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Code of Conduct

LAWRENCE MEMORIAL HOSPITAL

Code of Conduct
Lawrence Memorial Hospital is committed to conducting business in an ethical and honest manner and within the bounds of the law. This Code of Conduct is intended to provide employees, physicians, volunteers, vendors, and other agents of Lawrence Memorial Hospital with guidelines for conducting business in a manner which fulfills that commitment. The Code of Conduct is supplementary to the mission, vision and values of Lawrence Memorial Hospital and applies to all who provide services under the auspices of Lawrence Memorial Hospital or its affiliates.

The standards contained in this Code of Conduct are important, and therefore any violation will be handled in accordance with the Progressive Disciplinary Policy, as outlined in Personnel Policies or other applicable policies and procedures of Lawrence Memorial Hospital and its Medical Staff. In addition, referral of certain matters will be made to government and regulatory agencies as appropriate. The offender may also be responsible in a civil suit for losses or other damages caused by his or her inappropriate conduct.

The Corporate Compliance Program
The Corporate Compliance Program has been established to prevent the occurrence of illegal or unethical behavior, to stop any such behavior as soon as reasonably possible after it has been discovered, to discipline the individuals involved (including those who know of violations but fail to report them), and to recommend and implement changes in policy and procedure necessary to avoid a recurrence of any prior violation.

Questions and How to Report Violations of the Standards
It is important to Lawrence Memorial Hospital that employees have an effective way to get an answer to any question they may have about how to conduct their job. It is also important for employees and other agents to report any instance of a known or suspected violation of this Code of Conduct.

In the event that an employee has a question or concern or believes that someone is conducting their business in an illegal, unethical, or otherwise questionable manner, or violating Lawrence Memorial Hospital's policies, it is preferred that the employee first contact his or her supervisor to discuss the matter. There are times, however, when either the response the employee receives may be inadequate or the employee may feel uncomfortable in discussing the matter with his or her supervisor. In those cases, the employee should contact the Corporate Compliance Officer or call the toll free telephone hotline at 877.474.1363. All calls to the hotline are confidential, and the caller may remain anonymous. To ensure confidentiality, the telephone hotline is operated by an organization not affiliated with Lawrence Memorial Hospital. Calls are answered 24 hours and day, seven days a week. Follow up on all calls is available by a return call to the hotline. Callers will not be retaliated against in any manner for making reports as long as the information being report is, to the best of their knowledge, truthful.

Lawrence Memorial Hospital's Commitment to Compliance
Lawrence Memorial Hospital strives to . . .

Comply with the Law. Lawrence Memorial Hospital is subject to numerous local, state and federal laws pertaining to all aspects of its operation. All employees are required to understand and abide by those laws which are applicable to them in the performance of their jobs.

Provide Excellent Patient Care. Lawrence Memorial Hospital employees shall strive to treat all patients with a spirit of kindness, patience and understanding. Each patient is an individual and should be treated as such. Each patient should be respected, with their needs and desires considered as health care decisions are made. Steps shall be taken so that each patient understands his or her treatment needs and options, treatment methods utilized, and treatment outcomes. LMH will provide services in a manner that does not discriminate against any person because race, color, religion, national origin, age, disability, sexual orientation, or gender. At all times, competent and qualified individuals will provide appropriate care, while considering the safety and well being of the patients.

Protect Confidential Information. Lawrence Memorial Hospital is committed to maintaining the confidentiality of patient, personnel, and other proprietary information in accordance with applicable legal and ethical standards. Consistent with HIPAA (Health Insurance Portability and Accountability Act), we do not use, disclose, or discuss patient specific information with others unless it is necessary to serve the patient or otherwise required by law.

Adhere to Anti Referral and Health Care Fraud and Abuse Legislation. All employees of Lawrence Memorial Hospital are required to comply with laws which prohibit health care fraud and abuse. Activities that are prohibited include, but are not limited to:

  • Intentionally or knowingly making false or fraudulent claims for payment or approval
  • Offering or receiving remuneration (such as a kickback, bribe, or rebate) as an inducement to make a referral for the furnishing (or arranging for the furnishing) of any item or service
  • Submitting false information for the purpose of gaining or retaining the right to participate in a plan or obtain reimbursement for services
  • Referrals by a physician of Medicare or Medicaid patients to any entity for "designated health services" when the physician or an immediate family member has a financial relationship with the entity (unless the arrangement complies with applicable legal exceptions).

Not Accept Inappropriate Gifts or Gratuities. The following standards apply to the giving or receiving of gifts and gratuities.

Receiving Gifts from Patients and Vendors: Employees are prohibited from soliciting tips, personal gratuities or gifts from patients and vendors. Employees may, however, accept non monetary gratuities or gifts of a nominal value, such as cookies, flowers or candy if the gift would not influence, or reasonably appear to others to be capable of influencing, the employee's business judgment in conducting affairs with the patient or vendor.

If the value of the gift is substantial or there is any question regarding whether the gift meets this standard of reasonableness, the employee must seek prior approval from the Corporate Compliance Officer (who will take the request to the Compliance Committee for review) or refuse the gift and promptly return the gift to the vendor or patient. Substantial gifts to LMH can be made by contacting the Chief Development Officer for the LMH Endowment Association.

Giving Gifts to Patients and Vendors: Employees shall not offer or give money, services or other things of value with the expectation of influencing the judgment or decision making process of any purchaser, vendor, patient, governmental official or any other person.

An employee who is in doubt about whether a situation involving the giving or receiving of something of value is acceptable, should ask his or her supervisor, or the Corporate Compliance Officer.

Avoid Conflicts of Interest. It is the policy of Lawrence Memorial Hospital to prohibit its employees and other associates from engaging in any activity, practice, or act which conflicts with, or appears to conflict with, the interests of Lawrence Memorial Hospital, its patients or its vendors. Therefore, Employees, Medical Staff members, Board members, and other individuals must disclose to their supervisor or the Compliance Officer any potential conflict of interest they or their immediate family have in any firm which does business with Lawrence Memorial Hospital or which competes with Lawrence Memorial Hospital.

Follow All Antitrust Regulations. A number of activities engaged in by Lawrence Memorial Hospital are subject to state and Federal antitrust laws. Generally, these laws prohibit agreements or actions that may illegally restrain trade or reduce competition. Examples of activities that violate these laws include, but are not limited to, agreements among competitors to fix or stabilize prices, inappropriate exclusive dealings, and boycotts of specified suppliers or customers. Sharing information with a competitor, such as how prices are set, labor costs, or terms of supplier contracts may also violate anti-trust laws.

Keep Accurate and Complete Records. It is essential that Lawrence Memorial Hospital report accurate information to governmental entities and other third parties. In order to meet this obligation, it is equally essential that every employee accurately and clearly report the relevant facts or the true nature of a transaction. No employee should knowingly or with reckless disregard for the truth make any false or misleading statement on any form or to any other officer, employee or auditor for Lawrence Memorial Hospital. All patient records must meet the documentation standards required for quality care and to meet reimbursement regulations. Any individual who contributes to the medical record must provide accurate documentation and never alter or destroy anything that is part of the official medical record. Employee travel and entertainment related expenses must be accurately documented and supported when seeking reimbursement from the hospital. Medical records and other business documents will be retained in accordance with state and Federal law.

Conduct Political Activities According to the Law. Lawrence Memorial Hospital does not participate or intervene in (including the publishing or distributing of statements), any political campaign on behalf of or in opposition to any candidate for public office.

While Lawrence Memorial Hospital supports employee participation in the political process, employees are not permitted to use positions in Lawrence Memorial Hospital to try to influence the personal decisions of others to contribute or otherwise support political parties or candidates except as lawfully permitted through political action committees.

Lawrence Memorial Hospital may participate in lobbying activities or advocating the passage or defeat of certain legislation that pertains to issues that affect the healthcare community. Lobbying activities, or advocating the passage or defeat of certain legislation, shall not constitute a substantial part of the activities of Lawrence Memorial Hospital.

Protect the Environment. It is the policy of Lawrence Memorial Hospital to comply with all state and federal laws protecting the environment. Employees shall dispose of all waste and other materials and store all chemicals and substances in accordance with applicable laws and regulations. It is important to file all necessary environmental reports accurately and promptly and to cooperate fully with all governmental authorities in the event of an environmental incident.

Provide a Safe Workplace. It is the policy of Lawrence Memorial Hospital to comply with all applicable state and federal laws designed to improve workplace safety. Lawrence Memorial Hospital is committed to training employees to carry out their work in a manner that is safe for them, their coworkers and the patients they serve. LMH does not employ or contract with individuals or entities that are excluded or ineligible to participate in federal healthcare programs, suspended or debarred from federal government contracts, or has been convicted of a criminal offense related to the provision of healthcare items or services and has not yet been reinstated in a federal healthcare program, provided we are aware of such criminal offense.

Not Tolerate Harassment or Discrimination. It is Lawrence Memorial Hospital's policy not to discriminate on the basis of race, color, religion, national origin, age, disability, sexual orientation, or gender in providing services to patients or the public, nor in relation to employment practices. Furthermore, Lawrence Memorial Hospital prohibits harassment or discrimination of its employees in any form by supervisors, coworkers, customers or vendors.

Appropriately Use its Assets. All employees are charged with protecting and preserving Lawrence Memorial Hospital's assets and resources by following procedures to prevent their loss, theft or unauthorized use. No part of the net earnings of Lawrence Memorial Hospital shall inure to the benefit of, or be distributed to, its trustees, Executive Staff, employees or other private persons having directly or indirectly any personal or private interest in the activities of Lawrence Memorial Hospital, except to the extent that such payments constitute reasonable compensation for services rendered in the necessary course of Lawrence Memorial Hospital's business.

Protect Access to Information Systems. Lawrence Memorial Hospital is committed to protecting all aspects of its information systems. All employees and other associates with access to Lawrence Memorial Hospital's computerized information system shall sign and abide by Lawrence Memorial Hospital's Responsible Use Policy, including the protection of confidential passwords and other access information.

Adhere to Intellectual Property Laws. Lawrence Memorial Hospital is committed to adhering to all applicable intellectual property laws. All software used in connection with Lawrence Memorial Hospital's business must be properly licensed and used in accordance with that license. Additionally, Lawrence Memorial Hospital will respect the intellectual property and copyright laws regarding books, trade journals, magazines, and other applicable resources.

Research and Clinical Trials. Lawrence Memorial Hospital is committed to following high ethical and legal standards when conducting research and clinical trials involving human research subjects. LMH adheres to all local, state and Federal rules and regulations pertaining to research and clinical trials involving human subjects conducted by LMH employees and members of the medical staff. Patient rights will be respected during all phases of clinical trials. Any research involving human subjects must be done in accordance with the policies and procedures of the LMH Institutional Review Board.