Princjziples Responsibility KAISER CODE OF CONDUCT KAISER A Message from the Leadership Team Dear Colleagues, Kaiser Permanente’s physicians, dentists, and employees have earned the trust of our members, patients, customers, and business partners. This trust is based on our unwavering commitment to our mission of providing high-quality, affordable health care services and improving the health of our members and the communities we serve. Each of us has an integral role to play in securing our organization’s future: Kaiser Permanente’s reputation is in our hands. We are all accountable for understanding our Principles of Responsibility and fully supporting and behaving in accordance with these principles. We are at a very exciting juncture in our history with the implementation of health care reform. With our commitment to total health and our leadership in advancing 21st century health care, Kaiser Permanente has the opportunity to continue to define the future of health in this country. To do so, we will all need to do our part to uphold the reputation of excellence that Kaiser Permanente has earned over the years. Along with opportunities, health care reform also brings added scrutiny on compliance with new and existing laws, regulations, and accreditation standards by regulatory agencies and the public. Kaiser Permanente’s code of conduct, stated in the Principles of Responsibility, provides us with the clear guidance we need to do the right thing in taking on new opportunities and emphasizing the importance of meeting all laws and requirements. No code of conduct can anticipate every situation we might face as a health care organization; however, Kaiser Permanente’s Principles of Responsibility embraces our core values and guiding principles and is intended to serve as a resource to help guide us in exercising good judgment, asking questions when uncertain, and speaking up when needed. We urge you to read the Principles of Responsibility, refer to it often in your daily work, and discuss it with your colleagues and leaders. If you are aware of issues that might violate this code, you must report them to your chief or immediate supervisor, your human resources representative, your compliance officer, or the Kaiser Permanente Compliance Hotline. We are fortunate to be guided by principles that have served us well and that will continue to make us proud. Thank you for your conscientious work and the care you provide every day. Together, our efforts to act with integrity, perform ethically, and meet compliance requirements in all we do help protect our members’ health, our resources, and our good name. Sincerely, Bernard J. Tyson Jack Cochran, MD, FACS Chairman and Chief Executive Officer Executive Director Kaiser Foundation Hospitals The Permanente Federation, LLC Kaiser Foundation Health Plan, Inc. Hal Ruddick Executive Director Coalition of Kaiser Permanente Unions 1 CONTENTS A MESSAGE FROM THE LEADERSHIP TEAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 1. Do the Right Thing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.1 Does the Principles of Responsibility Apply to Me? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.2 Refer to and Follow Laws, Regulations, and Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.3 Where to Go for More Help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.4 At the Heart of It All: Five Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1. Improve Our Members’ and Patients’ Health and Wellness and the Nation’s Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2. Excel and Innovate in Our Professions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Respect Members, Patients, Customers, and One Another . . . . . . . . . . . . 7 4. Be Fair and Honest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 5. Demonstrate a Commitment to Compliance and Ethics . . . . . . . . . . . . . . . . 7 1.5 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS . . . . . 12 2. Respect Confidentiality, Privacy, and Security . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.1 Store Confidential Information Correctly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3. Focus Resources on Member and Patient Care . . . . . . . . . . . . . . . . . . . . . . . . 16 3.1 Detect and Prevent Fraud, Waste, and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 3.2 Follow Anti-Fraud Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4. Support Community Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 4.1 Disclose When Serving on Boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 5. Protect Our Assets and Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 5.1 Safeguard and Use Our Assets and Information Properly . . . . . . . . . . . . . . . . 20 5.1.1 Use Information Systems Appropriately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 5.1.2 Safeguard Confidential Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 5.1.3 Protect Intellectual Property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 5.1.4 Use Funds Appropriately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 5.1.5 Keep Track of Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 5.1.6 Entering Kaiser Permanente Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 5.2 Maintain Accurate Business Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 5.2.1 Retain and Destroy Company Records According to Policy . . . . . . . . . . . . . . 24 6. Protect Our Reputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 6.1 Market and Communicate About Kaiser Permanente Accurately and Strategically . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 6.2 Know What to Say When Speaking or Communicating Externally . . . . . 26 HELP MAKE KAISER PERMANENTE A BEST PLACE TO WORK . . . . . . . . . . . . . . . . . . . . . 28 7. Treat One Another with Dignity and Respect . . . . . . . . . . . . . . . . . . . . . . . . . . 28 7.1 Value Workforce Diversity and Inclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 7.1.1 Respect Member and Patient Diversity and Inclusion . . . . . . . . . . . . . . . . . . . . . 29 7.2 Foster a Harassment-Free Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 2 PRINCIPLES OF RESPONSIBILITY 7.3 7.3.1 7.3.2 7.3.3 7.3.4 7.3.5 7.4 Make Safety and Environmental Awareness a Priority . . . . . . . . . . . . . . . . . . . . . 31 Focusing on Workplace Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Reporting Work-Related Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Cooperating With Periodic Federal and State Inspections . . . . . . . . . . . . . . . 32 Minimizing Our Environmental Footprint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Reporting Environmental Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Know the Facts About Retaliation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 MAKE OBJECTIVE AND FAIR DECISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 8. Avoid Conflicts of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 8.1 Understanding How Conflicts of Interest Occur . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 8.2 How to Handle Conflicts of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 8.3 Guidance for Avoiding Conflicts of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 8.3.1 How to Handle Gifts and Business Courtesies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 8.3.2 Accepting Gifts from Grateful Members and Patients . . . . . . . . . . . . . . . . . . . . . 36 8.3.3 Gifts You Cannot Accept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 8.3.4 Giving Gifts Using Kaiser Permanente Resources . . . . . . . . . . . . . . . . . . . . . . . . . . 38 8.3.5 Honoraria and Speakers’ Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 8.3.6 Outside Employment, Including Self-Employment . . . . . . . . . . . . . . . . . . . . . . . . 39 8.3.7 Financial Interests and Investments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 8.3.8 Patient Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 8.3.9 Anti-Kickback Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 8.3.10 Physician Income and Investments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 8.3.11 Outside Directorships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 8.3.12 Employment of Relatives and Household Members . . . . . . . . . . . . . . . . . . . . . . . 42 8.4 Conflicts of Interest Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 8.5 Partner With Vendors to Support Our Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 8.5.1 Purchase and Contract Fairly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 8.5.2 Avoid Violations of Antitrust and Unfair Competition Laws . . . . . . . . . . . . . . 44 8.5.3 Choose Vendors and Independent Contractors Fairly . . . . . . . . . . . . . . . . . . . . 45 8.5.4 Oversight of Vendors and Independent Contractors . . . . . . . . . . . . . . . . . . . . . . 45 9. Meet Government Expectations and Cooperate With Government Inquiries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 9.1 Interacting Appropriately With Government Officials . . . . . . . . . . . . . . . . . . . . 47 9.2 Report Accurately to the Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 9.3 Follow Licensing and Certification Requirements . . . . . . . . . . . . . . . . . . . . . . . . . 48 9.4 Interacting With Individuals and Organizations Restricted by the Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 9.5 Protect Kaiser Permanente With Respect to Political Activities and When Making Personal Political Donations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 KNOW HOW TO GET HELP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 10. Speak Up if You Have Any Questions or Concerns . . . . . . . . . . . . . . . . . . . 50 10.1 Report Potential Compliance Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 10.2 Call the Kaiser Permanente Compliance Hotline . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 10.3 Compliance is Everyone’s Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 CONTENTS 3 INTRODUCTION INTRODUCTION Kaiser Permanente is committed to providing high-quality, affordable health care services and to improving the health of our members, our patients, and the communities we serve. The Principles of Responsibility supports this commitment. The Principles of Responsibility is Kaiser Permanente’s code of conduct: • It is our organization’s ethical compass. • It represents our workplace values. • It guides our work and our interactions with others. 1. Do the Right Thing Use the Principles of Responsibility as a guide to ensure that compliance is integrated into the work we do every day — be it service, care, or any operational duties such as planning, communications, and business processes. Refer to this code of conduct whenever you need guidance on appropriate actions in your work and whenever your instincts tell you that something doesn’t feel quite right. If you encounter situations in your work that aren’t addressed by the Principles of Responsibility, consult applicable policies or talk to any of the following: • Your chief or immediate supervisor. • Another supervisor or manager in your area. • Your compliance officer. • The contacts listed in the following sections of the Principles of Responsibility: • Section 1.3 Where to Go for More Help. • Section 10 Speak Up if You Have Any Questions or Concerns. 4 PRINCIPLES OF RESPONSIBILITY 1.1 Does the Principles of Responsibility Apply to Me? All Kaiser Permanente physicians, dentists, and employees are expected to use good judgment, be accountable for their actions, and conduct business with integrity and with the interests of members and patients in mind. You must also: • Complete all required compliance training. • Familiarize yourself with the policies, procedures, and standards that apply to your work. • Speak up if you are concerned or unsure about what you are being asked to do or what you see others doing. • Report violations of laws, regulations, and policies. • Cooperate with investigations of potential violations of laws, regulations, and Kaiser Permanente policies. • Refuse to participate in illegal or unethical acts. • Be guardians of Kaiser Permanente’s reputation and assets. Violation of this code of conduct could result in disciplinary action, up to and including termination of employment and possible civil or criminal charges. 1.2 Refer to and Follow Laws, Regulations, and Policies The Principles of Responsibility does not address every situation or issue that could arise in your work. This code provides general direction on a broad range of issues; however, laws and regulations may exist that have specific requirements for your particular job. Additionally, Kaiser Permanente has adopted policies and procedures that apply to your job and how you conduct yourself at work. Because these policies are more specific to particular jobs, and some are stricter than the standards of conduct in the Principles of Responsibility, be sure to read what applies to you. The Kaiser Permanente policies that apply to you can be found: • In your department. • In the Permanente Medical Group policies or policy manual for the physicians in each Permanente Medical Group. • In the Permanente Dental Associates policies or policy manual. • On your regional Kaiser Permanente intranet webpage. • In the Kaiser Permanente Policy Library at kpnet.kp.org/kpnpa. Remember, you are responsible for knowing which Kaiser Permanente policies apply to you and your job, and making sure you comply with them. INTRODUCTION 5 INTRODUCTION Compliance is everyone’s responsibility. There are no exceptions. Kaiser Permanente is committed to complying with all applicable laws and regulations and demonstrating high ethical standards in everything we do. Anyone who works for or on behalf of Kaiser Permanente is required to follow all applicable laws, policies, and this code of conduct. This applies to all Kaiser Permanente physicians, dentists, and employees (including executives and management), students, residents, interns, temporary employees, contingent workers, and volunteers. Independent contractors, vendors, and consultants are expected to read, understand, and adhere to our Vendor Code of Conduct when working with Kaiser Permanente. Kaiser Permanente physicians, dentists, and employees who manage the work of contractors and consultants must ensure that they abide by all applicable policies. INTRODUCTION 1.3 Where to Go for More Help You have many contacts and resources in addition to the Principles of Responsibility: • Speak with your chief or immediate supervisor, human resources representative, or compliance officer. • Speak with your steward and/or union representative, if you are a member of a union. • Access Kaiser Permanente’s compliance websites through kp.org/compliance or through your national, regional, or physician web portals for more information. • Call the Kaiser Permanente Compliance Hotline at 1-888-774-9100 or report using the Kaiser Permanente Webline at reportlineweb.com/kp. The hotline is available toll-free 24/7. You can make an anonymous report to a trained professional. 1.4 At the Heart of It All: Five Guiding Principles These guiding principles are intended to make it easier for you to do the right thing at work. They are at the heart of who we are and what we stand for. Keeping these guiding principles in mind when you do your job should make it easier for you to follow the standards of conduct in the Principles of Responsibility and help us continue to make Kaiser Permanente an organization of which we are proud to be a part. 1. Improve Our Members’ and Patients’ Health and Wellness and the Nation’s Health Care • Our cause is health. Our passion is service. We work to make lives better. • We deliver compassionate, personalized, and proactive care to our members and patients. • We act to improve the access, delivery, and funding of health care for the communities we serve. • We share our knowledge and innovations through research, our support of education for community health professionals and consumers, and by helping to inform public policy. 2. Excel and Innovate in Our Professions • We always strive to learn. We are dedicated to raising our own standards and the standards of our professions through continuous learning, performance improvement, research, training, adoption of new technology, and investment in state-of-the-art facilities. • We deliver care and services through teamwork, because it is through collaboration with others that we can be most effective. • We strive to be responsible stewards of the environment, and provide health care services in a manner that protects the environment now and for future generations. 6 PRINCIPLES OF RESPONSIBILITY 3. Respect Members, Patients, Customers, and One Another 4. Be Fair and Honest • We know that we must earn our distinguished reputation every day, and understand that each health care and business decision is an opportunity to demonstrate our commitment to ethics and integrity. • We recognize the trust others place in us, and recognize the responsibility of upholding that trust by being truthful and honest — always. 5. Demonstrate a Commitment to Compliance and Ethics • Compliance means we fully adhere to federal, state, and local laws and regulations; federal health care program requirements; licensing requirements; accreditation standards; and requirements of the Centers for Medicare & Medicaid Services and federal, state, and customer contracts. • We never retaliate against those who, in good faith, report suspected violations of laws, accreditation standards, and Kaiser Permanente policies. • Acting with ethics and integrity in our work means that we always try to do the right thing and make the best decisions, and that we seek help when the right thing or the best decision is not clear. 1.5 Definitions Some of the words used in the Principles of Responsibility have special meaning and are defined in this section. Abuse: Wrongful or improper use of Kaiser Permanente or government assets that is inconsistent with accepted, sound medical, business, or fiscal practices and directly or indirectly results in unnecessary costs to Kaiser Permanente or the government. Abuse may include abuse of position or authority that causes the loss or misuse of Kaiser Permanente assets and may be intentional or unintentional. Assets: Can be both tangible (physical) and intangible (intellectual). Assets include equipment (for example, cameras, ergonomic equipment, ultrasound equipment, and blood pressure cuffs), furniture, supplies, organization funds (including purchasing cards), electronic devices, voicemail and instant messages, email, knowledge, information, buildings, identification cards, time, and media sites (including Kaiser Permanente’s Facebook pages and YouTube channels). See Electronic devices for more information. INTRODUCTION 7 INTRODUCTION • When caring for our members and patients and serving our customers, we strive to act with courtesy, in a careful and considerate manner, and with professionalism. • We protect the privacy of our members and patients and respect their autonomy, customs, and beliefs. We involve them in decisions regarding their treatment and care according to their preferences. • We understand that we thrive when we respect one another. We are proud of our collegial environment, which honors diversity and inclusion. • We listen to and respect the opinions of others, even when our views differ. INTRODUCTION Board of directors: A group of persons having legally defined responsibilities and oversight of the activities of a particular company, association, or organization. Business partners: Individuals and entities with whom Kaiser Permanente has a business relationship. Examples include employer groups, brokers, customers, unions, and vendors. Business records: Information committed to writing in hard (paper) form or soft (electronic) form, and created to document or reference legal, business, or operational activities; also includes electronically stored information and emails. See the business record retention policy for your area for more information. Cash-equivalent gifts: These include checks, gift certificates, event tickets, gift cards, coupons, or anything with cash value. See Gifts and Modest gifts. Chief: An individual to whom a physician or dentist reports directly. Competitor: An individual or organization that offers products and services in some or all of the same categories as Kaiser Permanente and in some or all of the same geographical markets. Examples include health plans, health care insurance companies, hospitals, medical groups, independent physician associations, medical service providers, pharmacies, private practice psychologists, and physical therapy service providers. Conflict of interest: A situation in which financial interests or personal relationships influence professional judgment and decisions made on behalf of Kaiser Permanente. The appearance of a conflict of interest occurs when your personal or financial interests could be viewed by others as having the potential to influence your job-related judgment or decision making. Conflicts of interest questionnaire: An annual questionnaire for certain physicians, dentists, and employees that requires disclosure of information that may indicate perceived, potential, or actual conflicts of interest that may need to be monitored, managed, or eliminated. Contingent worker: An individual who works for a limited period of time at Kaiser Permanente, but is not on Kaiser Permanente’s payroll, including, but not limited to, individuals who provide patient care and allied health services (e.g., registry personnel), administrative/clerical (e.g., temporary agency personnel), IT professional, marketing, light industrial, engineering, telecommunications, and various business professional services. Contingent workers are not paid directly by Kaiser Permanente, but are paid by an external vendor or supplier that contracts with Kaiser Permanente for services. Customers: Individuals, families, and organizations (including employers, government agencies, and labor trusts), who contract with Kaiser Permanente to receive health benefits. 8 PRINCIPLES OF RESPONSIBILITY INTRODUCTION Electronic devices: Includes desktop computers, laptops, tablets, smart phones, flash drives, digital cameras, and any other devices that have the capability to manipulate and/or store data (for example: monitors, docking stations, clinical devices, mobile devices, remote access tokens, USB storage devices, printers, and air cards). See Assets. Employees: See Physicians, dentists, and employees. Entertainment: Includes but is not limited to sporting events, theater performances, movies, concerts, meals, and parties, regardless of value. Financial interest: Ownership interest in stocks, bonds, debt obligations, options, rights to buy or sell stock, shares in profits, investments, or other proprietary interests in companies. Does not include mutual fund shares or insubstantial share holdings of a publicly held company. Fraud: A deception or misrepresentation made intentionally or with reckless disregard of the truth, knowing that the deception could result in some unauthorized benefit to the perpetrator, another individual, or an entity. Gifts: Anything of value received with no expectation of anything given in return. See Cash-equivalent gifts and Modest gifts. See Section 8.3.1: How to Handle Gifts and Business Courtesies for exclusions. Health care providers: Includes physicians, dentists, and employees who provide patient care directly and any individual or business that provides health care services, such as a residential care facility or home health services. Honoraria: Anything of value given as a token of appreciation for services rendered, such as fees paid to a speaker. Immediate supervisor: An individual to whom an employee reports directly. This could be a supervisor with administrative authority, manager, director, chief, or executive. This term does not include union team leads, charge nurses, or other represented positions with directive authority. Independent contractor: A person or entity that enters into an agreement to provide services to Kaiser Permanente, and whose payments are reported to the Internal Revenue Service on an IRS Form 1099. Information systems: Includes electronic systems for medical and health plan records, email, voicemail, instant messaging, and the intranet and Internet. Kaiser Permanente or Kaiser Permanente entities: Kaiser Permanente consists of the following separate legal entities: Kaiser Foundation Hospitals; Kaiser Foundation Health Plan, Inc.; Kaiser Foundation Health Plan of Colorado; Kaiser Foundation Health Plan of Georgia, Inc.; Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.; Kaiser Foundation Health Plan of the Northwest; Camp Bowie Service Center; Health Care Management Solutions, LLC; Kaiser Health Plan Asset Management, Inc.; Oak Tree Assurance, Ltd.; Kaiser Properties Services, Inc.; Ordway International, Ltd.; Ordway Indemnity, Ltd; KP OnCall, LLC; INTRODUCTION 9 INTRODUCTION Kaiser Permanente International; KP Cal, LLC; Kaiser Hospital Asset Management, Inc.; Kaiser Permanente Insurance Company; Kaiser Health Alternatives; Kaiser Permanente Ventures, LLC; HAMI - Colorado, LLC; Lokahi Assurance, Ltd.; 1800 Harrison Foundation; Rainbow Dialysis, LLC.; Kaiser Hospital Assistance Corporation; Kaiser Hospital Assistance I, LLC; NXT Capital Senior Loan Fund I, LLC; OHP; Colorado Permanente Medical Group, P.C.; Hawaii Permanente Medical Group, Inc.; Mid-Atlantic Permanente Medical Group, P.C.; Northwest Permanente, P.C., Physicians and Surgeons; Permanente Dental Associates, P.C.; Southern California Permanente Medical Group; The Permanente Medical Group, Inc.; The Southeast Permanente Medical Group, Inc.; The Permanente Federation LLC; and Permanente Advantage, LLC. Kaiser Permanente is a registered tradename. Kaiser Permanente HealthConnect® and KP HealthConnect®: Kaiser Permanente’s electronic health information system. Management: Includes senior leaders (such as senior vice presidents, regional presidents, vice presidents, executive medical directors, associate and assistant medical directors, physicians-in-chief, area medical directors, etc.), middle managers (such as directors, department administrators, and chiefs), frontline supervisors (such as nurse supervisors and project managers), and any other position with direct reports. Medical Financial Assistance Program: One of Kaiser Foundation Hospitals’ and Kaiser Foundation Health Plan, Inc.’s charitable care and coverage programs. Member of the same household: See Relative and Personal relationship. Modest gifts: Items valued at less than $25 per person. See Cash-equivalent gifts and Gifts. Offensive: Includes products containing tobacco, weapons of any kind, or anything depicting nudity or deemed as lewd, vulgar, or in any way unpleasant. Performance improvement: A systematic approach focusing on systems assessment, scoping, prioritization, and execution via cross-functional teams to improve quality, reliability, and efficiency. Personal relationship: A relationship which includes, but is not limited to, dating/ sexual relationship, engagement for marriage or domestic partnership, or a business relationship, such as joint-ownership in an off-duty business venture. Physicians, dentists, and employees: This includes: • Physicians associated with the Permanente Medical Groups. • Dentists associated with the Permanente Dental Associates, P.C. • Full-time and part-time employees of Kaiser Foundation Health Plan, Inc. and its subsidiaries; Kaiser Foundation Hospitals and its subsidiaries; the Permanente Medical Groups; Permanente Dental Associates, P.C.; The Permanente Federation LLC; and Permanente Advantage, LLC. 10 PRINCIPLES OF RESPONSIBILITY Relative: A member of the immediate family of a physician, dentist, or employee, or a member of the immediate family of a physician, dentist, or employee’s spouse or domestic partner, including: • Spouse/domestic partner. • Parent/step-parent/parent in-law/step-parent in-law/in loco parentis. • Child/step child/legal ward/foster child/adopted child. • Daughter/step daughter/daughter-in-law/step daughter-in-law. • Son/step son/son-in-law/step son-in-law. • Sister/step sister/sister-in-law/step sister-in-law. • Brother/step brother/brother-in-law/step brother-in-law. • Grandparent/step grandparent. • Grandchild/step grandchild. • Aunt/uncle/nephew/niece/first cousin. • Any other person living in the physician, dentist, or employee’s household. Research sponsor: An entity that provides funding for a research study or an investigational product that is being tested in a study. Examples of research sponsors are individuals, pharmaceutical companies, device manufacturers, foundations, academic institutions, or governmental agencies. Research sponsor also includes the manufacturer of any product being evaluated in the research study. Kaiser Permanente entities are not research sponsors. Services: Services that are either complimentary or routine in nature and are not related to health care services. Examples include valet parking for members or patients, transportation for members or patients, and coffee carts. Signing authority: Physicians, dentists, and employees who have the authority to sign contracts, authorize payments, and/or have any decision-making authority over the selection of vendor products or services. Social media and social networking: Any Kaiser Permanente or publicly available website or software that enables users to post, send, receive, or otherwise share information of any type with other users. Examples include Facebook, Instagram, Twitter, Yammer, LinkedIn, and Yelp. Stocks: Any outstanding shares of a company. Vendor: Includes any individual or organization that offers, supplies, or sells products or services to Kaiser Permanente, including independent contractors such as consultants. Waste: The extravagant, careless, or needless expenditure of funds or the consumption of Kaiser Permanente assets that results from deficient or negligent practices, system controls, or decisions. INTRODUCTION 11 INTRODUCTION Regular basis: Occurs more than four times per year or more than once per quarter. PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 2. Respect Confidentiality, Privacy, and Security Much of the information we collect from patients — including medical condition, history, medications, and family illnesses — is very sensitive and protected under privacy and information security laws. In addition, we must abide by any business associate agreements that we have with self-funded health plans, which further restrict our access to and use of protected health information (PHI). Keeping data confidential, private, and secure is essential to: • Preserving the trust of our members and patients. • Providing quality health care. • Complying with federal and state regulations and Kaiser Permanente policies. • Protecting our reputation. 12 PRINCIPLES OF RESPONSIBILITY Consider This… My co-worker Abraham has missed a lot of work lately and, quite frankly, he doesn’t look so well. I’m worried that he is sick and I want to be there for him. Even though I’m not officially caring for him, is it okay for me to check his medical record to see how he’s doing in case there’s any way I can help? No. All members and patients — including your family, co-workers, and public figures — have a right to privacy. It’s great that you want to help your colleague, but it’s against the law for you to look at a medical record unless you need access to the information to do your job. PRESERVE THE TRUST For guidance specific to your area, refer to your policies and procedures and check with your chief or immediate supervisor. If you need more guidance, speak with your privacy and security officer or compliance officer. Looking up medical records without a business need to know is against the law, so play it safe and don’t look. Kaiser Permanente regularly checks electronic logs of what data has been accessed. Physicians, dentists, and employees who have accessed medical records inappropriately have been identified and disciplined — some have even lost their jobs. If you access medical records inappropriately, both you and our organization could face government penalties and fines. Unauthorized access endangers the trust our members and patients have in Kaiser Permanente and our good standing in the community. We must comply with federal and state privacy laws and protect all confidential information — PHI, personal information that includes employment-related information, and Kaiser Permanente business information. Failure to do so may result in: • • • • • • Disciplinary action. Termination of employment. Criminal prosecution by state attorneys general or U.S. attorneys. Sanctions. Disclosure to and/or discipline by your applicable licensing board(s). Personal fines. Physicians, dentists, and employees should always: • Access the minimum amount of information necessary to do your job, whether you are performing a clinical, administrative, and/or business role. The minimum necessary standard does not apply to disclosures to or requests by a health care provider for treatment purposes. • If there is a business need to access the PHI of a family member, friend, or third party (such as a co-worker), or your own medical record, follow all laws and policies and procedures that apply to your job. PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 13 PRESERVE THE TRUST • When handling confidential patient or member payment information (e.g., credit card information, account information, etc.) or working with our payment systems, follow all laws and policies and procedures that apply to your job. • Discuss patient information only when it is required for your job. • Keep electronic devices secure and passwords protected. • Keep email communications with patients in secured channels such as Kaiser Permanente HealthConnect® unless otherwise necessary to ensure continuity of care and allowed by the policies that apply to you. • Click on the ‘Send Secure’ button in the Kaiser Permanente email system to send sensitive email in an encrypted format or, when faxing information, verify that the fax number you are sending to is correct. • Make sure doors to restricted areas with sensitive information are kept locked. • Retrieve printouts containing PHI promptly from shared fax machines and printers. • Use a privacy screen on your computer monitor if the screen is visible and readable by others. • Log off of a shared computer or lock your computer before walking away from it so others cannot use it with your user identification. • Restrict access by vendors to PHI unless an appropriate process has been followed (for example, a vendor must sign a business associate agreement if it creates, receives, maintains and/or transmits PHI on behalf of a Kaiser Permanente entity or business associate under HIPAA). • Remove all non-essential information from an email before you forward it. • Make sure electronic documents do not contain unnecessary data. Ensure there are no hidden columns, rows, or tabs in spreadsheets before attaching and sending. Physicians and dentists should refer to the applicable Permanente Medical Group policy or Permanente Dental Associates policy. 14 PRINCIPLES OF RESPONSIBILITY Consider This… We mail printouts of patients’ lab results and sometimes the results accidentally go into an envelope addressed and mailed to a different member. We can just ask the individuals to throw away the results that don’t belong to them, right? Wrong. Improperly revealing PHI without authorization from a member or patient is a serious violation of that person’s privacy, even if it’s accidental. If this happens, notify your compliance officer as soon as you become aware as several notifications must take place. PRESERVE THE TRUST Errors like this are preventable. When mailing documents containing member or patient PHI, take time to check that the name on the document matches the name and address on the envelope. If you use a mail merge to address multiple envelopes, take additional time to verify that no errors in the mail merge process have occurred. By taking extra time to perform these checks, you can prevent an improper disclosure of PHI to one individual or to hundreds. For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor on how to handle PHI appropriately. 2.1 Store Confidential Information Correctly You should store confidential information such as PHI on Kaiser Permanente’s secured network servers rather than on electronic devices. If you have an essential business need to store confidential patient information on any electronic device (such as thumb drives, laptops, clinical devices, etc.) other than the systems located on the Kaiser Permanente network, you must obtain authorization as required by applicable policy or policies. If you get approval to store data on an electronic device, the data must be encrypted and you must take other special physical and security steps, such as password-protecting the device, to protect against the information being misused if the device is lost or stolen. Did You Know… Data saved on a Kaiser Permanente computer’s desktop or C drive doesn’t get backed up. If you save data to your computer’s desktop or C drive, it is not backed up regularly to our servers. This means you could lose that data. Also, if you store data on a device (like a thumb drive or CD) and there are technical problems with the device or the device is lost or stolen, you could lose the data because it is also not backed up on our secured servers. Check with your IT Help Desk to make sure you’re saving data correctly on network servers. PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 15 PRESERVE THE TRUST 3. Focus Resources on Member and Patient Care 3.1 Detect and Prevent Fraud, Waste, and Abuse Kaiser Permanente’s fraud control program protects our members and patients and preserves our resources to reduce costs and helps us provide affordable health care. This is part of our mission and values and requires that every physician, dentist, and employee be involved, committed, and participate. Many of our activities at work are monitored to prevent and detect fraud, waste, and abuse. Legally Speaking... Fraud is a deception or misrepresentation made intentionally or with reckless disregard of the truth, knowing that the deception could result in some unauthorized benefit to the perpetrator, another individual, or an entity. Examples: Embezzlement, false claims, kickbacks, bribery, false financial reporting, software piracy, credit card fraud, expense account fraud, identity theft, medical identity theft, false workers’ compensation claims, fraudulent vendor billing, member fraud, mail fraud, backdating documents, and falsifying timecards. Find Out More: Learn more about Kaiser Permanente’s fraud control program at: kp.org/compliance > Kaiser Permanente Employees and Physicians > National Fraud Control Program. 16 PRINCIPLES OF RESPONSIBILITY 3.2 Follow Anti-Fraud Laws Physicians, dentists, and employees must never participate in fraudulent activity at work. We must preserve our resources to provide the most affordable health care for our members and patients. If you are aware of any fraudulent activity, you must report it to your chief or immediate supervisor, compliance officer, internal audit services, controller, human resources representative, or the Kaiser Permanente Compliance Hotline at 1-888-774-9100. See Section 5.1: Safeguard and Use Our Assets and Information Properly for more on fraud, waste, and abuse prevention. See Section 10.1: Report Potential Compliance Issues for more on your protections when reporting suspected fraud. Physicians, dentists, and employees must document and code (where applicable) patient care provided in an accurate, complete, and timely manner. Claims and supporting medical record documentation must comply with all applicable coding requirements. This documentation is the basis for regulatory reporting and many other activities, including billing, quality reporting, and financial forecasting, so it is very important that it is accurate. For example, the federal False Claims Act provides for civil financial penalties for anyone who knowingly submits, or causes the submission of, a false or fraudulent claim to the government. Deliberate or reckless disregard for the truth or falsity of the claims submitted also can lead to violations. The False Claims Act includes a “whistleblower” provision that allows people outside the government to report fraud and potentially receive a portion of any money that is recovered in the case. If successful, the government can recover up to three times the amount at issue. PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 17 PRESERVE THE TRUST See Section 8.3.8: Patient Referrals, Section 8.3.9: Anti-Kickback Laws, and Section 8.5.1: Purchase and Contract Fairly for more on avoiding fraud. PRESERVE THE TRUST 4. Support Community Involvement Kaiser Permanente believes that, by serving our communities’ interests and overall social goals, we can help to improve the health of everyone, especially those who are most vulnerable in our communities. We believe everyone should have access to high-quality health care, regardless of their ability to pay. Kaiser Permanente takes a leadership role in our communities — creating and sponsoring programs as well as supporting physician, dentist, and employee involvement. We recognize our ability to influence changes that make communities healthier, and we believe in being visible and active participants in the communities where we live and work. In addition, Kaiser Permanente encourages physicians, dentists, and employees to participate in their communities and provides opportunities to volunteer in sponsored projects and contribute to not-for-profit organizations. If you are involved in community organizations, refer to the policies and procedures that apply to you or speak to your chief or immediate supervisor before soliciting contributions from co-workers. Find Out More: You can learn more about Kaiser Permanente’s Community Benefit Program at kp.org/communitybenefit. For community service and volunteer opportunities, visit kpcares.org. 18 PRINCIPLES OF RESPONSIBILITY Consider This… I’m active in a community-based organization. We are filling backpacks for kids getting ready to go back to school and need some supplies. Our department distributes sunscreen and water bottles at health fairs and I think the kids could use these items. Can I take some for our organization’s kids? No. Each region has community benefit goals and funding guidelines to address community needs. First speak to your chief, immediate supervisor, compliance officer, or refer to the policies that apply to you for additional guidance. Many of our physicians, dentists, and employees share their professional expertise by serving on a board of directors or on an advisory board for a community-based organization. If you volunteer in this manner you must make it clear to the organization that your involvement with them is as an individual, and that you do not represent Kaiser Permanente’s interests or perspectives. If a claim is made against you as a member of any such board for an alleged wrongful act you would be personally liable without recourse to Kaiser Permanente. You are encouraged to review the external not-for-profit, communitybased organization’s insurance coverage for board activities before volunteering. If you serve on a board of directors or advisory committee for an external not-forprofit community-based organization as part of your job responsibilities, make sure you review and abide by the policies that apply to you. You must immediately disclose in writing your service on boards of directors, boards or trustees, and advisory boards of community-based and other nonprofit organizations whether or not it is part of your job or on behalf of the organization to your chief or immediate supervisor, when: • These activities could conflict with the work or mission of Kaiser Permanente or with your individual job responsibilities. • The position is connected with an official city, county, state, or federal commission, board, or committee. • The organization may request a contribution in cash, goods, or services from Kaiser Permanente. PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 19 PRESERVE THE TRUST 4.1 Disclose When Serving on Boards PRESERVE THE TRUST 5. Protect Our Assets and Information 5.1 Safeguard and Use Our Assets and Information Properly Kaiser Permanente’s assets are to be used for Kaiser Permanente health care and business purposes only. They must be handled with care and protected against all forms of misuse, waste, damage, and loss. Do not use Kaiser Permanente assets for personal gain or benefit, or dispose of assets outside of authorized practices regardless of their condition or value. Consult with your chief or immediate supervisor to obtain the appropriate approvals before you donate Kaiser Permanente assets. Physicians, dentists, and employees must protect Kaiser Permanente’s assets. If you are aware of any fraudulent activity, you must report it to your chief or immediate supervisor, compliance officer, internal audit services, controller, or human resources representative. Consider This… In the past few years I’ve seen some of our regular patients struggle financially because they’ve had their work hours reduced or a family member has lost a job. A few of them have asked me if I can waive the registration copay. I feel so bad because I don’t want to be responsible for a member not coming in for an appointment because they can’t afford to, but I’m quite sure I can’t do this. What should I do? If patients cannot make their copay at the time of service, follow your area’s policies and procedures regarding copay collection or contact your immediate supervisor. Patients should be informed of available Medical Financial Assistance Programs or other programs. 20 PRINCIPLES OF RESPONSIBILITY Find Out More: For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor on where to direct members and patients for financial assistance. 5.1.1 Use Information Systems Appropriately Find Out More: See Section 2: Respect Confidentiality, Privacy, and Security to learn more about accessing information systems appropriately and the safeguards in place to protect patients and their health information. Kaiser Permanente information systems should never be used to engage in activities that are illegal, illicit, or violate Kaiser Permanente policies. The following activities are not allowed when using email, the intranet, or the Internet on Kaiser Permanente devices: • Sending mass emails asking co-workers to support personal or professional causes. • Gambling. • Viewing pornography or any other offensive, discriminatory, derogatory, or exploitative content. • Downloading and/or running external software not approved by Kaiser Permanente IT. • Downloading music and videos for personal use. Use of personal electronic devices or Kaiser Permanente devices for non-business reasons should never interfere with your job duties or detract from providing quality patient care and services. PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 21 PRESERVE THE TRUST Kaiser Permanente has many different information systems. Examples include KP HealthConnect®, email, voicemail, instant messaging, the Kaiser Permanente intranet, and access to the Internet over the Kaiser Permanente network. Kaiser Permanente’s information systems are tools for physicians, dentists, and employees to use in providing care to Kaiser Permanente members and patients and to conduct Kaiser Permanente business. They must be used in accordance with applicable policies. All communications, including electronic communications on Kaiser Permanente-owned hand-held devices, must be conducted in a professional, respectful, and lawful manner that is appropriate in a business environment. Consider This… I have noticed one of the receptionists in my department often makes personal phone calls when there is no one waiting. However, she continues talking on the phone when a member arrives at the desk and begins the check in process while continuing her personal conversation. This doesn’t seem right to me. Is it? PRESERVE THE TRUST You are right. These calls are detracting from the service quality that is expected at Kaiser Permanente. Use of devices for personal reasons should never interfere with your job duties. Consider This… My co-worker has a family owned business. I often see him using his computer to communicate with his customers. Is this okay? No. Kaiser Permanente information systems, including computers, cannot be used for personal benefit. While it’s understandable that you may need to handle some personal matters during work from time to time, such as scheduling appointments or following up with teachers, it is not acceptable to use Kaiser Permanente information systems to promote or maintain a personal business. Find Out More: For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor on using information systems. Also, you should know that when you use Kaiser Permanente information systems, all data and communications — including email and voicemail messages — become the property of Kaiser Permanente and can be monitored and reviewed. While Kaiser Permanente respects the privacy of physicians, dentists, and employees, it is legal for Kaiser Permanente to monitor your email and Internet usage (including the frequency and duration of visits to specific websites) and your access to information systems and tools — without your consent or prior notice. 5.1.2 Safeguard Confidential Information Confidential information, such as Kaiser Permanente’s financial data and reports, non-public business and clinical strategies and initiatives, pricing information, and other competitively sensitive information, should not be shared with anyone outside the organization, including members, unless you have received approval to disclose it from someone who is a decision maker for that confidential information. 22 PRINCIPLES OF RESPONSIBILITY This requirement is not intended to limit communications regarding matters unrelated to Kaiser Permanente, lawful off-duty conduct, or prohibit communications concerning wages, benefits, or other terms and conditions of employment or that otherwise are legally protected under the National Labor Relations Act or any other applicable law. 5.1.3 Protect Intellectual Property These assets help to keep Kaiser Permanente competitive and contribute to the body of knowledge that advances health care. All intellectual property generated in the course and scope of your employment with Kaiser Permanente is the property of Kaiser Permanente. If you suspect that any intellectual property has been used or disclosed inappropriately, stolen, or lost, you should report it right away to your chief or immediate supervisor, human resources representative, compliance officer, or the Kaiser Permanente Compliance Hotline at 1-888-774-9100. 5.1.4 Use Funds Appropriately Kaiser Permanente funds, which include anything that has or represents financial value, must be handled responsibly, honestly, and in strict compliance with Kaiser Permanente policies. Corporate credit cards must be used only for authorized business purposes and cannot be used for personal charges. 5.1.5 Keep Track of Assets Chiefs and immediate supervisors have a responsibility to keep track of the assets issued to physicians, dentists, and employees in their unit or department. Kaiser Permanente assets should be returned according to policy when a physician, dentist, or employee is promoted, is transferred, or leaves Kaiser Permanente. Chiefs and immediate supervisors should have a current list of all assets held by physicians, dentists, and employees and should review this list to ensure that it remains current. PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 23 PRESERVE THE TRUST Intellectual property is a legal concept which refers to and protects creations of the mind such as musical, literary, and artistic works; discoveries, inventions, and technical know-how; and words, phrases, symbols, and designs. These assets are protected by law by several forms of intellectual property rights, including patents, copyrights, trademarks, trade dress, and trade secrets. Examples of intellectual property at Kaiser Permanente include our research methods and results; our trademark registrations for Kaiser Permanente®, KP HealthConnect®, and Thrive®; and our copyright-protected educational materials and photographs in print and on kp.org. PRESERVE THE TRUST 5.1.6 Entering Kaiser Permanente Facilities While at work, to protect the safety and security of our members, patients, physicians, dentists, and employees, as well as Kaiser Permanente assets: • Wear your identification at all times. • If you see people without identification, offer to assist them in getting to their destination. • If you see people without proper identification or without an escort in a restricted area: • Offer to escort them to an appropriate area. • Get an authorized person to assist them. • Report them to security. • Do not provide unauthorized people access to Kaiser Permanente facilities. 5.2 Maintain Accurate Business Records It is important to maintain accurate business records, including providing the purpose of a business meal and individuals in attendance in expense reports, reporting financial and statistical information to third parties, and filling in timesheets. Never sign a document unless you know it to be accurate. Never create or change a document for the purpose of misleading anyone, and relevant information should never be intentionally left out, hidden, falsified, or covered up. Physicians, dentists, and employees who provide data or information they know or suspect is false are subject to discipline, up to and including termination of employment. Consider This… Our department is currently undergoing an internal audit. We have been under pressure to ensure that there are no findings. One of the documents was not dated. I was just going to backdate it. Is that okay? No. Misrepresenting the facts discredits you and Kaiser Permanente. There is never a good reason for falsifying any document. Document falsification can lead to serious consequences for you and Kaiser Permanente.   5.2.1 Retain and Destroy Company Records According to Policy Kaiser Permanente business records should be retained or destroyed according to federal, state, and local laws and regulations; applicable licensing, accreditation, and contractual requirements; and applicable Kaiser Permanente policy. Never destroy, change, or conceal any record if you have been instructed to keep it, or if you know or think it’s possible the record may be involved in an investigation or litigation. Find Out More: For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor on how to handle records and PHI appropriately. 24 PRINCIPLES OF RESPONSIBILITY PRESERVE THE TRUST 6. Protect Our Reputation 6.1 Market and Communicate About Kaiser Permanente Accurately and Strategically Federal and state laws protect the public from marketing that is deceptive and dishonest. Determining how, where, and to whom we advertise Kaiser Permanente products and services involves strategy, creativity, and consistency. It also involves being truthful and accurate. Authorization is required to communicate to the public or to professional audiences as a spokesperson or representative of Kaiser Permanente. Employees without authorization may not represent that they are communicating the views of Kaiser Permanente, or do anything that might reasonably create the impression that they are communicating on behalf of or as a representative of Kaiser Permanente. This includes communications in any printed, spoken, or electronic form, for example: speeches, interviews, advertisements, social media, or other digital media. External communications on behalf of Kaiser Permanente must be reviewed and approved by the appropriate national or regional communications group for your area: • Brand Marketing. • Marketing Communications. • Public Relations and Communications. • Communications or public affairs staff for your area. PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 25 Some materials, depending on their content and the audience, may also need to be reviewed by the Kaiser Permanente attorney for your area and your compliance officer to ensure that they have been approved by applicable federal and state agencies. It is also important that you not reproduce, use, or distribute printed materials that Kaiser Permanente does not own unless you have permission to do so. PRESERVE THE TRUST Physicians and dentists should follow applicable Permanente Medical Group policy or Permanente Dental Associates policy for these activities. Consider This… I want to let members know about a new support group we are offering at our medical center. I could easily make a flier and post it in our waiting area, but I’m told that we need to go through public affairs or marketing. Why all the bureaucracy? We want to make sure that we communicate with our members and patients consistently, in both written and oral communications and through the images we share (e.g., video, graphics, and photography). Kaiser Permanente has invested a great deal in building and promoting our brand, and we want to make sure that all external communications are consistent with our brand, whether we are communicating with our members or patients through a flier or an appointment reminder. Our communications and marketing staff are trained to comply with the wide variety of regulatory requirements governing member and patient communications, which can even include fliers. 6.2 Know What to Say When Speaking or Communicating Externally Whenever you act or identify yourself as a Kaiser Permanente physician, dentist, or employee, you have the responsibility to comply with the legal and regulatory obligations that apply to your job, protect confidential and proprietary information, and maintain the confidentiality of our members and patients. This responsibility extends to instances when you may be speaking externally about Kaiser Permanente. If you are speaking or writing on behalf of Kaiser Permanente, you must get approval from your immediate supervisor and your public affairs or external communications staff. If you are otherwise acting in your personal capacity about matters related to Kaiser Permanente, be careful to identify your opinions as your own and not those of Kaiser Permanente. Always maintain the confidentiality of our members and patients. If you receive any request to represent Kaiser Permanente in an interview, speaking engagement, or social media interaction, you must discuss it with your immediate supervisor and your public affairs or external communications staff. 26 PRINCIPLES OF RESPONSIBILITY Physicians and dentists should follow applicable Permanente Medical Group policy or Permanente Dental Associates policy when speaking externally. Find Out More: For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor on social media and communicating outside of Kaiser Permanente. PRESERVE THE TRUST PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS 27 HELP MAKE KAISER PERMANENTE A BEST PLACE TO WORK 7. Treat One Another with Dignity and Respect We believe that all our physicians, dentists, and employees have a right to receive fair and just treatment and that we all have the responsibility to treat one another respectfully. This extends to our relationships with members, patients, customers, vendors, the community, and anyone who comes into contact with Kaiser Permanente. 7.1 Value Workforce Diversity and Inclusion Kaiser Permanente has long been known for its leadership in workplace diversity and inclusion. Our acceptance of diverse ideas and backgrounds strengthens Kaiser Permanente, and creates an inclusive workplace environment in which everyone can thrive. Kaiser Permanente is committed to promoting and maintaining an inclusive, highperforming culture in which everyone celebrates innovative thinking, and makes full use of each other’s talents, experience, and backgrounds. 28 PRINCIPLES OF RESPONSIBILITY If you believe that you or any other Kaiser Permanente physician, dentist, or employee has been subject to discriminatory conduct, report it promptly to your chief, immediate supervisor, or human resources representative. You may also use the Equal Employment Opportunity Internal Complaint Procedure or the Kaiser Permanente Compliance Hotline at 1-888-774-9100. Chiefs and immediate supervisors must report allegations of discrimination to their Human Resources department immediately regardless of who is engaged in the alleged misconduct. 7.1.1 Respect Member and Patient Diversity and Inclusion Kaiser Permanente has the privilege of serving a diverse population. This privilege comes with the responsibility of considering and respecting members’ and patients’ cultural needs and values when we care for them or have contact with them and their families. BEST PLACE TO WORK Our goal is to deliver unbiased, culturally and linguistically appropriate health care and services that incorporate the diversity of health beliefs, practices, and communication preferences of our very diverse membership. Kaiser Permanente does not discriminate against patients on the basis of sex, age, economic status, educational background, race, color, religion, ancestry, national origin, sexual orientation, gender identity, disability, marital status, veteran status, or source of payment. Consider This… I get frustrated and irritated when I work with members or patients whose family and friends speak in another language. Is it okay for me to ask them to speak in English? No. Our members and patients have the option of speaking in their preferred language. If needed, offer interpretive services to ensure that you and the member or patient understand one another. For medical interpretation, consult your area’s policy. It’s important to remember that the health care setting can be stressful. When members and patients speak in their preferred language, they may be able to communicate the care or help they need more clearly than if they were required to speak in English. Find Out More: For additional guidance on respect and fair treatment for members and patients, refer to the policies and procedures that apply to you, check with your chief or immediate supervisor, or talk to your diversity or linguistic services department. HELP MAKE KAISER PERMANENTE A BEST PLACE TO WORK 29 7.2 Foster a Harassment-Free Environment We do not tolerate harassment of any kind by anyone in violation of Kaiser Permanente policies, whether it involves an employee, physician, dentist, executive, vendor, contractor, contingent worker, member, patient, or anyone else. We believe in personal dignity and respect for one another. Whether or not an offense was intended, harassment — or the perception that it exists or has occurred — is harmful and creates a less effective work environment. BEST PLACE TO WORK Harassment that violates Kaiser Permanente policies can take many forms. A few examples include: • Jokes, insults, threats, and inappropriate comments about a person’s race, color, sex, gender identity, age, religion, national origin, ancestry, citizenship, physical or mental disability, veteran status, sexual orientation, genetic information, or other status protected by applicable federal, state, or local laws. • Unwelcome sexual advances, sexual remarks, displays of offensive material, requests for sexual favors, and other unwelcome verbal or physical conduct of a sexual nature. • Verbal, physical, or visual conduct that disrupts another’s work performance or creates an intimidating, harassing, or hostile work environment. • Communicating or displaying offensive material in the workplace. If you are the victim of workplace harassment, or see or hear it taking place, you should report it immediately to your chief, immediate supervisor, human resources representative, or compliance officer. You can also use the Equal Employment Opportunity Internal Complaint Procedure or the Kaiser Permanente Compliance Hotline at 1-888-774-9100. Consider This… Two of my co-workers are constantly engaging in very obvious flirtatious behavior. While I think this is more talk than action, it makes many of us uncomfortable. Our supervisor just laughs about it and says it’s “harmless.” What should we do? Report it. These two employees are creating an uncomfortable work environment that could be impacting your team’s effectiveness. Raise the concern with your human resources representative or your compliance officer. Find Out More: For additional guidance on fostering a harassment-free environment, refer to the policies and procedures that apply to you, check with your chief or immediate supervisor, or talk to your human resources representative or compliance officer. 30 PRINCIPLES OF RESPONSIBILITY 7.3 Make Safety and Environmental Awareness a Priority We want to keep everyone who steps into a Kaiser Permanente facility safe. This includes members, patients, visitors, physicians, dentists, employees, vendors, and volunteers. We also want to ensure that the way we do business is mindful of short- and long-term environmental impact. 7.3.1 Focusing on Workplace Safety Safety is an important Kaiser Permanente value. Kaiser Permanente complies with all laws and regulations that govern workplace health and safety, and our standards often exceed minimum safety requirements. We all play a role in ensuring workplace safety. Kaiser Permanente’s senior leaders are responsible for having the right policies, procedures, systems, tools, equipment, and training in place, and for addressing unsafe conditions or security issues promptly. It is everyone’s responsibility to work safely and to report any unsafe conditions or security-related issues immediately. We must all work together to create a safe, secure, and injury-free workplace. You are required to: Did You Know… Kaiser Permanente is committed to protecting the safety, health, and well-being of physicians, dentists, employees, and other individuals in the workplace. Kaiser Permanente strives to provide a workplace free of substance and alcohol abuse. Kaiser Permanente encourages any individual experiencing alcohol or substance abuse problems to seek professional assistance. Physicians, dentists, employees, and their dependent family members can find such assistance through Kaiser Permanente’s employee assistance programs. These employee assistance programs offer free and confidential services provided by licensed and trained clinicians. For additional information concerning Kaiser Permanente’s commitment to a workplace free of alcohol or substance abuse or Kaiser Permanente’s employee assistance programs, refer to the policies that apply to you or speak with your chief, immediate supervisor, or human resources representative. HELP MAKE KAISER PERMANENTE A BEST PLACE TO WORK 31 BEST PLACE TO WORK • Participate in safety training programs. • Follow safety standards and incorporate them into workflows and performance improvement projects. • Report safety concerns as they arise to your chief, immediate supervisor, or safety manager. • Share and discuss ideas about improving safety with your co-workers and your chief or immediate supervisor. • Familiarize yourself with safety resources, including getting to know your safety manager. • Contact a security officer or law enforcement personnel, as appropriate, when a crime is in progress and/or an individual’s life could be in jeopardy. 7.3.2 Reporting Work-Related Injuries Kaiser Permanente is required to record and report work-related injuries. While we want to have zero occurrences of work-related injuries, they do occur, and it is critical that these accidents and incidents are reported. Laws require us to record and report these incidents, and doing so helps Kaiser Permanente put better mechanisms, processes, and practices in place to avoid them in the future. If you are involved in an incident, you must report it promptly to your chief or immediate supervisor and follow the necessary procedures. Consider This… I work in the mail room, and I like to do my work while listening to music. I put on some good tunes, stick my ear buds in, and I’m good to go! My supervisor makes me take the headphones out. Why? BEST PLACE TO WORK Having headphones in your ears interferes with your ability to hear others. This may pose a danger while you are moving around the mail room, walking down hallways, etc. Rules specific to a department are often implemented to avoid injuries. Find Out More: For additional guidance on safety, refer to the policies and procedures that apply to you, check with your chief or immediate supervisor, or talk to your safety manager or compliance officer. 7.3.3 Cooperating With Periodic Federal and State Inspections From time to time, federal and state agencies may make unannounced visits to our facilities to conduct inspections. Physicians, dentists, and employees must cooperate with these officials and contact a chief, immediate supervisor, compliance officer, and/or safety manager to assist with the inspection right away. See Section 9: Meet Government Expectations and Cooperate With Government Inquiries for more information about cooperating with periodic federal and state inspections. 7.3.4 Minimizing Our Environmental Footprint Kaiser Permanente is dedicated to environmental sustainability because a healthy environment has a direct and positive impact on both individual and community health. Kaiser Permanente physicians, dentists, and employees should reduce Kaiser Permanente’s environmental impact by reducing waste (for example, using less paper), participating in recycling programs, conserving energy and water, and using renewable resources whenever possible. If you have suggestions on ways that we could provide care or do business in a more environmentally sustainable manner, share them with your chief, immediate supervisor, facility green team member, or safety manager. 32 PRINCIPLES OF RESPONSIBILITY 7.3.5 Reporting Environmental Hazards If you know or suspect that an environmental hazard has occurred, you must notify your chief or immediate supervisor or safety manager as soon as possible. Improperly disposing of hazardous materials can have negative effects on people and the environment. It could also result in Kaiser Permanente facing regulatory and criminal charges and penalties. 7.4 Know the Facts About Retaliation Kaiser Permanente prohibits intimidation or retaliation of any kind against individuals who in good faith report or participate in the investigation of any compliance concern. Examples include retaliation between peers, immediate supervisors and employees, physicians and employees, dentists and employees, and vendors and employees. Anyone who attempts to retaliate against someone who, in good faith, reports or participates in the investigation of any compliance concern could be subject to disciplinary action, up to and including termination of employment. If you believe you or others are being retaliated against in any way for reporting or participating in the investigation of suspected illegal, unethical, or otherwise inappropriate acts, you must immediately contact your compliance officer or call the Kaiser Permanente Compliance Hotline at 1-888-774-9100. BEST PLACE TO WORK Kaiser Permanente is committed to creating a work place where physicians, dentists, and employees are protected from retaliation when you speak up and make a good faith report of inappropriate or suspicious activities or when you refuse to participate in wrongdoing. All Kaiser Permanente physicians, dentists, and employees are covered by the whistleblower protections in the federal False Claims Act and other federal and state whistleblower laws and regulations. The False Claims Act is intended to reduce fraud, waste, and abuse of federal funds by allowing private parties to bring suit on behalf of the government against people or businesses alleged to have committed fraud. The act also protects whistleblower physicians, dentists, and employees from retaliation by employers. Consider This… In comparing patient visits and the claims submitted over the past few months, I think the way my manager is filing Medicare reimbursement claims is not correct. I’m scared to say anything about it. I could get into a lot of trouble. What should I do? You should discuss your concerns with your compliance officer, speak with the Kaiser Permanente attorney for your area, or call the Kaiser Permanente Compliance Hotline at 1-888-774-9100. The False Claims Act and other federal and state whistleblower laws protect you. Kaiser Permanente will not discharge, demote, suspend, threaten, harass, or in any manner discriminate against physicians, dentists, or employees in retaliation for exercising their rights under these laws. HELP MAKE KAISER PERMANENTE A BEST PLACE TO WORK 33 MAKE OBJECTIVE AND FAIR DECISIONS 8. Avoid Conflicts of Interest Kaiser Permanente’s distinguished reputation as an innovator and health care pioneer has been earned through the efforts of physicians, dentists, and employees. Maintaining and protecting that reputation depends directly on our actions and the integrity with which we conduct our work. Workplace decisions must be made objectively and fairly. If you have a conflict of interest, or other persons reasonably could believe that you have a conflict of interest, the objectivity and fairness of your decisions could be questioned by your colleagues, co-workers, or even the federal and state government. In fact, many federal and state government agencies now have specific rules on conflicts of interest, and we must comply with them. 8.1 Understanding How Conflicts of Interest Occur Conflicts of interest occur any time relationships or personal financial interests influence, or might reasonably appear to influence, your ability to make an objective and fair decision based solely on what is best for Kaiser Permanente and the members and patients we serve. Actual or perceived conflicts of interest arise from many different kinds of relationships. The relationships addressed in the Principles of Responsibility are vendor relationships, employment relationships, and financial relationships. There are countless other kinds of relationships that you might have as a Kaiser Permanente physician, dentist, or employee that could generate an actual or perceived conflict of interest. Read the Kaiser Permanente policies that apply to you to check for other kinds of conflicts to avoid. 34 PRINCIPLES OF RESPONSIBILITY 8.2 How to Handle Conflicts of Interest When potential conflicts of interest are not handled correctly, they can put Kaiser Permanente at risk of fines, litigation, penalties, criticism from patients, interest groups, or government agencies, and negative media coverage. Investigating and resolving conflicts of interest can be costly. It takes time, money, and effort. These resources would be better spent taking care of our members and patients and improving our quality of care. Kaiser Foundation Hospitals and Kaiser Foundation Health Plan, Inc. are nonprofit tax-exempt organizations and their employees must follow rules that protect their tax-exempt status. To help manage conflicts of interest, policies are in place to provide guidance to physicians, dentists, and employees in a variety of roles. You should be aware of the policies that apply to you as they may be more restrictive than what is described here. For example, Kaiser Permanente physicians, dentists, and employees who have direct decision-making authority over the pharmaceuticals that Kaiser Permanente buys are not allowed to accept anything of value from any pharmaceutical manufacturer or distributor. In addition, some of the Permanente Medical Groups have adopted policies that prohibit any Permanente Medical Group physician or employee from accepting anything of value from a Kaiser Permanente vendor. If you think that you or a co-worker might have a conflict of interest, talk with your chief, immediate supervisor, or compliance officer. These situations are often not clear cut and they will be reviewed by experts on a case-by-case basis. 8.3 Guidance for Avoiding Conflicts of Interest 8.3.1 How to Handle Gifts and Business Courtesies You may be able to accept gifts only if the following criteria are met: • The gift does not violate any law or policy. • The gift cannot reasonably be seen as an attempt to gain an advantage or be considered a bribe, payoff, or insider deal. • The gift cannot be more than $25 per person per incident and is not given on a regular basis. Check your regional, local, or department policy because some areas have adopted a $0 limit. You should be aware of the policies that apply to you as they may be more restrictive than what is described here. Some Kaiser Permanente entities, such as The Permanente Medical Group, Inc., do not permit their physicians or employees to accept any gifts from Kaiser Permanente vendors. MAKE OBJECTIVE AND FAIR DECISIONS 35 OBJECTIVE & FAIR DECISIONS Creating and maintaining strong relationships with our members and patients, business partners, and customers is vital to our success. However, if you accept gifts from individuals or organizations that sell or offer to sell goods and services to Kaiser Permanente, you allow others to raise at least the possibility that your decision to do business with that vendor or prospective vendor was not made objectively or fairly and in the best interest of Kaiser Permanente. In addition, Kaiser Permanente physicians, dentists, and employees who have the authority to sign Kaiser Permanente contracts, authorize payment of Kaiser Permanente funds to vendors, or have decision-making authority over the selection of products or services purchased by Kaiser Permanente must not accept any gifts from a Kaiser Permanente vendor or prospective vendor. If you are offered or receive a gift that is not permitted, politely decline or return the gift, explaining that our code of conduct does not allow you to accept it. If this is not possible, consult your chief, immediate supervisor, or compliance officer. Some Kaiser Permanente entities and departments prohibit acceptance of business related meals or events that are paid for by a vendor. Check the policies that apply to you before accepting any such invitations. Unless the policies that apply to you specify otherwise, the meal or event must meet the criteria stated above. If the value of the meal or event exceeds the maximum that applies to you (i.e., $25 or maximum amount allowable by policy), you must obtain your chief’s or immediate supervisor’s permission to attend. If the value that you receive at the meal or event unexpectedly exceeds the maximum that applies to you, you must disclose it to your chief or immediate supervisor as soon as possible. In some cases, limited exceptions or waivers may be granted. Consider This… I am attending a product training at a vendor’s office. Is it okay for me to: OBJECTIVE & FAIR DECISIONS • Have a bagel and cream cheese that is provided during a break? • Be taken out for dinner at a restaurant after the session? Check the policies that apply to you. If your policy does not prohibit acceptance of meals and the food does not exceed $25 in value, it may be acceptable. A bagel may be fine, but a four-course meal at a steak house probably wouldn’t be. Find Out More: For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor. 8.3.2 Accepting Gifts from Grateful Members and Patients Sometimes members and patients want to express their appreciation for the care they received by giving a Kaiser Permanente physician, dentist, or employee a gift. You can accept modest gifts from grateful patients. Perishable items, such as food or flowers that cannot be returned, can be accepted and shared with others. Accepting goods or services at or below market value from patients or their relatives, in relation to your job, is equivalent to a gift. If you receive a more than modest gift from a patient, speak with your chief, immediate supervisor, or compliance officer. 36 PRINCIPLES OF RESPONSIBILITY Consider This… A patient I was caring for is a dog breeder. He is really appreciative of the care I gave and said that he would sell me one of his puppies at half his normal price. Can I accept? No. The discount off full price would be considered a gift. Let the patient know that it would not be appropriate for you to accept. 8.3.3 Gifts You Cannot Accept As a Kaiser Permanente physician, dentist, or employee, accepting certain gifts is prohibited. These include: • Tips for a complimentary or routine service. • Gifts or entertainments on a regular basis. • Cash or cash-equivalent gifts (for example, checks, gift certificates, gift cards, and coupons). • Weapons of any kind. • Tobacco of any kind. • Items that reasonably might be viewed as lewd, vulgar, pornographic, or offensive. Prohibited gifts must be refused, returned immediately to the sender, or donated appropriately. Consider This… OBJECTIVE & FAIR DECISIONS A new vendor just completed a project for my department and gave me a $50 gift voucher to say “thanks for the business.” I know that they received the Vendor Code of Conduct that says that gifts valued at more than $25 cannot be given or accepted. What should I do? Thank the vendor for the work and for the gift, but let the vendor know that you cannot accept the gift voucher because it exceeds the $25 allowable amount and because gift cards are not acceptable. You may also want to get a copy of the Vendor Code of Conduct (go to kp.org/compliance and click Vendors & Contractors), highlight the section on gifts and business courtesies, and give it to the vendor to explain your actions. Find Out More: If a situation comes up that falls outside of the above criteria, talk to your chief or immediate supervisor or compliance officer. In cases where Kaiser Permanente is an event sponsor, speak with your human resources representative, compliance officer, and public affairs or communications department in your area about how to handle tickets. MAKE OBJECTIVE AND FAIR DECISIONS 37 8.3.4 Giving Gifts Using Kaiser Permanente Resources Generally, Kaiser Permanente assets should not be used to purchase gifts for vendors, customers, union officials, or government officials. Sometimes doing so may be permissible. Before you offer a gift, meal, entertainment, or anything of value, you must ensure that doing so: • Does not violate any law, Kaiser Permanente policy, or contractual agreements. • Cannot be construed as a bribe, payoff, deal, or any other attempt to gain advantage. Just as we have policies about giving and receiving gifts, the recipient may have similar policies as well. Please make a prudent effort to ensure that the gift meets the recipient’s gift policy. See Section 9.4: Interacting With Individuals and Organizations Restricted by the Government as well as Section 9.5: Protect Kaiser Permanente With Respect to Political Activities and When Making Personal Political Donations for more on gifts, invitations, and donations involving government officials. 8.3.5 Honoraria and Speakers’ Fees OBJECTIVE & FAIR DECISIONS You cannot accept honoraria, speakers’ fees, or anything else of value from a vendor or research sponsor in exchange for teaching or giving presentations prepared in the course of work for Kaiser Permanente or presenting content related to Kaiser Permanente. For example, this includes payment for: • Time. • Travel expenses. • Meals. • Entertainment. • Recreational or social activities. If you are offered an honorarium when giving a presentation as a representative of Kaiser Permanente, you should turn over any honoraria to your Kaiser Permanente employer. Accepting honoraria for presentations prepared in your personal time on content that doesn’t relate to Kaiser Permanente may be acceptable but must meet the requirements in Section 8.3.6 Outside Employment, Including Self-Employment, and any other policy that applies to you. Find Out More: For additional guidance for situations involving honoraria, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor. 38 PRINCIPLES OF RESPONSIBILITY 8.3.6 Outside Employment, Including Self-Employment Outside employment, including self-employment, by physicians, dentists, or employees must always be avoided if it interferes or conflicts with Kaiser Permanente’s mission, business, or your work. Generally, physicians, dentists, and employees cannot: • Serve as a member of a board of directors or an advisory board of a Kaiser Permanente vendor (See Section 8.3.11: Outside Directorships). • Be directly involved in the sale of a product or service to Kaiser Permanente while employed by Kaiser Permanente. • Serve as a member of a board of directors, an advisory board, or as a consultant to a research sponsor of a study for which you are a researcher. You must also give written notice to your chief or immediate supervisor before working as a consultant, independent contractor, representative, or employee of any organization that is a competitor of Kaiser Permanente. If an outside organization you are working for becomes a competitor, disclosure is required at that time. Examples of outside organizations include another hospital, pharmacy, insurer, or medical provider. In addition, refer to the policies concerning outside employment or outside income that apply to you. These policies may be more restrictive than the requirements set forth in the Principles of Responsibility. You must comply with the policy of the Kaiser Permanente entity for which you work. If you work for Kaiser Permanente on an on-call or per-diem basis, you are not required to provide a written disclosure for work outside Kaiser Permanente. However, if you are asked to complete a conflicts of interest questionnaire, you must respond to all questions accurately, completely, and in a timely manner. OBJECTIVE & FAIR DECISIONS If you would like more guidance on this topic, check with your chief, immediate supervisor, human resources representative, or your compliance officer. 8.3.7 Financial Interests and Investments Conflicts of interest or the appearance of a conflict of interest can arise because of personal financial interests or investments held in vendors, customers, or competitors. Kaiser Permanente physicians, dentists, and employees must avoid situations where investments and outside income can influence or appear to influence decisions made on behalf of Kaiser Permanente. If you are a physician, dentist, or employee with authority or influence over purchasing from or contracting with vendors, contracting with customers, or competing with Kaiser Permanente’s competitors for business you must disclose to your chief, immediate supervisor, or compliance officer if you or anyone in your immediate family has a financial interest in any of these entities as soon as you know of the connection. Disclosure is also required if a relative or member of your household is employed by a vendor and can directly benefit from any transaction MAKE OBJECTIVE AND FAIR DECISIONS 39 under your authority or influence. This is especially important to keep in mind if your job duties and responsibilities change over time. Mutual fund shares and insubstantial share holdings of a publicly held company do not need to be disclosed. In addition, physicians, dentists, and employees who obtain confidential information as a result of their employment with Kaiser Permanente must avoid potential conflicts by not using this confidential information for personal financial gain. Consider This… I am organizing a retirement party for my manager, using Kaiser Permanente funds. My wife is a co-owner of a catering business and has provided catering services to other Kaiser Permanente departments. Can I use my wife’s business to cater the retirement party? As someone with authority or influence over selecting vendors, you are responsible for prioritizing Kaiser Permanente’s interests over your personal interests. In this situation, you must disclose your wife’s co-ownership in the business to your chief or immediate supervisor and recuse yourself from the contracting decision while that business is being considered. If you are a researcher, there are specific rules relating to holding investments and other interests in research sponsors. Please refer to the appropriate policy or your compliance officer for guidance. If you have questions about financial interests, investment requirements, or similar situations, ask your chief, immediate supervisor, or compliance officer. OBJECTIVE & FAIR DECISIONS 8.3.8 Patient Referrals Federal “Stark” law, also known as the “self-referral law,” prohibits a physician from referring Medicare patients for certain “designated health services,” or ordering these services for Medicare patients, from a provider where the physician has a compensation or ownership arrangement with that provider, unless the arrangement meets an exception. For example, a physician cannot refer a Medicare patient for laboratory services to a lab that the physician owns unless the arrangement meets an exception. Similar prohibitions apply to Medicaid. The exceptions are complex and include, for example, certain managed care arrangements, employment arrangements, and in-office ancillary services within group practices, where specific criteria apply. Some states also have adopted their own versions of self-referral laws. Consult your chief, immediate supervisor, or compliance officer before making such referrals. 40 PRINCIPLES OF RESPONSIBILITY 8.3.9 Anti-Kickback Laws The federal Anti-Kickback Statute makes it illegal for physicians and other persons to knowingly and willfully accept remuneration made in exchange for, or to induce, referrals of patients covered by federal health programs, which includes Medicare and Medicaid. Prohibited remuneration is defined broadly to include anything of value whether offered in cash or in kind, directly or indirectly. For example, if a hospital’s provision of compensation, services, or goods to physicians is intended to encourage referrals of Medicare patients to the hospital, they could be suspect under the Anti-Kickback Statute. “Safe harbor” exceptions apply to protect certain arrangements in a manner similar to, but not identical to, the Stark Law exceptions described above. Some states have adopted their own anti-kickback or antiinducement laws as well. Violations of these fraud and abuse laws can result in significant regulatory fines and penalties and, in the worst case scenario, exclusion from participation in federal health care programs and even criminal penalties, such as imprisonment. Violations also can lead to penalties under the federal False Claims Act. See Section 3.2: Follow Anti-Fraud Laws. In addition, violations can lead to nonpayment for services and/or disciplinary actions, and could form the basis for termination of a provider’s arrangement with Kaiser Permanente. Kaiser Permanente strives to comply with these complex requirements in our arrangements. If you have questions about any arrangements involving Kaiser Permanente or its physicians, dentists, or employees in light of fraud and abuse laws, please consult your chief, immediate supervisor, or compliance officer. OBJECTIVE & FAIR DECISIONS Consider This… A hospital has offered several Kaiser Permanente physicians and employees and their families free tickets to baseball games. Can we accept the offer? No. Such an offer could subject the hospital, and our physicians and employees who accept the offer, to penalties under the Stark Law and AntiKickback Statute. It’s important to recognize that this scenario gives rise to both conflict of interest and gift policy issues, as well as potential Stark and Anti-Kickback problems. Kaiser Permanente physicians and medical center employees are not permitted to accept such gifts. Find Out More: For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor and legal counsel for your area if you have questions about this area of the law. MAKE OBJECTIVE AND FAIR DECISIONS 41 8.3.10 Physician Income and Investments Physician partners and shareholders of the Permanente Medical Groups may not invest in or perform services for any organization providing health care services to patients in areas served by Kaiser Permanente, except as specifically permitted by Permanente Medical Group policy or as otherwise approved in writing by an authorized Permanente Medical Group senior leader. This includes any services that involve or require a medical license or medical expertise. Income earned by Permanente Medical Group physicians and employees for professional services performed outside of your Permanente Medical Group is subject to the policies of your Permanente Medical Group. 8.3.11 Outside Directorships Service on the board of directors of a vendor or potential vendor generally is not permitted. To serve on the board of a competitor requires written disclosure to your chief, immediate supervisor, or compliance officer. In addition to your written disclosure, written approval may be required. Refer to the policies that apply to you. These policies may be more restrictive than the requirements set forth in the Principles of Responsibility. You must comply with the policy of the Kaiser Permanente entity for which you work. For additional guidance, speak to your chief, immediate supervisor, or human resources representative. See Section 4.1: Disclose When Serving on Boards for more on being involved in other organizations’ boards of directors. OBJECTIVE & FAIR DECISIONS 8.3.12 Employment of Relatives and Household Members Employment decisions must always be made based on merit, qualifications, and competence. Kaiser Permanente permits relatives and members of the same household to work together if they are the most qualified candidates. However, the following are not allowed: • Reporting relationships — Physicians, dentists, or employees may not report directly to a relative or someone with whom they have a personal relationship. For example, a staff member cannot report to his aunt. Indirect reporting relationships must be avoided if they would create a conflict of interest or any other unethical or inappropriate work situation. For further guidance, talk with your chief or immediate supervisor, their manager, or your human resources representative. • Awkward working arrangements — Relatives or members of the same household working together may create a real or perceived conflict of interest or an unethical or inappropriate situation by being a risk to safety, security, operations, or morale. For example, if relatives or members of the same household working together always take the same lunch times, the resulting pressure for others to cover their time off could affect the department’s effectiveness. 42 PRINCIPLES OF RESPONSIBILITY • Employment decisions — You may not make hiring and/or compensation decisions, including promoting, or terminating employment regarding any relatives, members of your same household, or someone with whom you have a personal relationship. • Performance feedback — You may not provide performance feedback for any relatives or members of your same household. You must give written notice to your chief or immediate supervisor (in your current department or any that you transfer to) of any work situations involving the employment of relatives, members of your household, or someone with whom you have a personal relationship. For additional guidance, refer to policies and procedures for your area, and check with your chief or immediate supervisor. Some regions, Permanente Medical Groups, medical centers, and departments may have more restrictive policies that you must follow. If you would like more guidance on this topic, talk to your compliance officer. Consider This… I have an open position on my staff for an administrative assistant. I think my niece would be perfect. Can I hire her? If the position reports directly to you, then you cannot fill the position with your niece. The human resources hiring process and applicable policies should be followed when you hire for the position. Find Out More: MAKE OBJECTIVE AND FAIR DECISIONS OBJECTIVE & FAIR DECISIONS You should seek guidance from a compliance officer on potential conflicts about employment of relatives and household members in your department. Each situation should be considered individually. 43 8.4 Conflicts of Interest Questionnaire As a physician, dentist, or employee, you may be asked to complete a conflicts of interest questionnaire. If so, you must answer honestly, completely, and in a timely manner. Not doing so could lead to disciplinary action up to and including termination of your employment. The conflicts of interest questionnaire is not the only way for you to communicate a potential issue. Even if you are not asked, you must tell your chief, immediate supervisor, or compliance officer of any actual or potential conflict. Failing to do so could lead to disciplinary action up to and including termination of employment. 8.5 Partner With Vendors to Support Our Values Running a successful organization often requires using the professional expertise of others and buying materials and products from third parties. It is critical for Kaiser Permanente to build these vendor and contractor relationships with integrity to ensure that business dealings between all parties run smoothly and to protect the interests of Kaiser Permanente. Only physicians, dentists, and employees with authority to do so may purchase goods and services on behalf of Kaiser Permanente. The appropriate policy must be followed when contracting for goods and services. 8.5.1 Purchase and Contract Fairly Kaiser Permanente has negotiated contracts with some vendors that enable us to purchase products (such as office supplies) and services (such as express mail) that have a consistent quality at a discounted rate. Using only these select vendors helps reduce costs and improve quality. OBJECTIVE & FAIR DECISIONS Find Out More: You can find your preferred national contracted suppliers on the Kaiser Permanente intranet at kpnet.kp.org/buy/index.html. If you don’t think the national supplier can meet your needs, discuss with your manager and contact your local procurement and supply team to discuss solutions. 8.5.2 Avoid Violations of Antitrust and Unfair Competition Laws Antitrust laws prohibit working together with competitors to: • • • • Set prices, terms, or conditions of sale. Boycott customers or suppliers. Divide markets by customers, territories, or services. Limit free-market competition in other ways. Ask your Kaiser Permanente attorney if you ever question whether a business deal violates antitrust and unfair competition laws. 44 PRINCIPLES OF RESPONSIBILITY 8.5.3 Choose Vendors and Independent Contractors Fairly Only physicians, dentists, and employees who are authorized to enter into binding contracts on behalf of their respective Kaiser Permanente entity should attempt to do so. Selecting suppliers and vendors must be done fairly and objectively and applicable policies must be followed. The following factors should be considered carefully: • Kaiser Permanente purchasing policies. • The wellbeing of our members and patients. • The best interests of Kaiser Permanente. • Whether the vendor is likely to provide quality products and/or services as promised. • Affordability. Decisions about what goods and services Kaiser Permanente buys should be made objectively and fairly. No one should use or attempt to use his or her position to advocate for or against a vendor unfairly. The criteria and process used to select a vendor should be documented, and the terms and conditions of the purchase should be defined clearly. Mistakes or misunderstandings can occur if agreements are made orally, over the telephone, or in other informal exchanges. You must be aware of policy and disclosure requirements when contracting with a former Permanente Medical Group physician or employee, contracting with a former Permanente Dental Associates dentist or employee, or contracting with an organization that you have worked with in the past. 8.5.4 Oversight of Vendors and Independent Contractors Find Out More: Go to kp.org/supplier and select Compliance and Ethics for a copy of Kaiser Permanente’s Vendor Code of Conduct and the Principles of Responsibility. When you contract with a vendor, you are responsible for making sure that vendor is following Kaiser Permanente’s policies and all other requirements in the work that you are directing or have assigned to the vendor. If you ever have a concern about the relationship you have with a vendor or independent contractor, talk with your chief or immediate supervisor and refer to the Vendor Code of Conduct. MAKE OBJECTIVE AND FAIR DECISIONS 45 OBJECTIVE & FAIR DECISIONS Just as physicians, dentists, and employees are expected to treat our business partners fairly, vendors and independent contractors are expected to conduct business professionally and to follow Kaiser Permanente’s Vendor Code of Conduct. All vendors should be given a copy of and follow the Vendor Code of Conduct and familiarize themselves with applicable Kaiser Permanente policies. OBJECTIVE & FAIR DECISIONS 9. Meet Government Expectations and Cooperate With Government Inquiries Health care is a heavily regulated industry. Numerous local, state, and federal agencies are responsible for ensuring organizations operate in compliance with regulations. From time to time, federal and state agencies may make unannounced visits to our facilities to conduct inspections. You also may get an inquiry, subpoena, or other legal document from a government agency regarding Kaiser Permanente’s business or care. Physicians, dentists, and employees must cooperate with government officials. If you receive a government agency inquiry in the course of your work duties or a subpoena or other legal document that is not addressed to you personally, contact your chief, immediate supervisor, or compliance officer right away. If an agency representative or inspector approaches you at work: • Greet the representative or inspector. • Ask for identification. • Obtain information about the purpose of the visit or document request. • Find a location for the agency representative to sit that is free of protected health information and nonpublic information, if contact is made in person. • Follow your local notification process to let others know, as appropriate, about the visit. 46 PRINCIPLES OF RESPONSIBILITY Physicians, dentists, and employees should be accurate, complete, and truthful in responding to government agencies. Management-level employees should also coordinate responses appropriately with leadership, compliance, or legal, as appropriate. If, in the course of responding to a government agency, you discover or suspect that you or someone else has made a misrepresentation — either by saying something untruthful or by creating a misunderstanding or misimpression through an omission — you must correct it immediately. Consider This… I heard that Kaiser Permanente has been asked by the government to turn over documents for a grand jury investigation. I’d prefer not to provide them with my personal notes, which I always save just for my own reference. Would it be okay to destroy them? No. Deliberate destruction of documents that may be relevant in an investigation is illegal and against Kaiser Permanente policy. Never alter, conceal, or destroy documents or records if they have been requested by a government agency or if they are likely to be requested in connection with an investigation. 9.1 Interacting Appropriately With Government Officials Most government officials and their staffs are prohibited from accepting anything of value, including food, beverages, services, or gifts. 9.2 Report Accurately to the Government Any time that we are reporting to any federal, state, or local government agency, we must be accurate, complete, and timely. Here are some examples of this type of reporting: • Centers for Medicare & Medicaid Services cost reports — All cost and pricing information. • Corrective action plans — Responses to audit and investigation findings and observations. • Medical records — Medical care and services. • Claims — Diagnostic and procedural coding requirements. Physicians, dentists, and employees who provide false information could face criminal prosecution. MAKE OBJECTIVE AND FAIR DECISIONS 47 OBJECTIVE & FAIR DECISIONS Speak with your compliance officer, the Kaiser Permanente attorney for your area, and/or the government relations department if you are thinking of offering gifts to any government officials or their staffs, inviting them to any Kaiser Permanente event, or providing food and beverage during an unannounced visit. 9.3 Follow Licensing and Certification Requirements Regulations that apply to Kaiser Permanente include everything from federal and state licensure for professional practices to Medicare program participation requirements and building codes. You are responsible for following all professional licensing and certification requirements that apply to you. This includes ensuring these professional licenses and certifications are kept current. 9.4 Interacting With Individuals and Organizations Restricted by the Government The government keeps lists of individuals and organizations that have been excluded from government contracting; are not allowed to contract or subcontract with the Medicare, Medicaid, or other government health programs; or have opted out of Medicare programs. Everyone in Kaiser Permanente or doing business with Kaiser Permanente is checked for exclusion. We screen these lists prior to a job candidate becoming an employee of Kaiser Permanente and monthly after an individual is hired. If you are added to any of these government exclusion lists, you must provide written disclosure to your chief or immediate supervisor as soon as you become aware of it. Any existing or proposed employment, contract, or other association with any individual or entity on these lists will be handled on a case-by-case basis in accordance with the law and Kaiser Permanente policies. Find Out More: OBJECTIVE & FAIR DECISIONS For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor. 9.5 Protect Kaiser Permanente With Respect to Political Activities and When Making Personal Political Donations Kaiser Foundation Hospitals (KFH) and Kaiser Foundation Health Plan, Inc. (KFHP), as well as many of their subsidiaries, are tax-exempt organizations. The privilege of having a tax-exempt status comes with very strict rules under the Internal Revenue Code and Internal Revenue Service regulations. Federal law prohibits KFH and KFHP from engaging in any partisan political activities, defined as participating in or supporting campaigns of candidates for public office, including making campaign contributions to candidates for office, either directly or indirectly, through their employees or any other persons. Similarly, reimbursing employees for participation in any partisan political activity and using any organizational resources to support campaigns for candidates for public office would jeopardize this tax-exempt status. 48 PRINCIPLES OF RESPONSIBILITY Physicians, dentists, and employees must not use any KFH or KFHP resource, including but not limited to electronic and telephone communications equipment, office supplies, or facilities for the benefit of any campaign for public office or partisan political activity. Find Out More: For additional guidance, refer to the policies and procedures that apply to you and check with your government relations department if you have questions. If you are an employee of KFH or KFHP and are personally involved in politics, you must express your political views as an individual and not as a representative of KFH or KFHP. Your personal political activities or donations must occur on nonworking time and at your own expense. The rules are different for physicians, dentists, and employees of the Permanente Medical Groups and Permanente Dental Associates, which are taxable organizations. Each of the Permanente Medical Groups and the Permanente Dental Associates have adopted policies that relate to political activities. OBJECTIVE & FAIR DECISIONS MAKE OBJECTIVE AND FAIR DECISIONS 49 KNOW HOW TO GET HELP 10. Speak Up if You Have Any Questions or Concerns Kaiser Permanente’s Principles of Responsibility, our code of conduct, provides guidance about business behavior expected of physicians, dentists, and employees in our work and interactions with others. If you have concerns, there are many people and resources available to help you make ethical decisions, including: • Your chief, immediate supervisor, or management. • Your human resources representative. • Your steward and/or union representative. 50 PRINCIPLES OF RESPONSIBILITY • Your compliance officer. • Your Kaiser Foundation Hospitals; Kaiser Foundation Health Plan, Inc.; Permanente Medical Group; or Permanente Dental Associates legal counsel or department, as appropriate. • Internal audit services. • Your controller’s office. • The National Compliance, Ethics & Integrity Office or website at kp.org/compliance. • National, regional, and local policy websites. • The Kaiser Permanente Compliance Hotline at 1-888-774-9100. • Kaiser Permanente Webline at reportlineweb.com/kp. 10.1 Report Potential Compliance Issues Kaiser Permanente is committed to maintaining, as appropriate, confidentiality and anonymity for all individuals reporting compliance issues — real or perceived. You can seek guidance and report possible violations without fear of retaliation. It is better to report something you suspect is occurring than to ignore it because you aren’t certain it is true. Consider This… I think my boss has some stake in a side business that contracts with Kaiser Permanente for skilled nursing care. I’m not sure about it, though. I don’t want to report it in case I am wrong. What should I do? You should go ahead and report the issue to your compliance officer. If you prefer to make the report anonymously, you can call the Kaiser Permanente Compliance Hotline at 1-888-774-9100. Representatives from Kaiser Permanente’s National Compliance, Ethics & Integrity Office would rather follow up on this situation and discover that all relationships are legitimate than learn about a real conflict of interest situation through public criticism or other external sources. 10.2 Call the Kaiser Permanente Compliance Hotline An outside firm answers all calls to the Compliance Hotline. Calls are never recorded or traced. Trained operators answer calls 24 hours a day, seven days a week. You can remain anonymous when you call or you can reveal your identity — it’s up to you. When reporting a potential compliance issue, be prepared to provide detailed information. Without enough information it may not be possible to properly investigate the issue. KNOW HOW TO GET HELP 51 KNOW HOW TO GET HELP It’s always best to attempt to resolve an issue by talking with your chief or immediate supervisor or with any of the previously listed contacts. If after doing so, you are still unable to resolve the issue, you can call the Kaiser Permanente Compliance Hotline for physicians, dentists, and employees at 1-888-774-9100 or report using the Kaiser Permanente Webline at reportlineweb.com/kp. The information you provide is sent to the National Compliance, Ethics & Integrity Office for review and action. All appropriate calls to the Compliance Hotline are investigated. Intentionally making a false report is a serious violation of Kaiser Permanente policies. Anyone who does so will face corrective/disciplinary action. Kaiser Permanente encourages prompt, truthful reporting of all suspected violations of law or policy. 10.3 Compliance is Everyone’s Responsibility KNOW HOW TO GET HELP Kaiser Permanente’s reputation is in all our hands. We are fortunate to be guided by principles that have served us well and that will continue to make us proud. Thank you for reading the Principles of Responsibility with care, referring to it often, and committing to following it in your daily work. 52 PRINCIPLES OF RESPONSIBILITY a. r. I. .Arpl .1. 1-4. @un A KAISER