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  • Newport Hospital Ethical Business and Professional Behavior Code

  • Newport Hospital
    Ethical Business and 
    Professional Behavior Code

    Sections:

    Purpose

    Newport Hospital's board of trustees, senior management, medical executive committee and ethics committee have established this statement of organization ethics in recognition of the hospital's responsibility to patients, staff, physicians and the community we serve.

    The statement is designed to provide an ethical framework for decision making, personal and corporate behavior, strategic planning, and other actions associated with patient care, business and employee practices.
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    Responsibility

    It is the responsibility of every person associated with Newport Hospital—governing board members, medical staff, administration, management, employees, remote medical office staff, volunteers and students—to act in a manner that is consistent with this ethics statement and its supporting policies.

    It is the responsibility of the board and senior management to be consistent in their actions, to develop and maintain an organizational climate that supports ethical decision making and to focus attention on ethics in the everyday life of the organization.

    The integrity of Newport Hospital is diminished when any of these standards is violated. The hospital expects every individual associated with the Hospital to report any violation of this ethics statement to the appropriate manager, administrator, the board of trustees or the Ethics Committee. When possible and appropriate, confidentiality will be maintained.

    The Ethics Committee is available for consultation regarding any questions or concerns. Access to the committee is through any committee member.
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    General Principles

    All persons who work for or provide services to Newport Hospital are expected to adhere to ethical standards and to promote ethical behavior consistent with these standards. All actions should be judged by considering if the action is right, fair and in accordance with applicable laws and regulations. The Hospital's Statement of Values must be adhered to in all cases
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    Statement of Values:

    • Respect and dignity of the individual 
    • Excellence 
    • Honesty and fairness 
    • Stewardship of resources

    Those individuals whose behavior is found to violate ethical standards will he appropriately counseled, disciplined or penalized.
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    Respect For the Individual

    All people, including patients and their representatives, are to be treated fairly and with dignity, courtesy and respect. All persons are entitled to work in/to be cared for in an environment that is free of verbal, physical and sexual harassment, as well as free from discrimination and favoritism. To the extent that they are consistent with Newport Hospital's operational policies, do not harm others or interfere with treatment, all persons' religious beliefs, personal and spiritual values and cultural practices may be expressed and shall be respected. Further, all staff should ensure that the psychological, social, spiritual, educational, cultural and physical needs of patients and their families arc respected and should promote staff sensitivity to the full range of these needs.
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    Access to Services

    Newport Hospital provides care, to the full extent of its capabilities, to all people who need emergency care and to all residents of Newport County who need care without regard to the ability to pay. All patients are afforded a uniform standard of care throughout the organization and its remote medical offices. Only patients who request to be transferred, or whose specific condition or illness cannot be safely treated at Newport Hospital, are transferred to another facility which has agreed in advance to accept the patient. Patients will be discharged from Newport Hospital when, in the opinion of the attending physician, the patient's medical needs no longer require a hospital level of care, regardless of the status of or lade of insurance coverage.
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    Respect for Patient Autonomy

    Each patients autonomy and right to make decisions about his or her medical care or to refuse treatment shall be respected. The patient and/or the patients representative shall be given the information necessary to make informed decisions about medical care including the potential benefits and drawbacks of proposed treatments or procedures, the potential problems related to recuperation, the likelihood of success, the possible results of non-treatment, and any significant alternatives. To the extent possible, patients and/or their families will participate in decisions regarding care, without undue influence, especially care at the end of life. All caregivers will constantly seek to understand and respect the patients and the family's objectives for care. The patient's right to exclude any or all family members from participating in his or her care decisions will be respected, Bach patients dignity and positive self-regard will be preserved.

    No patients, including those in units with relatively long lengths of stays, will be required to work or perform tasks for the organization other than voluntarily participating in their personal care or those activities which are an integral part of their therapeutic plan of care.
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    Clinical Decision Making

    Clinical decisions (including tests, treatments and other interventions) will be made with integrity and in accordance with these ethical standards. Such decisions will be based on identified patient health care needs regardless of how Newport Hospital compensates or shares financial risk with its leaders, managers, clinical staff, and licensed independent practitioners.
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    Confidentiality

    All persons are responsible for ensuring the confidentiality of health care information consistent with sound medical practice and the delivery of health care by a multidisciplinary team of professionals.

    Sensitive information concerning personnel and management issues and hospital business will be maintained in the strictest confidence and utilized only by those individuals authorized to review and act upon such information.
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    Resolution of Conflicts

    Should conflict arise among those who participate in hospital and patient care decisions, whether this conflict is between members of administration, medical staff, employees, the governing body, or between caregivers and the patient, every effort will be made to resolve the conflict fairly and objectively. In cases where mutual satisfaction cannot be achieved, the patient representative, the administrator-on-call, social worker or the clergy, as appropriate, will be involved to oversee resolution of the conflict if the conflict involves ethical issues, assistance from the hospital's ethics committee may be requested via the vice president of nursing and patient care services or his/her designee.
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    Access to Protective Services

    All members of the health care team are responsible for ensuring that patients have access to information about the protective services they may require including guardianship and advocacy services, conservatorship and child or adult protective services. The social work department maintains lists of names, addresses and telephone numbers of pertinent state client advocacy groups including information regarding the patient's right to file a complaint with the Rhode Island Department of Health if he or she has a concern about patient abuse, neglect or about misappropriation of a patient's property in the facility.
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    Fair Billing Practices

    Accurate and prompt billing practices by the hospital will be maintained. All bills will reflect services actually provided and include dates of service. Bills for outpatient services will be itemized. Prompt assistance will be provided to patients and other payers in answering questions about charges. Every effort will be made to attempt to resolve questions and objections fairly and to the satisfaction of the patient while considering the best interests of the hospital and Lifespan as a whole. Such questions or objections will be handled professionally without real or perceived harassment.
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    Marketing

    All of Newport Hospital's communication, including disclosure of information, shall be clear, accurate and sufficiently complete so that such communication is not misleading. Health care advertising and marketing materials shall be truthful and fairly and accurately represent Newport Hospital, its capabilities and its level of licensure and accreditation. Advertisements will be judged for their frankness, clarity and demonstrable truths.
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    Competition

    In instances where there is the potential for competition between the hospital and individual physicians, the hospital will be guided by what is best for the patient and the community and secondarily by what is best for the hospital and medical staff. Where the hospital provides services which compete with services provided by a member or members of the medical staff, the hospital will, when referring a patient, inform the patient of all appropriate services available in the community and of any interest the hospital holds in any of these services. Given all relevant information, the patient is better able to make an informed decision when choosing between services. The hospital and physicians should compete on the basis of the quality of the service provided and not on set referral patterns.
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    Corporate Compliance/Code of Conduct

    Lifespan and Newport Health Care Corporation are committed to a continuing effort to maintain principles of ethical business conduct. To accomplish this, Lifespan has developed a system-wide Corporate Compliance Program which includes the Newport Health Care Corporation. This program has been reviewed and approved by the Newport Health Care Corporation board of trustees. The purpose of this program is to ensure that Lifespan and its affiliates conduct their operations and provide services in a manner consistent with the mission statement, vision, values and charitable purposes and with all applicable federal and state laws and regulations. The program consists of a mechanism for reporting, investigating, monitoring and responding to potential, threatened or actual violations of federal or state law. The program is intended to serve as a vehicle for Lifespan on an ongoing basis, to educate its employees and police itself, in order to prevent any violations of law from occurring and/or to minimize the impact, exposure or liability of any such violations.

    Every Newport Health Care Corporation manager has a copy of The Lifespan Corporate Compliance Program Manual and a copy is maintained in Newport Hospital's Library Resource Center. The manual includes the code of conduct and valuable information about laws, regulations and standards such as the Medicare/Medicaid Conditions of Participation, standards affecting the delivery of health care services and products such as professional licensing requirements and accreditation requirements of the Joint Commission on the Accreditation of Healthcare Organizations and Food and Drug Administration registration requirements, antitrust, fraud and abuse, anti-kickback and self-referral laws, laws affecting the recruitment of physicians, laws regulating tax-exempt organizations, laws regulating the disposal of hazardous and medical waste, environmental and OSHA laws and laws affecting employment, such as sexual harassment laws, the Americans with Disabilities Act and the federal Family Medical Leave Act.
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    Business Practices

    Business will be conducted in good faith, with integrity and in accordance with these ethical standards. Adherence to such standards should never be traded or compromised for financial, professional or other business objectives. This obligation includes dealing honestly with other health care providers, educational institutions, payers, internal and external customers, suppliers, competitors and financial partners.

    Business decisions will be based on the corporate mission, strategic plan and hospital resources. They will take into consideration the health care needs of the community served by the hospital with care given to avoid duplication of services, and services that are unnecessary or non-efficacious. As we work to provide care in a more cost-effective manner, we will strive to provide care that meets our standards. Newport Hospital will not be wasteful in the utilization of its resources. In all business matters, Newport Hospital will obey all relevant laws, regulatory standards and ethical codes.
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    Investment Practices

    The Newport Health Care Corporation will ensure that the assets of the Corporation are invested in a manner that is consistent with the overall mission, values and ethical standards of Newport Hospital. Investments will not be made in companies deemed to have significant activities contrary to good health.
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    Conflict of Interest

    All persons associated with the Newport Health Care Corporation and its subsidiaries should avoid actual or potential conflicts of interest (i.e., situations in which a person has the potential to direct or influence a decision to his or her own or family's gain or advantage or to expose Newport Hospital to harm as a result of a conflict of interest).

    Any person having any substantial investment, financial interest or compensation relationship, direct or indirect, in any supplier, client or competitor should make prompt and full disclosure to the president of the hospital or the board of trustees so that appropriate action may be taken to ensure that such conflict does not inappropriately influence important decisions. Trustees, board-level committee members, the chief executive officer, vice presidents, medical staff officers, department chairpersons, committee chairpersons and others as identified by the board will be required to complete an annual disclosure form identifying possible conflicts of interest.

    Likewise, any person associated with Newport Hospital shall not give or accept a gift, entertainment or other material benefit from any person or concern which does, or is seeking to do, business with Newport Hospital if such gift, entertainment or material benefit might influence the person's or the concern's medical or business decisions. Employees of Newport Hospital shall not accept gratuities or tips from patients other than a token of appreciation presented to a department.
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       |   Newport Hospital Ethics Committee