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Office of Healthcare Compliance

Office of Healthcare Compliance

1909 21st Avenue South
Nashville, TN 37212

phone: (615) 343-7266
fax: (615) 343-9138

email:
compliance.office
@vanderbilt.edu

VUMC Code of Conduct

Purpose
 

Vanderbilt University Medical Center (VUMC) is committed to the highest standards of ethics, honesty, and integrity in pursuit of its mission of education, research, patient care, and public service. All Directors, providers, staff, vendors, delegated entities, business associates, and other community members who participate in the work and mission of VUMC are expected to adhere to this Code of Conduct in the discharge of their duties. Consistent with other VUMC policies and procedures, the Code of Conduct provides guidance for the VUMC community, and sets forth our commitment to good practices and following the law.

Following this Code of Conduct will help you do the right thing. It will also protect you and the VUMC community. You are encouraged to talk with your supervisor if something is not clear, and the Office of Healthcare Compliance is always available to assist you.
 

Compliance with the Law
 

VUMC is committed to compliance with all applicable laws, rules, and regulations.  It is the responsibility of everyone at VUMC, including directors, providers, staff,  agents, representatives, contractors, vendors, and volunteers, to follow, in the course and scope of their work at VUMC, all applicable laws, rules, regulations and VUMC policies, as well as federal and state healthcare program requirements and maintain an environment that is committed to integrity and ethical conduct.

All VUMC community members are required to report any concerns that may be violations of law, regulation, contract, or policy to the appropriate party. VUMC will take no adverse action, and maintains a policy specifically prohibiting retaliation, against persons who make such reports in good faith.
 

Confidentiality
 

VUMC is committed to the appropriate protection of confidential information.  Federal and state laws and VUMC policies prohibit the unauthorized seeking, disclosing or giving of confidential information, contained in patient, research, employee or student records.  All members of the VUMC community are required to know and comply with laws and policies related to information privacy and security.

Prior to receiving a unique User ID and password, and annually thereafter, all members of the VUMC community including, but not limited to, providers and staff are required to complete confidentiality training and agree to abide by its content. Confidential information is to be accessed, used, and disclosed only when authorized and required to complete assigned job duties. User IDs, passwords, and other authentication devices are the equivalent of a signature within the information systems and must be safeguarded and never shared or disclosed. VUMC providers and staff are required to know and comply with laws and policies related to information privacy and security.

Additionally, members of the VUMC community are prohibited from sharing confidential information with competing providers, such as salaries or charges for services rendered.
 

Discrimination
 

VUMC is committed to the principles of diversity and equality and will not discriminate.  VUMC does not discriminate against individuals on the basis of their race, sex, religion, color, national or ethnic origin, age, disability, sexual orientation, gender identity, gender expression, military service, pregnancy, physical or mental  disabilities, genetic information, or any other class protected by applicable law in its administration of policies, programs or employment.
 

Harassment
 

VUMC prohibits harassment of any kind.  VUMC strictly prohibits harassment or contribution to any type of harassment. This includes, but is not limited to, sexual harassment or misconduct, treating colleagues in a disrespectful manner, retaliation, or bullying. Everyone is encouraged to report if they witness any type of harassment.
 

Conflicts of Interest
 

All members of the VUMC community should avoid potential or perceived conflicts of interest.  Individual conflicts of interest refer to situations in which an individual’s or family member’s financial, professional, or other personal considerations may directly or indirectly affect, or have the appearance of affecting, an individual’s professional judgment in exercising any VUMC duty or responsibility, including the conduct or reporting of research. Conflicts of interest can arise under many situations, including business relationships, purchasing decisions, gifts, use and appropriation of VUMC assets, research activities, student related activities, and activities related to family members.

In order to identify and review conflicts of interest and the appearance thereof, all members of the VUMC community are expected to disclose all outside activities and financial interests that might be or have the appearance of being conflicts of interest or commitment upon initial employment, and annually thereafter, as well as immediately if any changes in circumstances arise that may present a potential conflict of interest.
 

Research and Scientific Integrity
 

VUMC is committed to following all laws and regulations related to scientific research.  VUMC staff, providers, and health care professionals are responsible for accurate and complete documentation of research and health care services, the conduct of research with scientific integrity, and adherence to all applicable state and federal regulations particularly regulations relating to the protection of human and animal research participants and accurate reporting and appropriate expenditure of grant funds. In the interest of maintaining the highest standards of patient care and scientific integrity, researchers and physicians must familiarize themselves with all federal and state laws and any requirements of the funding sponsor governing their activities and with policies and procedures relating to misconduct in research.
 

Market Competition and Purchasing, Gifts, and Kickbacks
 

VUMC is committed to complying with state and federal antitrust (monopolies) and anti-kickback laws and regulations.  VUMC’s business practices prohibit setting charges in collusion with competitors, giving or receiving kickbacks, entering into certain exclusive arrangements with vendors, and sharing confidential information with competitors. When someone who can influence purchasing decisions made at VUMC takes money or anything of value from a vendor, it can be considered a kickback, which is illegal. For this reason, VUMC community members shall not accept any kind of gift, service or benefit from any vendor or vendor representative.
 

Patient Referrals
 

VUMC is committed to the lawful referral of patients to services outside VUMC for the delivery of appropriate patient care.  If a referring physician, or his or her immediate family member, has an ownership or investment interest in or a compensation arrangement with the entity to which a patient is referred, and payment for the referred services will be made from a federal or state health care program (such as Medicare, Medicaid and TennCare) a federal law, commonly referred to as the "Stark Law," may prohibit the referral. No VUMC providers shall refer a patient for services in violation of the law.

Additionally, members of the VUMC community should be aware that if someone refers a patient to another provider and receives something of value in exchange, it can be considered a kickback. Anti-kickback rules also apply to the recruitment of providers, recruitment of research subjects, and the acquisition of providers’ practices.
 

Billing and Claims


VUMC is committed to charging, billing, documenting and submitting claims for reimbursement for hospital and professional services in the manner required by applicable laws, rules and regulations.  All providers and staff should know and carefully follow the applicable rules for submission of bills and claims for reimbursement. 
 

Discharge Planning and Ancillary Service Referrals


VUMC is committed to appropriate discharge planning and the lawful referral of patients for ancillary health care services.  VUMC recognizes that the discharge of a patient to a residence or post-hospitalization provider is an important decision. In developing and implementing discharge plans, VUMC providers and staff act in the best interest of the patient, in the judgment of the health care provider. This includes the involvement and consent of the patient or patient's legal representative.
 

Emergency Treatment for Patients and Women in Labor and Patient Transfers
 

VUMC is committed to following state and federal laws and regulations with respect to the medical screening, stabilization, admission, and treatment of patients with emergency medical conditions and pregnant women who are in labor regardless of a patient's financial or insurance status.  Emergency services are available to all persons in need of those services without regard to their financial or insurance status. If any individual comes to the Emergency Department for a medical examination or treatment of a medical condition, VUMC must provide that individual with an appropriate medical screening examination to determine if an emergency medical condition exists, and if one does, VUMC must stabilize the emergency medical condition within its capabilities. VUMC’s commitment to patients is reflected in our willingness to help anyone in need, without discrimination of any kind.  
 

Environment


VUMC is committed to complying with all applicable environmental laws and to maintaining all necessary environmental permits and approvals.  Environmental compliance includes the proper handling, storage, use, shipment and disposal of all materials that are regulated under any applicable environmental law.


Controlled Substances


VUMC prohibits the unlawful possession, use, manufacture or distribution of illicit drugs and alcohol on its property or as part of any VUMC sponsored activity.  Health care professionals, including those who maintain Drug Enforcement Agency (DEA) registration, must comply with all federal and state laws regulating controlled substances.
 

Disciplinary Action


VUMC is committed to responding appropriately when anyone at VUMC violates law or policy.  All VUMC providers, staff and representatives must carry out their duties for VUMC as stated in these policies, and, as required by law, report violations of local, state or federal laws, rules or regulations to a supervisor, the Office of Healthcare Compliance, the Office of General Counsel or the Integrity Line. If any faculty, staff or representative does not report violations, knowing that such a failure violates a clear legal obligation, the individual may be subject to disciplinary action and may be terminated from employment. Such disciplinary conduct must abide by all substantive and procedural protections applicable to discipline in the Faculty Manual or, for staff, in the Human Resources Staff Guidelines. Disciplinary action may apply to a supervisor who knowingly directs or approves a person's improper actions, or is aware of those improper actions but does not act appropriately and within the supervisor's scope of authority to correct them, or who, by knowingly violating a clear legal or professional duty, otherwise fails to exercise appropriate supervision.
 

Response to Investigation


VUMC is committed to cooperating with government investigators as required by law.  If a member of the VUMC community receives a subpoena, search warrant, or other similar document, before taking any action, that person must immediately contact the Office of General Counsel or the Compliance Office.  The Office of General Counsel and the Compliance Office are responsible for authorizing the release or copying of documents. If a government investigator, agent, or auditor comes to the Medical Center, a supervisor, the Compliance Officer, the Office of General Counsel, or the Hospital Administrator-on-Call should be contacted before discussing any matters with such investigator, agent, or auditor.
 

Office of Healthcare Compliance


To assist VUMC with its commitment to appropriate conduct, all community members are encouraged to report violations of any law or policy to a supervisor, the Office of Healthcare Compliance, or the Integrity Line. It is the duty of all faculty, staff, and VUMC representatives to report Vanderbilt job-related criminal conduct of which they have actual knowledge or Vanderbilt job-related situations that endanger the health and safety of any individual. All reports are treated as confidential and are shared with others only on a bona fide need-to-know basis. VUMC will take no adverse action toward, and prohibits retaliation against, persons making reports in good faith. False accusations made with the intent of harming or retaliating against another person can subject the accuser to disciplinary action.
 

Statement of Receipt and Acknowledgment


Upon initial employment or contract and annually thereafter, VUMC faculty, staff, and representatives must acknowledge compliance with the Code of Conduct. 

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