Code of Conduct
WellStar has adopted this Code of Conduct as a demonstration of our unwavering commitment to honor all laws and regulations that govern the healthcare industry. The elements of this Code of Conduct include our Vision, Mission, Values, Basic Principles of Conduct, Standards of Service Excellence and Standards of Professional and Business Conduct and are incorporated into WellStar’s Corporate Compliance Program. This Code of Conduct serves to enhance and continually develop a culture that values compliance from the top-down and fosters compliance from the bottom-up throughout WellStar and among all workforce members.
This Code of Conduct is designed to provide overall guidance; however, it is not possible to address every situation. Guidance that is more specific may be provided in WellStar’s Policies and Procedures or in WellStar’s Employee Handbook. If there is no specific policy, this Code of Conduct becomes the policy. (If a policy and a Code of Conduct provision conflict, the policy governs.) This Code of Conduct is a “living document” meaning that it will be updated periodically to respond to changing conditions. Questions regarding this Code of Conduct, or any issue, should first be raised by an employee to his or her immediate supervisor, then through the chain of authority up to, and including, the Chief Compliance Officer, or WellStar Corporate Officers. Alternatively, issues may be reported to Human Resources or confidentially and anonymously to the Compliance Hotline.
Our Vision, Mission, Values, Principles, and Service Excellence
To deliver world class health care.
To create and deliver high quality hospital, physician and other related healthcare services that improve the health and well being of the individuals and communities we serve.
- We are dedicated to those we serve.
- We are dedicated to service.
- We are a team.
- We are committed to our employees.
- We are committed to our physicians.
- We are responsible to the community.
- We are WellStar Health System.
- Basic Principles of Conduct(H.E.A.R.T.)
Entrusted to you. Organizational and Patient Health Information entrusted to you should be held in the highest confidence.
Of the highest standard is expected of every workforce member and is our institutional cornerstone.
ABIDE BY LAWS, REGULATIONS, POLICIES AND PROCEDURES
There are many laws, regulations, policies and procedures that govern events and behaviors within and on behalf of our organization particularly those related to coding and billing, and relationships with referral sources and vendors. If you are uncertain about these requirements please ask for help. Guidance can be obtained through your supervisor or the Compliance Department at 678-331-6870.
That concern you. If you observe or have information about events or behaviors that you believe to be unethical, illegal, against policy, or against prescribed protocol you should report your concerns to your supervisor. Reports may also be made anonymously to the Compliance Hotline 1-888-800-5094.
TRUTHFUL, COMPLETE, AND ACCURATE COMMUNICATIONS
Should be the standard within the organization and when communicating with outside agencies, including government representatives. Remember - honesty is always the best policy.
Standards of Service Excellence
As we meet and exceed the expectations of our community, we lay the foundation of Customer Service through our Standards of Service Excellence. We work diligently and consistently to build a system-wide culture of service excellence wherein every employee is responsible and accountable for upholding the following Standards of Service Excellence:
We believe in making positive first impressions our first priority.
Apply the ten-foot rule. Initiate interaction with patients, guests or other employees within ten feet of you with a smile and warm hello. Help the facilities be and look their best. Create a sense of trust and respect with everyone, first impressions set the tone.
We believe in treating others as guests.
Apply the golden rule. Treat others as you wish to be treated. Be friendly and outgoing, show an interest in our patients and coworkers; help them feel welcome and important.
We believe in developing service recovery.
Be a problem solver. Take the initiative to find a solution or someone who can. Another important component of service recovery is to acknowledge, apologize and amend. Finally, turn negative into positive experiences.
We believe in communicating effectively.
Listen to understand. Listen with empathy and always communicate on someone’s level. Give your undivided attention and use appropriate words and tone, remember body language is 55% of the message you communicate.
We believe in serving others from a team-centered approach.
Be accountable for team effort and success. Be a mentor to those needing encouragement and direction. Make patient satisfaction a team effort.
We believe in projecting a positive attitude.
Always speak positively. Remember attitude sets the stage for success or failure. Positive attitude, ambition and enthusiasm are contagious.
We believe in making excellence the goal in everything we do.
Never settle for second best; expect the best from yourself and others. Exceed the expectations of others. The Customer Service department is available to facilitate any customer service initiatives, both internal and external.
Corporate Compliance Program
WellStar’s Corporate Compliance Program is a comprehensive self-governing program designed to proactively minimize the chances that a violation of law or government regulation occurs within the WellStar system (“System”). It is modeled on the seven basic elements proposed by the federal government’s Office of Inspector General (OIG) for developing effective Compliance Programs, and includes: (1) Policies and Procedures, (2) Designation of a Chief Compliance Officer, (3) Monitoring and Auditing, (4) Training and Education, (5) Open Lines of Communication, (6) Responding to Detected Deficiencies, and (7) Enforcing Disciplinary Standards. The Chief Compliance Officer reports directly to the CEO and the Board of Trustees and is responsible for the administration of WellStar’s Corporate Compliance Program as well as the day-to-day operation of WellStar’s Compliance Department. WellStar’s Compliance Department is responsible for regulatory, privacy, monitoring and auditing issues, and training.
The Chief Compliance Officer also chairs the Compliance Advisory Committee – a complement of multidisciplinary WellStar leaders. This committee has oversight responsibilities to ensure system-wide compliance with the fundamental elements of WellStar’s Corporate Compliance Program. In general, the committee addresses various compliance related issues and other applicable projects including but not limited to regulatory developments, internal and external audits and legal issues. Most importantly, the committee seeks to ensure that all compliance objectives are advanced according to expectations and properly executed. In furthering system-wide compliance, the Compliance Advisory Committee determines the scope of issues that warrant further review by the Board of Trustees and make recommendations accordingly. The Chief Compliance Officer, on behalf of the Compliance Advisory Committee, presents regular compliance reports to the CEO and the Board of Trustees Audit Committee. The Chief Compliance Officer also makes reports directly to the Board of Trustees from time to time. The diagram below provides an overview of the organizational structure of our Compliance Program:
Monitoring and Auditing
WellStar’s Compliance Department has a dedicated Coding Assurance team that is responsible for internal monitoring and auditing of documentation, coding, and billing patterns across WellStar physician offices and facilities. Coding Assurance audits focus on ensuring that all applicable state and federal laws and regulations are being followed; that underpayments and overpayments are identified early; payments are refunded appropriately when needed; and action plans are developed to mitigate against further occurrences. Additionally, each year the Coding Assurance team develops and executes an internal audit plan derived from the federal government’s annual OIG Annual Work Plan, internal issues of concern, and from various other issues within the healthcare industry. This audit plan is also utilized as an internal risk assessment tool.
Training and Education
WellStar’s Compliance Department staff members provide initial orientation and continuing compliance education for all new and existing employees. In addition, all employees are required to complete annual compliance training. The Compliance Department utilizes two basic platforms for training: on-line NetLearning modules and in-person training. In-person training includes lunch and learns, attending staff meetings, and periodic rounding throughout WellStar. In addition, the Coding Assurance team provides education and training when needed throughout WellStar. Education is also provided from outside healthcare consultants when applicable.
Personal Obligation to Report
WellStar believes each of its employees has an individual responsibility and duty to report their good faith belief of any violation of this Code of Conduct, WellStar policies or applicable law to his or her immediate supervisor, WellStar’s Compliance Department, or the Compliance Hotline and encourages each employee to do so.
Mechanism for Reporting - Compliance Hotline
WellStar operates an external, independent Compliance Hotline at 1-888-800-5094, available 24/7. It is WellStar's policy to not discriminate or retaliate against employees who report, based on a good faith belief that WellStar is not operating in accordance with applicable federal and state laws and regulations.
WellStar initiates corrective action and appropriate discipline when internal investigations reveal violations of this Code of Conduct, WellStar policies, and federal or state laws, rules, and regulations. Corrective Actions include, without limitation, refunding improper payments, notifying regulatory agencies, correcting the source of errors, and implementing monitoring processes to prevent future violations.
Employee actions which violate WellStar’s Employee Conduct Policy (PPP –1) or Employee Handbook can result in counseling reports or dismissal. Please refer to that policy for examples of improper employee conduct.
WellStar’s Code of Conduct is shared with all employees from inception of employment and is repeated with annual compliance training, which is incorporated into the employee’s annual review and must be completed by all employees. Each employee must acknowledge in writing that he/she received a copy of this Code of Conduct, understands it, and commits to honor it. This acknowledgement is maintained in the employee’s personnel file in the Human Resources Department.
WellStar provides a copy of this Code of Conduct to Vendors and Contractors as a condition of conducting business. Like WellStar employees, Vendors, and Contractors must acknowledge in writing that they received a copy the Code of Conduct, understand it, and commit to honor it. This acknowledgement is maintained on file in the Purchasing Department.
STANDARDS OF PROFESSIONAL AND BUSINESS CONDUCT
Please refer to WellStar’s policies and procedures for additional details regarding each Standard.
Patients and Communities Served:
WellStar is committed to providing quality health care in a manner that is appropriate, medically necessary and efficient without discrimination due to gender, age, disability, race, color, religion, national origin or ability to pay. WellStar strives to provide considerate and respectful care with recognition of patient’s dignity and right to privacy. WellStar employees, Medical Staff Members, and Allied Health Professionals are properly credentialed, experienced and licensed to meet the needs of WellStar’s patient population. To the extent possible, the patient (or the patient’s representative) is involved in decisions regarding care delivered. Generally, the patient’s health care provider or designee will inform patients about the therapeutic alternatives and risks associated with the care the patient seeks and obtain the informed consent of the patient or patient representative. To the extent possible, information will be provided in a language that the patient can understand.
Coding, Billing, and Accounting for Patient Services, Medical Necessity, and Covered Benefits
WellStar provides patients with services or items that are medically reasonable, necessary, and appropriate. WellStar submits claims for payment to all payers, including government, private insurance and individuals, for the services and items provided. WellStar personnel who are responsible for providing services, documenting, coding, billing, and accounting for patient care services work hard to ensure accuracy in the foregoing activities, compliance with all applicable state, federal, and payer regulations that apply due to WellStar’s participation in Medicare, Medicaid, and other state and federal government programs (“public health programs”), WellStar policies and procedures pertinent to these activities and the Corporate Compliance Program. WellStar prepares and submits cost reports and associated documentation according to all applicable regulations and contracts.
WellStar understands that patients expect to know the identity and qualifications of all WellStar employees, Medical Staff Members and Allied Health Professionals who provide services to them and to receive information regarding policies, procedures, and charges. All such personnel are required to wear identification badges which identify their name, title, affiliation with WellStar and photograph. WellStar instructs its employees to answer all questions from patients promptly and courteously or to refer the patient to an appropriate source.
WellStar provides an emergency medical screening examination and necessary stabilization of patients and treats pregnant women in labor regardless of the patient’s ability to pay or insurance status. Provided the WellStar facility has the capacity and capability, anyone with an emergency medical condition is treated. Patients with emergency medical conditions are only transferred upon the patient’s request or if the patient’s medical needs cannot be met at the WellStar facility and appropriate care is available elsewhere.
Freedom of Choice
When referring patients to providers of designated health services, such as home health agencies, medical equipment suppliers, or long-term care and rehabilitation providers, WellStar respects and honors a patient’s right to choose his or her own providers. WellStar also respects and honors, to the extent legally permitted, a patient’s right to refuse treatment.
Personal and Confidential Patient Information
WellStar makes all efforts to protect personal and confidential or privileged information about WellStar patients. WellStar abides by federal privacy and security regulations, including HIPAA, and applicable state laws. Our Notice of Privacy Practices informs patients about how we treat their health information. WellStar employees are trained about privacy and security regulations as these regulations apply to their duties. Confidential patient information is disclosed only on a “need to know” basis.
Research, Investigations, and Clinical Trials
WellStar respects the rights of research study participants, their well being, and their privacy. As applicable, WellStar utilizes an Institutional Review Board in research activities.
Adherence to Antitrust Laws
WellStar avoids engaging in anti-competitive behavior or agreements that restrain trade.
Conflicts of Interest
WellStar requires its employees to conduct their clinical activities and personal business in such a manner as to avoid potential or actual conflicts of interest.
Creation and Retention of Records
WellStar retains ownership of all patient and System records it creates. WellStar works hard to ensure that patient records are accurately prepared, securely maintained and retained as prescribed by law and WellStar policy. Accurate records are required for WellStar to retain applicable licensure and accreditation.
Government Requests for Information, Subpoenas and Search Warrants
WellStar cooperates with appropriately authorized governmental (federal, state and local) investigations and audits. If an investigator wishes to speak to a WellStar employee, the employee has the right to consult with the Legal Department or a personal attorney. Consulting with an attorney does not mean the employee is unwilling to cooperate.
Marketing and External Relations
WellStar adheres to fair business practices and fairly, accurately, and honestly represent itself and the products and services of the System.
Refusing Gifts and Tips and Preventing Improper Referrals, Kickbacks, and Influences on Clinical Decisions
WellStar does not permit its employees to accept nor offer, for themselves or for the System, gifts, tips, personal gratuities or anything of value from/to patients, vendors, or others, in exchange for referrals of business or the referral of patients. WellStar honors Federal regulations that prohibit referral of a patient to an entity in which a physician has a financial interest, and that prohibits WellStar to accept payment or other similar benefit in exchange for referrals of patients covered by Medicare or Medicaid.
Access to Electronic Media
WellStar provides its employees and others with access to electronic media. It is the responsibility of such persons to read, understand, and abide by WellStar’s Policies pertaining to the access and use of WellStar’s electronic media.
Confidential information about WellStar, including System strategies and operations is a valuable asset. Although WellStar employees may come in contact with and use confidential information to perform their jobs, confidential, proprietary and trade secret information (“Confidential Information”) must not be shared with others unless there is a “need to know” or it is permitted according to a contractual business relationship. WellStar Confidential Information includes, without limitation, personnel data maintained by the System; patient lists and clinical information; patient financial information; passwords; pricing and cost data; information pertaining to acquisitions, divestitures; affiliations and mergers; financial data; details regarding federal, state and local tax examinations of the organization or its joint venture partners; research data; strategic plans; marketing strategies and techniques; supplier and subcontractor information; and proprietary computer software. Occasionally, entities or persons seek disclosure of WellStar Confidential Information under Georgia’s Open Records Act or other similar statute requiring release of information. WellStar employees should immediately contact the Legal Department with any such requests.
Compliance Hotline and Non-Retaliation
WellStar operates an external independent Compliance Hotline at 1-888-800-5094, available 24/7. WellStar does not discriminate or retaliate against employees that report a good faith belief that WellStar is not operating in accordance with applicable federal and state laws and regulations. However, calls to the Hotline do not protect callers from appropriate disciplinary or legal action regarding their own performance or conduct.
WellStar promotes sound environmental and safety practices to ensure proper handling and disposal of medical and hazardous waste. WellStar takes all reasonable precautions to ensure the overall safety of patients, visitors, employees and other personnel and is committed to maintaining a smoke-free and drug free environment.
Fair Treatment of Personnel
WellStar prohibits discrimination in any employment-related decision on the basis of race, color, national origin, religion, sex, physical or mental disability, medical condition, ancestry, marital status, age, sexual orientation, citizenship or status as a covered veteran. WellStar is committed to providing equal employment opportunities and a work environment where each employee feels safe and is treated with fairness, dignity and respect.
Harassment and Discrimination
WellStar gives proper respect and consideration to everyone. Harassment of any type, including sexual harassment, is not tolerated and is strictly prohibited. Sexual harassment includes any unwelcome sexual advances or verbal or physical conduct of a sexual nature that is made a condition of continued employment, forms the basis for any employment decision, or otherwise interferes with an employee’s work performance, or creates an intimidating or offensive work environment. In this regard, all personnel are expected to conform to the standards of their respective professions and exercise reasonable judgment and objectivity in the performance of their duties. Any employee who has experienced, or has any knowledge of, an incident of discrimination or harassment must report the incident to his or her direct supervisor, the Human Resources Department, the Chief Compliance Officer, or the Compliance Hotline. Complaints will be investigated promptly and as confidentially as circumstances permit. If it is determined that a violation of this policy has occurred, WellStar will take prompt remedial action.
WellStar conducts queries with federal databases to ensure it does not conduct business with vendors, contractors, providers, or employed persons that have been sanctioned from participating in federal health care programs. WellStar rigorously screens all new employees, staff physicians, and vendors and makes a good faith effort to do the same with all contractors with whom we have a business relationship. As a follow up, WellStar conducts periodic additional screenings of all referenced parties to ensure ongoing compliance.
WellStar owns all intellectual property developed by its employees while employed with WellStar. Employees must promptly and fully disclose to WellStar all intellectual property that they have developed and they are prohibited from selling, transferring, or improperly disclosing WellStar’s intellectual property. As a condition of employment, or continued employment, each employee assigns to WellStar all rights, title and interest in any such intellectual property. Any questions should be directed to WellStar’s Legal Department.
Acknowledgment and Certification
Click HERE to download Acknowledgment and Certification Form
Office of Compliance and Insurance Services
WellStar Health System
Compliance Hotline 770-792-1555