Wellstar Code of Conduct
Performing honestly, ethically and with integrity
- Our Vision, Mission, Values,
- Basic Principles of Conduct,
- Standards of Service Excellence, and
- Standards of Professional and Business Conduct
Wellstar’s Vision, Mission and ValuesVISION: Deliver world-class healthcare to every person, every time. MISSION: To enhance the health and well-being of every person we serve. VALUES:
- We serve with compassion.
- We pursue excellence.
- We honor every voice.
Basic Principles of Conduct (H.E.A.R.T.)At Wellstar, in keeping with our values of compassion, excellence, and honoring our voices, we put our “heart” into all that we do and that includes living in a compliant culture as described below.
Honor confidences entrusted to you. Organizational and patient information entrusted to you should be held in the highest confidence.
Ethical behavior 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 (470) 644-0400.
Report events 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 at 1 (888) 800-5094.
Truthful, Complete and Accurate Communications
Truthful, complete and accurate communications is the standard within our 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. Every employee
is responsible and accountable for upholding the following Standards of Service
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 our patients’ quality of care and satisfaction a team effort.
We believe in projecting a positive attitude.
Always speak positively. Remember, attitude sets the stage for success or failure. A 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 Wellstar Health System (“System”). Wellstar’s Compliance Department is responsible for regulatory, privacy, monitoring and auditing issues, and training. 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:
- Policies and Procedures,
- Designation of a Chief Compliance Officer,
- Monitoring and Auditing,
- Training and Education,
- Open Lines of Communication,
- Responding to Detected Deficiencies, and
- Enforcing Disciplinary Standards.
Designation of Chief Compliance Officer & Compliance CommitteeThe Chief Compliance Officer (CCO) 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. The Chief Compliance Officer chairs the Corporate Compliance 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 Corporate Compliance Committee determines the scope of issues that warrant further review by the Board of Trustees and makes recommendations accordingly. The Chief Compliance Officer, on behalf of the Corporate Compliance Committee, presents regular compliance reports to the CEO and the Board of Trustees Audit Committee as well as submitting reports directly to the Board of Trustees from time to time.
Monitoring and AuditingWellstar’s Compliance Department performs monitoring and auditing of internal controls related to regulatory compliance, clinical standards, and coding assurance. Regulatory Compliance areas are audited continuously to ensure adherence to all federal, state, and local laws and regulations. Compliance in these areas allows Wellstar to maintain a positive standing with the Centers for Medicare and Medicaid Services (CMS). Clinical auditing aims to uphold the highest level of patient care and safety, while also following the guidelines set out by the government and accreditation agencies, like The Joint Commission. The Coding Assurance team is responsible for internal monitoring and auditing of documentation, coding, and billing patterns across Wellstar physician offices and facilities. Coding Assurance audits focus on the early identification of underpayments and overpayments, refunding payments when appropriate, and developing action plans to prevent further occurrences. Each year the Compliance Department develops and executes an internal audit plan derived from the federal government’s OIG Annual Work Plan, internal issues of concern, and various other issues within the healthcare industry. Additionally, periodic risk assessments are conducted across all areas of compliance based on industry trends and/or regulatory changes.
- Wellstar expects employees to fully cooperate with the Compliance department in the course of its audit and investigation activities. Wellstar also expects that employees will not improperly influence, manipulate, or interfere with any auditor engaged to perform audits of Wellstar’s books, records, processes, or internal controls. Wellstar employees should not conduct audits independently without the approval of the Compliance or Legal department.
Training and EducationWellstar’s Compliance Department team 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 hosted by the Organizational Learning Department. The Compliance Department utilizes multiple platforms for training, such as online learning modules and in-person training. In-person training includes lunch and learns, attending staff meetings, and periodic rounding throughout Wellstar facilities. The Compliance Department provides education and training when needed or requested by anyone within Wellstar.
(Refer to Policy CO-08 Compliance Training and Education Procedure)
Personal Obligation to Report
Wellstar believes each of its employees has an individual responsibility and duty and right to report their good faith belief of any violation of this Code of Conduct, Wellstar policies, wrongdoing, or applicable law. Compliance is everyone's responsibility.The following process should be followed:
- Talk to your supervisor, who is most familiar with the laws, regulations, and policies that relate to your work area.
- If you are not comfortable contacting your supervisor or if you do not receive an adequate response, talk to another member of the management team or Human Resources.
- If you still have questions, contact the Wellstar Compliance Officer at 1-470- 644-0400.
- You may also use the Compliance Hotline to report concerns and complaints. Individuals using the Compliance Hotline are given the option to make a report anonymously. The toll-free Compliance Hotline is 1-888-800-5094 and is available 24 hours a day, 7 days a week to report misconduct or other compliance-related issues or concerns.
- Wellstar does not discriminate or retaliate against employees who report a compliance concern, based on a good faith belief that Wellstar is not operating in accordance with applicable federal and state laws and regulations.
Mechanism for Reporting - Compliance Hotline 1-888-800-5094
Wellstar operates an external, independent Compliance Hotline, which is available anytime. All calls can be anonymous and will be treated confidentially to the extent permitted by law. However, calls to the hotline do not protect callers from appropriate disciplinary or legal action regarding their own performance or conduct.
Internal Investigations of ReportsWellstar is committed to investigating all reported compliance or privacy concerns promptly with confidentially to the extent possible. The Compliance Officer will coordinate any findings from the investigations and recommend corrective action or changes that need to be made. We expect all employees to cooperate with investigation efforts.
Corrective ActionWellstar 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, but are not limited to, targeted education, refunding improper payments, notifying regulatory agencies, correcting the source of errors, and implementing internal controls to prevent future violations. (Refer to Policy CO-06 and Job Aid Fraud, Waste & Abuse Reports and Investigations)
CareWellstar is committed to providing quality health care in a manner that is:
- Appropriate, medically necessary, and efficient,
- Without discrimination due to age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, gender identity or expression, or any other discrimination prohibited by law.
- Wellstar strives to provide considerate and respectful care with recognition of a patient’s dignity and right to privacy.
CommunicationWellstar 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. All such personnel is required to wear badges that identify their name, title, affiliation with Wellstar, and a photograph. The badge is worn above the waist, so it is visible to other individuals. Wellstar employees should answer all questions from patients promptly and courteously or refer the patients to an otherwise appropriate resource.
Documentation, Coding, Billing, and ReimbursementWellstar provides patients with services and/or items that are medically necessary and appropriate. Wellstar submits claims for services and/or items to all payers, including government, private/managed care insurance, and directly to individuals. Wellstar strives to accurately document, code, bill, and collect for patient care services. Wellstar submits cost reports and associated documentation according to all applicable regulations and contracts. If inappropriate payments are identified, they are refunded in a timely manner to the appropriate parties. We are committed to meeting all applicable state, federal, and payer mandates of government programs, including Medicare and Medicaid. (Refer to Policy CO-05 False Claims Prevention)
Emergency TreatmentThe Emergency Medical Treatment and Active Labor Act (EMTALA) requires Wellstar to provide emergency healthcare to anyone needing it regardless of citizenship, legal status, or ability to pay. Wellstar may only transfer or discharge emergency department patients with the patient’s informed consent, after stabilization or when their condition requires transfer to a facility that is better equipped to administer the treatment. EMTALA also applies to women presenting to an emergency department in active labor. (Refer to Policy LD-108 Emergency Medical Treatment and Labor Act – EMTALA)
Patient Freedom of ChoiceWellstar strives for meaningful involvement of patients and their caregivers when it comes to the patient care. Wellstar works with patients and their caregivers to determine what is best for their continued care, especially when referring patients to other healthcare facilities and professionals who provide care to discharged patients, such as home health agencies, skilled nursing facilities, nursing homes, primary care physicians, medical equipment suppliers, long- term care and rehabilitation providers, or community resources. Wellstar also respects and honors, to the extent legally permitted, a patient’s right to refuse treatment. (Refer to Policy CO-13 Advance Beneficiary Notice of Noncoverage)
Personal and Confidential Patient InformationWellstar is committed to providing the best possible care to all our patients. This includes treating our patients’ information with care, maintaining every patient’s confidentiality, and keeping their protected health information secure.
- Wellstar abides by federal privacy and security regulations, including HIPAA, HITRUST, HITECH, Cures Act, 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 they apply to their duties.
- Confidential patient information is disclosed only on a “need to know” basis.
- Wellstar honors the patient’s right to access their information in an efficient timely manner.
Research, Investigations, and Clinical TrialsWellstar respects the rights of research study participants, their well-being, and their privacy, and utilizes an Institutional Review Board in its research activities, as appropriate. (Refer to PS-88-01 Uses and Disclosures of Protected Health Information for Research Purposes)
Wellstar Business Compliance
Management Compliance Responsibilities
- Management has the added responsibility for demonstrating, through their actions, the importance of this Code as well as their commitment to compliant, and ethical behavior.
- Managers are responsible for promptly (working with the Compliance Department) addressing ethical and compliance questions, or concerns, raised by their staff/business associates and for taking the appropriate steps to deal with such issues.
- Managers are responsible for coordinating and communicating compliance-related concerns to the Compliance Department as prescribed by Wellstar’s policy.
- Managers have an obligation to:
- Know and follow all laws, regulations, and policies related to their duties;
- Know and educate their staff on how to report suspected or actual violations;
- Encourage others to ask questions and to report actual or suspected violations; and
- Know and educate their staff on Wellstar’s Non-Retaliation Policy.
Adherence to Antitrust LawsWellstar avoids engaging in anti-competitive behavior or agreements that restrain trade.
Conflicts of InterestAs a Georgia non-profit corporation and federal tax-exempt organization that relies on public trust and confidence, it is Wellstar’s policy to ensure that conflicts of interest do not interfere with or influence Wellstar business or clinical decisions. Conflicts of interest exist when an individual's personal, financial, or other interests could improperly influence or appear to influence the execution of their Wellstar responsibilities. Examples of Avoiding Conflicts of Interest/Kickbacks/Stark violations:
- Do not accept gifts of value greater than $100 from drug companies or vendors or suppliers.
- Do not participate in vendor incentive programs without disclosure.
- Do not refer patients to laboratories or other healthcare facilities in which you have a direct financial stake without disclosure.
- Do not accept a "kickback" (any payment intended to influence decisions) for any patient referral.
- For staff in decision-making positions, disclose any outside financial interests, community activities, or commercial activities, including those of immediate family members, domestic partners, or others with a significant personal relationship, that may represent a conflict of interest and affect professional performance.
Creation and Retention of RecordsWellstar retains ownership of all patient and business records it creates. Wellstar works to ensure that patient records are accurately prepared, securely maintained, and retained according to law. Wellstar’s licensure and accreditation standards require that we maintain accurate records. Wellstar expects everyone to maintain all corporate records to be true, accurate, and complete with company data being promptly and accurately entered in accordance with Wellstar’s and other applicable accounting principles. (Refer to Policy IM-05 Record Retention) (Refer to Policy RC-01, Medical Record Documentation and Completion)
Government Requests for Information, Subpoenas and Search WarrantsAny Wellstar employee who becomes aware of a government investigation or legal proceeding involving Wellstar or is approached by a government or law enforcement official must immediately notify the Compliance and Legal Departments. Wellstar cooperates with all 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. (Refer to Policy CO-02 Government Investigations or Legal Proceedings)
Marketing and External RelationsWellstar adheres to fair business practices and fairly, accurately, and honestly represents itself and the products and services of the System. It is WellStar’s policy that marketing, advertising, and community events with Affiliated Physicians comply with applicable laws and regulations, meet ethical standards, avoid and/or minimize conflicts of interest, and promote fair and open transactions. Advertising and Marketing services involving Referral Sources must be documented and reviewed by the Compliance Department and cannot violate Stark, Anti-Kickback, tax exemption laws, or any other relevant laws. (Refer to Policy CO-14 Job Aid 1 Marketing Frequently Asked Questions)
Gifts, Tips, and Personal GratuitiesAll gifts, entertainment, and business meals provided or received by a Wellstar employee must be reasonable and small enough that they do not influence decisions about our business or clinical care. Wellstar employees should be sure that even permitted items do not damage our integrity and public trust under the circumstances. Wellstar employees should never ask to receive a gift from any source and should not accept or solicit gifts from government officials. (Refer to Policy CO-03 Patient Gifts – Accepting and Offering) (Refer to Policy CO-04 Vendor Compliance & Ethics Policy and Job Aids 1, 2 & 3)
Preventing Improper Referrals, Kickbacks, and Influences on Clinical DecisionsAlthough Wellstar employees may accept gifts, entertainment, and business meals of nominal value in accordance with Wellstar policies, Wellstar does not permit its employees to accept or offer anything of value from patients, vendors or others that would be viewed as being in exchange for patient referrals or other business. The “value” may include not only money, but also entertainment or discounts. Wellstar employees should avoid situations where they may be questioned whether they are acting in the best interest of Wellstar or for personal gain. Contact the Compliance Department if you are unsure if a particular situation may raise concerns. (Refer to Policy CO-03 Patient Gifts – Accepting and Offering) (Refer to Policy CO-04 Vendor Compliance & Ethics Policy and Job Aids 1, 2 & 3) (Refer to Policy CO-09-01 Business Courtesies to Potential Referral Sources and Job Aids 1, 2 & 3) (Refer to Policy CO-11 Professional Services Agreements and Physician Employment Agreements and Job Aids 1 & 2)
Employees and Workplace
Employment PracticesWellstar prohibits discrimination and harassment based on race, color, gender, national origin, age, religion, disability, sexual orientation, gender identity, veteran status, marital status, or any other characteristic protected by applicable law. Wellstar follows all laws covering freedom of association, collective bargaining, immigration, and wages and hours, as well as laws prohibiting forced or child labor.
Acceptable Use of Wellstar ResourcesWellstar’s resources, including time, material, equipment, and information, are provided for company business use (e.g., not for personal or non-Company sponsored activities). Regarding technology resources, it is Wellstar’s policy to balance the protection of its data, applications, networks and computer systems, telecommunication systems, and equipment (collectively, “Technology Resources”) from unauthorized access, alteration, destruction, or illegal activity against the right of its team members to use Technology Resources in their daily jobs and for reasonable incidental personal use. Wellstar reserves the right to monitor, record, or periodically audit the use of its Technology Resources at any time and without notice. Users should have no expectations of privacy when using Wellstar Technology Resources. Regarding political activities, NO use of Wellstar resources, including e-mail, is appropriate for personally engaging in political activity. An employee may, of course, participate in the political process on his or her own time and at his or her own expense. While doing so, it is important not to give the impression they are speaking on behalf of or representing Wellstar in these activities. Employees cannot seek to be reimbursed by Wellstar for any personal contributions for such purposes.
Confidential InformationConfidential information about Wellstar 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 legitimate business purpose disclosed with prior authorization according to our policies, or it is permitted according to a contractual business relationship. Wellstar Confidential Information includes, without limitation, personnel data maintained by the System; patient data, such as patient lists, 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 statutes requiring the release of information. Wellstar employees should immediately contact the Legal Department with any such requests.
Social MediaSocial media refers to online communities and personal blogs in which users post information, personal messages, and other content. When social media is used inappropriately, it can violate patient privacy leading to significant damage to Wellstar and Wellstar’s staff through, without limitation:
- Breach of patient privacy causing harm to the patient
- Reputational harm
- Loss of patient trust
- Substantial fines and penalties
- Maintain patient privacy and do not share confidential information about Wellstar
- Do not use your personal devices to take pictures of patients or patient information.
- Do not post patient information or photographs to a website, social media page, or public forums – even if the patient is not identifiable
- If you identify your connection to Wellstar, make it clear you are speaking for yourself and not for Wellstar.
- Your social media activities should meet Wellstar’s high standards of professional conduct.
- Social media activity must not interfere with your work commitments.
- Contact Wellstar’s Marketing Department if you have questions.
EnvironmentWellstar promotes sound environmental and safety practices to ensure the 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.
Disruptive and Inappropriate BehaviorWellstar prohibits disruptive and inappropriate behavior. Disruptive and inappropriate behavior is conduct by an individual that intimidates others to the extent that quality and safety could be compromised. These behaviors may be verbal or non-verbal, may involve the use of rude or threatening language, or may involve physical contact. It is Wellstar’s policy that all individuals are to be treated courteously, respectfully and with dignity. Medical Staff members have a responsibility for the welfare, well-being and betterment of Wellstar patients and staff. Examples of inappropriate and disruptive behaviors include but are not limited to:
- Using abusive, profane, or obscene language or gestures in the presence of employees, customers, or visitors.
- Fighting or inciting others to fight on Wellstar premises; and
- Acts or behaviors that reflect unfavorably upon the reputation of Wellstar.
Disciplinary ResponseTo help each employee make the best and most successful contribution to the organization, Wellstar has adopted a system of disciplinary responses to employee job-related issues, as defined in our Human Resources Employee Discipline policy. Additionally, Wellstar Medical Staff has adopted a “Disruptive Behavior” policy that defines prohibited inappropriate or disruptive behaviors that could compromise the quality and safety of patient care. Please refer to Human Resources policies or the Medical Staff policies for further examples of improper employee conduct. (Refer to HR Policy 3024 Employee Corrective Action)
Ineligible PersonsIt is Wellstar’s policy to prohibit contractual or employment relationships with sanctioned individuals or companies, which includes those listed by a Federal Agency as debarred, excluded, or otherwise ineligible for participation in federally funded healthcare programs. It may also include those who have been charged with criminal offenses related to healthcare. Wellstar conducts queries with federal and state databases to ensure it does not conduct business with sanctioned individuals or companies. Wellstar rigorously screens all new employees, staff physicians, and vendors. As a follow-up, Wellstar conducts periodic additional screenings of all referenced parties to ensure ongoing compliance. (Refer to Policy CO-07 Prohibition Against Contracting with or Employing Excluded Persons)
Intellectual PropertyWellstar owns all employee intellectual property that relates to the employee’s job and is conceived, developed, and reduced to practice during the employee’s course of employment at Wellstar. Employees must promptly and fully disclose to Wellstar all employee intellectual property that meets the criteria. As a condition of employment or continued employment, each employee assigns to Wellstar all rights, title, and interest in any such employee intellectual property. Employees are also prohibited from selling, transferring, or improperly disclosing Wellstar’s Confidential Information or intellectual property. Any questions should be directed to Wellstar’s Legal Department.
Acknowledgment ProcessWellstar’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 or she received a copy of this Code of Conduct, understands it, and commits to honoring it. Wellstar provides a copy of this Code of Conduct to Vendors as a condition of conducting business. Like Wellstar employees, Vendors must acknowledge in writing that they received a copy of the Code of Conduct, understand it, and commit to honoring it throughout their relationship with Wellstar. Wellstar Compliance Department
793 Sawyer Road
Marietta, GA 30062
Compliance Hotline: 888-800-5094