Northside Hospital Code of Conduct

I. PURPOSE:

This Code of Conduct serves as Northside's guiding statement of ethical and compliance principles for Northside Hospital, Inc. and its affiliates, as well as Northside’s employees, management, Board of Directors, Medical Staff members and agents.  

II. POLICY:

This Code of Conduct is a summary of the ethical and legal standards by which NORTHSIDE employees, management, directors, members of the Medical Staff and agents will strive to conduct themselves to protect and promote system-wide integrity and to enhance NORTHSIDE’s mission. The Code of Conduct should be used as a guide to help NORTHSIDE’s employees, management, Board members, Medical Staff and agents make sound decisions in carrying out their day-to-day responsibilities. The Code of Conduct cannot possibly address all legal and ethical standards applicable to NORTHSIDE; therefore, policies and procedures applicable to specific legal and ethical standards will supplement the standards set forth in the Code. In addition, employees, management, Board members, Medical Staff and agents are expected to use good judgment in performing their responsibilities on behalf of NORTHSIDE. This document does not create any obligations not otherwise existing under applicable law.

III. APPLICABILITY OF THE CODE OF CONDUCT

A. Who must comply with NORTHSIDE’s Code of Conduct?

This Code of Conduct applies to all the following individuals at all facilities and services currently operated, managed or provided by NORTHSIDE or that will be operated, managed or provided by NORTHSIDE in the future: 

Employees: All individuals employed by NORTHSIDE;

Management: All NORTHSIDE employees with responsibility for performing management and oversight functions at NORTHSIDE, including executive management, directors, managers and supervisory personnel;

Board members: Members of NORTHSIDE's Board of Directors;

Medical Staff: Physicians and other health care providers who have received membership or clinical privileges to admit, treat or practice medicine at NORTHSIDE; and

Agents: All persons or entities that contract with or volunteer at NORTHSIDE to provide items or services that are materially related to NORTHSIDE’s provision of health care services, including, but not limited to, consultants, volunteers, residents, medical students, allied health students and faculty, and significant contractors and vendors.  

B. What are the expectations of NORTHSIDE employees?

• Read the standards of conduct and think about their application to your work. You should have a basic understanding of issues covered by each standard and the compliance policies and procedures that apply to your job function.  
  
• Seek assistance from your immediate supervisor or NORTHSIDE’s chief compliance officer (“CCO”) when you have questions about the application of the standards and other NORTHSIDE policies to your work. The CCO can be reached at Jorge.Hernandez@Northside.com or 404-851-6378.
  
• Understand the options that NORTHSIDE makes available to you for raising conduct or ethical concerns and promptly raise such concerns. You should raise such concerns with your immediate supervisor or the CCO. If you prefer to raise your concerns anonymously, NORTHSIDE has a hotline number for you to call at any time: 404-845-5907.  
  
• Cooperate in NORTHSIDE investigations concerning potential violations of law, the Code of Conduct, NORTHSIDE’s Compliance Program (“Compliance Program”), and NORTHSIDE policies and procedures.  
  

C. What are the expectations of NORTHSIDE management? 

1. Build and maintain a culture of compliance by:

• Leading compliance efforts through regular monitoring of compliance matters and programs.
• Leading by example, using your own behavior as a model for all employees.
• Encouraging employees to raise conduct and ethical questions and concerns.
  
• Seeking assistance from the CCO to address any questions or concerns for which you do not know the answer.
• Considering employee actions and judgments in promoting and complying with the Code of Conduct and other NORTHSIDE policies when evaluating and rewarding employees.
• Equipping the CCO with the necessary resources to promote the effectiveness of the Compliance Program.
  

2. Prevent compliance issues by:

• Identifying compliance risks and proposing additional policies and procedures that may be appropriate to address such risks.
  
• Identifying employees whose activities involve issues covered by NORTHSIDE policies.
  
• Providing education and counseling to assist employees to understand the Code of Conduct, NORTHSIDE policies, and applicable law.
  

3. Detect compliance problems by:

• Implementing and maintaining appropriate controls to monitor compliance and mechanisms that foster the effective reporting of potential compliance issues.  
• Promoting an environment that permits employees to raise concerns without fear of retaliation.
• Assisting in periodic compliance reviews that are conducted by the CCO or external auditors, to assess the effectiveness of NORTHSIDE’s compliance measures and to identify methods of improving internal controls.
  

4. Respond to compliance problems by:

• Pursuing prompt corrective action to address imperfections in compliance measures.
  
• Applying appropriate disciplinary action when necessary.
  
• Consulting with the CCO so that compliance issues are promptly and effectively addressed. 
  

5. Report potential compliance issues by:

• Promptly raising conduct or ethical concerns with your immediate supervisor or the CCO.
  
• If you prefer to raise your concerns anonymously, NORTHSIDE has a hotline number for you to call at any time: 404-845-5907.
  

D. What are the expectations of NORTHSIDE Board members?  

• Read the standards of conduct and think about their application to your role.
• Make decisions that are in the best interest of NORTHSIDE and which are not influenced by conflicts of interest.
• Ensure that the Compliance Program is free from undue restraints and influences and raise any compliance issues with the CEO or the CCO.
• Maintain the confidentiality of all compliance-related information provided to you.
  

E. What are the expectations of Medical Staff members?

• Read the standards of conduct and think about their application to your work.  Have a basic understanding of issues covered by each standard and the compliance policies that apply to the services you furnish to NORTHSIDE and our patients.
• For Employed Physicians, seek assistance from the Director of Physician Practice Management or CCO when you have questions about the application of the standards of conduct and other NORTHSIDE policies to your work.
• Actively participate in compliance activities as requested by the CCO and other NORTHSIDE administration.
• Assist NORTHSIDE in identifying compliance issues and in developing possible solutions to address those issues.
• Understand the various options that NORTHSIDE makes available to you for raising conduct or ethical concerns and promptly raise such concerns. You should raise such concerns with the CCO. If you prefer to raise your concerns anonymously, NORTHSIDE has a hotline number for you to call at any time: 404-845-5907.  
• Cooperate in NORTHSIDE investigations concerning potential violations of law, the Code of Conduct, NORTHSIDE’s Compliance Program, and NORTHSIDE policies and procedures.  
• Lead by example, using your own behavior as a model.
  

F. What are the expectations of agents?

• Read the standards of conduct and think about their application to the services you furnish to NORTHSIDE. You should have a basic understanding of issues covered by each standard and the supplemental compliance policies that apply to the services you furnish to NORTHSIDE.
• Actively participate in compliance activities, such as education and training, as requested by NORTHSIDE.
• Understand the various options that NORTHSIDE makes available to you for raising conduct or ethical concerns and promptly raise such concerns. You should raise such concerns with the NORTHSIDE supervisor responsible for your activities at NORTHSIDE or the CCO. If you prefer to raise your concerns anonymously, NORTHSIDE has a hotline number for you to call at any time: 404-845-5907. 
• Cooperate in NORTHSIDE investigations concerning potential violations of law, the Code of Conduct, NORTHSIDE’s Compliance Program, and NORTHSIDE policies and procedures.
  

IV. STANDARDS OF CONDUCT 

A. Patient Relationships: We are committed to providing a high quality of healthcare and services to address the needs of our patients, their families, visitors and the community. We strive to treat all patients in a manner that preserves their dignity, autonomy, and involvement in their own care. 

Principles: 

• We recognize the right of our patients to receive quality services provided by competent individuals in an efficient, cost effective and safe manner.
• We continually monitor the clinical quality of the services we provide and will endeavor to improve the quality of services provided.
• We strive to establish, maintain and consistently apply our policies related to patient care based upon identified patient needs, compliance with all legal requirements applicable to NORTHSIDE and NORTHSIDE's status as an industry leader in patient satisfaction and quality of care.  
• We strive to listen to our patients, their families and visitors to understand any concerns or complaints and involve patients or their authorized representatives in the decision-making process about their care.
• We strive to provide treatment and medical services without discrimination based on race, color, age, religion, national origin, gender, sexual orientation or disability.
  

B. General Legal and Regulatory Compliance: NORTHSIDE will continuously and vigorously promote appropriate compliance with applicable federal and state laws and regulations, and federal health care program requirements.

Principles:

• We continuously study our legal obligations and create policies and procedures that facilitate compliance with such legal obligations by our employees, management, Board members, Medical Staff and agents.  
• We continuously review all our departments and work to understand how our operations affect issues of compliance with ethical, moral and legal standards.
  
• We require our employees, management, Medical Staff and agents to understand the basic legal obligations that pertain to their individual job functions or services they furnish to NORTHSIDE and our patients, and require that they strive to make certain that their decisions and actions are conducted in conformity with such laws, regulations and policies and procedures.
• We support educational and other training sessions to teach NORTHSIDE employees, management, Board members and, as warranted, Medical Staff and agents, about the impact of the law on their duties, and to promote compliance with our collective legal obligations.  
• We support and maintain multiple resources for employees, management, Board members, Medical Staff and agents to voice any questions about the proper interpretation of a particular law, regulation or policy and procedure.  
• We embrace our charitable mission and monitor our obligations as a 501(c)(3) tax-exempt entity, including our responsibility to use our assets to further our charitable purpose.  For example, Northside may not contribute its funds to a political campaign, reimburse our employees for contributing their personal funds to a political campaign, or allow our employees to work on political campaigns during work hours.
  

C. Avoidance of Conflicts of Interest: Employees, management and Board members have a duty of loyalty to NORTHSIDE and, as a result, must avoid any activities or private interests that may influence or appear to influence the employee, manager or director’s ability to render objective decisions in the course of his or her job responsibilities, or other services he or she furnishes to NORTHSIDE.

Principles:

• We maintain policies and procedures that clarify situations in which an individual’s private interests may inappropriately interfere with NORTHSIDE’s interests, and will provide support through which employees, management and Board members may pose questions about whether a particular outside activity or relationship could be construed as a conflict of interest.
• We articulate expectations of the conduct of employees, management and Board members in order that such individuals remain free of conflicts of interest in the performance of their responsibilities and services to NORTHSIDE.
• We articulate expectations of the conduct of Medical Staff members and agents in their performance of services at or for NORTHSIDE and expect that such individuals will comply with their duties to NORTHSIDE and the ethical standards associated with their profession, if any.
  

D. Relationship with Payors: NORTHSIDE will strive to provide accurate billing to government payors, commercial insurance payors, and patients.

Principles:

• We will promote compliance with laws governing the submission and review of bills for our services and will deal with billing inquiries in an honest and forthright manner.
  
• We will implement reasonable measures to prevent the submission or filing of inaccurate, false or fraudulent claims to payors. 
• We will utilize systematic methods for analyzing the payments we receive and will reconcile inaccurate payments promptly after discovery. 
  
• When warranted, we will investigate inaccurate billings and payments to determine whether changes to current protocol or other remedial steps are necessary.
• We will review any cost reports to be filed with any government-funded health care programs to determine whether such reports accurately and completely reflect the operations and services provided to beneficiaries and to confirm that such reports are completed in accordance with applicable federal and state regulations and NORTHSIDE policies and procedures.  

E. Relationship with Physicians and Other Healthcare Providers: NORTHSIDE will monitor its business dealings to structure relationships with physicians and other healthcare providers consistent with relevant federal and state laws and regulations, and in furtherance of NORTHSIDE’s mission.  

Principles:

• We will accept patient referrals based on our ability to render appropriate healthcare services to the patient.
• We will strive to treat referral sources fairly and consistently and will not provide nor solicit remuneration that could be considered payment for referrals.
  
• We will maintain policies and procedures designed to ensure that NORTHSIDE does not enter into relationships with physicians and other healthcare providers that do not comply with relevant laws and regulations, including the federal anti-kickback statute and Stark law and any applicable state law equivalents.  
• We will educate and train the appropriate personnel on the primary laws and regulations governing patient referrals and other legal restrictions on the manner in which NORTHSIDE transacts business, including the penalties that may result from violations of such laws, and on NORTHSIDE's policies and procedures for ensuring compliance with such laws.
  

F. Work Environment: We recognize that a diverse workforce and safe work environment enriches the life experience of all employees and our community, and NORTHSIDE will continue to maintain this culture.  

Principles:

• We will provide equal employment opportunities to employees and applicants for employment without regard to race, color, age, religion, national origin, gender, sexual orientation, veteran status or disability, in accordance with applicable law.
• We will maintain policies and procedures designed to promote compliance with laws governing nondiscrimination in personnel actions, including recruiting, hiring, evaluation, transfer, workforce reduction, termination, compensation, counseling, discipline and promotions.  
• We will maintain “non-harassment” and “no tolerance” policies addressing workplace violence.
  

G. Information and Information Systems. We recognize that the provision of healthcare services generates business, financial, and patient-related information that requires special protection. We will establish systems designed to ensure such information is used appropriately and properly safeguarded.

Principles:

• We are committed to safeguarding the integrity of the documents, records, images and other information in our possession, and will develop systems and policies and procedures designed to:
• Promote the accurate and detailed documentation of all business, financial and patient transactions.
• Control and monitor access to NORTHSIDE communications systems, electronic mail, Internet access and voicemail to ensure that such systems are accessed appropriately and used in accordance with NORTHSIDE’s policies and procedures.
• Protect the privacy and security of patient medical, billing, and claims information by implementing appropriate physical, systemic and administrative measures to prevent unauthorized access to or use of patient information, and to track disclosures of such information as required by law.  
• Provide access for our patients and their legal representatives to patients’ medical, billing and claims information, as required by law.
  

H. Financial Controls. We recognize that we are expected to document, report, provide and maintain accurate and complete financial information.  

Principles:

• We will maintain policies and procedures to promote the accuracy of NORTHSIDE’s financial information so that this information reflects actual transactions and conforms to generally accepted accounting principles.
• We will further maintain other internal controls so that transactions are properly authorized and recorded in a manner that maintains accountability for NORTHSIDE’s assets.
• We will promote compliance with applicable laws related to accounting, auditing and financial disclosure.
  

V. VIOLATIONS OF THE CODE OF CONDUCT

NORTHSIDE is committed to promoting compliance with the Code of Conduct, and violations of the Code of Conduct may lead to discipline (up to and including termination of employment), termination of Medical Staff privileges, or termination of contracts with agents as appropriate. Disciplinary actions for employees and Medical Staff members will be in accordance with NORTHSIDE Human Resources policies and procedures and the NORTHSIDE/Medical Staff Bylaws and policies and procedures, as applicable. To assist in ensuring compliance with the Code of Conduct, NORTHSIDE has provided all employees, management, Board members, Medical Staff members and agents with a means of raising questions and concerns, and reporting any conduct that the employee, manager, director, member of the Medical Staff or agent suspects is in violation of this Code of Conduct, NORTHSIDE policies and procedures, and applicable laws and regulations. Employees, management, the Board, Medical Staff and agents are expected and required to communicate any suspected violations of the Code of Conduct, NORTHSIDE policies and procedures, and applicable laws and regulations to, as applicable, an immediate supervisor or the CCO. For anonymous reporting, NORTHSIDE has established a hotline, which is available 24 hours a day, 7 days a week: 404-845-5907. The CCO will be responsible for investigating reports received on this hotline, with assistance from the Legal Department as warranted.

The following list, while not exhaustive, describes the type of concerns and questions that employees, management, Board members, Medical Staff members and agents should raise with, as applicable, an immediate supervisor, the CCO or through NORTHSIDE’s hotline:  

• the possible submission of false, inaccurate, or questionable claims to Medicare, Medicaid or any other payor; 
• the provision or acceptance of payments, discounts or gifts in exchange for referrals of patients; 
  
• the utilization of improper physician recruitment techniques under applicable law; 
  
• allegations of discrimination; 
  
• potential breaches of confidentiality or privacy; and
  
• situations that could raise conflict of interest concerns.

VI. REVISIONS OF THE CODE OF CONDUCT

This Code of Conduct will be reviewed periodically by the Compliance Committee to ensure that it remains effective and current. No changes to the Code of Conduct or waivers of its requirements will be permitted or effective without the approval of the CEO.

REVISED: AUGUST 2020

Issued by Compliance Department

Approved by the Compliance Committee on March 17, 2006

Approved by Robert T. Quattrocchi, President and CEO on April 5, 2006

Approved by Northside Hospital, Inc. (“NORTHSIDE”) Board of Directors on May 1, 2006

Last reviewed and updated in August 2020