Message from YNHHS President and CEO Marna P. Borgstrom
Yale New Haven Health System is a leader in providing safe, high-quality, comprehensive patient care. We are committed to excellent service in day-to-day interactions with our patients and their families, visitors, other staff members and the communities we serve.
We rely on our education, training and experience, but it,s our values – integrity, patient-centered care, respect, accountability and compassion – that guide us as individuals and as an organization in the work we do. In our work, often we face new and difficult situations involving issues like patient confidentiality, conflicts of interest or financial reporting. To be best positioned to address these challenges, we all need a thorough understanding of our policies, and the rules and regulations that govern our work and our actions and decisions.
The Yale New Haven Health System Code of Conduct reflects our commitment to ethical business behavior, provides guidelines for making informed decisions, and presents an overview of the policies to which we must all adhere. If you are unsure about an issue or concerned about a possible violation, your organization's corporate compliance officer will provide guidance. Or, you may call the Compliance Hotline at 1-888-688-7744 or go to the Corporate Compliance/Privacy website. Thank you for your continued commitment to providing safe, high-quality care to the patients we are privileged to serve.
Marna P. Borgstrom
YNHHS President and CEO
Why We Have a Code of Conduct
Our Code of Conduct reflects our collective commitment and responsibility to uphold our organization's reputation, practice ethical business behavior, meet rigorous professional standards, and comply with the laws, regulations and policies that govern our work. The Yale New Haven Health System (YNHHS) Code of Conduct applies to every individual affiliated with YNHHS, whether employee, volunteer, member of the medical staff or Auxiliary at YNHHS and its Bridgeport, Greenwich, Yale-New Haven and Northeast Medical Group delivery networks.
The YNHHS Code of Conduct provides:
- An overview of the commitments that govern our work
- Tools for reporting concerns or suspected violations without fear of retaliation
- Guidance in making choices that may seem questionable or confusing We as individuals have a shared commitment to meeting applicable laws and industry standards and applying them to our day-to-day interactions.
The YNHHS Code of Conduct articulates our commitment to our values and ethical business behavior while reminding us that our overriding responsibility is to use sound judgment and personal integrity. It is the responsibility of each of us to understand and comply with all applicable organization policies and procedures and be able to locate them and review them periodically.
Vision Mission and Values
Corporate Compliance Program
The purpose of the Compliance and Privacy Program is to provide the system with clear ethical and compliance direction. In addition, the Compliance and Privacy Program is designed to prevent and detect violations of applicable law, Code of Conduct, and company policies.
Our Corporate Compliance Program is designed to enhance our understanding of acceptable behavior and appropriate decision-making.
It is everyone's duty to promptly report any activity that appears to violate the Code of Conduct or any laws, regulations, or organizational policies.
All YNHHS policies (including compliance and privacy) can be found on the YNHHS intranet.
Learn more about compliance
To access the Corporate Compliance Program page on the YNHHS intranet, go to Corp. Compliance/Privacy in the top navigation bar.
How to view compliance and privacy policies
To view specific Corporate Compliance policies, from the corporate compliance intranet page, click "Policies and Procedures" in the upper-left navigation box.
How to Report an Issue
- Contact your direct supervisor.
- Contact a higher level of management.
- Contact Human Resources if the issue involves a human resources concern such as work conditions, discrimination or harassment, theft or abuse of property and personal security.
- Contact the YNHHS Compliance Office (203) 688-8416 or your delivery network Compliance Officer.
- To make an anonymous report, call the Compliance Hotline at 1-888-688-7744 or visit the Corporate Compliance/Privacy website at www.ynhhscomplianceprogramhotline.com
Calling the Compliance Hotline
If you feel uncomfortable about your activities or those of others around you and are hesitant about making a report in person, call the 24-hour Compliance Hotline at 1-888-688-7744 or make a report on the Corporate Compliance/ Privacy website at: www.ynhhscomplianceprogramhotline.com.
The hotline is outsourced to an independent company that has trained professional personnel available to speak with you. You are not required to identify yourself. The hotline is not set up for caller ID and cannot trace calls. However, you may decide to identify yourself in order to provide information that may be helpful in an investigation.
Information you provide will remain confidential to the extent possible. You will be given a case number and a call-back date. You may call back again on or after the call-back date to determine whether action has been taken, but the nature and outcome of an investigation are always confidential.
Non-retaliation for reporting
We will protect any employee who reports a concern in good faith. While you are accountable for your own wrong-doing, anyone who retaliates against you for reporting a concern in good faith will be subject to disciplinary action. Report any retaliation or harassment immediately to your supervisor, another manager, the Compliance Office or the Compliance Hotline. Please see the YNHHS Non-Retaliation and Non-Retribution for Reporting policy for more information.
Why Call the Compliance Hotline
These are just a few of the concerns that might prompt you to call the hotline:
- Confidentiality of patient information
- Improper billing or practices
- Medical record cocumentation concerns
- Conflicts of interest
- Inappropriate use of YNHHS computers or equipment
- Workplace safety
- Any situation which places you, a patient, a co-worker or YNHHS at risk
Key Compliance Topics
Gifts & gratuities
No employee, member of the medical staff, volunteer, or member of the Board of Trustees may solicit or encourage a gift or gratuity from a patient or visitor. When gifts of a personal nature are offered by patients or visitors, they should be discouraged. The patient or visitor should be politely thanked, but told that employees, medical staff, volunteers and trustees are not permitted to accept gifts or gratuities. YNHHS personnel may never accept cash or cash equivalents, such as gift certificates or gift cards.
Gifts & business courtesies from vendors guidelines
YNHHS personnel may not offer or receive gifts unless such gifts are of a nominal value and are in accordance with these guidelines. Refer to policy on intranet for details. Under no circumstances may YNHHS personnel offer or receive a gift when the intent is to generate healthcare business. YNHHS personnel must disclose and, as appropriate, seek prior approval from their department manager when receiving or soliciting gifts as YNHHS personnel.
Employees and medical staff should request, use or disclose only the minimum amount of information necessary from patients' records, and only for patient care, billing or operations.
Employees' right to access Protected Health Information (PHI)
Employees may not use work access privileges to view the records of family members, friends, colleagues or others. Employees are granted access to electronic medical records (EMRs) for treatment, payment, or operations (TPO) purposes only.
Government exclusion from participation
YNHHS does not employ, contract with or otherwise utilize the services of any individual or organization that has been debarred or excluded from, or is otherwise ineligible to participate in, any federal healthcare program.
False claims & payment fraud prevention
All employees, contractors, agents and volunteers of YNHHS must immediately report to the delivery network Compliance & Privacy Officers or Chief Compliance & Privacy Officer any suspicion of fraud, waste or abuse in connection with the business of YNHHS. YNHHS engages in specific compliance efforts to detect and prevent fraud, waste and abuse.
Non-retaliation & non-retribution for reporting
YNHHS prohibits any acts of retribution, discrimination, harassment or retaliation against any employee who, in good faith, provides information or otherwise assists in an investigation or proceeding regarding any conduct which the employee reasonably believes to be in violation.
These are examples where the Code of Conduct can help guide your behavior:
Accessing Family Information
My mother-in-law is in the hospital and I'm a nurse working on another floor. Can I look up her lab results in Epic to see what is wrong and consult with her tonight? No. Family members, friends and co-workers are entitled to the same privacy as any other patient. You must obtain a release of information and request the records through Health Information Management (HIM) or MyChart proxy access.
May I post something that includes the YNNHS logo or has patient information on social media? If an employee chooses to be identified as related to the System, its hospitals or other entities, he/she must make it clear to the readers that the views expressed are the employee's alone and that they do not necessarily reflect the views of the System. Employees must avoid making defamatory statements about the System or its employees, patients, clients, partners, affiliates and others, including competitors. Disclosing any protected or confidential information (e.g., patient/employee/business) on social media or online is prohibited.
Entertainment & Gifts
What if a patient gives me a gift card to my favorite store? This would not be permitted. Thank the patient and direct him or her to your delivery network's Development/ Foundation office to make a charitable contribution.
I saw a co-worker photographing a celebrity in the hospital waiting room with his phone. I didn't take the picture — do I need to report it? This is a breach of patient privacy and you are required to report it.
I noticed a few instances in which the physician's office where I work was billing twice for services with a Medicare patient. Should I wait for someone to catch the error later? Billing and coding are high-risk areas and this may be considered a fraudulent claim. It should be reported immediately to your manager and/or the Compliance Department or Hotline.
Conflict of Interest
My brother sells the medical supplies we use in our office, and I do have budget authority. Do I need to disclose this? Yes. There is an easy-to-use conflict of interest tool available on Employee Self Service. If you do not have access to it, please call the Compliance Department at (203) 688-8416.
I co-own a separate physician practice and sometimes refer my patients there. Is this allowable? There are laws that regulate physician referrals; please check with Corporate Compliance and the Legal & Risk Services Department.
Will I get in trouble for reporting a possible violation? No. YNHHS has a non-retaliation policy that protects any employee who reports a concern in good faith.