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Code of Ethical Behavior

Code of Ethical Behavior

Purpose:

South Shore Hospital's code of ethical behavior is designed to help improve patient outcomes by respecting each patient's rights and conducting business relationships with patients and the public in an ethical manner.

Patients have a fundamental right to considerate care that safeguards their personal dignity and respects their cultural, psychosocial, and spiritual values.  These values often influence patients' perceptions of care and illnesses.  Understanding and respecting these values guides health care providers in meeting patients' needs and preferences.

We recognize that our conduct in the delivery of care and services to our patients and our business practices has a significant effect on each patient's response to our care.

We recognize our ethical responsibility to:

  • Carefully consider patients' values and preferences, including decisions to discontinue treatment;
  • Recognize our responsibilities under the law;
  • Inform patients of their responsibilities in the care process; and
  • Manage our relationships with patients and the public in an ethical manner.

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Policy:

South Shore Hospital has integrated our ethical responsibilities into our day-to-day operations.  Examples include:

1. MISSION, VISION AND VALUES STATEMENTS

Our mission, vision and values statements are widely communicated, and reflect our caring and ethical culture.

2. CODE OF ETHICS AND BUSINESS CONDUCT

Our Compliance Standards, "Always Doing the Right Thing," provides guidance to all employees and volunteers on what is required of them when faced with a variety of ethical and legal issues that may arise during their work.

Our Code of Ethics and Business Conduct and Physician Code of Ethics and Business Conduct ("The Code") provides more detailed ethical and legal standards for all South Shore Hospital management, board members, and physicians.  The Code was developed to assure that South Shore Hospital conducts its business and patient care practices in an honest, ethical and lawful manner.

The Code of Ethics and the Compliance Standards, together with South Shore Hospital's mission, vision, and values statement, provide the standards by which all South Shore Hospital management, employees and medical staff are expected to conduct themselves when representing the hospital in its dealings with patients, their families, other health care providers, payers, suppliers, and other entities.  Adherence to the Code and the Compliance Standards is a condition of continued employment by and/or affiliation with South Shore Hospital.  The Code and the Compliance Standards address, among other topics, the following:

  • Conduct in the workplace
  • Antitrust laws and competitive conduct
  • Dealing with suppliers and competitors
  • Marketing
  • Kickbacks
  • False claims or bills
  • Patient admissions, transfers and discharge
  • Environmental/biohazardous waste
  • Conflicts of interest
  • Confidentiality
  • Recording of business transactions
  • Gifts, favors and entertainment
  • Fundraising

Copies of the Code of Ethics and Business Conduct and the Compliance Standards may be obtained by contacting the Director of Compliance at 781-624-8828.

The Physician Code of Ethics and Business Conduct Code may be obtained by contacting the Medical Staff Office at 781-624-8219.

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3. TISSUE/ORGAN/BODY DONATION

In compliance with federal regulation 42CFR Part 482, 45 under the Code of Federal Regulations, Centers for Medicare and Medicaid Services, South Shore Hospital reports all deaths to the New England Organ Bank.  Implementation of this policy requires sensitivity to the family circumstances regarding potential donation. Compliance with this policy is documented in the patient's medical record.

4. MEDICAL RESEARCH PARTICIPATION

South Shore Hospital has an obligation to inform patients of research or educational activities that may affect their care.  Patients have a right to decide whether to participate in any experimental, research or educational activity.

The South Shore Hospital Institutional Review Board reviews research involving human participants.  Its primary concern is the protection of the rights and welfare of those participants.  This committee approves the initiation of such research, monitors its conduct, and, when necessary, suspends or terminates the research.  This committee has strict criteria for inclusion of patients and for obtaining informed consent.

5. MANAGING STAFF REQUESTS NOT TO PARTICIPATE IN AN ASPECT OF PATIENT CARE POLICY

South Shore Hospital recognizes that individual caregivers' personal cultural values, ethics and religious beliefs may, on occasion, be in conflict with the care or treatment to be provided to individual patients.  To recognize these conflicts, a procedure has been established whereby individual employees may request an accommodation based on their personal cultural values, ethics, or religious beliefs to remove themselves from the specific care required, provided that alternative arrangements can be made and that negative outcomes for the care and treatment of the patient are not incurred.

See Human Resources Policy VIII- D -Staff's Conflict in Care

6. MEDICAL STAFF BY-LAWS

As stated in the South Shore Hospital Medical Staff by-laws, the duties of Medical Staff Executive Committee include the responsibility "to take all reasonable steps to ensure professionally ethical conduct."

As part of the re-credentialing process, all physicians are required to acknowledge that they have received, read, and understood the South Shore Hospital Physician Code of Ethics and Business Conduct.

Located in the Medical Staff Office - Compliance Department

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7. MEDICAL STAFF CREDENTIALS POLICY AND PROCEDURE MANUAL

South Shore Hospital's procedure for processing applications for medical staff appointment mandates that: three letters of recommendations be sent to our CEO from persons who have recently worked with the applicant and directly observed his/her performance over a reasonable period of time, and who can and will provide reliable information regarding current clinical ability, professional performance and judgment, ethical character and ability to work with others.

8. PATIENT COMPLAINT POLICY

South Shore Hospital welcomes comments from patients and their families regarding our services.  Comments — both negative and positive — are used as opportunities to enhance our services.

It is our policy to promptly resolve patient/family complaints (grievances), as well as to share positive comments about patient/family experiences.  Lodging a complaint or grievance will not compromise a patient's access to care.

9. ETHICS CONSULTATIONS

When ethical issues in a patient's care arise, the staff involved with the patient and/or the patient's family may seek the involvement of the Ethics Committee to help resolve their concerns.

All requests for ethics consultations for acute, outpatient and emergency care at the hospital should be directed to the Chair of the Ethics Committee of the hospital.

All requests for ethics consultations in the home care division should be directed to the Chair of the Ethics Committee of the home care division.

10. CREDIT AND COLLECTION POLICY

The Patient Accounting department at South Shore Hospital is responsible for accuracy in billing and for the prompt collection of charges from patients for services provided in order to maintain financial solvency of the institution.

The hospital will seek payment by the patient or guarantor of all charges not covered by acceptable health insurance plans.

The Patient Accounting department may authorize special financial arrangements when all health insurance benefits and covered services have been assigned to the hospital for direct payment, and/or when a determination has been made as to the patient's ability to pay for services.

The hospital budgets for free care, which is made available to eligible patients who are unable to pay all or part of their accounts.

The Patient Accounting department provides prompt and courteous financial counseling.

The Patient Accounting department submits universal billing forms and assists patients in filing all necessary forms with third party insurers or responsible parties.

South Shore Hospital will not discriminate on the basis of race, color, national origin, citizenship, alien, religion, creed, sex, sexual preference, age for persons beyond the age of majority, or handicap, in its policies or their application, concerning the acquisition and verification of financial information, payment plans, or eligibility for free care.

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11. MARKETING

South Shore Hospital's marketing and public affairs programs are designed to inform interested parties about our physicians, programs, and services.  Marketing and public affairs programs include, but are not limited to, advertising, direct mail, media relations, publications, sales promotion, public policy advocacy, speaking engagements, events, and seminars.  We are committed to promoting truthful and accurate information at all times to all audiences.  Our marketing and public affairs programs comply with ethical standards of leading industry and professional associations, including the American Hospital Association, American Association of Advertising Agencies, Direct Marketing Association, Public Relations Society of America, American Marketing Association, and Foundation for Public Affairs.

12. FUNDRAISING

South Shore Health and Educational Foundation raises funds for South Shore Hospital and its programs, including South Shore Visiting Nurse Association and Hospice of the South Shore.  The Foundation recognizes its responsibility to assure that needed resources are vigorously and ethically sought and that the intent of the donor is honestly fulfilled.  The Foundation embraces the national Society of Fundraising Executives Code of Ethical Principles and Standards of Professional Practice, which guide the solicitation and use of charitable funds in manners that comply with all applicable local, state, provincial, federal, civil, and criminal laws.

13. EMERGENCY DEPARTMENT ADMISSION, TRANSFER AND DISCHARGE

Every patient who presents to the Emergency Department is entitled to a medical screening examination and stabilizing treatment.

If a patient elects to refuse a medical screening examination or appropriate stabilizing treatment, the hospital has the obligation to attempt to take reasonable steps to assure that the patient understands the risks and benefits of their decision and secure a written refusal from the patient or appropriate individual.

All patients discharged from the Emergency Department will have an appropriate follow-up plan that will be documented by the nurse.

Stable emergency patients will be transferred in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA) guidelines under the following conditions:
1. No beds available
2. Patient request
3. Physician request (higher level of care required)
4. Insurance request
5. Psychiatric admission without concurrent medical conditions requiring hospitalization

Patients who are acutely ill or injured and who need to be transferred to another unit within the facility will be accompanied by competent personnel to insure the continuity of optimum care.

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14. CONFIDENTIALITY

All South Shore Hospital patients have the right to expect that those affiliated with our organization (employees, physicians, volunteers, board members, students, contractors, and others) will safeguard their privacy at all times and in all situations.

Confidential information may only be reviewed, shared or discussed when it is necessary to provide patient care, to perform our jobs, or in approved research.  Medical information may only be disclosed when patients authorize it or when it is required by law.  There are no exceptions.

We take responsibility for safeguarding our patients' personal and medical information.  It is our legal and ethical responsibility, and it is vital to our patients' well-being and to our organization's continued success.

Violations of our confidentiality policy are grounds for disciplinary action, including termination.
See Administrative Policy VII- A -Confidentiality

15. PAIN MANAGEMENT

South Shore Hospital understands that pain is a negative physiological and psychological event best measured by the individual in pain.  Compassionate caring includes the recognition, assessment and management of pain in the early stages by interdisciplinary health care providers, or prevention of pain prior to its beginning, if predictable.  Pain control is achieved through both pharmacological and non-pharmacological therapies tailored to the individual.  The institution's health care providers are responsible for participating in pain management education through classes, clinical counseling and self-learning modules based upon the Acute Pain Management Clinical Practice Guidelines and Management of Cancer Pain Clinical Practice Guidelines set forth by the Agency for Health Care Policy and Research. Patients and/or significant others will be informed/educated regarding pain management.

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