BUSINESS INTEGRITY PROGRAM
Policy Manual
APPROVED: MAY 14, 1998
by BOARD OF DIRECTORS
WASHINGTON COUNTY HEALTH SYSTEM
formerly titled “Legal Compliance Program”
Revised 7/2000
1. General Policy
Washington County Health System will obey all laws that control its operation, whether
they are laws of the city, county, state or federal government. The Health System will
also follow the highest standards of business and professional ethics. This Program is a
solemn commitment by the Health System to its patients, the community, government
agencies, and ourselves.
The Health System intends to comply with all laws and standards, whether or not they are
included specifically in this manual. Just because a rule is not specifically listed does not
mean that it can be ignored. The Health System will follow all laws and rules to the very
best of its ability. All employees must do the same.
Who does the Business Integrity Policy apply to?
This Business Integrity Program applies to all Health System employees, and to those
who have professional staff membership.
This Business Integrity Program will apply to any business connected with the Health
System by ownership, partnership, or other affiliation. Washington County Health
System includes many organizations. Some are:









Washington County Hospital Association, Inc.
Washington County Hospital Endowment Fund, Inc.
Washington County Hospital Endowment Development Company, Inc.
Antietam Health Services, Inc.
Hagerstown Medical Laboratory
Diagnostic Imaging Services
Tristate Health Partners
Maryland Physicians Care
Robinwood Surgery Center
What does our Business Integrity Program cover?
This manual states the Health System’s policy in many specific areas. (See the Table of
Contents for details.) All employees and professional staff members must follow these
policies. Many of these laws are complex and some are the result of court cases. Our
policy manual only deals with general principles. Not every possible situation can be
covered. If you ever have doubt about how to proceed, seek advice from your supervisor
or the Director of Business Integrity.
What are my responsibilities?
If there are questions about policies or laws, employees should ask their supervisor.
Members of the Business Integrity Management Advisory Committee or the Director of
Business Integrity are also sources for help and information.
All employees should review this Program each year to make sure that their own actions
are appropriate. Employees must participate in other training provided by the Health
System as needed.
All employees must report apparent violations of the Business Integrity Program.
Reports should be made to the employee’s supervisor or the Director of Business
Integrity. The reports are confidential, and information is only shared on a “need-toknow” basis. The Health System will not take adverse action against anyone who makes
a report in good faith, even if there is no violation. Deliberately false, malicious, or
frivolous reports may be cause for discipline against the employee making the report.
The Health System has also established a telephone service, called the Compliance Line,
for anyone who wishes to make a report anonymously. The number is 301-790-7950, or
888-847-9247 (toll-free.)
What happens if someone doesn’t follow the Program?
Employees who violate any laws or ethical standards will be disciplined. Employees who
knowingly do not report improper conduct will be disciplined. The result may be a
written warning, repeat training, or corrective counseling, and may include termination of
employment. Supervisors or managers may also be disciplined if they direct or approve a
worker’s improper act. Supervisors or managers may also be disciplined if they are
aware of a worker’s improper act and do not correct it.
Professional staff members who violate the program may have their privileges suspended
or revoked.
Who is in charge of the Business Integrity Program?
The Program is guided by a Business Integrity Management Advisory Committee and a
Director of Business Integrity. These people are responsible for reviewing our
compliance policies and any specific situations that may arise.
The Business Integrity function reports to the Health System Board of Directors, and the
CEO of the Health System.