Code of Conduct
(Hospitals and Health Systems)

Summary

This template provides a form code of conduct for a large hospital or health system. It is intended as a drafting aid. Although it provides standard provisions, terms, and conditions typical to this type of document, it will require modification specific to the drafting organization. This template includes practical guidance, drafting notes, and optional clauses. A healthcare organization's code of conduct demonstrates the organization's commitment to compliance by its members. Healthcare providers (e.g., physicians and hospitals) and their vendors are required by federal law, including the Affordable Care Act, Social Security Act, and Health Insurance Portability and Accountability Act (HIPAA), to adopt effective compliance programs to prevent, detect, and correct fraud, waste, and abuse, as well as to secure protected health information (PHI), among other requirements. As part of its compliance program, these organizations must develop written policies and procedures and standards of conduct that: • Articulate the organization's commitment to compliance • Describe the organization's compliance expectations • Implement the organization's compliance program • Provide guidance to employees on dealing with compliance issues • Identify how to communicate compliance issues to appropriate organization personnel • Describe how potential compliance issues are investigated and resolved –and– • Include a policy of non-intimidation and non-retaliation for good-faith participation in the organization's compliance program See, e.g., 42 C.F.R. § 422.503(b)(4)(vi)(A). See also 42 U.S.C. § 1395cc(j) and 45 C.F.R. § 164.316. The organization's code of conduct typically serves as an overview and introduction to its larger compliance program, oftentimes referring or citing to other organization policy and procedure documents that support or supplement each of the seven criteria listed above. For more on healthcare generally, see Healthcare Fundamentals Resource Kit and Summer Associate Resource Kit: Healthcare. For additional information on the structural elements of compliance programs and building successful healthcare compliance plans, see Compliance Programs for Healthcare Providers, Healthcare Compliance Plan Elements, and Implementing a Healthcare Compliance Plan. For a checklist guiding attorneys through key legal and business questions that healthcare providers should consider when building a compliance program, see Healthcare Compliance Program for Providers Checklist.