Code of Conduct for Healthcare – 18 things to include

Pieces of paper with the words "Right" and "Wrong" symbolizing what a code of conduct for healthcare can help with.

Many healthcare organizations of any size have a Code of Conduct. These codes are designed to demonstrate the organization’s dedication to ethical behavior and compliance with the healthcare services organization’s policies and procedures.

Codes of conduct also describe the management’s commitment to integrity and excellence in the organization. And the codes typically apply to a wide range of staff, including employees, physicians, independent contractors, volunteers, and even vendors. But what is the motivation for all this emphasis on ethical conduct?

In this Article …


Regulatory Requirements for a Code of Conduct for Healthcare Organizations

It might be surprising to learn that there are very few healthcare services that are required to have a Code of Conduct based on regulations.

Skilled Nursing Facilities are among the only type of healthcare services that are required by regulation to have written compliance and ethics standards. These regulations (Title 42 of the Code of Federal Regulations, Section 483.85) were issued in 2017 in accordance with the provisions of the Affordable Care Act of 2010. The regulations supersede the Health and Human Services, Office of the Inspector General (OIG) Compliance Program Guidance for Skilled Nursing Facilities issued on March 16, 2000.

The regulations say the compliance and ethics standards should be “reasonably capable of reducing the prospect of criminal, civil, and administrative violations under the Act and promote quality of care….”

By contrast, the OIG Guidance describes the reason for a Code of Conduct as “a foundational document that details the fundamental principals, values, and framework for action within the organization.” A different slant to say the least.

OIG Code of Conduct Guidance for Other Healthcare Organizations

The OIG has published compliance program guidance for several other types of healthcare organizations, all of which mention standards of conduct or code of conduct as part of the policies and procedures of the organization.

For instance, in the Guidance for Hospitals, the standards of conduct should reflect: “the organizations mission, goals, and ethical requirements of compliance and reflect a carefully crafted, clear expression of expectation for all hospital governing body members, officers, managers, employees, physicians, and where appropriate, contractors and other agents.”

Some of the Guidance documents mention issues like affirming a commitment to compliance with all State and Federal Laws and only mention managers and employees. But it is safe to say all the Guidance is encouraging healthcare organizations to foster a sense of doing the right thing in all circumstances.

What does a sample Code of Conduct cover?

Sometimes it seems like a Code of Conduct duplicates an organization’s employee handbook or personnel policies. It is true that both types of documents may touch on the same topics, especially things like safety and professional behavior. The difference is that a Code of Conduct should also ideally be mostly inspirational vs. mostly prescriptive.

A typical Code of Conduct might cover the following 18 items:

The Vision, Mission, and Values of the Organization
A commitment to observing all applicable laws and avoiding any impropriety, dishonesty, or wrongdoing; embracing honesty and integrity in providing services and dealing with people in good faith.
Definitions of the Compliance Program and covered individuals
Essential Principles – basically a list of essential principles of the legal and ethical behavior of the organization. For example: “Avoid actual and potential conflicts of interest, including actions that may give the appearance of a conflict of interest”.
An explanation of the Compliance Program and the duty to report actual or suspected violations
Quality of Care or Services, including meeting customer expectations and maintaining patient dignity; treating everyone you serve with respect and responding to concerns; acting according to the standards of your profession
Patient Confidentiality, including compliance with HIPAA regulations and maintaining information security
Safeguard the organization’s assets and the assets of patients or residents
Act in accordance with laws such as the Stark Law and the Anti-Kickback Statute when dealing with referral sources
Bill for services in accordance with all applicable rules and regulations
Compliance and transparency for employees with respect to conflicts of interest, gifts and entertainment, kickback referrals, and bribes
Maintain a professional environment of non-discrimination and avoiding harassment of fellow staff members or patients
Maintain the confidentiality of all business and patient information
Comply with all environmental laws and regulations applicable to the organization
Avoiding marketing and advertising efforts that do not accurately reflect the technical quality of services available
Keep accurate and complete financial records of the practice or service
Be committed to cooperating with government investigations and internal investigations
Fairly administer the disciplinary practices of the organization


Documenting Covered Individuals Acknowledgement

All of the OIG Guidance documents recommend education for covered individuals about the conduct code. And they recommend documenting that covered individuals have received a copy of the Code of Conduct, acknowledging their understanding of the Code and their responsibilities.

How Often Should a Code of Conduct be Revised?

As changing conditions result in changes to the Code of Conduct, revised versions should be distributed to covered individuals. Laws and regulations change slowly over time, and usually reflect evolutionary, vs. revolutionary changes. But as community, ethical and professional standards evolve, organizations committed to ethical behavior should update their Code of Conduct. A review of the need for changes every couple of years is the minimum.

It is always appropriate to remind covered individuals that the motto of any compliance program or Code of Conduct is “Do the right thing, always”. Then it is up to management to support and advocate for them when they do!

When you need proven expertise and performance

Jim Hook, MPH

Mr. James D. Hook has over 30 years of healthcare executive management and consulting experience in medical groups, hospitals, IPA’s, MSO’s, and other healthcare organizations.