Vanderbilt University Medical Center, including its hospitals, subsidiaries, and owned affiliates (collectively, VUMC), is committed to the highest standards of ethics, honesty, and integrity in pursuit of its mission of education, research, patient care, and public service. All individuals who participate in the work and mission of VUMC are expected to adhere to this Code of Conduct. This includes all directors, officers, clinicians, staff, non-employed providers with medical staff privileges, representatives, delegated entities, contractors, vendors, and volunteers of VUMC or of any VUMC subsidiary or affiliate that adopts this Code of Conduct. Consistent with other VUMC policies, the Code of Conduct sets forth our commitment to good practices and following the law.
Following this Code of Conduct helps you do the right thing. It also protects you and everyone involved with VUMC’s mission. You are encouraged to talk with your supervisor or main VUMC business contact if you have a concern. The Office of Compliance & Corporate Integrity (OCCI) is always available to help address questions and concerns.
Compliance with the Law
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, and VUMC policies, as well as the program requirements for federal and state healthcare programs, and for government contracts and research grants. VUMC’s 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.
Federal, state, and international laws and VUMC policies prohibit the unauthorized access to, or use or disclosure of, confidential information contained in patient, research, employee, or student records and information that is personal to, or relates to the identity of, individuals (Personally Identifiable Information). You must know, and comply with, privacy laws and policies applicable to your work with and for VUMC.
Prior to receiving a VUMC User ID and password, 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 other authentication methods are the equivalent of your personal signature within VUMC’s information systems and must never be shared or disclosed with other individuals.
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, meaning that 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).
Diversity, Inclusion, Cultural Humility and Cultural Competence
VUMC is committed to the principles of diversity, inclusion, and equality.
Everyone at VUMC acts with awareness and sensitivity to the diverse cultural characteristics, values, and beliefs of our colleagues, our patients, and the public. This awareness and sensitivity are essential to shape individual perspectives and affect interpersonal interactions in a positive way. 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, color, sex, religion, national or ethnic origin, age, disability, sexual orientation, gender identity, gender expression, genetic information, or any other class protected by law. You are expected to immediately report any potential discrimination or harassment you may witness.
Conflicts of Interest
VUMC avoids potential or perceived conflicts of interest.
Individual conflicts of interest refer to situations in which 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 any VUMC duty or responsibility, including the conduct or reporting of research. 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 all 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 the time of initial employment and annually thereafter, as well as immediately when a new potential conflict of interest arises. VUMC’s policies provide detailed information about conflicts of interest situations and disclosure requirements.
Research and Scientific Integrity
VUMC is committed to following all laws and regulations related to scientific research.
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 all regulations and other requirements pertaining to the protection of human and animal research participants and accurate reporting and appropriate 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.
Market Competition and Ethical Business Practices
VUMC is committed to complying with state and federal antitrust and anti-kickback laws and regulations.
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 each will accept from payers or patients 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.
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.
Patient Referrals and Patient Selection of Providers
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 referral to our care and referrals we make to other health care providers. If someone offers, asks for, pays 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 any potential kickback activity to their supervisor, department head, OCCI, or to the VUMC Integrity Line.
Many financial arrangements may be considered kickbacks. Examples include an employment agreement that rewards a referring physician by paying too much salary, or a lease for space or equipment that rewards a community physician for referrals 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 Anti-Kickback Statue. To avoid violations, you will coordinate with the OLA or other applicable legal counsel to review, prior to final agreement or signature, proposed contracts and financial arrangements with clinicians and clinician family members.
Patients choose to receive health care from VUMC only because of the exceptional quality of our services.
VUMC follows federal law prohibiting gifts or other benefits to patients that might influence their choice of providers. This prohibition applies to all patients, regardless of insurance source or status, includes providing any free or discounted services and to waivers of copayments that are not based upon VUMC’s financial assistance and discount policies. The OLA and OCCI answer questions about VUMC’s policies, the federal law, and its exceptions.
Billing and Claims
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 in all cases and at all times. Everyone at VUMC providing patient care services or involved in billing 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 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 these discharge discussions.
Emergency Treatment for Patients and Women in Labor and Patient Transfers
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 individual comes to the Emergency Department for a medical examination or treatment of a medical condition, VUMC must provide that individual with an appropriate medical screening examination to determine if an emergency medical condition exists, and, if such a condition exists, VUMC stabilizes the emergency medical condition within our capabilities. VUMC also maintains financial assistance policies to ensure that access to care is provided on a fair and consistent basis.
VUMC complies with all applicable environmental laws and to maintaining all necessary environmental permits and approvals.
Environmental compliance includes the proper handling, storage, use, shipment, and disposal of all materials that are regulated under any applicable environmental law.
VUMC prohibits the unlawful possession, use, manufacture, or distribution of controlled substances, illicit drugs and alcohol on its property or as part of any VUMC sponsored activity.
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 is committed to responding appropriately when anyone at VUMC violates law or policy.
Everyone at VUMC carries out their duties according to this Code of Conduct, applicable VUMC policies, and as required by law. If you violate a law or policy or do not report such suspected violations, you may be subject to disciplinary action up to, and including, termination of employment or contract for services. Disciplinary conduct abides by all applicable protections in the Faculty Manual or in the Human Resources Staff Guidelines. Disciplinary action may also apply to a supervisor who knowingly directs or approves a person's improper actions, or is aware of those improper actions but does not act within their authority to correct them, or who otherwise fails to exercise appropriate supervision.
Response to Investigation
VUMC is committed to full cooperation with government investigators, as required by law.
If in your work at VUMC, you receive a subpoena, search warrant, or other similar document related to VUMC, then, before taking any other action, you or your supervisor must immediately contact OLA or the subsidiary organization’s legal counsel. If a government investigator, agent, or auditor comes to any VUMC office or facility, you should ask the person for their business card, have them be seated in a public waiting area, and contact your supervisor. Before providing any access to, or discussing any matters with, such investigator, agent, or auditor, you or your supervisor should contact OLA or the subsidiary organization’s legal counsel and, where applicable, the Hospital Administrator-on-Call.
Reporting Compliance Concerns
VUMC investigates all concerns brought to our attention.
To assist VUMC with its commitment to compliant and ethical conduct, everyone at VUMC is expected to report actual or potential violations of any law or policy or other concerns to a supervisor, their department head, OCCI, or anonymously to the VUMC Integrity Line. It is your duty to report all actual or suspected situations that endanger the health and safety of any individual. All reports to OCCI are treated as confidential and are shared with others only on a bona fide need-to-know basis. No one at VUMC may take adverse action toward, or permit retaliation against, persons reporting concerns in good faith. False accusations made with the intent of harming or retaliating against another person can subject the accuser to disciplinary action.
Statement of Receipt and Acknowledgement
Upon initial employment or contract, and annually thereafter, you will acknowledge awareness of and compliance with this Code of Conduct.
To view this policy in a PDF via PolicyTech, click here
Last Revision Date: May 2022