Reporting Compliance Concerns

Compliance Policy #907

The Hospital shall establish a reporting system whereby employees and other agents can  report suspected criminal conduct or other violations of law, regulations or the Hospital's compliance standards and policies by others within the organization without fear of retaliation.

Responsibility: All Hospital Personnel


Duty to Report

All employees and agents of the Hospital shall have a duty to report any suspected wrongdoing or violation of applicable laws, regulations or the Hospital's compliance standards or policies.   Employees who fail to fulfill
this duty may be subject to disciplinary action, pursuant to Compliance Policies #6 and 6A.

Methods of Reporting

Suspected misconduct or violations of the Hospital's compliance standards andpolicies may be reported by any of the following methods:

1. Directly contacting the Hospital's Compliance Officer at Ext. 2230;

2. Contacting the employer's supervisor or the manager or director of the employee's department.  Supervisors, managers and directors who receive such reports shall forward them immediately to the Compliance Officer;

3. Submitting a written report using the Compliance Report Form, which may be obtained from the Compliance Officer or the Department of Human Resources; or

4. Such other means as may be established by the Compliance Officer or Compliance Committee.

Regardless of how a report is made, to be useful in the detection and prevention of misconduct, the report must contain specific information regarding the suspected misconduct, including when and how the conduct occurred or is occurring, the persons involved in the conduct, and the specific nature of the conduct.  Employees may report suspected violations anonymously.  The Hospital encourages persons making anonymous reports to maintain contact with the Compliance Officer, however, so that the Compliance Officer may obtain any additional information needed to properly investigate the report.

Confidentiality of Reports

The Hospital shall treat reports of suspected misconduct as confidential to the greatest extent possible, subject to the Hospital's obligation to investigate the report and take appropriate action to correct any violations or misconduct.  The Hospital shall take reasonable steps to maintain confidentiality of the identity of any person providing information to the Hospital.  The Hospital cannot, however, guarantee complete confidentiality of
the identity of persons who make reports, due to the Hospital's obligations to investigate and correct misconduct and its obligations to report certain misconduct to state and federal authorities.

No Retaliation; False Reports

The Hospital prohibits any form or retaliation against any employee or agent for filing a bona fide report under this Policy or for assisting in any investigation regarding compliance matters.  Persons who engage in such retaliation shall be subject to discipline pursuant to Compliance Policies #6 and 6A.  However, if after investigating any report, the Hospital determines that the report is not bona fide or that an employee has provided false
information regarding the report, disciplinary action may be taken against the individual who filed the report or gave the false information.

No employee shall be subject to disciplinary action solely on the basis that he or she mistakenly reported what he or she reasonably believed to be an act of wrongdoing or a violation of law or of the Hospital's compliance standards or policies.  An employee will be subject to disciplinary action, however, if it is determined that the report of wrongdoing was knowingly or willfully fabricated by the employee or was knowingly or willfully distorted, exaggerated, or minimized to either injure someone else or to protect himself or herself.  An employee  "knowingly" provides false information if he or she knows or reasonably should know that the information is false or intentionally or recklessly disregards whether or not the information is false.

Discipline of a Reporting Employee

An employee whose report of misconduct contains admissions of personal wrongdoing is  not guaranteed protection from disciplinary action simply because he or she made the report.  In determining what, if any, disciplinary actions may be taken against a reporting employee, the Corporate Compliance Officer will take into account an employee's own admission of wrongdoing, provided, that the employee's involvement was not previously known to the Hospital or its discovery was not imminent, and that the admission was complete and truthful.  The weight to be given to self- reporting will depend on all facts known at the time the Hospital makes its discipline decisions and the applicable discipline procedures set forth in the Hospital's compliance policies.

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