Standards of Conduct
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Letter from the President and Chief Executive Officer
Dear Saint Joseph’s Health System Team Member:
Our mission as a Catholic health system, grounded in the heritage of the Sisters of Mercy, forms the basis for
creating and maintaining an ethically and legally responsible corporate culture. For this reason, Saint Joseph’s
Health System (SJHS) Board of Trustees has directed the development of the Corporate Compliance Program to
ensure this mission continues to flourish.
The purpose of the Corporate Compliance Program is to promote compliance with legal duties and System
policies, support an organizational culture of compliance, foster ethical conduct, and provide guidance to SJHS
Team Members. In support of the Corporate Compliance Program’s purpose, our Standards of Conduct are clear,
concise statements of our commitment to follow applicable laws and our ethical obligations. These Standards of
Conduct apply not only to employees, but we expect those who are affiliated with SJHS to adopt them as well.
Because our commitment to the Corporate Compliance Program is important to the success of our mission, any
conduct that violates the law and our ethical obligations may lead to serious consequences, including termination
of employment or medical staff membership. The Standards of Conduct should serve as your guide to the
Corporate Compliance Program. The Standards of Conduct cannot describe every situation you may encounter,
nor are they intended to do so. They do, however, reflect our deep commitment to our core values and mission
which serve as the focal points of our work each day.
If you have questions, are unclear about the appropriate course of action, or encounter a situation which you
believe may violate these Standards, I encourage you to seek the guidance of your immediate supervisor, a
member of management or the Corporate Compliance Department. You may also call the Corporate
Responsibility Hotline (1-877-STJOES1) at any time to report your concerns anonymously. You have my
personal guarantee that adverse action will not be taken against you for asking questions, raising a concern related
to these Standards of Conduct or reporting possible improper conduct in good faith.
Ethical and legal conduct in the care of our patients and in our business dealings is of the utmost importance to
SJHS and to me, personally. As part of our commitment to the people of our community, all Team Members have
an obligation to act with the highest integrity and comply with all applicable rules, regulations as well as SJHS
policies and procedures. Together we can maintain a culture in which everyone who enters our doors can
continue to receive care rooted in the integrity, honesty and compassion which has made Saint Joseph’s the
successful health system it is today.
Yours truly,
Kirk Wilson
President and Chief Executive Officer
Saint Joseph’s Health System
Table of Contents
Mission, Vision and Core Values …………………………………………………………………………………
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Obligation to Those We Serve and Those Who Serve …………………………………………………………..
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Our Patients
Patient Rights and Responsibilities ………………………………………………………………………...
Delivery of Quality Healthcare Services …………………………………………………………………...
Admission, Transfer and Discharge ………………………………………………………………………..
Research and Clinical Trials ……………………………………………………………………………….
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Legal/Regulatory Compliance
Documentation, Coding and Billing ……………………………………………………………………….
Federal False Claims Act, Program Fraud Civil Remedies Act, State False Medicaid Claims Act, and
O.C.G.A. 49-4-146.1(b) ……………………………………………………………………………………
Sanctioned/Excluded Individuals and Entities ……………………………………………………………..
Relationships with Referral Sources ……………………………………………………………………….
Response to Government Investigations……………………………………………………………………
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Information Security, Confidentiality and Retention
HIPAA Privacy and Security Compliance …………………………………………………………………
Record Retention …………………………………………………………………………………………...
Use of Proprietary Information ………………………………………………………………………….....
Electronic Media …………………………………………………………………………………………...
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Financial Reporting
Accounting …………………………………………………………………………………………………
Cost Reporting ……………………………………………………………………………………………..
Tax Exempt Status …………………………………………………………………………………………
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Workplace Conduct and Employment Practices
Employee Rights and Responsibilities ……………………………………………………………………..
Verification of Qualifications ……………………………………………………………………………...
Conflict of Interest …………………………………………………………………………………………
Outside Interests and Activities ……………………………………………………………………………
Health and Safety …………………………………………………………………………………………..
Use of Alcohol and Illegal Drugs …………………………………………………………………………..
Equal Employment Opportunities ………………………………………………………………………….
Verbal and Non-Verbal Abuse and Sexual Harassment …………………………………………………...
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Marketing, Fundraising, Vendor and Political Activities
Antitrust Laws ……………………………………………………………………………………………...
Marketing of Healthcare Services ………………………………………………………………………….
Fundraising and Contributions ……………………………………………………………………………..
Vendor Relations …………………………………………………………………………………………...
Political Activities ………………………………………………………………………………………….
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Environmental Compliance ……………………………………………………………………………………….
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Corporate Compliance Program
Purpose ……………………………………………………………………………………………………..
Program Structure ………………………………………………………………………………………….
Oversight and Implementation ……………………………………………………………………………..
Leadership Responsibilities ………………………………………………………………………………..
Written Standards of Conduct/Policies and Procedures ……………………………………………………
Training and Education …………………………………………………………………………………….
Investigation ………………………………………………………………………………………………..
Auditing and Monitoring …………………………………………………………………………………..
Corrective Action …………………………………………………………………………………………..
Evaluation of Employee Performance ……………………………………………………………………..
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Compliance Questions/Concerns
Reporting …………………………………………………………………………………………………...
Non-Retaliation …………………………………………………………………………………………….
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Compliance Resources …………………………………………………………………………………………….
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Affirmation Statement ………………………………………………………………………………………….....
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Notes:
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These Standards of Conduct are effective March 2010.
All references to “SJHS” or the “organization” refer to Saint Joseph’s Health System, Inc., and/or its affiliates, as
applicable.
The use of the term “Team Members” in this document is intended to include employees, officers, medical and affiliated staff,
volunteers, vendors and any anyone else affiliated with Saint Joseph’s Health System, Inc.
This document contains references to various SJHS policies and procedures. Policies and procedures are available on the
SJHS intranet site, or through a member of management.
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Mission
Furthering the healing ministry of the Sisters of Mercy, Saint Joseph’s Health System, a member of Catholic Health East,
gives tangible expression to Christ’s merciful love by providing compassionate, clinically excellent health care in the spirit of
loving service to those in need, with special attention to the poor and vulnerable.
To fulfill this mission we commit ourselves to:
 Honor the intrinsic dignity of all persons, both those we serve and those who serve.
 Make a positive difference in the health of our communities.
 Collaborate with those who share our mission and values.
 Advocate for a compassionate and just society.
 Lead in clinical innovation.
We pledge to pursue our mission in ways that reflect our responsibility to conduct our business affairs with integrity, based on
sound ethical and moral standards. We also strive to hold those with whom we conduct business to these same standards.
Vision
Inspired by our healing Mission and guided by our Core Values, we will be the Southeastern leader for compassionate, high
quality, accessible, cost-effective, innovative, adult health care.
Core Values
Our core values below reflect our responsibility to achieve health care excellence for our community. These values are used
to guide our conduct and business decisions.
1. Reverence for each person
We believe that each person is sacred.
2. Community
We collaborate with our neighbors to improve our life together.
3. Justice
We advocate for a society in which all can realize their full potential and achieve the common good.
4. Commitment to those who are poor
We give special attention to those who are poor or underserved.
5. Stewardship
We care for and strengthen the health ministry and all resources entrusted to us.
6. Courage
We dare to take the risks our faith and values demand of us.
7. Integrity
We keep our word and are faithful to who we say we are.
8. Excellence
We hold ourselves to high standards of quality and professionalism.
9. Compassion
We are moved by human suffering and strive to heal body, mind and spirit.
Obligations to Those We Serve and Those Who Serve
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For our patients and their families, we are committed to provide excellent, timely service at a fair price and in the
appropriate setting.
For our employees, we are committed to fairness in employment opportunities, just compensation and benefits,
providing a safe and healthy work environment and respecting the rights due every employee.
For our physicians, we are committed to working with providers in ways that advance the interests of our patients as
an effective means of stewardship of scarce resources.
For our regulators, we are committed to compliance with all applicable laws, regulations and ethical business
practices.
For the community, we are committed to promote access to needed care and the good health of all in the community.
For our volunteers, we are committed that our volunteers feel a sense of purpose in their work and receive
recognition for such work.
For our vendors, we are committed to fair competition and a sense of responsibility required of a good customer.
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Our Patients
Patient Rights and Responsibilities
We want all our patients to have the best possible care and we strive to meet their health care needs, accordingly, we support
the right of patients to ask and be informed about all aspects of their care.
We commit to the following:
 Patients are the primary decision-makers in their own health care decisions.
 Provide information regarding diagnosis, treatment, research options and prognosis in a language patients can
understand.
 Provide care without regard to race, gender, creed, marital status, sexual orientation, age, national origin or disability.
 Maintain the confidentiality of medical, financial and personal information in accordance with the Health Insurance
Portability and Accountability Act (HIPAA) requirements.
 Provide, upon request, reasonable estimates of charges for medical care and understandable bills listing charges for
services.
 Admit only those patients whom physicians have determined require our services.
 Perform only services that the facility is licensed to provide.
 Ensure all patients receive appropriate discharge planning.
 Respect patient advance directives and resuscitation orders in accordance with the law and our mission and values.
Based in the dignity enjoyed by every human being, these patient rights will be respected, and every effort is made to help
patients and their families understand and exercise their rights and responsibilities.
Delivery of Healthcare Services
SJHS is committed to providing a high quality of care to its patients through the delivery of health care services in a
responsible, reliable, ethical and appropriate manner. Delivering nationally recognized quality healthcare starts the moment a
patient comes to SJHS. Health care services are rendered by physicians, nurses and other qualified health care providers
through the use of professional skills and judgment, and in accordance with customary and recognized standards of care.
Through the support and involvement of the Board of Trustees, management, medical staff and employees, SJHS promotes
innovation, excellent data management, performance improvement, proactive risk assessment, and commitment to customer
satisfaction and patient safety. Performance data from all patient services, clinical support services and contracted services
are collected organization-wide to assess the stability of existing processes, identify opportunities for improvement, and to
initiate changes that will lead to, measure and sustain improvement.
Admission, Transfer and Discharge (EMTALA Compliance)
It is the policy of SJHS to conduct admissions, transfers, diversions and discharges in an ethical manner and in accordance
with applicable local, state and federal regulations, including the federal Emergency Medical Treatment and Active Labor Act
(EMTALA). Penalties for violating EMTALA may include significant fines. Admission, transfer and discharge policies are
based on the needs of the individual person with an emergency medical condition and the ability of SJHS to meet that need,
and not on the individual’s ability to pay or current fiscal conditions of the organization. Patients whose specific condition or
disease cannot be safely treated are transferred to an accepting organization only under such circumstances and in accordance
with applicable laws, regulations and SJHS policies.
Research, Investigations, and Clinical Trials
SJHS complies with federal and state laws and regulations governing research, investigations and clinical trials. We do not
tolerate intentional research misconduct. Research misconduct includes making up or changing results or copying results from
other studies without performing the clinical investigation or research. The SJHS Institutional Review Board is responsible
for the review, prospective approval, and continued oversight of all research involving human subjects that involve SJHS
facilities. Claims for services provided as part of a clinical trial will be submitted in accordance with payor policies and SJHS
will not charge for items or services for which payment from the trial sponsor has been received.
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Legal/Regulatory Compliance
Documentation, Coding and Billing
SJHS complies with the clinical documentation, coding and billing requirements of government health care programs and
private health insurance plans. Team Members and personnel engaged on behalf of SJHS who are involved in
documentation, coding and billing are expected to be familiar with and to comply with the applicable requirements.
We commit to the following:
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Individuals, including physicians, who contribute to medical records, provide sufficient, accurate and timely
documentation of information.
Physician and hospital records and medical notes used as a basis for claim submission are appropriately organized
in a legible form and maintained in accordance with policy and applicable laws.
Claims are submitted for services and products that have been provided, properly documented, ordered by a
physician or other appropriately licensed individual and are believed to be medically necessary.
Identified billing errors are documented, corrected and reported in a timely manner following discovery.
Systems or processes which may cause potential billing errors are researched and concerns are resolved and
payment adjusted as necessary.
Questions about charges are addressed promptly and courteously.
Payment plans and/or assistance are provided for those determined to be unable to pay.
The compensation structure for billers and billing consultants does not provide financial incentives to upcode
claims or to otherwise bill improperly.
Credit balances are processed and remitted to the appropriate payor in a timely manner.
Federal False Claims Act, Program Fraud Civil Remedies Act of 1986 (PFCRA), State False
Medicaid Claims Act and O.C.G.A. 49-4-146.1(b)
The federal False Claims Act makes it a crime for any person or organization to knowingly make a false record or file a
false claim with the government for payment. “Knowing” can include deliberate or reckless ignorance of facts that make
the claim false. The State of Georgia has adopted a similar law related specifically to Medicaid claims. Additionally, the
PFCRA creates administrative remedies for making false claims separate from and in addition to, the judicial or court
remedy for false claims provided by the False Claims Act.
Under both state and federal laws, a person who knows a false claim was filed for payment can file a lawsuit on behalf of
either the state or federal government and, in some cases, receive a reward for bringing original information about a
violation to the government’s attention. Penalties for violating either the federal False Claims Act or the Georgia State
False Medicaid Claims Act can be up to three times the value of the false claim, plus a fine of $5,500 to $11,000, per claim
and in certain situations, potential exclusion from participation in federally funded healthcare programs.
These laws protect anyone who files a false claim lawsuit from being fired, demoted, threatened or harassed by their
employer for filing the suit against the employer. If a court finds that the employer retaliated, the court can order the
employer to re-hire the employee and to pay the employee twice the amount of back pay that is owed, plus interest and
attorney’s fees.
Georgia also has enacted a statute which makes it unlawful for any person or provider to accept Medicaid overpayments or
payments to which they are not entitled. This statute has both criminal and civil penalties which may be applied by
prosecution depending on the proof of intent to commit the violation.
SJHS supports compliance with these laws by:
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Monitoring and auditing to prevent and detect errors in coding or billing.
Informing Team Members that they are personally obligated to report to SJHS any concern about a possible false
claim.
Investigating all reported concerns and correcting any billing errors discovered.
Protecting Team Members from adverse action when they report any genuine concern.
Establishing policies and procedures which detail the manner in which SJHS detects and prevents fraud, waste and
abuse.
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Sanctioned/Excluded Individuals and Entities
Federal law prohibits government reimbursement to individuals or entities that are excluded or ineligible to participate in
federally funded healthcare programs. Violation of this law may result in substantial fines for the organization. SJHS does
not knowingly arrange, contract with or bill for services rendered or arranged for by an individual or entity that is excluded
or ineligible to participate in a federally funded health care program. SJHS periodically searches the HHS Office of
Inspector General, the General Services Administration and the Department of Treasury lists for excluded or ineligible
persons and entities including, but not limited to, Team Members, contractors and vendors. Team Members are required to
promptly notify their supervisor or the Corporate Compliance Department if they become excluded or ineligible.
Relationships with Referral Sources
SJHS is subject to various federal and state regulations regarding financial arrangements with physicians and other referral
sources. The penalties for violating these regulations include substantial fines and penalties, potential criminal conviction
and/or exclusion from participation in federally funded healthcare programs. These regulations include:
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Anti-kickback Statute – prohibits knowingly offering to pay, or receiving cash or anything else of value in exchange
for referring patients or services paid for by the government.
Stark Law – The Stark law bans Medicare payments to entities providing certain services if patients were referred
by doctors who have a financial relationship with the entity, subject to certain exceptions.
Georgia Self Referral Act – a health care provider may not refer a patient for the provision of designated health
services to an entity in which the physician has an investment interest, subject to certain exceptions.
SJHS abides by these laws when entering into any financial arrangement with referral sources, including leases, contracts,
leadership positions, recruitment, joint ventures and payment for services rendered. Nothing of value is offered or
accepted in return for making a patient referral. No payment or other type of consideration is ever given to anyone with
the expectation that it is dependent upon the admission, recommendation or referral of patients.
Response to Government Investigations
Various external organizations may contact SJHS or individual Team Members to initiate a compliance-related
investigation. SJHS complies with any lawful and reasonable request or demand made as part of a government
investigation. Team Members will cooperate with government investigations, and are expected to provide truthful
responses to government inquiries. It is imperative, however, that SJHS protect the rights of SJHS and its personnel. Any
Team Member who receives an inquiry, visit, subpoena, or other legal document, at work or at home, regarding SJHS
business from a governmental agency shall notify his or her supervisor, Vice President or the Chief Compliance Officer
immediately.
“There is a big difference between what you have the right to do
and what is right to do.”
- Justice Potter Stewart
January 26 , 1915 – December 7 , 1985
Associate Justice of the United States Supreme Court
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Information Security, Confidentiality and Retention
HIPAA Privacy and Security Compliance
We are committed to the integrity, accuracy and confidentiality of information for the benefit of those we serve. SJHS
complies with federal and state laws and regulations, including HIPAA, regarding the confidentiality of patients’ medical,
financial, personal and other personal information. Confidential patient information is not reviewed or disclosed without a
legitimate business purpose, written authorization in accordance with SJHS policies and procedures, or as otherwise
required by applicable federal or state law. Breaches of unsecured patient information will be reported to the Office of
Civil Rights in accordance with the Health Information Technology for Clinical and Economic Health (HITECH) Act.
Violations of privacy and security regulations may be punishable by substantial fines.
Record Retention
In the normal course of our business, records are created and maintained to comply with legal, regulatory and accreditation
requirements. SJHS record retention polices are reviewed periodically to ensure continued compliance with applicable
federal, state and local laws and regulations. Certain records are required to be maintained for specific periods of time.
SJHS requires adherence to the following guidelines on record retention:
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Records are prepared accurately, completely and in a timely manner.
Medical and other patient records are properly safeguarded and accessibility is permitted only to authorized
personnel.
Records are maintained in a logical, systematic order to facilitate prompt recovery.
Information is maintained for the time periods prescribed by federal, state or local laws, or SJHS record retention
policies.
Destruction of SJHS records prior to expiration of the prescribed time period for record retention is prohibited.
Records are never destroyed in anticipation of a request from any government agency, or in anticipation of, or in
connection with, any judicial proceeding or lawsuit.
Use of Proprietary Information
SJHS business affairs are only discussed as required in the normal course of conducting business. Team Members are
required to safeguard confidential information regarding SJHS business affairs and are responsible for information
security. Team Members are prohibited from attempting to obtain confidential information for which they have not
received access authorization. Copyrighted information is used in accordance with applicable laws.
Electronic Media
All electronic systems including email, intranet, internet, telephones and voice mail are the property of SJHS and are used
for business purposes in accordance with our information system policies and procedures. Individuals who abuse this
privilege are subject to disciplinary actions and/or termination.
“When we do the best that we can, we never know what miracle is
wrought in our life, or in the life of another.”
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- Helen Keller
June 27 , 1880 – June 1 , 1968
Educator
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Financial Reporting
Accounting
It is the obligation of SJHS to determine that assets and liabilities are accounted for in compliance with all tax and
financial requirements, generally accepted accounting principles and SJHS policies. The financial reporting system for
SJHS contains accurate entries that reflect all items of income and expense, all assets and liabilities and all financial
transactions of SJHS. To meet this obligation, SJHS relies on truthfulness and integrity in accounting practices on the part
of SJHS personnel. SJHS personnel never engage in any arrangement that results in false, artificial, or misleading entries
being made in any accounting records.
Cost Reporting
Cost reports submitted on behalf of SJHS should be accurate, complete and comply with applicable laws and regulations.
The following are general cost reporting guidelines:
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Costs are based on appropriate and accurate documentation.
Allocation of costs to various cost centers is accurate, supported by verifiable and auditable data.
Accounts containing both allowable and unallowable costs are analyzed to determine the unallowable amount that
should not be reported.
Costs are properly classified.
Fiscal intermediary prior year audit adjustments are implemented and either not claimed for reimbursement or
clearly identified as protested amounts on the cost reports.
Related parties are identified.
Bad debts are reported on the cost report in accordance with applicable statutes, regulations, guidelines and
policies.
Non-reimbursable cost centers are properly reported on the cost reports.
Senior level SJHS financial managers review cost reports before submission to intermediary to ensure accuracy of
reporting.
Failure to accurately report costs associated with SJHS’ provision of healthcare services may result in penalties and
damages as outlined in the federal False Claims Act.
Tax-Exempt Status
SJHS is recognized as a tax-exempt organization because SJHS operates to serve the public rather than a private interest
and the assets of the organization do not benefit private individuals. Payment for goods and services are made at fair
market value. In addition, SJHS complies with bond covenants that place certain restrictions on the use of its tax-exempt
financed facilities.
We commit to:
 Timely filing of required tax and tax related forms and information.
 Adhere to and monitor our Conflict of Interest policies.
 Evaluate compensation practices and policies, including reasonableness studies.
 Undertake and document activities that improve community access to healthcare, as well as the overall health of
our community.
 Evaluate and document the reasoning behind our charity care practices, including documenting the value and
types of care provided at or below cost to our community.
 Evaluate the value of our tax-exempt status in comparison to the community benefits and charity care we provide.
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Workplace Conduct and Employment Practices
Employee Rights and Responsibilities
Employees of SJHS have a right to be treated in a fair and respectful manner, without regard to race, gender, creed,
marital status, sexual orientation, age, national origin or disability. SJHS promotes a positive, healthy work environment
and encourages employees to learn, grow and develop.
The following rights and responsibilities guide workplace conduct:
Employees will:
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Practice the core values of compassion, honesty, respect, responsibility, integrity, teamwork and stewardship.
Uphold professional standards, judgment and objectivity, even in difficult situations.
Report events that are not in keeping with values, organizational policies or laws, to supervisors, management, or
the Corporate Responsibility Hotline.
Not accept disrespectful or unfair treatment toward themselves or others.
Know what constitutes harassment and will not allow intimidating or harassing behavior to continue or go
unreported.
Employees and physicians may request to be relieved from participating in aspects of a patient’s care where the
prescribed care is in conflict with deeply held values or beliefs.
Share the responsibility of maintaining an ethical corporate culture.
Verification of Qualifications
SJHS, through its credentialing and licensure verification processes, makes appropriate efforts to verify that SJHS Team
Members of the medical staff are appropriately licensed, certified or otherwise qualified for their role with SJHS.
Conflict of Interest
Individuals, particularly those involved in making business and financial decisions for SJHS, have a responsibility to act
in the best interests of our organization, to be fair in making business decisions and to avoid conflicts of interest. Such
individuals are encouraged to use professional judgment and avoid situations that lead to actual or perceived conflicts of
interest. If an individual is unsure if a conflict of interest exists, he/she will consult his/her immediate supervisor, the
Corporate Compliance Department or Legal Services for clarification or guidance.
Outside Interests and Activities
SJHS employees will not engage in, directly or indirectly, any conduct that is disloyal, disruptive or damaging to SJHS.
Employees are not to accept full-time, part-time or temporary employment with any organization that does business with
SJHS unless the employee has received specific permission from his/her department director or higher level of
management. This prohibition on outside employment includes employees who serve as an advisor or consultant to any
organization that does business with or for SJHS.
Health and Safety
The Occupational Safety and Health Administration (OSHA) assures job safety and health protection for workers by
regulating working conditions. SJHS provides a work environment free from recognized hazards that could cause serious
harm to a Team Member. Team Members comply with the OSHA standards, rules and regulations that apply to their own
actions and conduct on the job. Team Members are required to report unsafe or unhealthful conditions that might exist in
the workplace to their department heads.
The following general safety rules apply in work places:
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Obey warning signs and signals that point out dangerous conditions.
Exercise caution when operating any type of mechanical equipment.
Use safety equipment appropriate to specific jobs.
Do not wear loose clothing and jewelry while working on or near equipment and machines.
Report accidents, regardless of severity, immediately to supervisor.
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Use of Alcohol and Illegal Drugs
SJHS is committed to an alcohol and drug free work environment. All candidates for employment are required to
successfully pass a pre-employment drug screening examination. Team Members are subject to disciplinary action, up to
and including separation from SJHS, for:
 Arriving at work in an intoxicated state.
 Bringing illegal drugs, non-prescribed controlled substances or alcoholic beverages to work.
 Testing positive on a drug screen while working.
 Diverting patient medication.
 Illegally manufacturing, dispensing, selling or buying alcohol or drugs on SJHS premises.
Behavior that suggests a Team Member is under the influence of alcohol or illegal drugs while at work is reported to a
supervisor and/or the Human Resources Department or the Corporate Responsibility Hotline.
Equal Employment Opportunities
SJHS prohibits discrimination on the basis of race, religion, color, sex, age, national origin, disability or veteran status.
This policy of equal opportunity relates to all phases of employment, including recruitment, placement, promotion,
training, transfer, layoff, termination, rate of pay, benefits. There is equal opportunity to participate in all systemsponsored activities, events and programs. SJHS fully complies with the requirements of the Americans with Disabilities
Act (ADA). As such, reasonable accommodations are made available to employees and applicants for employment with a
disability, as long as the accommodations do not create an undue hardship on SJHS.
Verbal and Non-Verbal Abuse and Sexual Harassment
SJHS maintains a productive environment free from verbal and non-verbal abuse and sexual harassment. Verbal and nonverbal abuse includes language that is abusive, disrespectful or denigrating or that is obscene or profane; non-verbal
threats; behavior that includes violent temper outbursts, the throwing of objects or threatening mannerisms; and hostile
humor, rumor or gossip that may be damaging to an individual or his or her reputation.
Sexual harassment includes unwelcome physical or verbal sexual conduct where submission to the conduct is either an
explicit or implicit condition of employment or a basis for employment decisions. Conduct that has the purpose or effect
of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile or offensive work
environment is also harassment.
Team Members who engage in verbal or non-verbal abuse or sexual harassment are subject to appropriate disciplinary
action, up to and including separation from SJHS. Incidents of verbal or non-verbal abuse and sexual harassment are
reported to a supervisor or the Human Resources Department or the Corporate Responsibility Hotline.
“Empathy is patiently and sincerely seeing the world through the other
person’s eyes. It is not learned in school; it is cultivated over a lifetime.”
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- Albert Einstein
March 14 , 1879 – April 18 , 1955
Theoretical Physicist
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Marketing, Fundraising, Vendor and Political Activities
Antitrust Laws
Antitrust laws are designed to promote fair competition. SJHS complies with federal and state antitrust laws including
laws concerning price fixing, allocation of markets, group boycotts, tying arrangements, monopolization, collusion with
competitors, exclusive dealing, price discrimination and unfair trade practices. SJHS does not enter into agreements or
understandings with competitors that unlawfully limit or restrict competition and or that limit or restrict the purchasing
decisions of SJHS.
Marketing of Healthcare Services
SJHS does not engage in any unethical, abusive or illegal marketing or advertising of health care services. SJHS does not
make, and does not permit any Team Member to make unethical or illegal payments to anyone to induce the use of SJHS
health care services. SJHS presents itself to the community through its marketing activities in a manner true to its mission
and capabilities. Specific claims about the quality of SJHS services are supported by evidence to substantiate the claims
made. SJHS does not use advertisements or marketing programs that might cause confusion between our services and
those of our competitors. SJHS does not disparage the service or business of a competitor.
Fundraising and Contributions
SJHS preserves and protects its reputation for sound business practices and avoids the appearance of impropriety in all
fundraising activities and acceptance of contributions. SJHS Team Members are prohibited from undertaking fundraising
activities or accepting contributions or other things of value that in any way influence the decision-making process with
any purchaser, supplier, customer, government official or other person. All fundraising activities will be conducted by or
in coordination with Saint Joseph’s Mercy Foundation and in accordance with the policies and procedures of SJHS. The
Foundation President operates within the National Society of Fund Raising Executives (NSFRE) Code of Ethical
Principles and Standards of Professional Practice.
Vendor Relations
We are committed to fair, ethical and legal business practices in obtaining all necessary goods and services. Vendor
selection is based on objective criteria for high-quality products and services at a reasonable cost. We do not disclose
prices paid by SJHS or negotiated terms to anyone outside the organization, except as may be required by law. The
solicitation of anything of value from current or potential vendors or suppliers of items and services in exchange for
continued business relationships is expressly prohibited.
Political Activities
SJHS complies with all federal and state laws regarding political contributions and gifts to government officials. SJHS
does not offer, make payments or give anything of value to a government official or government agency representative
with which SJHS has or is seeking to obtain a contractual, business or financial relationship, or that regulates any
activities or obligations of SJHS. SJHS also does not offer, make, accept or receive payments or anything of value in
order to obtain a competitive advantage for contracts that involve the provision of health care services to beneficiaries of
any federal, state or local government health care program.
Environmental Compliance
SJHS manages and operates its business in a manner that respects the environment and conserves natural resources. Team
Members strive to utilize resources appropriately and efficiently, to recycle where possible, dispose of all waste in
accordance with applicable laws and regulations, and report the presence of hazardous chemicals or conditions. SJHS
works cooperatively with the appropriate authorities to remedy any environmental contamination for which SJHS may be
responsible.
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Corporate Compliance Program
Purpose
The Corporate Compliance Program (“Program”) has been established to promote compliance with the legal duties
imposed upon it as a health care entity (in addition to those already contained in System policies), support an
organizational culture of compliance, foster and assure ethical conduct, and provide guidance to SJHS Team Members.
Program Structure
The Program is based on the DHHS Office of Inspector General’s (OIG) Compliance Program Guidance for Hospitals,
and the OIG’s Supplemental Compliance Program Guidance for Hospitals which, in turn, are based on the United States
Sentencing Commission’s Federal Sentencing Guidelines. The Program includes the following elements.
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Oversight (Structure and Organization)
Standards of Conduct/Policies and Procedures
Compliance Training and Education
Investigation (Enforcement and Discipline)
Auditing and Monitoring
Corrective Action (Response, Correction and Prevention)
Reporting Process/Non-retaliation (Communication)
Oversight
The SJHS Board of Trustees has primary oversight and accountability for the Program. This is accomplished through
the Board’s Compliance and Internal Audit Committee. This committee has delegated the management oversight to
the Corporate Responsibility Committee, a multi-disciplinary committee composed of senior management.
The Chief Compliance Officer (CCO) is responsible for day-to-day direction and Program implementation.
The CCO works closely with SJHS departments to foster and enhance a culture of compliance and implement Program
initiatives.
Entity Compliance Officers (ECOs) assist with the implementation and oversight of the Program within the various
entities of SJHS. The entities with ECOs established are:
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Saint Joseph's Hospital of Atlanta
Saint Joseph’s at East Georgia
Saint Joseph’s Medical Group
Saint Joseph’s Mercy Care Services
Saint Joseph’s Mercy Foundation
Saint Joseph’s Translational Research Institute
Saint Joseph’s Service Corporation
Leadership Responsibilities
Members of SJHS management have additional responsibilities associated with the Corporate Compliance Program.
While all SJHS Team Members are expected to follow our Standards of Conduct, management is expected to set the
example for responsible and ethical behavior.
Executives, directors, managers and supervisors have the responsibility to promote a culture that supports compassion,
honesty, respect, responsibility, integrity, teamwork and stewardship among employees and physicians. This requires the
promotion of open communication; zero tolerance of fraud, abuse and waste; encouragement of educational and training
sessions; and cooperation with requests for information on a timely basis. Each member of the management team is
accountable for the implementation of the Corporate Compliance Program in his or her own area.
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Written Standards of Conduct and Policies and Procedures
The most tangible evidence of the SJHS commitment to compliance are the Standards of Conduct. Representing a guiding
set of principles, the Standards of Conduct are designed to be a concise set of statements of commitment. The Standards
of Conduct are designed to work with the SJHS Employee Handbook and other policies and procedures.
Integral to the Program are compliance related policies and procedures developed to provide specific guidance to SJHS
Team Members. These policies establish expected actions or work-related behaviors. Policies may be updated from time
to time as is necessary to reflect new situations or expectations of those providing services for SJHS, or to reflect changes
in law or regulation.
Failure to adhere and comply with the Standards of Conduct or SJHS policies and procedures is grounds for disciplinary
action. The level of disciplinary action, including the potential for employment termination, will be determined by the
seriousness of the violation without respect to the employees’ benefit to the System.
Compliance Training and Education
SJHS employees and physicians receive education and training on the Program and Standards of Conduct. For employees
and new physicians, training begins with their orientation to SJHS. Training takes a variety of forms including, but not
limited to, in-person training class, the use of an educational video, online education, the use of the Employee Handbook
and the Standards of Conduct booklet. Ongoing education is required on an annual basis for employees as a condition of
continued employment with SJHS. Failure to complete the initial or ongoing education requirements will result in
disciplinary action. Additional training is encouraged for all Team Members employed by SJHS whose services are
reflected on patient bills, as well as for all billing, registration, coding and collection personnel.
Investigation
Reports of known or suspected violations of law, regulation, the SJHS Corporate Compliance Program or other
misconduct are forwarded to the Chief Compliance Officer who is responsible for directing an investigation, in
consultation with the Vice President of Legal Services. The purpose of these investigations is to determine the root cause
of the problem, short and long-term resolutions, corrective action plans, the need for retaining outside expertise or legal
counsel and any obligation for self-disclosure.
Auditing and Monitoring
An integral part of the SJHS Corporate Compliance Program is auditing and monitoring various aspects associated with
the Corporate Compliance Program. The Chief Compliance Officer, with the assistance of others, conducts or directs
periodic audits of risk areas identified by the Corporate Responsibility Committee, as well as those identified by the state
and federal Offices of Inspector General or other federal and state regulatory agencies. Additionally, each department
manager or director is responsible for developing and maintaining appropriate on-going, periodic quality assurance to
ensure compliance with policies, procedures, and regulatory requirements.
Corrective Action
When a compliance issue is identified through monitoring, reporting of possible issues, investigations, or otherwise, a
corrective action plan is developed to address that issue, including prompt identification of overpayments and repayment,
where necessary. Corrective action plans also include steps to be taken to respond to the issue and to prevent similar
occurrences in the future.
Evaluation of Employee Performance
All SJHS employees are expected to act in a manner that recognizes and supports the SJHS corporate compliance efforts,
including adherence to the SJHS Corporate Compliance Program and applicable federal and state laws. Employee
performance, including adherence with the Corporate Compliance Program and completion of annual education
requirements, is evaluated annually.
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Compliance Questions/Concerns
Reporting
Questions and concerns about the appropriate way to handle various situations may and often do arise. SJHS strives to
promote an environment where all individuals can feel comfortable and confident in following the right course of action
in their daily work. All members of management are expected to actively encourage and reward open communication
within their areas of responsibility and throughout SJHS.
Individuals are obligated to report activities or practices that may violate law, regulation or policy. SJHS has several
resources available to those who encounter a situation that raises a compliance concern. Team Members are encouraged
to first report the matter to their supervisor, a member of management or the Corporate Compliance Department, and give
the Health System a reasonable opportunity to conduct an appropriate investigation and take any needed corrective action.
Individuals may also report their concerns anonymously through the Corporate Responsibility Hotline (1-877-STJOES1).
The Corporate Responsibility Hotline is available 24 hours a day, 7 days a week, 365 days a year, through an outside
company. The Corporate Compliance Department will investigate or direct the investigation of each call and assist in
determining the appropriate course of action.
Regardless of the manner in which a report is made, any information supplied, including the reporter's identity, will be
kept in confidence to the extent possible and legal.
Non-Retaliation
SJHS does not permit retaliation against any Team Member for reporting compliance issues. However, reckless or
intentional false accusations are prohibited and offenders will be subject to disciplinary actions. Additionally, the action
of reporting the possible violation does not protect the individual from the consequences of their own violations or
misconduct. Concerns about possible retaliation or harassment should be reported to the Chief Compliance Officer.
Corporate Integrity Agreement
SJHS and SJHA have entered into a Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human
Services’ Office of Inspector General. The CIA, which will be in effect through 2012, requires us to maintain our
Corporate Compliance Program, report certain potential violations of federal healthcare program laws to the government,
subject certain aspects of our Corporate Compliance Program to internal and external audits, and submit reports to the
federal government regarding our compliance with the CIA. The full text of the CIA and accompanying information is
available to Team Members on our intranet site and by request to the Corporate Compliance Department.
“Real integrity is doing the right thing, knowing that nobody's going
to know whether you did it or not.”
- Oprah Winfrey
H
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January 29 , 1954 – Present
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Entertainer
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Compliance Resources
Chief Compliance Officer
678-843-7732
Corporate Responsibility Hotline
877-STJOES1
(877-785-6371)
Web Sites
Centers for Medicare & Medicaid Services –
http://www.cms.hhs.gov/
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Health & Human Services Office of the Inspector General –
http://www.oig.hhs.gov/
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Georgia Department of Community Health –
http://www.dch.georgia.gov
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The Joint Commission
http://www.jointcommission.org/
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Saint Joseph’s Health System, Inc.
Standards of Conduct
Affirmation Statement
An integral part of the implementation of the Corporate Compliance Program is assuring that Team Members and others
affiliated with SJHS understand and are knowledgeable regarding the Corporate Compliance Program and applicable
federal and state laws. SJHS Team Members are held responsible and accountable for adhering to the Standards of
Conduct and policies and procedures outlined in the Corporate Compliance Program.
Employees are required to sign a statement as part of their initial compliance training affirming that they understand and
agree to abide by the Standards of Conduct and the requirements of the Corporate Compliance Program.
Documenting your Commitment
Please read and sign this acknowledgment:
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I certify that I have received a copy of Saint Joseph’s Health System Standards of Conduct and that I have
read, understood and will abide by the content.
I understand that I am responsible for knowing and following the Standards of Conduct as a condition of my
continued affiliation with SJHS.
I also understand that I am obligated to report any actual or perceived violations of the Standards of Conduct,
the Corporate Compliance Program, including department compliance policies or state or federal law to a
supervisor, member of management, the Corporate Compliance Department or the Corporate Responsibility
Hotline.
Signature _____________________________________________
Print Name ____________________________________________
Employee Number_______________________________________
Date __________________________________________________
Your affiliation with SJHS:
� Employee – Department: ____________________________________________________________________
� Medical or Affiliate Staff – Practice Name: ______________________________________________________
� Contractor or Agency – Company Name: ________________________________________________________
� Board of Trustees/Board of Directors
� Student, Resident, Fellow
� Volunteer
� Other: ___________________________________________________________________________________
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5665 Peachtree Dunwoody Road, N.E. • Atlanta, Georgia 30342
678-843-7001
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