Development of Compliance

Standards

Compliance Policy #901

Boulder Community Hospital shall establish compliance policies, standards of conduct, procedures and protocols to be followed by its employees and other agents that are reasonably capable of reducing the prospect of violation of applicable laws.

Responsibility: All Hospital Personnel

PROCEDURE

The Hospital's general philosophy with respect to standards of conduct is expressed in the Hospital's Compliance Statement of Philosophy and its Code of Ethics.  In addition, the Hospital shall establish policies, standards of
conduct, written procedures and protocols designed to promote compliance with applicable laws.

The Hospital's compliance policies shall be developed under the direction of the Hospital's Compliance Officer, and as applicable, the Compliance Committee, subject to approval by the Board of Directors.  Each Hospital
department shall develop specific standards of conduct, protocols and procedures, subject to approval by the Compliance Committee, to assure thatthe activities of the Department are in compliance with specific laws and
regulations.

Regularly, and at least annually, the Compliance Officer, in consultation with the appropriate department director, manager or other member of Hospital management shall identify those activities for which specific compliance
standards, protocols and procedures shall be developed.  Such activities may include those which have been identified as areas of concern by the Board of Directors, Chief Executive Officer, Compliance Committee or regulatory agencies and shall include activities which have been identified as potentially not in compliance with applicable laws or regulations by the Hospital or a court or government agency with jurisdiction over the Hospital.
The list of activities identified for development of specific standards, procedures and protocols shall be approved by the Compliance Committee and provided to the Board of Directors annually.

Each department director, manager or other member of Hospital management, in consultation with the Compliance Officer, shall be responsible for the timely development of specific standards of conduct, procedures and protocols for those areas identified by the Compliance Officer and Compliance Committee. Each standard of conduct shall also identify how compliance with the standard will be verified.  The compliance standards are subject to approval by the Compliance Officer and/or the Compliance Committee.

Department directors, the Compliance Officer and the Compliance Committee shall regularly review and update the Hospital's compliance policies andstandards of conduct as necessary to conform to revisions of applicable laws and regulations.


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