Code of Conduct 

Compliance Policy #900


Boulder Community Hospital ("the Hospital") aspires to the highest ethical standards of conduct and commitment of its best effort to comply with all applicable laws and regulations that govern its operations.  In this regard, the Hospital has developed this Code of Conduct, as well as Compliance Policies to guide all employees in the conduct of the Hospital's business.

The purpose of this Code of Conduct is to remind all employees of the Hospital's mission and beliefs and to give direction and guidance to the employees of Boulder Community Hospital regarding the responsibility we all share to provide quality healthcare to our patients and to conduct all patient care and business activities ethically, with integrity, and consistent with applicable laws. This Code of Conduct is intended to be a summary of conduct expected of all Hospital employees and other persons affiliated with the Hospital.  Employees should also consult the specific Hospital policies and procedures which apply to the employee's duties at the Hospital.  All employees are responsible for being familiar with and abiding by this Code of Conduct and other policies, procedures and protocols governing their conduct at the Hospital.

Principles of Conduct

The foremost principle guiding Boulder Community Hospital in all of its activities is to do the right thing, the first time, and all the time.  We strive to conduct all of our activities with integrity and honesty and in accordance with applicable laws and the most ethical business practices.  We want to provide our patients the best and most ethical service possible.  The culture of the Hospital and all its activities should at all times exemplify our commitment to ethics, integrity and quality service.


The Hospital's mission drives its commitment to quality care and ethical business practices.  The focal point of that mission is to assure that patients receive high-level, comprehensive care in support of their physical, emotional, and spiritual needs and to provide access for all.  As the community hospital, we provide emergency care to all in need regardless of their ability to pay.


As described in its Belief Statement, the Hospital believes that it should be a leader in Boulder County.  We should exemplify, as an employer, the integrity and worth of each employee.  As a business, we should be accountable for our financial viability.  As a partner, we should have a good relationshipwith other healthcare providers, physicians, and hospitals.  As a member of the community, we should be a good community citizen.  As a visionary, we need to anticipate trends and take the initiative in responding to change.


The Hospital strives to earn the trust and respect of our patients, their families and significant others, healthcare providers, our affiliated physicians, our regulators, our third party payers, our suppliers, and our volunteers.  We are guided by the general principles of professionalism, compassion, and justice.  Employees are responsible for being familiar with and following the Hospital's Code of Ethics, which obligates all employees and others affiliated with the Hospital to provide quality patient care and respect for all persons, to avoid conflicts of interest, and to follow ethical business practices.

Standards of Conduct

The following are a summary of general guidelines summarizing the standards of conduct that Boulder Community Hospital expects of all employees and other persons affiliated with the Hospital.  These standards are a summary of the Hospital's expectations for its employees and are not meant to be all-inclusive.  Individual departments will also develop their own standards, consistent with these guidelines and Hospital policies, specific to the functions of the department.  Employees should refer to applicable Hospital and department policies, procedures and protocols when a specific question or issue arises. Failure to follow these Standards of Conduct or other Hospitalpolicies may result in disciplinary action, up to and including termination of employment.

1. Professional Ethics and Patient Care

    a. Employees shall at all times perform their functions in adherence to the highest ethical and professional     standards.

    b. Care providers should follow the code of conduct and standards of practice of their respective professional organizations.

    c. All patients shall be treated with dignity and respect.

    d. All patient information shall be kept confidential as required by law.

    e. Appropriate informed consent will be obtained from patients or other appropriate persons as required by law.  The applicable state and federal laws affecting healthcare providers will be reviewed at employee orientation and training sessions.  Laws and regulations specific to particular department functions will be incorporated in department procedures and protocols and reviewed at department training and education sessions.  Employees are responsible for knowing and following all legal requirements relevant to performance of their job duties.

2. Claims Submission and Payment

     a. All billing and collection activities shall be performed in accordance with all applicable state and federal laws, contractual requirements and Hospital policy.

     b. All services provided by the Hospital and its employees shall be properly and adequately documented in accordance with applicable laws and contractual requirements.

     c. Claims for payment to a government program or private payer shall be submitted only for services which were performed and only where there is adequate and proper documentation that the service was performed in accordance with applicable laws and/or contractual requirements.  Unless otherwise permitted by law or a private payer contract, claims shall be submitted for payment only if the services provided were medically necessary and ordered by a physician or other appropriately licensed provider.  Employees are responsible as permitted by law or contract, for being familiar with the applicable documentation and medical necessity requirements for the services they provide or for which they are responsible for submitting claims.

      d. No employee shall submit or cause to be submitted false information to a government agency, patient, third party payer, vendor, or to the Hospital. This includes presenting claims for an item or service the employee knows or should know was not provided, was fraudulent, was not medically necessary, was based on a code which would result in greater payment than the codeappropriate for the item or service, or was rendered by a provider the employee knows has been excluded from participating in a federal health program or is otherwise not authorized to provide the service.

      e. Periodic audits and reviews of billing practices will be conducted to assure that accurate and appropriate bills are submitted to Medicare, Medicaid, other federal health programs, private payers and patients. Employees are responsible for cooperating with and participating in these reviews as requested.

      f. The Hospital shall monitor patient and payer credit balances and shall promptly refunds all amounts due.  The Hospital shall promptly refund any payments made by state or federal agencies or private payers which were made erroneously and of which the Hospital is aware.

     g. Employees shall not steal, embezzle or otherwise convert to the benefit of another person, or intentionally misapply any funds, money, premiums, credits or other assets of any healthcare benefit program, including Medicare, Medicaid or a private payer.

3. Relationships with Third Parties

    a. Arrangements with physicians, vendors and other third parties will comply with all applicable federal, state and local laws and regulations, including I.R.S. rules which apply to the Hospital as a tax-exempt organization. Employees who perform contracting services should be familiar with theapplicable laws and regulations affecting their area of contracting and should consult with their supervisor, the respective Vice President, the President, or the Compliance Officer if they have any questions or are unsure about a particular contractual arrangement.

     b. No employee shall knowingly and willfully solicit, offer to pay, pay or receive, anything of value, either in cash or in kind, directly or indirectly, in return for:

        (i) referring an individual for any item of services covered by a federal health program, including the Medicare, Medicaid or the Tricare programs; or

        (ii) leasing, purchasing or ordering or arranging or recommending leasing, purchasing or ordering any good, facility, service or item covered by federal health program, including the Medicare, Medicaid or Tricare programs.

[Note: Certain arrangements may be permissible under "safe harbors" created by federal regulations.  Employees should check with their supervisor, the respective Vice President, the President or the Compliance Officer for the rules which apply to a particular arrangement.]

Physicians who have a compensation or ownership relationship with the Hospital shall not refer certain designated healthcare services, as defined by law, covered by a federal health program, including Medicare, Medicaid or Tricare, to the Hospital unless the arrangement is permitted by law.

[Note: Certain relationships (e.g., employment contracts, certain leases and other independent contractor agreements) are permitted if they comply with federal laws and regulations.  Employees who are responsible for entering into contractual relationships with physicians should be generally familiar with the laws governing such contracts and should consult with their supervisor, the respective Vice President, the President or the Compliance Officer for the rules which apply to a particular arrangement.]

     c. All contracts between the Hospital and a physician, and other contracts as specified by Hospital policy, shall be approved in accordance with applicable Hospital contracting policies.

     d. All marketing services and materials distributed by the Hospital shall be honest, clear, fully informative, and of anon-deceptive nature.

4. Conflicts of Interest

     a. Employees must avoid any activity or conduct which conflicts or appears to conflict with the interests of the Hospital.  All employees shall be familiar with and abide by the Hospital's Conflict of Interest Policy.

     b. Employees may not directly or indirectly participate in any personal business or professional activity or have a direct or indirect financial interest which conflicts with the Hospital's interests or the employee's duties and responsibilities as an employee of the Hospital.

     c. There are many types of conflicts of interest and no definition or set of guidelines can anticipate all of them.  The types of activities which may create a conflict of interest are described in the Hospital's Conflict of Interest Policy.  Employees should consult with their supervisor if they are unsure whether a particular activity creates a conflict of interest.

5. Reporting Compliance Matters

     a. In order to assure compliance with applicable laws, the Hospital encourages all employees to ask questions, clarify their responsibilities and bring to the Hospital's attention suspected wrongdoing and areas for improvement.

     b. All employees have an obligation to assist the Hospital in promoting and assuring compliance with applicable laws, and to assist and cooperate with the Hospital in any compliance investigation.

     c. All employees and agents of the Hospital have a duty to report any suspected wrongdoing or violation of applicable laws or Hospital policies or procedures.  Employees should be familiar with and follow the Hospital's
Compliance Policy for Reporting Compliance Issues and Concerns which addresses how reports are made and procedures for responding to reports.

     d. Reports may be made directly to the Compliance Officer at ext. 2230, the employee's supervisor or the manager or director of the employee's department as described in the Hospital's Compliance Policy for Reporting ComplianceIssues and Concerns.  Reports may be made anonymously, but the Hospital encourages employees to identify themselves in order to aid in the investigative process.

     e. No employee shall make a report he or she knows or reasonably should know is false.  No employee shall make a report for the purpose of harassing or retaliating against another person.

     f. No employee shall retaliate against any employee or other person for making a report, requesting clarification about applicable laws or policies, or participating in any investigation.

6. Government Investigations

     a. The Hospital is committed to full compliance with all state and federal laws and will cooperate appropriately with government authorities in any investigation of the Hospital or its employees.

     b. Any employee who receives a subpoena, inquiry or other legal document regarding the Hospital's business, whether at home or in the workplace from any government agency, will immediately notify his or her supervisor, who will immediately notify the Compliance Officer.  The Compliance Officer will be responsible for coordinating the Hospital's response to a government inquiry or investigation.

     c. For additional information, refer to Hospital Compliance Policy regardingCooperation with Government Agencies.

7. Records

     a. Each employee shall maintain the necessary patient or business records required for the employee's position.  All patient records shall comply with the applicable legal requirements.

     b. An employee shall not create any false patient or other Hospital record or falsify any information in a patient or other Hospital record.

     c. All patient and other Hospital records shall be retained as required by law and the Hospital's Record Retention Policy.  An employee shall not destroy any patient or Hospital record unless authorized by the Hospital's Record Retention Policy.

8. General

     a. When questions as to the appropriateness of any action arise, employees should consult with the Hospital Compliance Plan and Policies, Hospital general policies, any member of management, or the Compliance Officer.

     b. The conduct of all of the Hospital's business should reflect the ethical conduct of business in any venue.  The intent is to treat others, whether government or non-government, as we would expect to be treated.

     c. Any question pertaining to this Code of Conduct should be referred to the Director of the appropriate department or, his or her designee, a member of Administration, or the Compliance Officer at Ext. 2230.


Code of Ethics - BCH Policy and Procedure Manual
Conflict of Interest - BCH Policy #210
Compliance Policies - BCH Policy #'s 901 - 910
Mission & Belief Statement - BCH Policy and Procedure Manual
Confidentiality - BCH Policy #401
Record Retention - BCH Policy #428

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