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Section One: Duke Medicine Compliance
THE CODE OF CONDUCT
The Code of Conduct is designed to provide you, a valued member of our organization, with a clear understanding of what is expected in the workplace. The Code applies to every employee, governing board member, member of the medical staff, student, volunteer, as well as to those with whom we do business. This Code does not cover every situation. Instead, it provides broad guidelines that are detailed in each entity’s policies and procedures.
DUHS Policies: PDF Document
PDC Policies: pdcchannel.mc.duke.edu/pdc*
SOM/SON Policies: http://oarc.duke.edu/compliance*
*access is restricted based on locaion
WHICH LAWS AND REGULATIONS APPLY TO OUR WORK?
We strive to comply with the laws, regulations, standards, and policies that apply to Duke Medicine. These address activities such as: (1) honoring patients’ rights; (2) maintaining and retaining records; (3) billing and coding for services; (4) negotiating grants and contracts; (5) providing a safe working environment free from disruptive and inappropriate behaviors; (6) protecting the health and safety of human and animal subjects in research; (7) complying with licenses and permits; (8) protecting the confidentiality of patient, business, and personal information; and (9) complying with all laws governing federal- and state funded health care programs and the requirements of insurance companies.
THE COMPLIANCE PROGRAM
Compliance is understanding your job responsibilities and following the rules and policies that apply to Duke Medicine. Our Compliance Program was created to make sure that our workforce is properly trained to follow all the laws, regulations, and policies that relate to our operations and to provide a way for the workforce to raise compliance concerns and ask questions.
DUHS, PDC, and SOM/SON have compliance officers that oversee our Compliance Program. The DUHS, PDC, and SOM/SON Compliance Offices are responsible for facilitating 1) delivery of compliance training to all of our workforce members, including employees, physicians, volunteers, vendors, and others within our organization; 2) monitoring activities to review business practices to make sure we comply with applicable laws, regulations, and policies; 3) responses to questions and concerns of staff; and 4) processes that assure compliance problems are reported and addressed. These compliance offices answer questions about compliance issues and work with the Office of Counsel to respond to government inquiries.
Entities within our organization also have individual facility compliance officers who work with the DUHS, PDC, and SOM/SON Compliance Offices to support compliance activities within his or her facility or division.
Each entity within Duke Medicine has a Compliance Committee that is responsible for: (1) implementing, maintaining, and improving the Compliance Program and this Code; (2) making sure we uphold the standards in this Code; and (3) making sure that people can report compliance concerns without fear of retribution or retaliation.
WHAT IF I THINK A LAW OR POLICY IS NOT BEING FOLLOWED?
You must report it. If employees, governing board members, members of the medical staff, students, volunteers, or vendors suspect that a law, regulation, policy, or this Code is being violated:
- Contact management or your supervisor about your concern or problem.
- If you feel uneasy talking to your supervisor, voice your concern to the next supervisory level, up to and including the highest level of management.
- You may also contact your facility compliance officer, or the DUHS, PDC, or SOM/SON Compliance Officer.
- Call the Integrity Line at 1-800-826-8109 to report anonymously.
THE INTEGRITY LINE 1-800-826-8109
Sometimes you may wish to report a compliance concern anonymously and not through the normal chain of authority. In that case, report your concern through the Integrity Line: 1-800-826-8109.
- Calls to the Integrity Line are not traced. Callers do not have to give their name; however, they may do so in order to provide additional information if needed. If callers do identify themselves, their confidentiality will be protected to the extent permitted by law.
WHAT WILL HAPPEN IF I REPORT A COMPLIANCE CONCERN?
Duke Medicine Compliance Offices evaluate all reports promptly, completely, and fairly. The respective office does not act on any report until it makes sure the report is valid.
- Duke Medicine Compliance Offices protect the confidentiality and other rights of all personnel, including anyone who is the subject of a compliance complaint.
- Anyone who violates applicable policies, laws, regulations, or this Code may be disciplined. People may also be disciplined if they do not report a compliance violation. Disciplinary action may include being terminated or having a contract revoked.
- You may ask the Compliance Office how your report was investigated and what the results were. The office will provide information to the extent permissible.
The Compliance Reporting and Non-Retaliation and Non-Retribution Policy ensures that no one is penalized for reporting what they honestly believe is a compliance problem. However, if someone purposely falsifies or misrepresents a report of wrongdoing— whether to protect him or herself or to hurt someone else—that person will not be protected under this policy (staff.dukehealth.org).
Non-Retaliation/Non-Retribution Policy (staff.dukehealth.org)
- There will not be any retaliation as a result of reporting in good faith, regardless of whether or not a violation is found to have occurred.
- Retaliation is a violation of the Compliance Program and will not be tolerated and must be reported.
- Reports of retaliation will be investigated thoroughly and quickly and can result in disciplinary action, up to and including termination of employment.
EXPECTATIONS FOR CONSULTANTS AND VENDORS
Consultants, service providers, vendors, and independent contractors (“vendors”) are an integral part of Duke Medicine’s performance of its activities, and it is a priority of ours to ensure that vendors, along with us, participate in the Compliance Program and uphold the Code of Conduct, Duke Medicine policies, applicable laws and regulations, and Joint Commission standards when providing services to and for us.
Vendors are required to participate in the Duke Medicine Compliance Program as demonstrated by vendors’ review and acknowledgment of the Code of Conduct. To ensure vendors’ participation, all vendor staff are required to register and complete the necessary training prior to entering one of our facilities.
Duke Medicine provides all vendors with a copy of the Code of Conduct. We make relevant training and education programs available to vendors. It is required that vendors also abide by our Vendor Policy.
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