-time basis as an independentcontractor. For my part-time services, Iget an hourly rate with no taxes beingwithheld. Am I doing anything wrong?

I am a nurse at a THR hospital and Iwould like to work as an employee of atemporary nurse staffing agency. Can Iwork as an agency nurse at a differentTHR hospital?

As long as both your full and part-timesupervisors and administrators knowof your dual duties, you individually arenot in violation of the Code.However, all of your THR compensa-tion must be subjected to applicablepayroll tax withholdings and wage andhour regulations. In this case, yoursupervisors must coordinate with thePayroll Department to assure that allpayments are made through thepayroll system so that overtime, ifapplicable, is paid, appropriatewithholdings are made and your W-2Form is correct.

If you wish to seek part-time work atanother THR hospital, the work shouldbe performed as an employee of theother THR hospital. An employeecannot be an employee at one hospitaland an agency nurse or contractor atanother hospital.



Employees May Not be Compensated as Independent Contractors for Job Related Activities

I am a hospital employee in the PlantOperations and MaintenanceDepartment and I also own a personalpainting business. Is it OK for myhospital to hire me on weekends or afterhours to personally perform paintingwork at the hospital?

I am a nurse and would like to contractwith THR’s research entity as a classinstructor for a weekend educationalprogram. I will do all preparation on myown time. Is it OK for me to be anindependent contractor for these servicesunrelated to my job duties?

Since your normal job duties includepainting and maintenance work, thehospital may not hire you as anindependent contractor for thosesame duties. Any activity that fallswithin your hospital job descriptionmust be carried out as an employeeand must be paid through Payrollbased on THR policies. On the otherhand, if you own a painting companyand your employees will perform thework outside of your entity, it may bepossible for your painting company tocontract with THR, assuming there areno conflicts of interest. The THR ChiefCompliance Officer must approve thecreation of a new vendor file.

If you prepare all materials on yourown time, you may be an instructor asan independent contractor.


SolicitationSolicitation, canvass or distribution of literature is not permitted on THR propertyunless the activity is a THR sponsored and approved program. This policy is designedto prevent disruption to operations, interference with patient care and inconvenienceto patients, customers, visitors or other employees. THR sponsored and approvedprograms include selected charitable organizations,THR Foundation campaigns oractivities, auxiliary programs, ReachOut THR activities, employee benefit-relatedprograms and discounts, or other programs authorized by THR or the entityPresident. Activities authorized by the entity President should be coordinated withthe entity Human Resources Department. Specific guidelines for THR sponsored andapproved programs are posted on the Intranet.

Recognition of and participation in employee work/life events is permitted withmanager approval. Such events include birthdays, weddings, birth of a child, holidaycelebrations, length of service and other work/life events. Event notices should notbe communicated through the THR communication system, such as email. Suchnotices can be posted in common work areas, if employee participation or donationof money is not required. Notices should not be posted on bulletin boards sincethese boards are only for communication of THR information to patients, employeesand for notices required by law. Employee work/life events should never disruptnormal operations.

Non-employees may not solicit employees or distribute brochures, coupons or othermaterials on THR property. Tenants of THR owned buildings may post notices ofbuilding amenities such as food service, if approved by THR Real Estate and executivemanagement.

SEE ALSOIn This Book: Donations, Grants and Other Charitable Gifts; Electronic Communications and Data;

Confidential Information; Conflicts of Interest; Vendor Endorsements, Demonstrations andEducation.

THR Policy: Solicitation and Distribution.


I am helping my son sell candy bars toraise money for his little league team. Isit OK to sell the candy to my co-workersduring our break periods?

While THR believes in supportingcommunity organizations, too muchsolicitation can be disruptive and putpressure on employees to give tocauses they may not support.Therefore, employees should notsolicit co-workers to purchase itemsor donate money even when used fora good cause.



I am participating in a walk-a-thon for alocal charity that I personally support. Isit OK for me to ask my co-workers tosponsor me by making a pledge?

I heard unions may be trying to solicitTHR employees in their campaignactivities. If a union member tries tosolicit my participation or gives meliterature while I am on THR property,what should I do?

A charity asked me if THR would providea donation to the charity’s educationalevent. The charity will put THR’s nameon its website, posters and otherpublications listing THR as a donor. DoesTHR donate funds to this type of thing?

You should not ask co-workers tomake a pledge or give money. If thewalk-a-thon is a THR sponsored orapproved activity, it is OK toencourage employee participation bywalking in the event, but co-workersshould not be asked for money.

THR is committed to providingemployees a safe, healthy and satisfyingworkplace including appropriatebalance between work and family life.As a property owner,THR has a rightto determine who and what type ofactivities are allowed on THR-ownedproperty. However, any individual orgroup has the right to demonstrate onpublic property. Union membersshould be directed to the property’spublic area which is normally theproperty’s outer edge. If unionmembers try to stop or disrupt trafficupon entering our campus, contactyour entity security department.

All donation or sponsorship requestsshould be sent to one of the THRFoundations or to the THRCommunity Benefit Department forconsideration.



Do Not Solicit on THR Property Without Prior Approval

A company wants to sponsor a specialwebsite for THR employees to buy thecompany’s products at a discount. Is itOK for me to work with the company toget this set up?

Is it OK for me to organize a weddingshower for a co-worker and hold theevent in a conference room after work?

You should refer the company to theTHR Human Resources Department.The company’s program will beevaluated and, if approved as anemployee benefit program, will beoffered to THR employees throughHuman Resources processes. Go toPC Online for a listing of approvedemployee discount purchasingprograms.

It is OK to share and celebrateemployee work/life events as a group,if approved by your manager.Participation must be voluntary andmust not disrupt the department’snormal operations. Further, the eventnotice may be posted discretely in acommon work area.Notices should not be posted onbulletin boards. These boards are onlyfor communication of THR informationto patients, employees and noticesrequired by law.


Use of Licensed Property or Copyrighted Materials

It is THR’s policy to comply with license agreements, copyright laws or otherrestrictions that govern the use of software, published materials or restrictedproperty. Copying software or other restricted materials without authorization mayviolate those agreements, may be illegal and could subject you to disciplinary actionup to and including termination. You must never make copies, resell or transferproducts or materials created by another company or by THR, unless authorized bythe author or under an applicable agreement such as a software license agreement,copyright laws or another agreement authorizing such activities.

THR has an agreement with Copyright Clearance Center to reproduce and distributecontent, in print or electronic format, as often as needed for internal use only. Underthe license, employees can photocopy excerpts from newspapers, magazines, journalsand other copyright-protected works licensed by Copyright Clearance Center. Theagreement applies only to text-based works listed in Copyright Clearance Center’sonline catalog. This agreement does not permit a THR employee to reproduce thefull publication. However, portions of the publication or specific articles may bereproduced for internal use. Contact a librarian at 817-250-3167 to determine if apublication, magazine, newsletter or publisher is covered under this agreement.

Employees must comply with property rights of others including patents, trademarks,service marks and trade secrets. Property rights govern an individual’s or company’sright to control the use, sale or distribution of its developed product or service.Property created as part of an employee’s job function becomes the property ofTHR.

SEE ALSOIn This Book: Corrective Action for Violation of THR’s Code of Business Ethics; Confidential Information.

THR Policy: THR Intellectual Property Protections.


Only one of the computers within ourdepartment has a specialized softwareprogram needed by other employees.For efficiency purposes and to achieveuniform document format, we simplycopied the software onto the othercomputers in the department. Does thisaction violate the Code?

Without approval from THRInformation Services, you may haveviolated the license agreement for thespecialized software program.Appropriate authorization from thelicensor is required to place anysoftware on your computer.



Honor Intellectual Property Laws

I would like to copy an article out of apublication that is copyrighted. Is it OKfor me to make copies of the article anduse the copies inside THR?

What types of items are subject tocopyright laws?

I would like to send copies of anewsletter that is copyrighted. Is it OKfor me to make copies of the newsletterand use the copies inside THR?

Can I forward an entire electronicpublication internally?

If you plan to copy a single article forinternal use, you must first determine ifthe publication is included under THR’scopyright agreement with CopyrightClearance Center. Authorization tocopy excerpts from licensed works forinternal use is provided through thatagreement. Contact a librarian at 817-250-3167 for more information.

Copyrighted items may include articlesfrom publications,TV and radioprograms, videotapes, musicperformances, photographs, trainingmaterials, manuals, documents,software programs, databases andInternet pages.

Copying and sending an entirecopyrighted newsletter is notpermitted under THR’s agreement.You must obtain prior written approvalfrom the publisher to copy the fullnewsletter.

Most subscriptions do not permitforwarding of entire copyrightedelectronic publications. However,select articles for internal use may beforwarded under THR’s agreementwith Copyright Clearance Center.Contact the librarian at 817-250-3167to verify if the specific publications arecovered.


Use of ResourcesTHR has internal control procedures designed to provide appropriate acquisition, useand disposition of THR assets and resources. THR resources may not be used forany unlawful purpose or used in a manner inconsistent with THR’s mission, vision,values or THR policies. In addition, no employee should make THR resourcesavailable to others for use in a non-THR business activity.

Assets must be recorded accurately in THR books and records and disposed of inaccordance with THR policies. Special policies and procedures apply to the handlingand management of assets containing protected health information or THRconfidential data. Please refer to THR Privacy and Information Security policies forcomplete information.

Always follow THR’s Asset Transfer, Disposal and Sale policy when selling or disposingof THR assets that are no longer needed in your department. Sale or disposal ofassets should be handled in coordination with THR Supply Chain Management.

SEE ALSOIn This Book: Books, Records and Accounts; Confidential Information; Electronic Communications and

Data.

THR Policy: Asset Transfer, Disposal and Sale.


I often take my office laptop computerhome overnight to work on personalprojects. Is that OK?

My supervisor often asks me to dopersonal work for him. This includestyping personal letters, running errandsand scheduling personal appointments.Is this OK?

While it is tempting to “borrow” officeequipment, the equipment belongs toTHR and should not be removed fromthe workplace for personal use. Onthe other hand, using your laptopoutside the workplace for THRbusiness is acceptable. However, becertain the laptop does not containprotected health information orpersonal sensitive information beforetaking the laptop from the workplace.

While your supervisor mayoccasionally ask for your help onpersonal business, such requestsshould be infrequent. The requestshould never interfere with theconduct of THR business.



Use THR Resources for Business Only

My department has unused furnitureand old equipment. Can I sell or give theitems to employees?

THR’s Asset Transfer, Disposal and Salepolicy must be followed whendisposing of assets. Contact THRSupply Chain Management forassistance. Unsold THR items areavailable for purchase on an Internetauction site. Employee bids for theitems will be handled by the auctionsite manager in the same manner asany other bid submitted.


Donations, Grants and Other Charitable Gifts

Most THR entities are charitable organizations and are qualified to receive tax-deductible gifts and donations. Donations are often solicited through the HarrisMethodist Health Foundation or the Presbyterian Healthcare Foundation as a part ofthe Foundations’ fundraising activities. To qualify as a donation, grant or charitable gift,the transaction must be a voluntary transfer of cash or property without anexpectation of benefit by the donor. Donations, grants or contributions (whethercash or non-cash) should be directed to the appropriate THR Foundation wheneverpossible. The Foundation will make sure all gifts and donations are properly recordedand acknowledged based on Internal Revenue Service requirements.

In some cases, a donor may be a current or future THR vendor or supplier. If avendor or supplier wishes to make a charitable contribution, the vendor or suppliershould be referred to the appropriate THR Foundation. As a general rule,THR entitystaff should not solicit or accept vendor donations, grants or other charitablecontributions at the departmental level. However, if the vendor company has aseparate and independent grant-making division that makes donations using objectivecriteria and based upon a grant request, it is permissible for a department managerto submit the grant request. In all cases, the grant request must be submitted directlyto the grant-making division and must be handled entirely through the independentdecision-making channels. Further, the process must not involve discussions or otherinteraction with the company’s sales or marketing representatives.

Physician participation in fund-raising activities as experts in medical technologies orservices can add greatly to proposals or grant requests. If a physician will be involvedin a fundraising proposal to a THR vendor, specific guidelines must be followed.Contact the THR Chief Compliance Officer for more information on these guidelines.

SEE ALSOIn This Book: Relationships with Suppliers and Representatives; Solicitation; Vendor Endorsements,

Demonstrations and Education.THR Policy: Asset Transfer, Disposal and Sale.



I am a department manager. Is it OK forme to ask one of my suppliers for adonation to fund equipment for mydepartment?

We are sponsoring an entity approvedcommunity benefit event and would likelocal restaurants or vendors to contributesnacks and prizes. Is it OK for me to asklocal restaurants or vendors to do this?

Is it OK for me to ask one of my suppliersfor a donation to fund the cost of sendingemployees to an educational seminar orsimilar event? What if the suppliervoluntarily approaches me?

Make the appropriate THR Foundationaware of your needs. Let theFoundation handle fundraising efforts tomeet the need. Since you and yourstaff have direct business relationshipswith suppliers, you should not asksuppliers for donations or gifts.Solicitation of suppliers or salesrepresentatives by departmentpersonnel constitutes a conflict ofinterest and may be perceived aspressuring the supplier for donations inexchange for future or past business.

It is OK to solicit local restaurants orretailers for items that will be used inthe community benefit activity. As ageneral rule,THR vendors should notbe solicited. If a vendor offers tocontribute items in support of acommunity benefit event, the itemsshould be of low value and must bedonated independent of any purchasingarrangement. A vendor should neverfeel pressured to make a donation.

You should not solicit suppliers oraccept funding of departmentaleducation. If you become aware of asupplier who wishes to make adonation for educational purposes,direct the supplier to one of the THRFoundations. THR Foundationsmaintain education endowment fundsthat are dedicated to the promotion ofmedical education where it is mostneeded within THR. You must avoideven the perception that receiving a giftmight affect your objectivity or decisionmaking. Donations for educationalpurposes should not be marked forspecific employees or pre-arranged foruse by a specific person, physician ordepartment that the supplier doesbusiness with. Educational funds will bedisbursed in a fair manner under THRFoundation guidelines.



THR Foundations Should Handle Charitable Donations

I am active with the Girl Scouts andwould like to ask a THR supplier tomake a contribution to the annual GirlScout fundraising drive. Is it OK for meto ask the supplier if they would considermaking a donation to the Girl Scouts?

Is it OK for my department to make adonation to a charity or sponsor a charityevent?

A physician is participating in acharitable mission trip and asked for adonation of pharmacy items. Can wegive items to the physician?

You should not solicit current orprospective vendors or suppliers fordonations to good causes you maysupport. The Girl Scouts shouldcontact the supplier directly as a partof their independent fundraisingactivities and without yourinvolvement. You must avoid even theperception that the supplier isexpected to make a donation due toyour position with THR.

Department funds are to be used foroperational purposes only. As analternative, the ReachOut THRprogram provides THR employees anopportunity to support local charities.ReachOut THR guidelines are locatedon the Intranet.

THR cannot give supplies or otheritems directly to a physician. However,it may be possible to donate certainpharmaceutical items directly to thecharity depending on the facts andcircumstances. THR developedguidelines for the donation of itemssuch as supplies, drugs and equipmentfor charitable purposes. Any suchdonations should be handled by THRSupply Chain Management. Also referto the Asset Transfer, Disposal and Salepolicy.


Fair and Accurate Representation of Products and Services

You should strive to fairly and accurately represent THR and its services. Avoid falseand misleading advertising and reject high-pressure treatment or misleading marketingand sales tactics. It is THR’s policy that all marketing materials reflect services andproducts in compliance with applicable advertising and nondiscrimination laws. Verbaland written communications must be true, fair and accurate. A quick advantagegained through even slight misrepresentation or exaggeration can compromise andendanger THR’s reputation. Advertising and promotional materials must be approvedby THR Legal Services prior to publication.


Representation of THR Must be Truthful, Accurate and Fair

In an advertising campaign, newtechnology offered in a THR hospital isreferred to as “state of the art.” Since theTHR hospital is the only hospital in theMetroplex offering this technology, canwe accurately make this claim?

The term “state of the art” implies themost up-to-date technology availablein the industry at the time. Becauseother hospitals may be offering evenmore advanced technology withoutour knowledge, we can’t always knowfor sure that the technology is truly“state of the art”. To provide fair andaccurate verbal and writtencommunications, it would be better todescribe the advanced technologywithout a claim that the technology is“state of the art”. THR Legal Servicesmust approve all advertisement.


Gifts to Physicians or PractitionersTHR is committed to compliance with all laws and regulations that govern businessrelationships with referral sources. Such laws include Federal Stark referral laws(Stark) and Medicare/Medicaid fraud and abuse laws.

Any gift or courtesy given to a physician, physician group or other referringpractitioner must be documented and recorded in the THR Business CourtesiesDatabase. In addition, the following guidelines must be followed:

• Cash or cash equivalents (gift certificates) are never permitted as gifts in anyamount;

• All gifts must be tracked in the THR Business Courtesies Database, and thetotal value of gifts during the year must not exceed the limit set by theCenters for Medicare and Medicaid Services (approximately $325 per year,per physician);

• Gifts may not be provided in response to a solicitation by the physician (orhis/her office staff) and

• The volume or value of admissions or referrals generated by the physician(s)must never be a factor.

Contact THR Legal Services with any questions you may have.

SEE ALSOIn This Book: Business Courtesies: Gifts; Relationship with Suppliers and Representatives.

THR Policy: Business Courtesies Provided to Physicians; Voluntary Leadership Services by Physicians.


I am responsible for providing informationon hospital services to physicians. Aphysician’s office staff has asked me tobring lunch in order for me to get anappointment. What should I do?

You should refuse any solicitation for agift or courtesy by a physician or aphysician’s office staff. Unsolicitedmeals or gifts may be given as abusiness courtesy, but the value mustbe tracked in the THR BusinessCourtesies Database. Meals, gifts orcourtesies must be handled withoutregard to the volume or value ofbusiness done between the hospitaland the physician practice.



Track Gifts in the THR Business Courtesies Database

I work in a department that is growing inpatient volumes and revenue. In largepart, this success is due to specificphysicians who routinely admit patients.Is it OK to thank these specificphysicians by sending a gift basket?

A group of 20 physicians serve on ahospital advisory committee to provideinput regarding hospital activities. Thephysicians have been paid for their timethroughout the year. The hospital wouldlike to treat all of the physicians to anice dinner to celebrate the successfulcompletion of a project. Is thisacceptable?

THR purchases local sporting eventtickets. Can I give these tickets tophysicians as a business courtesy withoutviolating the Code?

It is not acceptable under current lawsto single out specific physicians basedon the number of admissions orreferrals to your department. If a“thank you” gift is planned, the samegift must be provided to all physicianswho are credentialed to performprocedures in your departmentwhether or not they refer patients.Additionally, each physician gift must betracked in the THR BusinessCourtesies Database.

If the physicians have been paid forattending hospital meetings, there willbe a written agreement. Theagreement may contain languagepermitting an appreciation gift asadditional compensation. “Thank you”gifts permitted under a writtenagreement are acceptable and are nottracked in the THR BusinessCourtesies Database. All other giftsmust be entered into the trackingDatabase. Contact THR Legal Servicesor the THR Compliance Hotline if youhave questions.

The tickets must be tracked in theTHR Business Courtesies Database.Before giving tickets to a physician, youmust check the Database to verifywhether the value of the tickets, whenadded to other gifts, will cause thephysician to exceed the annual giftlimit.


HonorariaEmployees are often asked to speak or participate in non-THR presentations abouttheir areas of expertise. On these occasions, you cannot disclose THR confidentialdata or hold yourself out as a THR agent. Public distribution of THR materials at anon-THR meeting must be approved by your supervisor.

An employee participating in a non-THR meeting may keep an honorarium.However, if the employee prepared or gave his or her presentation during THR workhours and/or traveled to the event at THR’s expense, the honorarium should begiven to THR. If you have access to THR confidential information, you must notengage in outside activities or speaking events and use the confidential information.

If an employee has questions or concerns about honoraria, he/she should speak withhis/her supervisor or call the THR Chief Compliance Officer to discuss the specificfacts of the situation.

SEE ALSOIn This Book: Outside Activities; Conflicts of Interest; Confidential Information.


Honoraria May be Kept if the Presentation is Prepared Outside Your Business Hours

I recently presented an eveningdiscussion on computer technology to thelocal chapter of the professionalorganization in which I belong. Mypreparation time was during THRworking hours. In recognition of myefforts, the chapter gave me a gift worthmore than $200. May I keep the gift?

I have been asked to speak at anindustry trade conference. I preparedthe information on my own time and willtake PTO to attend. Can I accept anhonorarium and let the trade associationpay for my travel expenses?

You should not personally keep thegift. The Code prohibits your personalacceptance of honoraria (cash or non-cash) for presentations prepared orpresented on THR’s time. If youaccept the gift, you must give it to THRfor use in THR activities. Receiving aninexpensive thank you gift would notviolate the Code. An inexpensive giftwould generally be worth $100 orless.

The trade association can pay yourexpenses and you may keep thehonorarium. THR proprietaryinformation that is consideredconfidential should not be used in yourpresentation.


Outside ActivitiesYou should not engage in any outside employment, consulting agreements or otheractivities that might affect your fairness and independent judgment in carrying outyour THR work duties.

If you have access to THR confidential data, you must not work for any outsidecompany or contract service that involves the use of such data.

SEE ALSOIn This Book: Conflicts of Interest; Confidential Information; Honoraria.


As a physical therapist, I often work withpatients who eventually need hometherapy care. Occasionally, patients askme if I can personally treat them athome. May I give these services and notviolate the Code?

Is it OK for me to “go into business” withone or more of my direct reports toperform consulting or other services forcustomers who are not competitors orsuppliers of THR?

I have been asked to serve as an expertwitness in a healthcare related case. Is itOK for me to agree to serve as anexpert witness?

You may give this care as long as youdo not steer business to your hometherapy practice as a result of youraccess to THR patients and medicalrecords and you notify your supervisorof the activity. You would violate theCode if you directly approached orsolicited patients for your ownpersonal business. Further, you mustnot make personal business cards orother promotional material available topatients or others on THR premises.

As a supervisor, it is inappropriate foryou to engage in an outside businessactivity with employees who report toyou in your THR position. Suchoutside activities may affect yourfairness in performing your supervisoryduties with these THR employees.

Employees may not be an expertwitness in any medical or other healthrelated litigation without obtainingwritten and formal authorization fromTHR Legal Services.



Employees Outside Employment Should Not Conflict with THR Responsibilities

A THR vendor asked me to participate inmeetings about a vendor product. Thepurpose of the meeting is to providegeneral product data and seek feedbackfrom potential users. The group meetingwill be held off THR property and on theweekend. The vendor will pay all traveland lodging expenses and I will also bepaid a consulting fee or honorarium formy work. Is it OK for me to attend themeeting and keep a consulting fee orhonorarium for my work? What if I givethe fee or honorarium to mydepartment?

If attending the meeting is importantto your job duties, you may attendwith the prior approval of yoursupervisor. However, you should notaccept compensation of any kind inexchange for your work. Likewise, youshould not accept vendor paid travelor lodging. You must remainindependent in your job duties anddecision making. After attending themeeting, you will most likely beexpected to make recommendationsand/or present data to THR that couldinfluence buying decisions related tothe vendor’s product(s). Acceptingvendor payment for travel orparticipation creates a conflict ofinterest. Vendors should useestablished THR business channelsduring regular working hours toprovide data and seek productfeedback. Donating the fee orhonorarium to your department doesnot remove the conflict of interest.The fee or honorarium should not beaccepted.


Relationships with Suppliersand Representatives

THR requires ethical business dealings in all aspects of employee activities. THRexpects employees to treat suppliers fairly and honestly, giving clear instructions abouttechnical and business requirements and appropriate feedback about product orservice quality. It is THR’s policy to provide minority and/or woman-ownedbusinesses a chance to compete on an equal basis with other vendors in acompetitive marketplace.

All purchasing relationships must be independent, fair and free from conflicts ofinterest. No vendor or vendor representative will be given special favors based upona family relationship to a THR officer, employee, board member or medical staffmember.

Federal and state laws, including the Medicare and Medicaid fraud and abuse laws,prohibit giving kickbacks and paying for patient or business referrals. Consistent withthese laws,THR strictly prohibits an employee from asking, taking or giving money oranything of value, either directly or indirectly, in return for the referral of any item orservice provided by THR or its affiliates.

Purchase contracts involving discounts, rebates or other cost reductions must be fullystated in the written agreement and all such cost reductions must be properlyrecorded in THR’s accounting records and Medicare cost reports.

Specific THR employees have authority to commit THR to a contract or purchaseagreement. Refer to the THR Approval, Authorization and Responsibility Matrixwhich defines signature authority by job title. Your Supply Chain ManagementDepartment should always be involved in purchasing transactions.

Under no circumstances should an employee engage in agreements to buy somethingfrom a supplier based on the supplier’s commitment to buy goods or services fromTHR. THR does not allow employees to accept anything of value from a vendor inreturn for the vendor’s provision of goods or services to THR or any of its affiliates.

Employees must report activities or conduct, which they suspect may be unethical orillegal, to their supervisor or the THR Chief Compliance Officer. Any employee foundto have been involved in inappropriate business dealings will be subject to correctiveaction including involuntary termination, if warranted. Employees are encouraged toask questions about business matters that appear suspicious. Inquiries may be madeto the THR Chief Compliance Officer directly or by calling the THR ComplianceHotline.

SEE ALSOIn This Book: Corrective Action; Conflicts of Interest; Gifts to Physicians or Practitioners; Request for

Quote Process; Vendor Endorsements, Demonstrations and Education; Donations, Grantsand Other Charitable Gifts.

THR Policy: Progressive Corrective Action.



Treat Suppliers Fairly, Honestly and with Respect

Is it OK to purchase a supply item froma company that is owned by a hospitalboard member or a physician medicalstaff member?

I received a sales call from a salesrepresentative who is the son of amedical staff physician. Does this createa problem?

If a board member or physician has aproduct that he or she would like tosell to THR, the product must beevaluated through a fair process in thesame manner as any other prospectivesupplier. The product may be a goodopportunity at a reasonable price;however, the board member orphysician should be directed to THRSupply Chain Management. SupplyChain Management will carry out anindependent and fair product reviewusing knowledgeable reviewers.The board member or physician mustnot be involved in any way that wouldsway the decision-making process. If adecision is made to buy the product,the product will be made available toall THR entities through normal SupplyChain Management processes.

As long as THR’s independent and fairpurchasing processes are strictlyfollowed, this does not create aproblem. Special favors must not begiven to sales representatives based onhis or her relationship to a physician orany other person affiliated with THR. Ifyou feel pressured in any way, consultwith your supervisor or call the THRCompliance Hotline.


Product Samples, DemonstrationEquipment and Acceptance of Vendor

ProductsTHR may receive vendor products as a sample or for demonstration and evaluationpurposes. Acceptance of a vendor product or service that is intended to induce apurchase, prescription or product recommendation is strictly prohibited. Further,THRand its employees will not endorse or recommend specific products to patients.Discussions with patients must be based solely on objective clinical data andconsistent with the physician’s order and patient choice.

Sometimes, the hospital may need to sample a product or test equipment prior topurchase. In these instances,THR Supply Chain Management should be contacted tocoordinate and approve acceptance of samples or demonstration equipment.Employees should not accept free items or reduced prices in return for futurepurchases. Any such offer should be reported immediately to THR Supply ChainManagement or the THR Chief Compliance Officer.

THR Supply Chain Management will follow the standards listed below whenreviewing agreements for samples, demonstration equipment or other acceptance ofvendor products.

Test Samples and Demonstration Equipment:

• The item must be for testing or demonstration purposes only;

• The amount supplied must be reasonable and must not exceed what isnecessary for timely review;

• Unused samples and demonstration equipment must be promptly returnedto the supplier ; and

• There must be a clear understanding that the product or equipment will bereviewed fairly with any purchase decision being made strictly on the meritsof the product.

Acceptance of Vendor Products for Patient Evaluation:

Some companies offer samples for patient trial use to enable the patient to evaluatewhether to purchase the same product after discharge. These arrangements must beapproved by THR Supply Chain Management and must be offered under a writtenagreement with the manufacturer that meets at least the following requirements:

• The arrangement must be part of a published program that is widely offeredto a broad sector of healthcare organizations whether or not theorganization purchases any product from the vendor;

• Sampling quantities must be limited to what is needed to permit patients toevaluate whether to purchase the product after discharge;


• If a discharge pack is provided, the contents must be of nominal value andonly for the patient to take home;

• Employees must not personally receive the benefit of any vendor productsor programs;

• Employees must not endorse or promote any products to patients; and

• Vendors with sampling programs should be given an equal chance toparticipate if the product quality is comparable and all requirements aremet.

SEE ALSOTHR Policy: Purchasing Agreements for Supplies, Services and Equipment – Discounts, Rebates and

Other Arrangements.


A baby formula company has a programwhere the company provides samplebaby formula to hospitals at no cost foruse by patients. Formula samples arealso provided to new mothers in adischarge pack. Is it OK to participate inthe program?

A vendor has a program where diabetes-testing devices are provided to thehospital at no cost for distribution topatients in a discharge pack. Is it OK toaccept discharge packs and supply themto patients to take home for evaluation?

It is acceptable to participate in theprogram if the baby formula is offeredby the vendor under an industry-wideprogram. The program must beindependent of any other hospitalpurchasing arrangement and meet therequirements specified above. All suchprograms must receive prior approvalfrom THR Supply Chain Management.

It is OK for the hospital to participatein the vendor’s patient evaluationprogram if the items being distributedare of low value and the program isprovided under a written agreementthat has been approved by THR SupplyChain Management. The patientshould be advised that other productsare available in the marketplace.



Follow Guidelines for Vendor Samples

A vendor will supply equipment at nocharge if the hospital purchasesdisposable supplies. Is this OK?

A vendor has offered to supply five freedemonstration laser printers for mydepartment to evaluate. I can keep theprinters at the end of the review period,if I make a commitment to purchase allof my printers from this vendor. Should Iaccept?

Nothing is “free”. The cost of theequipment is included in the supplyprice as a hidden cost. THR has strictpolicy requirements that require clearwritten documentation, spelling outthe cost of all supplies and equipment,including any discounts or rebates.Further, all equipment and suppliesmust be properly recorded in THR’sbooks and records and for cost reportpurposes. THR Supply ChainManagement must handle all contractsand should be contacted with allpricing questions or concerns.

Acceptance of five demonstrationprinters is more than needed toevaluate the printer’s quality andperformance. In addition, since theprinters will still have value at the endof the demonstration period, theymust be returned to the vendor unlessthe demonstration equipment isincluded in a purchase agreement andhandled properly for accountingpurposes. Keeping the printerswithout proper accounting treatmentcould be viewed as an unrecordeddiscount or rebate.


Request for Quote ProcessBefore buying products or services,THR employees should contact THR Supply ChainManagement and follow all policies and procedures. A sufficient number of qualifiedvendors should be contacted to obtain competitive prices and to evaluate the qualityof products or services. In addition to being a good business practice, this process isimportant because THR is a tax-exempt organization. Accordingly, contracts forgoods or services must not exceed fair market value. The contract payment isespecially critical when goods or services are provided by a physician or a physiciangroup. When contracting with physicians,THR must comply with federal and statelaws such as Stark referral laws and Medicare/Medicaid fraud and abuse laws. In mostcases,THR Supply Chain Management staff will take primary responsibility for thecontracting process.

Bids and price quotes may be solicited by sending out requests for proposals orthrough telephone calls. THR recognizes that obtaining bids and price quotes maynot always be practical. For example, all THR construction projects are managed bythe THR Facilities Development Department to provide overall project efficiency.Further, a vendor may be a sole source provider of the service or the service may beso unique that other suppliers are not readily available. Likewise, the size of theanticipated purchase may not warrant obtaining formal bids. In any event, sufficientresearch should be done to provide confidence that the product or service meetsTHR quality requirements and that the price is competitive.

When the product selection process requires an on-site visit to a vendor location toreview the product, the written requests for proposal should specify that an on-sitereview is required. The written proposal should specify how many reviewers will beinvolved and whether the prospective vendor must pay the travel expenses. Anyrequirement for an on-site review must be limited to the time needed for the reviewand should include a limited number of reviewers, normally one or two.

SEE ALSOIn This Book: Relationships with Suppliers and Representatives; Conflicts of Interest.

THR Policy: Business Travel, Entertainment and Expense Reimbursements.



My manager signed a contract forsignificant services after receiving a bidfrom only one vendor. Is there a problemwith this?

A current vendor has a new productthat easily fits into an existing system.Do we need to go through a quoteprocess for this new product?

A physician has recommended my entitypurchase a product from a company hepartially owns. It appears the producthas merit. How do I handle thissituation?

Managers do not have authority tosign contracts under the THRApproval, Authorization andResponsibility Matrix. Further, itappears the manager did not workwith THR Supply Chain Managementto pursue competitive bids. Thecontracting process (bidding,negotiation and vendor selection)should be coordinated with SupplyChain Management and include acompetitive, open, arms-lengthcontracting approach. THR may notreceive the highest qualitygoods/services at the best price if onlyone bid is obtained. More than onebid should be obtained anytime thetransaction is significant unless thevendor is a sole source provider orthere are other unique facts. If youhave a question about a specifictransaction, call THR Supply ChainManagement and follow its purchasingpolicies.

All major purchases must follow therequest for quote process. ContactTHR Supply Chain Management forhelp.

Refer the physician’s request to THRSupply Chain Management. Theproduct may be a good option at areasonable price and one that THRmay want to pursue. An independentreview will occur. Based on thereview’s outcome and other bids, a fairdecision will be made through normalSupply Chain Management process. If adecision is made to buy the product,the product will be made available toall THR entities through normal SupplyChain Management processes.




Request Proposals for Significant Transactions

THR is thinking of buying new high-techequipment for my area. My supervisorasked me to review the equipment. Avendor invited me to the East Coast toattend an equipment demonstration.May I attend the demonstration withoutviolating the Code?

You may attend, if a demonstration isnecessary to carry out the review andyour supervisor approves the visit. Inmost cases,THR should pay for yourhotel and airfare to the demonstrationunder the THR Business Travel,Entertainment and ExpenseReimbursements policy. Acceptingreasonably priced meals andentertainment at the event is OK. If aformal written Request for Proposal(RFP) was sent to specific vendors andall respondents must (as a conditionof the RFP) give a demonstration, it isacceptable for an out-of-town vendorto pay reasonable travel expenses. Inthese instances, follow the terms andconditions noted in the RFP.

Vendor Endorsements,Demonstrations and Education

Employees should not endorse or promote a specific vendor or vendor products orservices to patients, employees or business associates. Vendors should not use theTHR or hospital entity name or logo in press releases, advertising materials, brochuresor articles without THR’s prior approval. Vendors may include THR or a hospitalentity name on a customer list. THR employees should not write articles or providequotes about a vendor or a vendor’s products.

Vendors sometimes request on-site demonstrations for prospective customers at aTHR facility. On-site demonstrations are permitted if specific guidelines are followed,including:

• Vendor on-site demonstrations should be infrequent and not disrupt entityoperations.

• If possible, there should be a written agreement with the vendor and includedemonstration details.

• If payment for employee time and effort is involved, the amount must bereasonable and the agreement must clearly state what the payment is for.Payment includes cash or “in kind” compensation.

• THR personnel must not appear to be vendor “sales” agents and the on-sitedemonstrations must be fair in all aspects.

Vendors may wish to sponsor education events for patients, the community,employees or physicians. These requests may be in the form of a sponsorship,donation or grant. THR restricts vendor participation in education events and specificguidelines must be followed.

Patient and Community Education:• Vendors may provide charitable donations to fund objective patient healthcare

education. Acceptance of donations is allowed. However, there must be noappearance that THR is “endorsing” the vendor or its products.

• The vendor’s participation must be purely passive and philanthropic.• Event materials must refer to the vendor as a donor. Words such as “in

partnership” or “co- sponsor” should not be used. The event should be aTHR controlled activity and the vendor may be acknowledged as a donorsuch as, “We wish to thank XYZ Company for financial support of thiseducational program.”

• The vendor should not have a promotional table at the community event andliterature should not be distributed.

• It is acceptable for the vendor representatives to attend the session, but thevendor should not be a speaker or participate in the THR educationalprogram other than as an attendee/sponsor.


THR Employee Education Events:THR’s Solicitation and Distribution policy applies to employee educational events.Specifically, this policy prohibits vendors, suppliers or others from distributingliterature on THR property. If the event is sponsored by THR primarily for THRemployees, vendors may not distribute literature or have booths. If you havequestions regarding employee educational events, contact your entity HumanResources Department.

THR Physician Education Events:• You must work with THR’s Research and Education Institute in all aspects of

the physician education sessions. This will assure federal laws concerningreferral sources are followed.

• All printed materials, brochures and arrangements with vendors must meetthe Accreditation Council for Continuing Medical Education (ACCME)requirements for accreditation of continuing medical education.

• Vendors may attend and participate as permitted by ACCME accreditationrules.

You may call the THR Chief Compliance Officer with any questions regarding vendorparticipation or sponsorship of education events.

SEE ALSOIn This Book: Confidential Information; Relationships with Suppliers and Representatives; Solicitation;

Donations, Grants and Other Charitable Gifts.

THR Policy: Solicitation and Distribution.


THR recently bought a product and thevendor has asked that I provide a quotefor a news release. Can I give thisquote?

My department recently installed newtechnology. I have been asked if thevendor can perform an on-sitedemonstration for a potential customer.Is this OK?

All vendor requests involvingpromotional activities should beprocessed through the THR SystemCommunications Department.Generally, quotes or testimonials arenot allowed since these may beperceived as an endorsement of thevendor or the vendor’s product.

THR employees may participate in on-site demonstrations as long as specificguidelines are agreed to in advance.These guidelines are posted on theTHR Intranet and are summarizedabove.




Do Not Endorse Specific Vendor Products to Patients or Employees

A pharmaceutical company has offeredto provide financial sponsorship forspecific medical staff education. Can thisoffer be accepted?

Contact the THR Chief ComplianceOfficer to discuss the proposal. If theevent serves to maintain, develop orincrease scientific knowledge and skillsthat the participant will use to providesafe and effective services to patients,the proposal may be OK. In addition,the program must not involvepromotion of the pharmaceuticalcompany’s products.

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Inside Back CoverLeft Blank Intentionally

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Questions about business ethics, compliance or information in the booklet?

Call the THR Compliance Hotline at 1-800-381-4728or e-mail [email protected].

code of business ethics - texas health resources

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