Code of Conduct | Our Reponsibilities Toward Others |
Financial & Business Standards | Integrity in our Interactions

THE CODE OF CONDUCT

The Duke University Health System (DUHS) Code of Conduct is designed to give everyone at DUHS a clear understanding of what is expected of him or her in the workplace and as a representative of DUHS. The Code applies to every DUHS employee, governing board member, member of the medical staff, and volunteer, as well as to those with whom we do business.

This Code does not cover every situation. Instead, it provides broad guidelines that are detailed in DUHS policies and procedures. The DUHS Compliance Office and the DUHS Facility-Based Compliance Officers can provide more information upon request.

WHAT IS COMPLIANCE?

Compliance is Duke University Health System's commitment to comply with all laws and regulations relating to its operations.

THE COMPLIANCE PROGRAM

The DUHS Compliance Program was created to make sure that the Health System is following all laws and regulations that relate to its operations.

The program is directed by the DUHS Chief Compliance Officer. The Chief Compliance Officer is an independent reviewer who oversees compliance throughout the Health System. The officer will make sure that any compliance problems reported to him or her are investigated and resolved.

The DUHS Compliance Office monitors business practices to make sure they comply with laws and regulations. This office is responsible for making sure compliance problems are reported and resolved, answering questions about compliance issues, and working with the DUHS Office of Counsel to respond to government inquiries. In addition, this office is responsible for educating staff, volunteers, and others at DUHS about compliance.

Each component of DUHS has a Facility-Based Compliance Officer who works with the DUHS Compliance Office to support compliance activities within his or her facility or division.

Finally, the DUHS Board of Directors has created an Audit and Compliance Committee. The committee has three main responsibilities: (1) implementing, maintaining and improving the Compliance Program and this Code; (2) making sure DUHS upholds the standards in this Code; and (3) making sure that people can report perceived or actual compliance violations without fear of retribution or retaliation.

WHAT IF I THINK A LAW OR POLICY IS BEING BROKEN?

You must report it. If DUHS employees, governing board members, members of the medical staff, or volunteers suspect that a law, regulation, policy, or this Code is being violated, they should report it through the chain of command.

  • Contact your direct supervisor about your concern or problem.

  • If you feel uncomfortable with talking to your direct supervisor, voice your concern to the next supervisory level, up to and including the highest level of management.

  • You may also contact your DUHS Facility-Based Compliance Officer, or the DUHS Chief Compliance Officer.

THE INTEGRITYLINE       1-800-826-8109

Sometimes you may not wish to report a compliance concern through the normal chain of command. In that case, report your concern through the IntegrityLine: 1-800-826-8109.

  • Calls to the IntegrityLine will not be traced. Callers do not have to identify themselves; however, they may do so in order to be of assistance in giving further information about the situation. If callers choose to identify themselves, their confidentiality will be protected to the extent permitted by law.

WHAT WILL HAPPEN IF I REPORT A VIOLATION?

DUHS has a Compliance Reporting and Non-Retaliation and Non-Retribution Policy. The policy ensures that no one will be subject to any adverse action just because they report what they honestly believe is a compliance violation. However, if DUHS determines that someone purposely made up, exaggerated, or otherwise distorted a report of wrongdoing-whether to protect themselves or to hurt someone else--that person will not be protected under the policy.

  • You may ask the Compliance Office how your report was investigated and what the results were. The office will provide information to the extent permissible by law.

HOW DOES DUHS HANDLE COMPLIANCE CONCERNS?

DUHS MAINTAINS A "ZERO TOLERANCE" POLICY TOWARD VIOLATIONS OF APPLICABLE LAW OR OTHER WRONGDOING.

  • The DUHS Compliance Office evaluates all reports of wrongdoing promptly, thoroughly, and fairly. The office does not act on any report until it makes sure the report is valid.

  • The Office protects the confidentiality and other rights of all personnel, including anyone who is the subject of a compliance complaint.

  • Anyone who violates applicable policies, laws, regulations, or this Code may be disciplined. People may also be disciplined if they do not report a compliance violation. Disciplinary action may include being terminated or having a contract revoked.

  • The DUHS Chief Compliance Officer may decide that DUHS's integrity could be harmed if a person under investigation remains at DUHS. If so, that person may be removed from his or her current work until the investigation is completed.

  • No one will be protected by claiming that they broke a law or regulation to benefit the Health System. DUHS does not condone such conduct.

EXPECTATIONS FOR THIRD-PARTY CONSULTANTS AND VENDORS

DUHS expects all third-party consultants, service providers, vendors and other contractors to abide by the terms of this Code. They are also expected to uphold applicable laws and regulations related to the performance of their services to and on behalf of DUHS.

DUHS provides all third-party consultants, service providers, vendors, and other contractors with a copy of this Code. We also make relevant training and education programs available to them. Upon request, DUHS also provides them with policies that relate to their relationship with DUHS.

WHICH LAWS AND REGULATIONS APPLY TO DUHS?

DUHS strives to comply with all federal, state, and local laws, regulations, and licensing and accreditation standards that apply to it, and to its own policies.

These laws, regulations, standards and policies address activities such as: (1) maintaining and retaining records; (2) admitting and referring patients; (3) advertising and marketing services; (4) billing and coding for services; (5) negotiating grants and contracts; (6) providing a safe working environment; (7) complying with licenses and permits; (8) protecting the confidentiality of patient, business, and personal information, and information concerning patients' rights; and (9) complying with all laws governing federal- and state-funded health care programs and the requirements of third-party payors.

The DUHS Chief Compliance Officer, Audit and Compliance Committee, and Board of Directors will consult the DUHS Office of Counsel, as necessary, on legal compliance issues.

OUR RESPONSIBILITIES TOWARD OTHERS

PATIENT CARE AND PATIENT RIGHTS

DUHS is committed to treating patients with dignity and respect. Here are some specific ways we do that:

  • We tell our patients who we are and what we do.

  • We give our patients a list of all their rights and responsibilities upon admission.

  • We provide information about patients' rights throughout their care and treatment.

  • We provide compassionate, quality care regardless of race, religion, gender, sexual orientation, age, and/or physical or mental disabilities, or payment source.

  • We honor patients' rights to make their own health care decisions. This includes the rights to refuse treatment and to consult with the ethical decision-making body of the facility providing their care. Under certain circumstances patients may lose these rights or have them transferred to another person.

  • We respect patients' privacy, personal property, and the confidentiality of medical records.

  • We afford patients the opportunity to be considered for voluntary participation in research and investigational projects, as appropriate.

  • We ensure that our patients give informed consent in making all decisions related to health care treatment and research projects.

  • We provide emergency medical care and treatment to any patient regardless of a patient's ability to pay.

  • We ensure that, if a patient has an emergency medical condition, we treat and/or admit the patient and only transfer the patient after he or she has been stabilized.

PATIENT REFERRALS, CONSULTATIONS, AND AFFILIATED PHYSICIANS

DUHS strives to maintain the highest standards in accepting patient referrals and interacting with other health care providers.

  • We abide by laws relating to patient referral.

  • We make and accept patient referrals and consultations based on medical needs, the personal choice of the patient and referring physician, and our ability to provide the services needed.

  • We make and accept patient referrals and consultations without regard to monetary gain.

  • We do not pay anyone or offer benefits to anyone for providing or inducing a referral or consultation.

  • Our relationships with physicians associated with DUHS comply with all applicable laws.

DUHS has adopted a policy for reviewing and approving all physician agreements with DUHS. If you have a question about relationships between DUHS and any referring/consulting physician, contact the DUHS Chief Compliance Officer or the DUHS Office of Counsel.

THE WORK ENVIRONMENT

DUHS works to ensure that all employees and others at DUHS have the best possible work environment.

  • We follow all federal, state, and Equal Employment Opportunity Council laws and regulations for recruiting and retaining qualified employees.

  • We maintain a harassment-free work environment.

  • We keep our workplace drug- and alcohol-free. We know that the ability to think clearly and react appropriately is critical in a health care setting. We report to work free of impairment from drugs and alcohol.

  • We follow all laws, regulations, and policies related to environmental health and safety, including fire, chemical, biological, radiation, and electrical safety.

  • We make sure that medical waste and hazardous materials are handled, transported, and disposed of properly.

  • We take reasonable steps to keep our workplace safe and avoid harming ourselves, co-workers, patients, or visitors.

  • We report all incidents and accidents according to departmental policies.

  • We attend safety training as required.

  • We understand our responsibilities during disasters, severe weather, and other emergencies.

  • We follow practices that reduce the spread of infection, such as washing hands, wearing personal protective equipment, and following isolation procedures.

  • We store all drugs, pharmaceuticals, chemicals, and radioactive materials safely and maintain proper records.

DUHS is committed to making sure that our employee hiring, screening, and disciplinary procedures and policies meet the requirements of the Compliance Program.

EDUCATION AND TEACHING

Education and teaching are part of the core mission of the Health System. We provide and encourage continued learning for DUHS personnel and our associated health care providers. We educate future health care providers and leaders. We educate patients and their families, significant others, or caregivers about a patient's condition and care. And we educate the communities we serve about health care topics of concern to them.

  • When students or trainees participate in patient care, we provide the supervision needed to ensure that all aspects of patient care are appropriate.

  • We provide meaningful and practical learning experiences for health care students and trainees.

  • We provide training and education that supports individuals' career development and advances the performance of the organization as a whole.

  • We seek out and obtain the education we need to keep our skills current.

DUHS' education program works to ensure that every employee, governing board member, member of the medical staff, and volunteer understands this Code of Conduct and the basic principles of the Compliance Program. All of these people sign a statement showing that they have received a copy of this Code and agree to abide by its terms.

RESEARCH

  • DUHS is committed to fostering biomedical research which is in full compliance with applicable federal and state regulations and policies.

  • Research which may involve human subjects, laboratory animals, biohazardous or recombinant DNA materials, and radiological hazards must adhere to and comply with legal and ethical standards, all applicable federal and state laws and regulations, and DUHS policies.

  • We educate all personnel involved in Institutional Review Boards for human subjects and the Institutional Animal Care and Use Committee for animal subjects about applicable laws, regulations, and guidelines, including those of the Office for Protection of Research Rights.

FINANCIAL AND BUSINESS STANDARDS

CODING AND BILLING

Coding is the way we identify and classify health information (such as diseases and procedures) to document care in a patient's medical record. Billing is the way we submit charges for the services we have provided. DUHS's coding and billing practices comply with all laws governing federal- and state-funded health care programs, and with the requirements of third-party payors.

  • We are committed to timely, complete, and accurate coding and billing. We bill only for services that we actually provide and believe to be medically necessary.

  • We select billing codes that we believe in good faith accurately represent the services that we provide and document in the medical record according to regulatory requirements and guidelines.

  • We address and respond to billing and coding inquiries and questions.

  • We correct any inaccuracies in billing in a timely manner. We alert the payer and submit refunds as required by applicable laws and policies.

DUHS encourages employees to report concerns regarding the appropriateness of coding and billing practices to either the appropriate supervisor or the DUHS Compliance Office.

FINANCE

DUHS maintains its accounting records according to generally accepted accounting principles.

  • We maintain a system of administrative and accounting controls to: (1) safeguard DUHS's assets (see section below); (2) make sure accounting data are accurate and reliable; and (3) make sure that we follow laws, regulations, and policies.

  • We cooperate fully with internal and external auditors and any regulatory agencies who examine our books and records.

SAFEGUARDING OUR ASSETS

DUHS "assets" include more than facilities, property, equipment, inventory, office supplies, and funds. Our assets also include employee time, business strategies, financial data, computer software, patents and trademarks, inventions and devices, and other information that DUHS owns.

Everyone is responsible for using DUHS assets properly.

  • We take appropriate steps to protect DUHS assets against loss, theft, or misuse. We report possible loss or theft to the appropriate supervisor.

  • We handle any purchase, transfer, or sale of assets in accordance with applicable policies and procedures.

  • We do not use materials, equipment, or other assets for purposes not directly related to DUHS business without prior approval from our respective supervisors.

  • We do not photocopy or distribute material from books, periodicals, computer software, or other sources if doing so would violate copyright laws.

CONTRACTS

DUHS employs the highest business standards in selecting, negotiating, and approving all contracts with third parties.

  • We maintain confidentiality regarding pricing and terms of contracts.

  • In contracting with third parties, we comply with all laws and regulations, specifically including the receipt of fair market value in the payment and receipt of services and products.

  • We inform third party consultants, service providers, vendors, and other contractors that they are expected to comply with this Code.

RECORDKEEPING

DUHS stores medical and billing records in a safe and secure place for the time required by law or policy.

  • We truthfully and accurately maintain all paper and electronic data, including medical records and financial reports, in accordance with applicable laws, regulations, and policies.

  • We ensure that only authorized individuals can access medical and billing records.

  • We do not remove medical and billing records from our files except under a court order or as otherwise required by law.

  • We do not alter, falsify, or manipulate any record, contract, or other document.

DUHS maintains a recordkeeping system for documents related to the Compliance Program.

INTEGRITY IN OUR INTERACTIONS

CONFIDENTIALITY

At DUHS, we use confidential information--whether medical, staff-related, business, financial, or personal--only as needed to do our jobs.

We respect and maintain the confidentiality of:

  • Patient/client identity and diagnosis, treatment, financial, and other personal or family information;

  • Personal and professional information and information about personnel actions;

  • Organizational and non-public information (which should not be used for anyone's personal advantage, gain, or profit);

  • Private financial, pricing, and cost information not of public record;

  • The trade secrets, patents, trademarks, inventions, and devices of DUHS and others;

  • Computer software programs;

  • Third-party service provider, vendor, or contractor information; and

  • In general, we do not discuss sensitive topics about the operations of DUHS with any competitors, service providers, vendors, or other contractors without the approval of the appropriate supervisor. We also do not obtain confidential information about competitors of DUHS through improper means.

COMMUNICATION AND MARKETING

DUHS uses various forms of communication to provide and receive information between employees, those whom we serve, those with whom we conduct business, and the public. Communication may occur verbally or through written documents, electronic mail (e-mail), facsimile (fax), voice mail, patient information and other information systems, audio and video recordings, and marketing.

  • We make sure we use all forms of communication appropriately.

  • We keep sensitive information confidential, both when it is communicated and when it is stored.

  • We keep identification (IDs) and passwords secure.

  • We release information to the media, public, and courts only through the appropriate channels (according to policy).

  • We may use marketing and advertising activities to educate the public, provide information to the communities we serve, increase awareness of our services, and recruit colleagues.

  • We present all communication regarding our services, including marketing and advertising, in a truthful and informative manner that provides a fair representation of services and care provided.

CONFLICTS OF INTEREST

A conflict of interest arises when our activities, associations, or positions outside our relationship with DUHS conflict with our responsibilities to DUHS and the people we serve.

  • We avoid any situation in which our participation is, or may appear to be, in conflict with the mission, values, and interests of DUHS.

  • We avoid any position or financial interest in any outside organization when such a relationship would improperly influence our professional objectivity or the performance of our duties. Should a potential conflict of interest arise, we will immediately disclose the situation to our immediate supervisor or to the DUHS Chief Compliance Officer.

  • In our business relationships with third-party consultants, service providers, suppliers, vendors, and other contractors, we base all our decisions on quality of services and products, competitive pricing, and organizational policy--not on personal relationships or personal benefit.

  • We do not offer, solicit, or accept any gifts or gratuities that may influence or appear to influence our objectivity in performing our duties at DUHS. Nominal gifts that do not compromise our performance may be accepted or given. If we are unsure about whether a gift is nominal in value or is otherwise acceptable, we discuss the situation with our immediate supervisor. Supervisors should consult with the DUHS Facility-Based Compliance Officer or the DUHS Chief Compliance Officer for questions they may have about gifts.

POLITICAL ACTIVITY AND CONTRIBUTIONS

DUHS encourages its employees to vote and participate in the political process. However, the use of DUHS property or funds to support a political cause, party, or candidate for public office is prohibited.

  • We do not use DUHS assets, such as telephones, copiers, and our work time, to support any political activity.

  • We clearly indicate that the political views we express as individuals are our own and not those of DUHS.

GOVERNMENT INVESTIGATIONS

We fully comply with the law and cooperate with any appropriate request by a government agency for information. Any inquiry, civil investigative demand, subpoena, or request of another agency regarding DUHS or any facility, division, or person associated with DUHS should be reported to the DUHS Chief Compliance Officer, DUHS Facility-Based Compliance Officer, or the administrator on call. This notification will ensure that the appropriate individuals, including DUHS Legal Counsel, are made aware of the request and can properly respond to it, and that all patient privacy rights are maintained.

WE WANT YOUR FEEDBACK

DUHS wishes to assure that our Compliance Program effectively communicates compliance issues at all levels of the organization. The DUHS Compliance Office periodically sends out random surveys to obtain feedback on how well the Compliance Program is working. Responses may be made on an anonymous basis.

The Compliance Program and this Code may be modified to reflect future changes in laws and regulations, or to improve compliance at DUHS. DUHS encourages your suggestions to the DUHS Compliance Office to make the Compliance Program better.

If You Need Additional Information

If you have questions about the Code or the Compliance Program, or need additional information, contact:

DUHS Compliance Office - (919) 668-2573