Muskegon Family Care
Muskegon, MI
POLICY/PROCEDURE
POLICY NUMBER:
Page 1 of 3
TITLE: ORGANIZATIONAL INTEGRITY PROGRAM
EFFECTIVE DATE:
8/1/2007
REVISED DATE:
REVIEWED:
PURPOSE: To provide for an organizational integrity program for Muskegon Family Care
SCOPE: All sites, programs, paid staff, contracted staff, providers, students, board members,
volunteers, contractors, vendors and others acting on behalf of Muskegon Family Care
COMPLIANCE: Organizational Integrity Officer, Organizational Integrity Committee
PRECAUTIONS: None
DEFINITIONS:
“Organizational Integrity” means both complying with all legal, professional and ethical
obligations that apply to all Muskegon Family Care operations, as well as creating and
maintaining a culture that allows Muskegon Family Care employees and collaborators to embody
the mission and values of Muskegon Family Care as well as their own professional standards and
legal and ethical obligations.
POLICY:
Muskegon Family Care is committed to complying with all legal, professional and ethical
obligations that apply to its various businesses, and to fostering a culture that enables all
Muskegon Family Care employees and collaborators to fulfill their legal, professional and ethical
obligations. In pursuit of that goal, by this Policy, Muskegon Family Care adopts an
Organizational Integrity Program, modeled after the Trinity Health Organizational Integrity
Program implemented by Mercy General Health Partners, as a statement of its commitment to
achieving full compliance with those legal, professionals and ethical obligations.
The specific form of the Organizational Integrity Program will change from time to time as new
challenges arise and new methods of encouraging integrity become available. However, the
Organizational Integrity Program will include at all times the following essential elements:

Operation of the Program will be under the guidance of the Muskegon Family Care
Executive Director. There will be an appointed Organizational Integrity Officer, who
must be a member of the Muskegon Family Care Senior Leadership Team and will be
responsible for implementing the Organizational Integrity Program within Muskegon
Family Care.

At least semi-annual reports by the Organizational Integrity Officer to the Muskegon
Family Care Board of Directors (or a committee thereof) regarding the Organizational
Integrity Program.

Publication and periodic reconsideration of Muskegon Family Care Standards of Conduct
that outlines principles and standards of conduct used by all employees and collaborators
of Muskegon Family Care in carrying out the affairs of the organization.

Mechanisms that encourage employees and collaborators to report violations of the
Standards of Conduct, to investigate such violations and to recommend appropriate
sanctions against violators of the Standards.

Processes to educate all employees and collaborators within Muskegon Family Care
about their legal, professional and ethical obligations within the healthcare workplace
generally and within Muskegon Family Care specifically.

Processes to include questions in the annual employee performance review to evaluate
each employee’s commitment to organizational integrity, ethical behavior, and adherence
to applicable laws and regulations. Employee awareness of and compliance with the
Organizational Integrity Program, including Standards of Conduct, will be made a
standard component of each annual employee evaluation.

Procedures to monitor and audit the actions of all programs, departments, employees and
associates within Muskegon Family Care to ensure that they live up to the legal,
professional and ethical standards that are expected as the norms of behavior within
Muskegon Family Care.

Employment policies to ensure that compliance with those legal, professional and ethical
standards is considered an essential element of all employment conditions within
Muskegon Family Care, including as an element of the performance appraisal of
management level personnel.

Systems to correct as quickly as possible any deviation from those legal, professional and
ethical standards by the use of effective enforcement tools.
PROCEDURE:
1. Integrity Reporting System: Muskegon Family Care will maintain a telephone reporting
system that is staffed 24 hours a day, 7 days a week by an outside organization
professionally trained to handle such calls. The telephone reporting system will not use
caller ID. Callers may be asked if they are willing to identify themselves so that an issue
may be followed up with the caller after the call ends. All calls will be treated
confidentially, and callers may remain anonymous if they so choose. The caller’s
2.
3.
4.
5.
information will be transcribed and provided by the outside organization in written form
to the Muskegon Family Care Organizational Integrity Officer, usually within 24 hours.
Investigation Process: All calls will be given appropriate attention and follow-up.
Depending on the allegations described in the call, certain matters may be investigated by
the Organizational Integrity Officer or Senior Management Staff as appropriate. Results
of the investigation will be shared with the Organizational Integrity Committee and
appropriate action steps will be documented.
Reporting Process: Muskegon Family Care employees, providers, volunteers,
contractors and others acting on behalf of Muskegon Family Care are required to report
possible violations of the Muskegon Family Care Standards of Conduct, Muskegon
Family Care policies and procedures and/or laws and regulations relating to Muskegon
Family Care business activities. The Integrity Reporting System phone number will be
published to all Muskegon Family Care employees. Employees will be encouraged to
follow a process for reporting possible violations as follows:
a. Use existing Human Resources or other policies and procedures within the
organization, including contacting the employee’s immediate supervisor.
b. In the event the employee is not comfortable discussing the matter with their
immediate supervisor or is not satisfied with the answer received, the employee
should contact the next level manager or supervisor.
c. If the matter has not yet been appropriately resolved to the employee’s
satisfaction, the employee should contact Muskegon Family Care’s
Organizational Integrity Officer.
d. If none of the above steps has appropriately resolved the employee’s concerns, the
employee should contact the Organizational Integrity line.
Non-Retaliation / Non-Retribution for Reporting Concerns: All employees and
business partners have a responsibility to report, in good faith, concerns about actual or
potential wrong-doing and are not permitted to overlook such situations. Timely
disclosure of these concerns is required. Any action directed against an employee for
making a good faith report of their concerns, by any means, is prohibited. No one at any
level of the organization is permitted to engage in retaliation or harassment against an
employee or collaborator for reporting concerns. Anyone who engages in such retribution
is subject to discipline, up to and including dismissal on the first offense. All substantive
instances of retaliation or harassment against anyone reporting such concerns will be
brought to the attention of the Organizational Integrity Officer. This does not mean that
employees or others will be shielded from the consequences of doing something wrong
(under current employment policies) simply by reporting their actions. However, a
prompt and forthright disclosure may be considered a constructive action.
Corresponding procedures will be established to provide for consistent, documented
means to manage follow-up and resolution of Integrity Reporting System Calls.
Approved:
___________________ Date ___________
Donna M. Littlejohn, Executive Director
____________________ Date ___________
Clara Shepherd, Board President