Code of Professional Conduct

The Washington Hospital Healthcare System (WHHS) is committed to excellence in:

• Patient care
• Education and training
• Research
• Stewardship of district resources

WHHS follows the Patient First Ethic; all decisions made and actions taken are based on what is in the best interest of the patient.

To further the goal of excellence and the Patient First Ethic, all at WHHS are expected to adhere to the Code of Professional Conduct in their interactions with patients, colleagues, other health professionals, students and the public.

For the Code, there is reference to "staff." In this context, the term staff includes, the board of directors, employees, members of the medical staff, volunteers, contracted workers, students and instructors.

The Code of Professional Conduct is a series of principles that govern professional interactions. The Code consists of two complementary sections: professional obligations and professional ideals. "Obligations" refer to professional behaviors that are required by the ethical foundation of the WHHS Ethics Statement. "Ideals" refer to professional behaviors that professionals at all levels should attempt to acquire because they enhance professional excellence.

The Code applies to all staff at WHHS involved in the clinical, teaching, research and administrative activities of the Center. Because of its broad reach, certain portions of the Code will be more directly applicable to some disciplines than to others. For example, the clinical portions apply to physicians, nurses, technicians and all other professionals engaged in patient care. Similarly, those portions pertaining to teaching and research apply to all professionals engaged in teaching and research regardless of discipline or level of training. The portions pertaining to students apply to trainees at all levels. The general portions of the Code, which discuss confidentiality, conflicts of interest, interpersonal relations and the professional ideals apply to all WHHS staff.

Failure to meet the professional obligations described below represents a violation of the WHHS Code of Professional Conduct. Infractions of the professional obligations of the Code will be dealt with by the appropriate WHHS disciplinary committees and processes. Failure to meet the professional ideals, although less serious, also may be grounds for disciplinary review.

A. Professional Obligations

1. Respect for Persons
   * Maintain the Patient First Ethic.
   * Treat patients and staff with the same degree of respect you would wish them to show you.
   * Treat patients with kindness, gentleness and dignity.
   * Respect the privacy and modesty of patients.
   * Do not use offensive language, verbally or in writing, when referring to patients or their illnesses.
   * Do not harass others physically, verbally, psychologically or sexually.
   * Do not discriminate on the basis of sex, religion, race, disability, age or sexual orientation.
   * Refrain from behavior that includes intimidation, foul language, threats of violence or retaliation.
   * Refer to patients by their name, not by their diagnosis or location.
   * Avoid the use of first names without permission in addressing adult patients.
   * Respect with tolerance, the religion, culture and customs of patients, visitors and staff.
   * Realize that patients and their visitors are in an environment that can be unfamiliar and frightening. Communicate frequently in language that a layperson can understand.
2. Respect for Patient Confidentiality
   * Do not share medical information with anyone except those health care professionals integral to the care of the patient or within the context of Hospital operations.
   * Do not discuss patients or their illnesses in public places where the conversation may be overheard.
   * Do not publicly identify patients, in spoken words or in writing, without adequate justification.
   * Do not invite or permit unauthorized persons into patient care areas of the institution.
   * Do not share your confidential computer system passwords.
   * Do not access confidential patient information without a professional "need to know."
   * Do not misuse electronic mail.
   * Do not remove confidential patient information from the premises. Staff that must do this in the scope of their job must assure appropriate safeguards are in place to protect the information.
3. Honesty
   * Be truthful in verbal and in written communications.
   * Do not cheat, plagiarize, or otherwise act dishonestly.
   * Maintain accurate, honest records of patient care and business activities, which include following procedures to correct and amend records and to make late entries in medical records.
4. Integrity
   Integrity means strict adherence to a code or set of values such as this Code of Professional Conduct, the American Nurse's Association's Code of Ethics for Nurses, or the American Medical Association's Code of Ethics.
   * Acknowledge your errors of omission and commission to colleagues, supervisors and patients.
   * Make patient care decisions based on patients' needs and desires not on financial preferences or compensation.
   * Do not knowingly mislead others.
   * Do not abuse special privileges, e.g., making unauthorized long-distance telephone calls.
5. Responsibility for Patient Care
   * Obtain the patient's informed consent for diagnostic tests or therapies and respect the patient's right to refuse care or procedures.
   * Assume responsibility for the patients under your care until you have handed off (transferred) the care to another professional and that professional has acknowledged the transfer of care.
   * Follow up on ordered laboratory tests and complete patient record documentation promptly and conscientiously.
   * Assure that all patients' tests and treatments are completed and followed up appropriately.
   * Coordinate with your team the timing of information sharing with patients and their families to present a coherent and consistent treatment plan.
   * Do not abuse alcohol or drugs that could diminish the quality of patient care or your professional performance.
   * Do not develop romantic or sexual relationships with patients; if such a relationship seems to be developing, seek guidance and terminate the professional relationship.
   * Do not abandon a patient. If you are unable/unwilling to continue care, you have an obligation to assist in making a referral to another competent practitioner willing to care for the patient.
6. Professional Growth & Awareness of Limitations
   * Be aware of your personal limitations and deficiencies in knowledge and abilities and know when and whom to ask for supervision, assistance or consultation.
   * Know when and for whom to provide appropriate supervision.
   * Students and other trainees should have all patient workups and orders reviewed and countersigned by the appropriate supervisor.
   * Do not involve patients in personal issues or solicit for personal gain.
   * Do not engage in unsupervised involvement in areas or situations where you are not adequately trained.
7. Deportment as a Professional
   * Clearly identify yourself and your professional level to patients and staff; wear your name badge at all times above the waist and in plain view.
   * Always maintain the confidentiality of business information and trade secrets.
   * Dress in a neat, clean, professionally appropriate manner. Maintain professional composure despite the stresses of fatigue, professional pressures, or personal problems.
   * Do not make offensive or judgmental comments about patients or staff, verbally or in writing.
   * Do not criticize the medical decisions of colleagues in the presence of patients or staff or in the medical record.
   * Do not access confidential staff information without a professional need to know.
   * Do not abuse alcohol or drugs that could diminish the quality of patient care or professional performance.
   * Do not participate in political campaigns including the wearing of political buttons and discussion of political issues while on WHHS premises.
8. Avoiding Conflicts of Interest
   * Resolve clinical conflicts of interest in favor of the patient.
   * While on the premises do not accept gifts of value from drug companies or vendors or suppliers.
   * Do not participate in vendor incentive programs without disclosure.
   * Do not refer patients to laboratories or other healthcare facilities in which you have a direct financial stake without disclosure.
   * Do not accept a "kickback" (any payment intended to influence decisions) for any patient referral.
   * For staff in decision-making positions, disclose any outside financial interests or commercial activities, including those of immediate family members, domestic partners or others with a significant personal relationship, that may represent a conflict of interest and affect professional performance.
9. Responsibility for Peer Behavior
   * Take the initiative to identify and help impaired staff with the assistance of the Employee Assistance Program, Employee Health Services, Physicians' Well-Being Committee or other appropriate referrals. (Impairment includes, but is not limited to, alcohol and/or drug abuse, depression, other physical or mental illness).
   * Report serious breaches of the Code of Professional Conduct to the appropriate person, if unsure, discuss the situation with your supervisor or department chair. You may report directly to the Compliance Officer.
   * Indicate disapproval or seek appropriate intervention if you observe less serious breaches.
   * No action of retaliation or reprisal shall be taken against anyone who reports suspected fraud or improper conduct.
   * Anyone who attempts to or encourages others to retaliate against an individual who has reported a violation will be subject to disciplinary action.
10. Respect for Personal Ethics
    * You are not required to perform procedures (e.g., elective abortions, termination of medical treatment) that you, personally, believe are unethical, illegal, or may be detrimental to patients.
    * Should a patient request a treatment contrary to your personal values but consistent with current standards of care, you have a duty to refer the patient to another practitioner or facility for such treatment.
11. Respect for Property and Laws
    * Adhere to the regulations and policies of WHHS, e.g., policies governing fire safety, hazardous waste disposal and universal precautions.
    * Adhere to local, state and federal laws and regulatory standards.
    * Do not misappropriate, destroy, damage, or misuse property of WHHS.
12. Integrity in Research
    * Report research results honestly in scientific and scholarly presentations and publications.
    * When publishing and presenting reports, give proper credit and responsibility to colleagues and others who participated in the research.
    * Report research findings to the public and press honestly and without exaggeration.
    * Avoid potential conflicts of interest in research; disclose funding sources, company ownership and other potential conflicts of interest in written and spoken research presentations.
    * Adhere to WHHS policies and procedures that govern research using human subjects.
13. Use of WHHS' Computer Systems
    * Obtain proper authorization before using WHHS computing resources.
    * Do not use WHHS computing resources for purposes beyond those for which you are authorized.
    * Do not share access privileges (account numbers and/or passwords).
    * Do not electronically transmit or distribute material that would be in violation of existing WHHS policies or guidelines.
    * Respect the privacy of other users. More specifically, do not read, delete, copy, or modify another user's data, information, files, e-mail or programs (collectively, "electronic files") without the other user's expressed permission.
    * Do not intentionally introduce any program or data intended to disrupt normal operations (e.g., a computer "virus" or "worm") into WHHS computer systems.
    * Do not perform forgery or attempt forgery of e-mail messages.
    * Do not circumvent or attempt to circumvent normal resources limits, log-on procedures, or security regulations.
    * Do not use WHHS information technology resources for any private activity. Do not export WHHS systems for personal use.
    * Endeavor to use WHHS information computing resources in an efficient and productive manner. Avoid game playing, use of streaming video or audio, printing excessive copies of documents, files, data, or programs; or attempting to crash or tie-up computer resources.
14. Respect for Business Ethics
    * Charge patients for all and only clinical services provided at the appropriate level as defined by WHHS policy.
    * Ensure that payment requests from vendors, employees and other payees are processed promptly, accurately and with the appropriate level of documentation.
    * Do not promise payments to vendors or other payees or sign contracts that are beyond the scope of your authority.
    * Report all and only hours worked on employee timecards.
    * Submit authorized employee timecards that follow the rules and regulations of the bargaining unit, WHHS, the State of California and the Federal government.
    * Do not take or borrow property or cash from patients, visitors or WHHS.
    * Do not use WHHS supplies for personal use.
    * Record all financial transactions accurately and promptly.
    * Provide reports and other information that is accurate, complete, relevant, timely and understandable.
    * Do not offer patients discounts or write/offs without proper approval.
    * Maintain the confidentiality of employee information.
    * Maintain the confidentiality of WHHS' financial information.
    * Code medical records accurately, consistent with industry guidelines. Do not upcode to improve reimbursement.

B. Professional Ideals

1. Clinical Virtues
   * Cultivate and practice clinical virtues, such as caring, empathy and compassion.
2. Conscientiousness
   * Fulfill your professional responsibilities conscientiously.
   * Notify the responsible supervisor if something interferes with your ability to perform tasks effectively.
   * Learn from experience and grow from the knowledge gained from errors to avoid repeating them.
   * Dedicate yourself to lifelong learning and self-improvement by implementing a personal program of continuing learning and continuous quality improvement.
   * Complete all tasks accurately, thoroughly, legibly and in a timely manner, this may include attending and participating in meetings and conferences.
   * Follow through on whatever you have agreed to do.
   * Avoid patient involvement when you are ill, distraught or overcome with personal problems.
3. Collegiality/Cooperation
   * Cooperate with all other members of the Health Care System.
   * Teach others.
   * Be generous with your time when answering questions from staff, patients and visitors.
   * Shoulder your fair share of the institutional burden by adopting a spirit of volunteerism and altruism.
   * Use communal resources (equipment, supplies and funds) responsibly and equitably.
4. Objectivity
   * Avoid providing professional care to members of your family or to persons with whom you have a close, personal relationship.
5. Responsibility to Community
   * Avoid unnecessary patient or societal health care monetary expenditures.
   * Provide appropriate emergency services to all patients regardless of their ability to pay.
   * Avoid behaviors that impair the community's confidence in the Healthcare System.
   * Demonstrate behavior that ensures the future viability of the Healthcare System for the residents of the District.

Additional guidelines regarding Professional Conduct exist in some departments and affiliated organizations of WHHS including, but not limited to, the Medical Staff, Volunteer Services and Information Services.