Download a PDF of the Code of Ethical Conduct booklet

To All Employees
The basis of the Code of Ethical Conduct at North Oaks Health System is “doing the right things right.” But the question is, how do you know what the right thing is? With constant changes in the laws and regulations that govern health care, the answer to that question becomes more difficult each day. We work in a demanding and very complicated environment where the answers aren't always black and white. That means that every day, it is mandatory that we conduct ourselves in an ethical manner and that we use good business judgment in all of our activities.

This booklet is intended to provide a basic overview of the policies under which North Oaks operates. I encourage you to refer to it often.

Since our beginning, North Oaks has based all that we do around a strong sense of values. The heart of our work ethic in dealing with our patients, visitors, employees, volunteers, physicians and community is “CARE.“ This stands for “Courtesy, Attitude, Respect and Enthusiasm.” We deliver on our promises and apply ethical standards in all our interactions. In short, we focus on “doing the right things right.”

James E. Cathey Jr.
President/CEO
North Oaks Health System

[back to top]

Code of Ethical Conduct
North Oaks has a comprehensive Ethics and Compliance Program, which is a vital part of the way we conduct ourselves at North Oaks Health System. We strive to deliver health care compassionately and to act with absolute integrity in the way we do our work and in the way we deal with our patients, visitors, business associates, physicians and each other.

North Oaks provides services pursuant to appropriate federal, state, and local laws and regulations, and the Conditions of Participation for federal health care programs.

It is our responsibility to conduct all business and patient care practices in an honest, decent, proper manner and to maintain compliance with all applicable laws. It is the responsibility of the governing board, administration, employees and volunteers to ensure compliance with this code of ethical conduct.

Anyone aware of violations or suspected violations of laws, regulations, the Conditions of Participation, or System policies and procedures should report them immediately to a supervisor or director, the Senior Vice President of Human Resources, the Assistant Vice President of Corporate Compliance, or the Values Line.

[back to top]

How to Communicate Questions or Concerns
Reporting concerns about what may be unethical or illegal conduct is expected of every North Oaks employee. We want to make you feel comfortable reporting such concerns. If you're ever faced with an ethical question or dilemma, here are the recommended steps you should take:

1. Speak with your immediate supervisor or department director.

2. Ifheorsheisnotavailable,orifyou'renot comfortable in that situation, contact the Senior Vice President Quality Resources/ Chief Compliance Officer at 230-6580 or the Assistant Vice President of Corporate Compliance/ Compliance Officer at
230-6224.

3. You can use the Values Line by calling 230-3333. You don't have to give your name, and it's available for you 24 hours a day.

[back to top]

Values Line
North Oaks offers the Values Line, a 24-hour, confidential phone line set up for employees to report any concerns or questions of a legal compliance or ethical nature. The purpose of the Values Line is to encourage you to report what you feel may be unethical or illegal conduct and to provide guidance in the interpretation of relative policies. Calls to the Values Line will be treated confidentially and may be placed anonymously, although the ability to contact the caller will provide the means to gain complete information. Instructions for use of the line and options for the caller are explained in the introductory message when the call is placed. Calls made to the Values Line will be promptly addressed. Also, remember, according to law, you cannot be disciplined for making a report of a compliance concern.

[back to top]

Individual Responsibilities:
Responsibilities for employees and volunteers:

1. Conduct your job duties in accordance with the Code of Ethical Conduct and System policies and procedures.

2. Treat others as you wish to be treated.

3. Utilize the components of the CARE program— Courtesy, Attitude, Respect and Enthusiasm—in all interactions associated with the System.

4. Take personal responsibility to report any violations or suspected violations of the Code of Ethical Conduct or other North Oaks policies and procedures.

Additional Responsibilities for Leaders:

1. Educate, direct and supervise the employees and/or volunteers in your department so that they understand and comply with the Code of Ethical Conduct and North Oaks and/or departmental policies.

2. Develop and update, as necessary, departmental policies and procedures to carry out the functions of your department.

3. Promptly follow-up on employee or volunteer reported concerns.

4. Promptly advise the Assistant Vice President of Corporate Compliance of reported violations of the Code of Ethical Conduct.

[back to top]

Compliance Topics
North Oaks Health System has policies and procedures in place to address compliance topics in detail, and they are available on the NONet. Some of the topics covered and of interest to most employees and volunteers include:

Gifts
General guidelines include:

1. No cash can ever be accepted.

2. The gift must be promotional and of nominal value (no substantial resale value).

3. Employees are prohibited from soliciting (asking/requesting) gifts, except as approved for System-wide, sanctioned fundraising activities for charitable organizations.

4. Gifts that would influence or appear to influence an employee or volunteer in the conduct of their duties or responsibilities must be declined.

North Oaks Health System Property
It is the policy of North Oaks that:

1. Neither instruments nor equipment can be removed from the premises of North Oaks facilities for personal use by anyone.

2. No one can use North Oaks' equipment, including computers or supplies, for their personal use. This includes on- or off-site use.

[back to top]

Conflict of Interest
Employees, volunteers and members of the Board of Commissioners must avoid actions that involve, or appear to involve, a conflict of interest with their obligations to North Oaks. You also must take great care not to speak for the hospital on personal matters of opinion. No one may use the name of North Oaks to endorse or further the efforts of any political candidate or other endeavor by an individual or business.

[back to top]

In Conclusion...
Compliance is an ongoing effort on behalf of all of us ... a continuous effort to find ways to improve our performance.

Our goal is to maintain an ethical environment and an effective compliance program. We want a place where you are proud to work, where you respect the decisions of your supervisors and where we all act in an appropriate manner that is consistent with the “doing the right things right” motto of the Compliance program. We want to provide this environment while complying with all legal and regulatory guidelines. We will know we have done that when every employee can answer a firm “yes” to the following questions:

1. Do you believe that management is committed to ethical practices?

2. Do you understand our Code of Ethical Conduct?

3. Do you know the procedure for reporting unethical or questionable practices?

4. Do you feel comfortable reporting ethical issues or dilemmas?

5. Are you given the education and tools necessary to perform your job in a legal and ethical manner?

We thank you for your commitment to the team effort that compliance and ethical practices represent. “Doing the right things right” is only possible when we all pull together. Thank you for the vital part you play in this challenge!

Sandy Patterson,
Senior Vice President Quality Resources/ Chief Compliance Officer

[back to top]