Transcription
Code of Conduct
Cleveland Clinic October 2021 Code of Conduct 2
Dear Colleagues:We have built a worldwide reputation at Cleveland Clinic ofproviding outstanding clinical care enhanced by innovativeresearch and education. Because of caregivers who live ourvalues, we have earned the confidence of our patients and therespect of our communities.The name Cleveland Clinic stands for honesty and integrity at thehighest level. Our Cleveland Clinic Code of Conduct ensures wecontinue to deliver on our promise to always do the right thing.The Cleveland Clinic Code of Conduct is part of our overallprogram of corporate compliance. It states the ethical principlesthat rule our business and determine our actions in theworkplace. Medical and business decisions can be complex.The Code of Conduct guides us to make the right choices.All Cleveland Clinic trustees, caregivers, volunteers and service providers are required to observethis Code of Conduct, abide by our legal and regulatory compliance policies, and conduct theiractivities in an ethical manner.We are all accountable for staying true to our values and our professional code of conduct.We must work together to ensure our workplace environment is one that supports transparencyand always doing the right thing for our patients and one another.If you have any questions about the Code of Conduct, or ethical concerns regarding anysituation arising at Cleveland Clinic, please contact your supervisor, the Department of HumanResources, the Office of Corporate Compliance, or the Law Department. If you wish to remainanonymous, you may call the confidential reporting line at 1.800.826.9294.Thank you for helping Cleveland Clinic become the best place for healthcare delivery and thebest place to work in healthcare.Sincerely,Tomislav Mihaljevic, MDChief Executive Officer and President, Cleveland ClinicCleveland Clinic October 2021 Code of Conduct 3
Code of ConductPurposeCleveland Clinic is committed to the highest standards of business ethics. We pursue honesty and transparency in theprovision of healthcare services as well as in the management of business affairs. The Code of Conduct, which has beenadopted by the organization, supplements the mission, vision and values of Cleveland Clinic and is an integral part of ourcorporate compliance program. Policies and procedures that support the Code of Conduct can be accessed on the intranet orobtained from a supervisor in hard copy form.Our Code of Conduct provides guidance to all in carrying out daily activities within appropriate ethical and legal standards.The Code of Conduct provides standards to protect and promote integrity and to enhance Cleveland Clinic’s ability to achieveits mission and compliance goals. The Code of Conduct is not intended to cover all situations and does not address ethicsrelated to medical care.Who must abide by the Code of Conduct?The Code of Conduct applies to the operations of Cleveland Clinic, at all Cleveland Clinic locations and regional hospitals,and other entities within the Cleveland Clinic enterprise, the Cleveland Clinic Employee Health Plan, and to all individualsand entities who provide services through or for Cleveland Clinic. This includes caregivers, clinical practitioners, volunteers,students, contractors, vendors, board members and officers and others conducting business for, or on behalf of ClevelandClinic. Because the Code of Conduct is integral to our value of integrity, Cleveland Clinic will impose disciplinary action orother appropriate measures against those who fail to adhere to its principles. .Cleveland Clinic October 2021 Code of Conduct 4
1. Integrity in Patient CarePatient RightsCleveland Clinic continuously strives toward a culture ofpatient safety and delivering world-class care to all of ourpatients. Caregivers are expected to honor the rights ofpatients and to treat patients with dignity and respect whilepromoting a safe care environment.Patient confidentiality must be respected at all times.Patient information, including photos, must not be postedto a website, social media page or public forum withoutappropriate authorization from the patient. Caregivers mustprotect patient information at all times by knowing andfollowing the requirements of Cleveland Clinic’s privacyand security policies.Emergency TreatmentCleveland Clinic will provide a medical screeningexamination and, if appropriate, stabilizing treatment toall patients who come to a Cleveland Clinic dedicatedemergency department for emergency treatment, regardlessof their ability to pay. Cleveland Clinic will only transferpatients with emergency medical conditions to anotherfacility in compliance with state and federal requirementsand Cleveland Clinic policies.ResearchCleveland Clinic is committed to following ethical standardsin full compliance with federal and state laws and regulationsin any research, investigations and clinical trials conducted.Cleveland Clinic is committed to integrity in disseminatingappropriate, valid scientific results in accordance withapplicable regulations and guidelines. It is Cleveland Clinic’spriority to protect the rights of it subjects. As in all financialaccounting and record keeping, Cleveland Clinic’s policy is tosubmit accurate and complete costs related to research grants.2. Integrity in Billing andFinancial PracticesAccurate Books and AccountsCleveland Clinic payments and other transactions are tobe properly authorized by management and are to beaccurately and completely recorded in accordance withgenerally accepted accounting principles and establishedcorporate policies. This serves as a basis for managing thebusiness and is important in meeting obligations to patients,suppliers and others. Cleveland Clinic’s high standard ofaccuracy and documentation is necessary for tax andfinancial reporting requirements.The duty to report accurate and truthful information alsoapplies to our internal dealings. All work time and expenserecords are to be reported accurately and honestly.BillingCleveland Clinic is committed to prompt, complete andaccurate billing that complies with all applicable laws, rulesand policies. Caregivers who handle patient charges, claimsand records are to accurately document and report all servicesand supplies that are billed. Cleveland Clinic prohibits itscaregivers or agents from knowingly presenting, or causingto be presented, claims for payment or approval, which arefalse, fictitious or fraudulent. When an overpayment isidentified, Cleveland Clinic will promptly return the amountreceived in excess of the amount due and payable under anyregulatory requirements.Cleveland Clinic October 2021 Code of Conduct 5
3. Integrity in the Work PlaceConfidential InformationAppropriate Use of ResourcesCaregivers, as well as with those who enter into businessor professional relationships with Cleveland Clinic, areobligated to maintain the confidentiality of patients,personnel and other proprietary information. Sharing ofconfidential information with other caregivers or othersoutside the organization is strictly forbidden, unless theperson requesting the information has a legitimate reasonto receive it for Cleveland Clinic business-related purposesand the information is shared in an appropriate manner asto best protect the information. Confidential informationincludes but is not limited to protected health information,which may be accessed, used or disclosed only in accordancewith Cleveland Clinic privacy and security policies.Theft, carelessness and waste have a direct impact on theorganization’s success. Those employed or performing dutiesfor Cleveland Clinic have a duty to preserve and protect theassets of the organization and to ensure their efficient use.Cleveland Clinic computers, systems and computer accountsare intended for business use only. All information transmitted or stored in its computers, cellular phones and systems,including email, text and voicemail messages, is consideredbusiness information of Cleveland Clinic even if consideredpersonal by a caregiver. Cleveland Clinic may use or reviewsuch information as it deems appropriate.Intellectual PropertyCleveland Clinic is committed to adhering to all applicableintellectual property laws. Additionally, Cleveland Clinicwill respect the intellectual property and copyright lawsregarding books, trade journals, magazines and otherapplicable resources. All software used in connectionwith Cleveland Clinic business must be properly licensed,and used in accordance with that license.Outside Activities and EmploymentCleveland Clinic caregivers and other service providersowe a duty of complete loyalty to the Cleveland Clinic andshould refrain from directly or indirectly performing duties,incurring obligations, or engaging in business or professionalrelationships where there is or would appear to be a conflictof interest. No outside activity may interfere with jobperformance.Family and WorkEmployment of an immediate relative (including but notlimited to a spouse, parent, stepparent, child, stepchild, sister,brother, son-in-law, daughter-in-law, sister-in-law, brother-inlaw, mother-in-law, father-in-law) is not permitted where acaregiver has a direct or indirect administrative, supervisoryor decision-making authority over the related person.Travel and EntertainmentTravel and entertainment expenses of a caregiver must beconsistent with their job responsibilities and the needs andresources of Cleveland Clinic. Caregivers are encouraged toparticipate in and attend educational workshops, seminarsand training sessions. Caregivers are expected to be goodstewards of Cleveland Clinic resources when participating inapproved business travel or when seeking reimbursement forapproved business expenses.Drug Free Work PlaceCaregivers, contractors or vendors may not be under the influence of alcohol or illegal drugs on company property or duringwork time. Caregivers are required to report any unsafe situations to their manager or the Human Resources department.Valuing Diversity, Equity and InclusionCleveland Clinic values a culture where caregivers embracediversity, equity and inclusion throughout the enterprise. Werespect and appreciate our similarities and differences; theyenable us to better serve our patients, one another, and ourglobal communities.Cleveland Clinic October 2021 Code of Conduct 6
3. Integrity in the Work PlacecontinuedProhibition on Discrimination, Harassmentand RetaliationCleveland Clinic is committed to providing a workenvironment in which all individuals are treated withrespect and dignity. It is the policy of Cleveland Clinic toensure that the work environment is free from discriminationor harassment on the basis of race, color, religion, gender,sexual orientation, gender identity, pregnancy, marital status,age, national origin, disability, military status, citizenship,genetic information, or any other characteristic protected byfederal, state, or local law. Cleveland Clinic prohibits anysuch discrimination or harassment, and also prohibitsretaliation against any caregiver for bringing or lodging acomplaint of discrimination or harassment or engaging inany other activity protected by law.Professional ConductIntimidating and disrespectful behaviors disrupt the cultureof safety and prevent collaboration, communication, andteamwork, which are required for safe and highly reliablepatient care. Cleveland Clinic also has codes of conduct thataddress specific healthcare professional responsibilities topatients and each other. Healthcare professionals must alsofollow the ethical standards dictated by their respectiveprofessional organizations.Gift Giving and ReceivingCleveland Clinic strives to preserve and protect its reputationof integrity at all times. Accepting gifts, entertainment ormeals from outside sources may create an appearance ofimpropriety and may violate Cleveland Clinic policies.Caregivers are always prohibited from soliciting tips,personal gratuities or gifts from any source.Political ActivityCleveland Clinic does not participate or intervene in anypolitical campaign on behalf of, or in opposition to, anycandidate for political office. While Cleveland Clinic supportscaregiver participation in the political process, caregivers arenot permitted to use their position in the organization to tryto influence the personal decision of others to contribute, orto otherwise support political parties or candidates, exceptas lawfully permitted through political action committees.Cleveland Clinic may choose to support specific issues withthe approval of the Law Department.Marketing and AdvertisingMarketing and advertising activities may be used for thefollowing purposes: to educate the public, to provideinformation to the community, to increase awareness ofour services and to recruit caregivers. Marketing materialsand media announcements are to be presented in a truthful,fully informative and non-deceptive manner.Media RelationsAll requests from news reporters, the general public or otherexternal parties for information should be referred to theCorporate Communications Media Relations Office. All mediarequests must be coordinated by a Corporate Communicationsrepresentative. Caregivers should never release informationto journalists or to the public without permission of CorporateCommunications.Caregivers are generally prohibited from offering gifts ordiscounts to patients or physicians except in limitedcircumstances and with approval by senior management.Caregivers should consult with their supervisor or the LawDepartment for additional guidance.Cleveland Clinic October 2021 Code of Conduct 7
4. Legal and RegulatoryComplianceAll activity by or on behalf of Cleveland Clinic is tocomply with all applicable federal, state and local lawsand regulations.Excluded, Denied and Restricted Party ScreeningCleveland Clinic will not employ or conduct business withindividuals or entities that have been denied, debarred, orexcluded through relevant sanctions or regulations, or who areotherwise ineligible for participation in federal or state healthcare programs. As a condition of employment, caregiversare required to notify Human Resources immediately if theyare currently, or to the best of their knowledge, will be in thefuture, listed by the federal Department of Health and HumanServices Office of Inspector General, the General ServicesAdministration or the applicable state Medicaid Exclusion andSuspension List as a person who is excluded from participation in federal or state healthcare programs.Trade Restrictions and Export ControlsCleveland Clinic is committed to complying with all applicable export, import and trade compliance laws in all countriesin which we conduct business. All transactions, even if notcrossing country borders, may be subject to national andinternational trade and/or export controls. Caregivers mustbe aware of, and strictly follow, these laws, rules andregulations when conducting business.Fair Labor PracticesCleveland Clinic requires and ensures that all aspects of itsemployment practices are in full compliance with applicablelaws and regulations, including those concerning hours,compensation, opportunity and working conditions.Human RightsHealthcare providers are often the first professionals to havecontact with human trafficking victims. All those required tocomply with this code must be vigilant for signs of humantrafficking in any aspect of our business and supply chain andto comply with Cleveland Clinic policies and procedures forreporting such concerns.Adherence to Health and Safety LawsCleveland Clinic caregivers and other healthcare providers areexpected to comply with laws designed to improve workplacesafety, such as properly controlling and monitoring dangerousmaterials and maintaining safe equipment.Environmental ProtectionCaregivers are to dispose of all waste and other materialsand store all chemicals and substances in accordance withapplicable laws and regulations. It is important to file allnecessary environmental reports accurately and promptlyand to cooperate fully with all government authorities inthe event of an environmental incident.Fraud, Waste and AbuseCleveland Clinic policies and various federal and state lawsprohibit fraudulent claims activity. The federal False ClaimsAct and state fraud and abuse prevention laws prohibitconduct such as knowingly submitting a false or fraudulentclaim or using or making a false statement to get a falseor fraudulent claim paid. Other laws governing Medicaidprogram integrity also look for ways to reduce fraud andabuse. Cleveland Clinic and its caregivers and other serviceproviders can be prosecuted for filing inaccurate claims forreimbursement, and can be subject to civil fines, criminalpenalties or both.Performing routine audits or reviews and monitoring, alongwith internal controls, helps Cleveland Clinic prevent anddetect fraud, waste and abuse.Cleveland Clinic expects caregivers to report known orsuspected activity of this type to the Corporate ComplianceOffice. Caregivers who lawfully report false claims or otherfraudulent conduct or who otherwise assist in an investigation,action or testimonies are protected from retaliation to thefurthest extent possible under both federal and state laws.Regulation of Controlled SubstancesMany prescription drugs, controlled substances and othermedical supplies are governed and monitored by specificregulatory organizations and are to be administered by anauthorized provider’s order only. Prescription and controlledmedications and supplies are to be handled properly andonly by authorized individuals to minimize risks to ClevelandClinic patients.Cleveland Clinic October 2021 Code of Conduct 8
4. Legal and RegulatoryCompliance continuedNot-for-Profit Tax-Exempt StatusInsider TradingCleveland Clinic is a tax-exempt entity because of its charitablemission. Cleveland Clinic provides benefits that includehealthcare services, medical training, education, research andcommunity outreach activities. Cleveland Clinic must use itsresources in a manner that furthers the public good ratherthan the private or personal interest of any individual or entity.No caregiver of the Cleveland Clinic shall use non-publicinformation acquired through employment at Cleveland Clinicto trade in the securities of any company, or buy or sell anyproperty or assets.AntitrustCleveland Clinic engages in activities that are subject tofederal and state antitrust laws. Generally, these laws prohibitcompetitors from entering into agreements to fix prices or toreduce price competition. Cleveland Clinic caregivers shouldnot provide information about Cleveland Clinic business to acompetitor. In addition, caregivers are to refrain from engagingin unfair practices that might restrict competition.Anti-Kickback/Anti-BriberyCleveland Clinic prohibits its caregivers and other serviceproviders from engaging in conduct that improperly influences,or even appears to improperly influence, business-relateddecisions. This includes, but is not limited to, offering, paying,asking for, or accepting any money, cash equivalents, or otherbenefit in exchange for patient referrals, purchases, leases ororders. Benefits include non-monetary incentives suchas hospitality, internships, employment, and any item oropportunity that would be of value to the recipient. Allcontracts, interactions with referral sources, and businessrelationships are to follow all applicable laws and regulations.Anti-Corruption LawsCleveland Clinic caregivers and parties acting on ourbehalf will not offer, authorize or promise to provide anythingof value, directly or indirectly, to a government official orother person or entity in connection with Cleveland Clinic’scross-border transactions that does or might appear to securean improper advantage in obtaining or retaining business.Responding to Government InquiriesCaregivers are advised to consult with the Law Departmentand the Cleveland Clinic Chief Integrity Officer beforeresponding to any non-routine requests from or on behalfof local, state or the federal government to make sure thatcontacts with government entities are handled properly.Cleveland Clinic caregivers are to cooperate with anygovernment inquiry and always be clear and truthful inresponse to those inquiries. When a caregiver is aware ofan existing or potential government inquiry they are not toalter or destroy records and should consult with the LawDepartment if there are questions.Cleveland Clinic October 2021 Code of Conduct 9
5. Ethical ResponsibilityAbiding by the Code of Conduct is a condition ofemployment for every Cleveland Clinic caregiver.Caregivers are required to participate in all trainingactivities required by Cleveland Clinic.Reporting Any Suspected or Actual ViolationsCaregivers and those affiliated with Cleveland Clinic havea responsibility to report any suspected or actual violationof the Code of Conduct or other policy irregularities to asupervisor, the Corporate Compliance Office or the LawDepartment. For those who wish to remain anonymous, thereport may be submitted through one of the Cleveland Cliniccompliance reporting lines. However, it is important tounderstand that the compliance reporting line is intendedto supplement, not replace, other channels for communicating questions and concerns within the organization.It should be used when other avenues of communicationhave not been effective.Non-retaliationThere will be no negative consequences or retaliation for goodfaith reporting of possible misconduct.Management ResponsibilitiesManagers must set an example and take action whencompliance and ethical issues are raised. They are responsiblefor ensuring that their caregivers know the content of the Codeof Conduct. Managers are responsible for seeking help fromthe Compliance Office for themselves and their caregiverswhen the right action is not clear and when questions arise.Cleveland Clinic October 2021 Code of Conduct 10
Resources and Contact InformationViolations or suspected violations of the law, Cleveland Clinic policy or this Code should be reported. The Compliancereporting line is intended to supplement, not replace, other channels for communicating questions and concerns within theorganization. It should be used when other avenues of communication have not been effective or you are uncomfortable withdisclosing your identity when reporting a concern. The call will not be traced. Anonymity, if requested, will be protected up tothe limits of the law.Cleveland Clinic Chief Integrity Officer.1.216.444.3692Corporate Compliance Office.1.216.444.1709Florida Compliance Office.1.772.419.2975Akron Compliance Office .1.330.344.5941Law Department.1.216.448.0200Florida Law Department.1.954.689.5700 Ext. 65700Enterprise-wide Anonymous Reporting.1.800.826.9294Anonymous e-mail reporting option is also available from the Corporate Compliance a-ConcernCleveland Clinic October 2021 Code of Conduct 11
The name Cleveland Clinic stands forhonesty and integrity at the highest level.Our Cleveland Clinic Code of Conductensures we continue to deliver on ourpromise to always do the right thing.21-CCC-2075423
students, contractors, vendors, board members and officers and others conducting business for, or on behalf of Cleveland Clinic. Because the Code of Conduct is integral to our value of integrity, Cleveland Clinic will impose disciplinary action or other appropriate measures against those who fail to adhere to its principles. . Code of Conduct
