L E A D I N G T E A C H I N G C A R I N G
E M P L O Y E E H A N D B O O K
C o d e o f C o n d u c t
2 2 2 2 I
C O D E O F C O N D U C T
We will:INTELLECTUAL PROPERTY
We will:COST CONTROL
We will:ENVIRONMENTAL MANAGEMENT
We will:WHO WE ARE AND WHAT WE STAND FOR
WE WILL CONDUCT ALL OUR
INTERACTIONS ETHICALLY
AND RESPONSIBLY
WE OBTAIN AND USE HEALTH SYSTEM
RESOURCES WISELY
3 3 3 Code of Conduct
SAFEGUARD OF ASSETS
We will:NEPOTISM: FAMILY, FRIENDS, AND WORK
(REFERENCE POLICY – HR 0414)
We will:
SECONDARY EMPLOYMENT (REFERENCE
POLICY - HR 0421)
We will:
COMPETING FAIRLY
We will:GIFTS, ENTERTAINMENT, AND GRATUITIES
(REFERENCE POLICY - ADMIN 0037)
We will:BRIBES, KICKBACKS, AND ILLEGAL PAYMENTS
We will:POLITICAL ACTIVITY (REFERENCE POLICY
-HR 0311)
We will:
INSIDER RELATIONSHIPS
We will:4
4 Code of Conduct 4
CONFIDENTIAL INFORMATION (REFERENCE
POLICY - ADMIN 0067)
We will:PATIENT INFORMATION
We will:EMPLOYEE INFORMATION
We will:BUSINESS INFORMATION
We will:COMMUNICATION AND THE PUBLIC
We will:MEDICAL BILLING
We will:AUDITS AND INVESTIGATIONS
We will:HEALTH AND SAFETY
We will:WE PROTECT CONFIDENTIAL AND OTHER
SENSITIVE INFORMATION
WE REPORT INFORMATION ACCORDING
TO THE LAW
5 5 5 Code of Conduct
VIOLENT ACTS AND HARASSMENT
We will:DISRUPTIVE BEHAVIOR (REFERENCE POLICY
ADMIN 0204)
We will:COMPLIANCE OFFICE
Purpose Management FunctionsCOMPLIANCE OFFICE OPERATIONS
Independence and AuthorityWhen To Get Help
Employee Relations
Seeking Advice
6 6 Code of Conduct 6
REPORTING MISCONDUCT
FALSE CLAIMS
http://intranet.unchealthcare.org/site/w3/ complianceCONTACTING THE COMPLIANCE OFFICE
In Person By Phone By E-mail [email protected] By MailCONFIDENTIALITY
RESPONSE
PROTECTION
7 7 7 COC: Questions and Answers
PATIENTS
2 "EPDUPSIBTPSEFSFEBTQFDJöDESVHGPSB patient, and the patient refuses to take it. What should the employee do?
Q: A nurse has an elderly patient in his/her care. The patient is scheduled for surgery. The nurse notices that the woman sometimes understands what’s going on around her and sometimes doesn’t. An employee also notices an advance directive sticker on the patient’s chart. What if, just before surgery, the patient tells the employee that he/she wants to go back to his/her retirement home and be left in peace. What should the employee do?
EMPLOYEES, VOLUNTEERS, AND STUDENTS
OF UNC HEALTH CARE AND UNC SCHOOL
OF MEDICINE
Q: The clinic gets very busy during the day. Employees don’t always have time to create a receipt for a patient when he/she gives money. Can an employee clip the payment to the encounter form and deal with it later?
2 8IFOBTVQFSWJTPSJTOPUJOUIFPóDF BO employee’s co-worker spends a lot of time on QFSTPOBMDBMMTBOETVSöOHUIFOFU8IBUDBO the employee do?
Q: Patient accounts representatives often deal with patients who are irate about their bills. Sometimes an employee feels that he/she is being verbally abused. What should the employee do in these situations?
C O D E O F C O N D U C T :
Q U E S T I O N S A N D A N S W E R S
WE WILL CONDUCT ALL OUR
INTERACTIONS ETHICALLY AND
RESPONSIBLY
8
8 COC: Questions and Answers 8
Q: What is meant by “need to know”?
Q: What is Protected Health Information (PHI)?
Q: What is Protected Health Information (PHI)?
Q: What type of patient information should be LFQUDPOöEFOUJBM
Q: To whom should an employee refer questions regarding release of patient information?
WE PROTECT CONFIDENTIAL AND OTHER
SENSITIVE INFORMATION
9 9 COC: Questions and Answers 9
Q: To whom should an employee refer questions regarding the privacy and security of
DPOöEFOUJBMJOGPSNBUJPO
Q: Is a supervisor allowed to give a professional reference on the employee to a potential employer?
2 8IBUJTiDPOöEFOUJBMCVTJOFTTJOGPSNBUJPOw
2 *TUIFSFBEJòFSFODFCFUXFFOQSJWBDZBOE DPOöEFOUJBMJUZ
MEDICAL BILLING
Q: How can employees who register outpatient clinic visits be sure the insurance information given to them is valid and current?
Q: As a patient accounts representative, an employee receives physician and patient requests to change the diagnosis or
procedure coding on a patient’s account or claim. How can the employee ensure that SFRVFTUTBSFTBUJTöFEBOE BUUIFTBNFUJNF submit accurate and valid information to our payers?
Q: A lab technician spoke with a patient today who says his/her insurance was billed
incorrectly for services he/she did not receive. Should the employee handle this problem or call someone else?
WE REPORT INFORMATION
ACCORDING TO THE LAW
10
10 COC: Questions and Answers 10
Q: The physicians with whom a medical coding specialist works have told an employee to bill VTJOHBTQFDJöD$15DPEFUIBUIFTIFLOPXT will be reimbursed, but does not think is accurate. What should the employee do?
Q: How does an employee know whether he/she IBTTVóDJFOUMZEPDVNFOUFEUIFTFSWJDFUIBU he/she has given a patient
Q: What processes should an employee follow to verify that a patient has been charged correctly?
Q: An employee registers specimens for an ancillary department. The employee sometimes does not have all the information he/she needs to complete the required screens, so he/she uses the “self-pay” option. Is this appropriate?
Q: A charge entry clerk in a busy clinic does not know which physician provided service for a certain patient who was in the clinic yesterday. What should the employee do?
Q: An employee who works in Patient Accounts has been receiving returned claims and patient calls concerning possible duplication of charges. This is occurring on a fairly regular basis, and the employee wonders whether it is a systems error. What should the employee do?
Q: There are so many changes in regulations and laws. How can an employee be sure that his/her department knows about the changes and is in compliance with all these laws?
11 11 COC: Questions and Answers 11
AUDITS AND INVESTIGATIONS
Q: If an employee receives a call from a
government agency concerning some type of investigation, what should the employee do? Should he/she answer any questions?
Q: It appears to be common practice for government investigators to contact employees at their homes or at other MPDBUJPOTBXBZGSPNUIFPóDF*GUIJT happens to an employee, what are the employee’s rights and how should he/she handle the situation?
INTELLECTUAL PROPERTY
Q: An employee sometimes takes work home and uses his/her personal computer. Can employees install and use department-purchased software (e.g., compact disc or diskettes) on home computers?
Q: An employee needs to copy several magazine BSUJDMFTGPSTUBòUSBJOJOH5IFBSUJDMFTIBWF copyright notices, but the employee only plans to use them for his/her training. Is this appropriate?
COST CONTROL
Q: An employee is concerned that a vendor may be delivering inferior products to UNC Health Care. Whom should the employee notify?
WE OBTAIN AND USE HOSPITAL
RESOURCES WISELY
12
12 COC: Questions and Answers
ENVIRONMENTAL MANAGEMENT
Q: An employee notices that another employee in his/her work area does not always use a sharps container when he/she disposes of needles and other sharps. What should the employee do?
Q: Whom should an employee contact in the event that he/she sees a spill that appears to be hazardous?
NEPOTISM: FRIENDS, FAMILY, AND WORK
Q: A married couple works in the same area in a department. They have the same BSFBTVQFSWJTPSCVUEJòFSFOUJNNFEJBUF supervisors. Is this appropriate? What about when they work on weekends with the same immediate supervisor?
Q: Under the nepotism policy, is it appropriate for live-in partners to work in the same department or area? What about roommates?
2 8IPGBMMTVOEFSUIFEFöOJUJPOPGiDMPTF family relative”?
SECONDARY EMPLOYMENT
Q: An employee has a permanent part-time position in the lab. He/she also works on contingency at the Duke Medical Center lab picking up extra shifts when he/she needs money or has extra time. Duke is a competitor, but why does the employee have to get permission to work a second part-time job? Does working at Duke jeopardize the employee’s employment here? Since the employee’s working arrangement at Duke is not permanent, does the employee need to get permission every time he/she can get an extra shift?
WE AVOID CONFLICTS
OF INTEREST
13 13 COC: Questions and Answers
Q: An assistant to a senior manager in the billing department is interested in getting a weekend job at a local bookstore. Is this a DPOøJDUPGJOUFSFTU
Q: A vendor with whom we do business is impressed with an employee’s knowledge of his/her product and would like the employee to conduct a workshop for new organizations that have recently purchased the product. The employee will CFSFJNCVSTFEGPSIJTIFSFòPSUT*TUIJTB DPOøJDUPGJOUFSFTU
COMPETING FAIRLY
Q: An employee is asked by his/her supervisor to call hospitals in the area and ask how much they are being paid by managed care companies to perform coronary bypass surgery. Is that appropriate for the employee to do?
GIFTS, ENTERTAINMENT, AND GRATUITIES
2 .BZBOFNQMPZFFBDDFQUøPXFST CBLFE goods, pizza parties, or other gifts from a patient or family? Is it appropriate to accept gifts from vendors, such as architects and building contractors, who often send these around the holidays?
Q: A vendor who was awarded a contract with 6/$)FBMUI$BSFPòFSTBOFNQMPZFFBOEUIF employee’s husband an all-expense-paid trip to the Outer Banks. The employee would like UPBDDFQUUIFWFOEPSTPòFSCFDBVTFIFTIF has not had a vacation in a long time. Is this appropriate?
2 "WFOEPSIBTPòFSFEUPQSPWJEFB
department with free equipment if he/she buys a certain number of catheters. Is the employee permitted to accept that vendor’s PòFS
14
14 COC: Questions and Answers
2 "WFOEPSIBTPòFSFEBQJ[[BMVODIGPSBMM UIFTUBòJOUIFEFQBSUNFOUBOENPOFZUP put in a fund for future employee parties if the department uses his/her product. This sounds good but does not feel right. What should the employee do?
Q: One of the vendors with whom we do business has invited an employee to
participate on his/her team for an upcoming DIBSJUZXBML*TUIJTBDPOøJDUPGJOUFSFTU
Q: Our department recently completed a project with a vendor. Today the vendor sent an employee two tickets to a UNC basketball game. Is it appropriate for the employee to accept them?
BRIBES, KICKBACKS, AND ILLEGAL PAYMENTS
2 "WFOEPSPòFSTBOFNQMPZFFBHJGU DFSUJöDBUFUPIFMQNBLFTVSFUIFWFOEPS JTTFMFDUFEUPQSPWJEFUFNQPSBSZTUBóOH services to UNC Health Care. Is the employee permitted to accept that money?
POLITICAL ACTIVITY
Q: An employee’s brother-in-law is running for Chapel Hill Town Council, and the employee is the campaign manager. Is it appropriate for the employee to post campaign signs and distribute campaign materials to other employees and visitors?
Q: An employee is very concerned about plans to locate a low-level nuclear waste site in Wake County and would like to circulate a petition for his/her co-workers to sign. Is that appropriate for the employee to do?
INSIDER TRADING
Q: Can an employee invest in a publicly traded company that does business with UNC Health Care?
HEALTH AND SAFETY
Q: An employee knows another employee in his/her department never wears his/ her personal protective equipment. The employee worries that this could lead to an exposure. The employee does not know what to say to make him/her realize that he/she is putting himself/herself at risk. What should the employee do?
15 15 COC: Questions and Answers
Q: An employee takes safety very seriously, but feels that his/her supervisor does not really care. What can the employee do?
2 "OFNQMPZFFJTBXBSFPGUIFTQFDJöDTBGFUZ initiative that is required for patient safety, but when he/she tries to follow the safety requirements, physicians and fellow workers laugh.
VIOLENT ACTS AND HARASSMENT
2 "OFNQMPZFFSFDFOUMZHBWFBTUBòNFNCFS an unsatisfactory rating on his/her
performance evaluation. Over the next TFWFSBMXFFLT UIFTUBòNFNCFSFYQSFTTFE unhappiness with the evaluation in several ways. It began with verbal abuse that escalated to physical threats of violence. Verbal threats included statements such as “We’ll settle this outside.” What should the employee do?
Q: An employee’s supervisor sometimes says things at work that sound bad and make the employee uncomfortable. The supervisor tells “dirty” jokes about females and tells negative stories and jokes about minorities. The supervisor is always careful to avoid making these remarks around women and minorities. It just does not seem right. Is this sexual harassment or discrimination?
Q: During a home health visit, a nurse is threatened by a patient’s spouse and is told to leave. The patient wants and needs home health services to continue despite the spouse’s objections. What should the nurse do? The employee is concerned for his/her safety as well as the patient’s health and safety and does not want to abandon the patient.
16
16 COC: Questions and Answers
Q: An employee in a department is involved in an apparently abusive relationship at home. On occasion, the employee talks about his/her troubles to others at work. The employee’s stories of his/her home situation cause concern for all employees’ safety at work. Everyone is worried about how to put an end to this problem, but they are also worried the spouse will become angry and come to work to harm him/her. What should employees do?
DRUGS IN THE WORKPLACE
Q: An employee in a department observes another employee who reports to work exhibiting unusual behavior. The employee is staggering, and has slurred speech and the smell of alcohol on his/her breath. What should the employee do?
17 17 COC: Questions and Answers
