Code of Conduct

Vanderbilt University Medical Center, including its hospitals, subsidiaries, and owned affiliates (collectively, VUMC), is committed to living our Credo values and to the highest standards of ethics, honesty and integrity in education, research, patient care, and public service. Everyone who works for VUMC or at any of our locations must adhere to this Code of Conduct. This includes all directors, officers, clinicians, staff, non-employed providers on our medical staff, delegated entities, contractors, vendors, and volunteers.

Our commitment to ethical behavior is further described in VUMC's compliance Policies. These are available 24/7 to workforce and medical staff members via PolicyTech.

Following this Code of Conduct helps you do the right thing. It protects you, your co-workers, and the entire VUMC community. No Code of Conduct can cover every job situation you may encounter. These principles, however, can guide you toward strong everyday ethics.

You are encouraged to bring forward concerns about VUMC practices or your work here. Workforce members may discuss these concerns with your supervisor or department head. Anyone may contact the VUMC Compliance Office at (615) 343-7266 or by email at compliance.office@vumc.org.

The Compliance Office provides regulatory and ethical advice to the VUMC workforce. The Compliance Office also ensures that VUMC investigates all concerns brought forward, including those brought confidentially or anonymously.

VUMC is committed to compliance with all applicable laws, rules, and regulations.

VUMC strives to maintain an environment that is committed to integrity and ethical conduct. It is the responsibility of everyone at VUMC to follow all applicable laws, rules, regulations, grant terms, and VUMC policies. All VUMC policies are available in PolicyTech. VUMC subsidiaries and affiliates may have their own policies, which their organization makes available to them.

VUMC is committed to the appropriate protection of confidential information.

Numerous laws and VUMC policies prohibit any unauthorized access to, or use or disclosure of, confidential information contained in patient, research, employee, or student records. This specifically includes personal information identifies patients or other protected individuals. You must know, and comply with, all VUMC privacy policies and our requirements for protecting personal information.

Upon hire and annually thereafter, you will complete confidentiality training and must agree to abide by VUMC policies protecting confidential and/or proprietary information. Confidential information is to be accessed, used, and disclosed only when authorized by law and policy and required to complete assigned job-duties. User IDs, passwords, and system access methods are the equivalent of your personal signature within VUMC’s information systems and must never be shared with anyone else.

Additionally, you are prohibited from sharing VUMC’s confidential business and operations information with third parties, unless a non-disclosure agreement has been signed by both the third party and VUMC. Some confidential information, such as payer contract terms and supplier contract pricing, is competitively sensitive. It is not available to the public and could be used by one of VUMC’s competitors or vendors to make business decisions that could harm VUMC, our patients, or other consumers through higher prices, reduced choices, or lower quality. You may only disclose VUMC’s competitively sensitive confidential information to others at VUMC or elsewhere who need the competitively sensitive information to perform their duties for VUMC. You may never disclose VUMC’s competitively sensitive confidential information to individuals or entities who are not part of VUMC without the express approval of VUMC’s Office of Legal Affairs (OLA).

VUMC treats our employees, patients, and the communities we serve with dignity and respect. Everyone is welcome at VUMC, but all behaviors are not. VUMC, or anyone working on our behalf, does not discriminate against individuals in any activity, including provision of healthcare services, participation in research or employment based on race, color, sex, religion, national or ethnic origin, age, disability, sexual orientation, gender identity, gender expression, military service, pregnancy, genetic information or any other class protected by applicable law.

VUMC treats its employees, patients, and the communities we serve with dignity and respect.

VUMC strictly prohibits harassment or contribution to any type of harassment. Everyone at VUMC is expressly prohibited from acts of retaliation or bullying. This includes, but is not limited to, harassment or intimidation based on race, sex, religion, color, national or ethnic origin, age, disability, veteran status, sexual orientation, gender identity, gender expression, genetic information or any other class protected by law. You must report any potential discrimination or harassment you may witness.

VUMC avoids potential or perceived conflicts of interest.

Conflicts of interest occur when an individual’s or family member’s financial, professional or other personal considerations may directly or indirectly affect or have the appearance of affecting an individual’s professional judgment in exercising their duties. Conflicts of interest can arise under many situations, including business relationships, purchasing decisions, gifts, use and appropriation of VUMC assets, research activities, student-related activities and activities related to family members.

You must disclose outside activities and financial interests that might be, or might have the appearance of being, conflicts of interest or commitment with your duties to VUMC. These disclosures are made at hire or credentialing and annually thereafter. You must immediately report any new potential conflict of interest when it arises to the Office of Faculty Affairs or the Conflicts of Interest Office.

VUMC maintains the highest standards of patient care and scientific integrity.

VUMC individuals engaged in research are responsible for the accurate and complete documentation of research activities and clinical investigations, the conduct of research with scientific integrity, and the adherence to all applicable state and federal regulations. You are required to follow VUMC requirements pertaining to the protection of human and animal research participants and to the reporting and expenditure of grant funds. If you are engaged in research, you must familiarize yourself with all applicable federal and state laws, contractual or other requirements of the funding sponsor and VUMC policies governing your research activities.

VUMC never condones or participates in any form of human trafficking or forced labor.

Health care workers are often first to recognize victims of human trafficking. Everyone at VUMC remains vigilant for signs of potential human trafficking in our clinics, emergency departments, research conducted in foreign countries or wherever we interact with patients. Contact the Vanderbilt University Police Department if you suspect a patient is being trafficked or is a victim of forced labor.

VUMC ensures its business practices conform to state and federal laws restricting VUMC from anticompetitive practices.

We do not discuss with competing providers health care charges or expected payment rates or the rates each will pay its employees. VUMC never agrees with any other health care provider or business not to compete for the patients they will serve or the services they will provide. VUMC never agrees with any third party to refuse to deal any other suppliers, health care providers, health insurance plans or other payers or purchasers of their services.

VUMC is committed to the lawful referral of patients.

VUMC does not offer, ask for, pay or accept anything of value in exchange for patient referrals, regardless of the patient’s insurance coverage. This prohibition includes both referrals to our care and referrals we make to other health care providers. If someone offers, asks for, pays for or accepts something of value in exchange for a health care order or referral, it can be considered an illegal kickback. You are expected to report potential kickbacks to your supervisor or to the Compliance Office.

You are strictly prohibited from giving or receiving kickbacks, entering into certain exclusive arrangements with vendors, and from sharing confidential information, such as the details of confidential proposals or pricing submitted by other vendors. Anyone at VUMC who can influence purchasing decisions does not accept money, services, unrestricted grants, or anything of value from our vendors. Such gifts can be considered illegal. You will never take any action that could interfere with the impartial discharge of your duties or reflect adversely on VUMC’s reputation or integrity.

Many financial arrangements may be considered kickbacks. An example includes an employment agreement that rewards a referring physician or their family member by paying too much salary. Another example would be a lease for space or equipment that rewards a referring physician by charging too little rent. VUMC ensures all business arrangements with potential referral sources are in writing and comply with applicable laws and regulations, including the federal Stark Law and AntiKickback Statue. To avoid violations, VUMC negotiators coordinate with OLA to review proposed contracts and financial arrangements for full compliance.

Patients choose to receive health care from VUMC only because of the exceptional quality of our services and our outstanding efforts in clinical research.

VUMC follows federal law prohibiting gifts or other benefits to patients that might influence their choice of providers. This prohibition on gifts and benefits applies to all patients and potential referral sources. No one at VUMC provides any free or discounted services or any waiver of coinsurance that are not based upon VUMC’s financial or patient assistance policies. OLA and the Compliance Office can answer policy and legal questions about discounted services.

VUMC is committed to charging, billing, documenting, and submitting claims for reimbursement accurately and in the manner required by applicable laws, rules, and regulations.

VUMC’s claims for our hospital and professional services are subject to several important laws, regulations, and payer rules. VUMC upholds these billing standards at all times and invests many resources to prevent and detect billing errors. Everyone at VUMC providing patient care services or involved in billing for those services must understand and carefully follow the applicable rules for documentation, coding, and submission of claims for reimbursement. Improperly billed claims and improperly retained overpayments can result in the imposition of substantial fines and penalties to VUMC and in serious consequences for the individuals involved. You must promptly report improperly billed claims so that VUMC may return any overpayments received.

VUMC maintains full and accurate business records.

You must never create or help create any clinical, financial or other records intended to be false or misleading. A key example is altering payment records to hide the actual person receiving the money or the actual purpose for the payment. Another example is making clinical documentation appear as if a clinician was present when they were not. Mistakes do happen, and often records must be corrected. You should consult with your supervisor or the Compliance Office if you are unsure how to correct an honest mistake.

VUMC also retains our historical records as required by our policies and applicable law. You should never discard or destroy important business records, especially those relating to patient care or research, without consulting those record retention policies. You must never dispose of any records that relate to government inquiries. OLA will guide you on how to preserve such records under inquiry. If in doubt whether a record can be destroyed, you should speak with your supervisor or contact OLA.

VUMC is committed to following state and federal laws and regulations with respect to the medical screening, stabilization, admission and treatment of patients with emergency medical conditions and pregnant women who are in labor, regardless of a patient’s financial or insurance status.

Emergency services are available at VUMC to all individuals in need of those services, without regard to their financial or insurance status. If any patient comes to a VUMC Emergency Department for treatment, VUMC provides an appropriate medical screening and examination to determine if an emergency medical condition exists. If such a condition exists, VUMC team members stabilize the emergency medical condition within our capabilities.

VUMC is committed to appropriate discharge planning and the lawful referral for post-acute care.

VUMC recognizes that the discharge of a patient to a residence or post-hospitalization provider is an important decision. In developing and implementing discharge plans, VUMC clinicians and hospital staff, in their professional judgment, act in the best interest of the patient. This includes the involvement and consent of the patient or patient’s legal representative in discharge discussions.

VUMC does not employ or engage in health care services with individuals excluded from participation by a government entity.

VUMC performs regular screenings to ensure our workforce members, community medical staff members and vendors are not excluded or otherwise ineligible due to formal government sanctions. You must immediately report any business with excluded individuals to the Compliance Office. You must also immediately report any new or pending sanctions to Human Resources and or your department head.

VUMC supports members of the VUMC Community in expressing your own opinions and engaging in political and community activities. However, this must be done on your own time and in your individual capacity without the appearance of speaking or acting on behalf of VUMC.

Community members may not use VUMC resources when engaging in political activities. VUMC is subject to laws and regulations that prohibit participation in political activities, such as campaign fundraising and providing gifts to public officials. VUMC and individuals acting on behalf of the institution must also comply with institutional policies, laws, and regulations governing public policy advocacy/lobbying interactions with public officials. VUMC disavows any opinions or activities that are not expressly pre-authorized by VUMC leadership.

VUMC community members never use non-public information in our possession to buy or sell property or financial assets.

In our research and clinical missions, VUMC community members may possess or learn valuable information that isn’t yet available to the general public. Examples include new medical drugs and devices, clinical effectiveness of certain procedures or investments or closures of real estate locations. Using this non-public information for financial gain is known as insider trading. This is not only can subject you to disciplinary action, but insider trading in stocks and bonds can be a serious crime.

VUMC does not condone violence, threatening behavior or harassment in any form.

VUMC is a place of healing. Everyone here must be and will be treated with respect. VUMC is committed to providing a safe environment to work and seek care. We will not tolerate any acts of violence or threats against any member of the VUMC Community.

VUMC complies with all applicable environmental laws and maintains all necessary environmental permits and approvals.

Environmental compliance includes the proper handling, storage, use, shipment and disposal of all materials that are regulated under applicable environmental law.

VUMC is a drug and alcohol-free workplace.

VUMC prohibits the unlawful use or distribution of alcohol and illegal drugs on VUMC property. VUMC community members may not be under the influence of illegal drugs or alcohol while performing their VUMC duties. Workforce members who engage in improper behavior regarding illegal drugs may be subject to serious criminal and financial consequences. Any unsafe situations regarding a co-worker’s impairment should be reported immediately to Human Resources.

VUMC prohibits the unlawful possession, use, manufacture, or distribution of controlled substances.

Clinicians and other VUMC health care professionals, including those who maintain Drug Enforcement Agency (DEA) registration, comply with all federal and state laws regarding the prescription, handling and storage of controlled substances.

VUMC directs our assets and effort for community benefit in Tennessee and beyond.

VUMC is a tax-exempt charitable entity under federal law. Everyone at VUMC devotes VUMC’s assets and space solely to furthering our clinical, research and educational missions. It is never acceptable for any VUMC community member to divert VUMC resources for personal gain.

VUMC fully cooperates with government investigators, as required by law.

VUMC workforce members may receive a subpoena, search warrant or similar document related to VUMC activities. If a government investigator or auditor comes to your location, you should ask for their business card, seat the investigator in a public waiting area and contact your supervisor. Before taking any other action, you or your supervisor must immediately contact VUMC Accreditations and Standards. Accreditations and Standards will work with OLA and facility leadership to fully cooperate wherever needed.

VUMC responds appropriately when anyone at VUMC violates law or policy.

Everyone at VUMC carries out their duties according to this Code of Conduct, VUMC policies and as required by law. If you violate a law or policy or do not report a known violation, you may be subject to disciplinary action up to and including termination of employment. Disciplinary proceedings abide by applicable protections in the Faculty Manual or in the Human Resources Staff Guidelines. Disciplinary action may also apply to supervisors or co-workers who knowingly direct improper actions or is aware of improper actions but does not act to correct or report those actions.

VUMC senior leaders and supervisors have a special responsibility as daily ethical examples.

Leaders and managers must exemplify the VUMC Credo each and every day. Leaders also take full responsibility for ensuring their clinicians, caregivers, staff members and others are aware of and abide by this Code of Conduct. Leaders must make good faith attempts to investigate and resolve any concerns involving their area. Where needed, leaders should consult with internal subject experts or with the Compliance Office.

Our ethical expectations apply to everyone on VUMC property.

Vendors and contractors will abide by this Code of Conduct and applicable policies when engaging with VUMC community members. Vendors refrain from Failure to abide by VUMC expectations can result in the termination or curtailment of vendor agreements.

VUMC values and protects those who raise concerns.

No one at VUMC may retaliate against, or assist in retaliating against, persons who report concerns in good faith. This protection includes even when investigation can’t substantiate the concern. False accusations made to harm or retaliate against other people, however, can subject the accuser to disciplinary action.

Upon hire and annually thereafter, you will acknowledge awareness of and your compliance with this Code of Conduct.