2. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 1 OBJECTIVES for BUSINESS INTEGRITY TRAINING

3. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 2 Definition of Integrity/Ethics “Integrity is shown by how we behave when no one else is watching.” “Integrity is shown by how we behave when no one else is watching.”

4. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 3 Identify Parties With an Interest in the Health System’s Business Ethics  Patients  Family Members  Community  Staff  Physicians

5. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 4 Identify Parties With an Interest in the Health System’s Business Ethics (cont)  Regulators  Donors  Media  Board of Directors  Other Providers

6. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 5 Identify Potential Consequences of a Lack of Integrity The government can use administrative, civil or criminal laws to punish health care providers who break the rules. Lose your job Lose your job Fines & Penalties ($2,000 to $50,000 per occurrence!) Fines & Penalties ($2,000 to $50,000 per occurrence!) Possible Imprisonment Possible Imprisonment Most severe is “exclusion” from Medicare Most severe is “exclusion” from Medicare

7. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 6 Recognize the Scope of Issues Relating to Business Integrity Physicians have rules to follow to calculate their bills, both in and out of the hospital Physicians have rules to follow to calculate their bills, both in and out of the hospital Nurses and therapists have to document many aspects of patient care Nurses and therapists have to document many aspects of patient care Dietary staff must maintain records of patient’s diet and food allergies Dietary staff must maintain records of patient’s diet and food allergies

8. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 7 Recognizing the Scope of Issues Relating to Business Integrity (cont) Facilities must maintain proper records on use of incinerator Facilities must maintain proper records on use of incinerator Employee Health & Safety handles our OSHA program Employee Health & Safety handles our OSHA program Clinical Engineering has to maintain all medical equipment Clinical Engineering has to maintain all medical equipment

9. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 8 Recognizing the Scope of Issues Relating to Business Integrity (cont) Central processing, laundry, and environmental services staff have standards relating to infection control that must be followed Central processing, laundry, and environmental services staff have standards relating to infection control that must be followed The Finance departments have to prepare many reports relating to employment and IRS rules. The Finance departments have to prepare many reports relating to employment and IRS rules. Every employee has the responsibility to report a suspected breach of ethics or fraud. Every employee has the responsibility to report a suspected breach of ethics or fraud.

10. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 9 Recognize the Health System’s Statement of Business Integrity/Business Integrity Program Manual & explain its purpose Think of these materials as the blocks and mortar of a building’s foundation – everything else in our business integrity program is built upon it. Think of these materials as the blocks and mortar of a building’s foundation – everything else in our business integrity program is built upon it. REMEMBER: The Statement of Business Integrity says that the Health System will seek to identify and correct any illegal, unethical or unprofessional behavior.

11. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 10 If you experience times where you are uncertain what to do, ask yourself a few questions:  Is it illegal?  If I do this, how will I feel? (If you think it would make you feel uncomfortable, don’t do it.)  If I did this what would my friends and family think? Statement of Business Integrity (cont.)

12. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 11 Evidence of Integrity Honesty Honesty Privacy Privacy Safety Safety Cooperation Cooperation Respect Respect Accuracy Accuracy

13. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 12 Evidence of Integrity (cont) Appropriate disclosures Appropriate disclosures Fairness Fairness Dignity Dignity Non-discrimination Non-discrimination Compliance with laws Compliance with laws Assistance Assistance

14. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 13 Benefits to Having a Business Integrity Program Minimize the risk of fines & penalties, which could have a severe impact on the ability to fund new programs, purchase new equipment, and improve facilities, wages and benefits, etc. Minimize the risk of fines & penalties, which could have a severe impact on the ability to fund new programs, purchase new equipment, and improve facilities, wages and benefits, etc. Organization will have a good reputation Organization will have a good reputation Most important, the community would suffer – we exist to serve the community Most important, the community would suffer – we exist to serve the community

15. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 14 Identify Your Responsibility Every job has standard procedures to be followed – ask yourself if you would want someone to “skip a few steps” if they were part of your team (nursing, dietary, administration, etc.) caring for your family or friends. Every job has standard procedures to be followed – ask yourself if you would want someone to “skip a few steps” if they were part of your team (nursing, dietary, administration, etc.) caring for your family or friends. Everyone is responsible to follow their area’s policies and procedures, AND to be alert to instances where rules are ignored. Everyone is responsible to follow their area’s policies and procedures, AND to be alert to instances where rules are ignored. Be an active participant in seeking solutions to any areas needing improvement Be an active participant in seeking solutions to any areas needing improvement

16. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 15 Identify the Roles of the Director of Business Integrity & the Internal Auditor Minimize risk to the health system Minimize risk to the health system Serve as resources to the health system Serve as resources to the health system Periodically review the procedures of each department or unit within the Health System to add value and improve operations Periodically review the procedures of each department or unit within the Health System to add value and improve operations

17. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 16 Identify the Roles of the Director of Business Integrity & the Internal Auditor Serve as resource to staff – maintains confidentiality and objectivity Serve as resource to staff – maintains confidentiality and objectivity Report regularly to senior management and Board of Directors of the Health System Report regularly to senior management and Board of Directors of the Health System

18. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 17 Identify Ongoing Educational Requirements All employees are encouraged to have 1-3 hours of continuing education per year All employees are encouraged to have 1-3 hours of continuing education per year Materials are provided to managers each month for ongoing training Materials are provided to managers each month for ongoing training

19. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 18 Identify How to Report a Concern Ask your supervisor Ask your supervisor Ask your supervisor’s manager Ask your supervisor’s manager Call our Director of Business Integrity, Shana Wolfe Call our Director of Business Integrity, Shana Wolfe Call our Compliance Line to make an anonymous report Call our Compliance Line to make an anonymous report  Extension 7950  Local 301-790-7950  Toll-free 888-847-9247 THERE WILL BE NO RETALIATION FOR REPORTING A CONCERN THERE WILL BE NO RETALIATION FOR REPORTING A CONCERN

20. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 19 Your Personal Commitment Your personal commitment to integrity is not something you pick up when you start work each day – it is part of who you are. It is also a cornerstone of operations at Washington County Health System.

21. 7/3/2015WASHINGTON COUNTY HEALTH SYSTEM, INC. 20 NOT THE END… JUST THE BEGINNING!!