Wellstar Code of Conduct
Standards of Professional and Business 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, credo, 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. 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.
Basic Principles of Conduct (H.E.A.R.T.)
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 1 (888) 800-5094.
Truthful, Complete and Accurate Communications
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 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.
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. The Chief Compliance Officer also 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 make 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. The Chief Compliance Officer also makes reports directly to the Board of Trustees from time to time.
Monitoring and Auditing
Wellstar’s Compliance Department performs monitoring and auditing of areas 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 from 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.
Training and Education
Wellstar’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.
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. Compliance is everyone's responsibility.
Mechanism for Reporting
Wellstar operates an external, independent Compliance Hotline, which is available anytime. In accordance with our policy, Wellstar does not discriminate or retaliate against employees who, based on a good faith belief that Wellstar is not operating in accordance with applicable federal and state laws and regulations, make a report to the hotline. All calls are 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.
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, but are not limited to, refunding improper payments, notifying regulatory agencies, correcting the source of errors, and implementing monitoring processes to prevent future violations.
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 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. Wellstar employees, Medical Staff Members, and Allied Health Professionals are properly credentialed, experienced, and licensed to meet the needs of Wellstar’s patient population. 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 or needs. The healthcare provider or designee will involve the patient (or the patient’s representative) in healthcare decisions. Informed consent will be obtained from the patient (or patient’s representative) when required. Information will be provided in the patient's preferred language when available.
Wellstar understands that patients expect to know the identity and qualifications of all Wellstar team members, Medical Staff Members, and Allied Health Professionals who provide services to them. All such personnel are required to wear badges which identify their name, title, affiliation with Wellstar, and photograph above the waist, so it is visible to other individuals. Wellstar team members should answer all questions from patients promptly and courteously or refer the patients to an otherwise appropriate resource.
Documentation, Coding, Billing and Reimbursement
Wellstar provides patients with services and/or items that are medically necessary and appropriate. We submit 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.
The 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.
Patient Freedom of Choice
Wellstar strives for meaningful involvement of patients and their caregivers when it comes to patients’ 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.
Personal and Confidential Patient Information
Wellstar makes every effort to protect personal, 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 team members 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.
Research, Investigations and Clinical Trials
Wellstar 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.
Adherence to Antitrust Laws
Wellstar avoids engaging in anti-competitive behavior or agreements that restrain trade.
Conflicts of Interest
As 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.
Creation and Retention of Records
Wellstar 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.
Government Requests for Information, Subpoenas and Search Warrants
Any Wellstar employee that 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 team member, 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 represents itself and the products and services of the system.
Gifts, Tips and Personal Gratuities
All 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 business or clinical care. Wellstar team members should be sure that even permitted items do not damage our integrity and public trust under the circumstances. Wellstar team members should never ask to receive a gift from any source, and should not accept or solicit gifts from government officials.
Preventing Improper Referrals, Kickbacks and Influences on Decisions
Although Wellstar team members 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 team members 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.
Team Members and Workplace
Acceptable Use of Technology Resources
It is Wellstar’s policy to balance 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 use of its Technology Resources at any time and without notice. Users should have no expectations of privacy when using Wellstar Technology Resources.
Confidential information about Wellstar is a valuable asset. Although Wellstar team members 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 team members should immediately contact the Legal Department with any such requests.
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.
Disruptive & Inappropriate Behavior
Wellstar 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 language, may be threatening or may involve physical contact. Examples of inappropriate and disruptive behaviors include, but are not limited to: using abusive, profane or obscene language or gestures in the presence of team members, customers or visitors; fighting or inciting others to fight on Wellstar premises; and acts or behaviors that reflect unfavorably upon the reputation of Wellstar. Our Anti-Harassment/Anti-Sexual Harassment policy prohibits harassment of any kind and our Anti-Retaliation policy prohibits retaliation against employees who report in a good faith any instances of harassment. To 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.
Wellstar team members who participate in unlawful behavior are subject to the terms of Wellstar’s Team Member Discipline policy and as such may be subject to immediate termination depending on the level of effect that the offense has upon Wellstar and its concerns.
It 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 that 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 team members, staff physicians, and vendors. As a follow up, Wellstar conducts periodic additional screenings of all referenced parties to ensure ongoing compliance.
conceived, developed, and reduced to practice during the team member's course of employment at Wellstar. Team members 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 team member intellectual property. Team members 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.