Code of Ethical Conduct Example Scenarios

We mail printouts of patients’ lab results and sometimes the results accidentally go into an envelope addressed and mailed to a different member. We can just ask the individuals to throw away the results that don’t belong to them, right?

Wrong. Improperly revealing PHI without authorization from a member or patient is a serious violation of that person’s privacy, even if it’s accidental. If this happens, notify your compliance officer as soon as you become aware as several notifications must take place.

Errors like this are preventable. When mailing documents containing member or patient PHI, take time to check that the name on the document matches the name and address on the envelope. If you use a mail merge to address multiple envelopes, take additional time to verify that no errors in the mail merge process have occurred. By taking extra time to perform these checks, you can prevent an improper disclosure of PHI to one individual or to hundreds.

For additional guidance, refer to the policies and procedures that apply to you and check with your chief or immediate supervisor on how to handle PHI appropriately.

I’m active in a community-based organization. We are filling backpacks for kids getting ready to go back to school and need some supplies. Our department distributes sunscreen and water bottles at health fairs and I think the kids could use these items. Can I take some for our organization’s kids?

No. Each region has community benefit goals and funding guidelines to address community needs. First speak to your chief, immediate supervisor, compliance officer, or refer to the policies that apply to you for additional guidance.

In the past few years I’ve seen some of our regular patients struggle financially because they’ve had their work hours reduced or a family member has lost a job. A few of them have asked me if I can waive the registration copay. I feel so bad because I don’t want to be responsible for a member not coming in for an appointment because they can’t afford to, but I’m quite sure I can’t do this. What should I do?

If patients cannot make their copay at the time of service, follow your area’s policies and procedures regarding copay collection or contact your immediate supervisor. Patients should be informed of available Medical Financial Assistance Programs or other programs.

I have noticed one of the receptionists in my department often makes personal phone calls when there is no one waiting. However, she continues talking on the phone when a member arrives at the desk and begins the check-in process while continuing her personal conversation. This doesn’t seem right to me. Is it?

You are right. These calls are detracting from the service quality that is expected at Kaiser Permanente. Use of devices for personal reasons should never interfere with your job duties.

My co-worker has a family-owned business. I often see him using his computer to communicate with his customers. Is this okay?

No. Kaiser Permanente information systems, including computers, cannot be used for personal benefit. While it’s understandable that you may need to handle some personal matters during work from time to time, such as scheduling appointments or following up with teachers, it is not acceptable to use Kaiser Permanente information systems to promote or maintain a personal business.

Our department is currently undergoing an internal audit. We have been under pressure to ensure that there are no findings. One of the documents was not dated. I was just going to backdate it. Is that okay?

No. Misrepresenting the facts discredits you and Kaiser Permanente. There is never a good reason for falsifying any document. Document falsification can lead to serious consequences for you and Kaiser Permanente.

I want to let members know about a new support group we are offering at our medical center. I could easily make a flier and post it in our waiting area, but I’m told that we need to go through public affairs or marketing. Why all the bureaucracy?

We want to make sure that we communicate with our members and patients consistently, in both written and oral communications and through the images we share (e.g., video, graphics, and photography). Kaiser Permanente has invested a great deal in building and promoting our brand, and we want to make sure that all external communications are consistent with our brand, whether we are communicating with our members or patients through a flier or an appointment reminder. Our communications and marketing staff are trained to comply with the wide variety of regulatory requirements governing member and patient communications, which can even include fliers.

I get frustrated and irritated when I work with members or patients whose family and friends speak in another language. Is it okay for me to ask them to speak in English?

No. Our members and patients have the option of speaking in their preferred language. If needed, offer interpretive services to ensure that you and the member or patient understand one another. For medical interpretation, consult your area’s policy.

It’s important to remember that the health care setting can be stressful. When members and patients speak in their preferred language, they may be able to communicate the care or help they need more clearly than if they were required to speak in English.

Two of my co-workers are constantly engaging in very obvious flirtatious behavior. While I think this is more talk than action, it makes many of us uncomfortable. Our supervisor just laughs about it and says it’s “harmless.” What should we do?

Report it. These two employees are creating an uncomfortable work environment that could be impacting your team’s effectiveness. Raise the concern with your human resources representative or your compliance officer.

I work in the mail room, and I like to do my work while listening to music. I put on some good tunes, stick my ear buds in, and I’m good to go! My supervisor makes me take the headphones out. Why?

Having headphones in your ears interferes with your ability to hear others. This may pose a danger while you are moving around the mail room, walking down hallways, etc. Rules specific to a department are often implemented to avoid injuries.

In comparing patient visits and the claims submitted over the past few months, I think the way my manager is filing Medicare reimbursement claims is not correct. I’m scared to say anything about it. I could get into a lot of trouble. What should I do?

You should discuss your concerns with your compliance officer, speak with the Kaiser Permanente attorney for your area, or call the Kaiser Permanente Compliance Hotline at 1-888-774-9100. The False Claims Act and other federal and state whistleblower laws protect you. Kaiser Permanente will not discharge, demote, suspend, threaten, harass, or in any manner discriminate against physicians, dentists, or employees in retaliation for exercising their rights under these laws.

I am attending a product training at a vendor’s office. Is it okay for me to:

• Have a bagel and cream cheese that is provided during a break?
• Be taken out for dinner at a restaurant after the session?

Check the policies that apply to you. If your policy does not prohibit acceptance of meals and the food does not exceed $25 in value, it may be acceptable. A bagel may be fine, but a four-course meal at a steak house probably wouldn’t be.

A patient I was caring for is a dog breeder. He is really appreciative of the care I gave and said that he would sell me one of his puppies at half his normal price. Can I accept?

No. The discount off full price would be considered a gift. Let the patient know that it would not be appropriate for you to accept.

A new vendor just completed a project for my department and gave me a $50 gift voucher to say “thanks for the business.” I know that they received the Vendor Code of Conduct that says that gifts valued at more than $25 cannot be given or accepted. What should I do?

Thank the vendor for the work and for the gift, but let the vendor know that you cannot accept the gift voucher because it exceeds the $25 allowable amount and because gift cards are not acceptable. You may also want to get a copy of the Vendor Code of Conduct (go to kp.org/compliance and click Vendors & Contractors), highlight the section on gifts and business courtesies, and give it to the vendor to explain your actions.

I am organizing a retirement party for my manager, using Kaiser Permanente funds. My wife is a co-owner of a catering business and has provided catering services to other Kaiser Permanente departments. Can I use my wife’s business to cater the retirement party?

As someone with authority or influence over selecting vendors, you are responsible for prioritizing Kaiser Permanente’s interests over your personal interests. In this situation, you must disclose your wife’s co-ownership in the business to your chief or immediate supervisor and recuse yourself from the contracting decision while that business is being considered.

A hospital has offered several Kaiser Permanente physicians and employees and their families free tickets to baseball games. Can we accept the offer?

No. Such an offer could subject the hospital, and our physicians and employees who accept the offer, to penalties under the Stark Law and Anti-Kickback Statute.

It’s important to recognize that this scenario gives rise to both conflict of interest and gift policy issues, as well as potential Stark and Anti-Kickback problems. Kaiser Permanente physicians and medical center employees are not permitted to accept such gifts.

I have an open position on my staff for an administrative assistant. I think my niece would be perfect. Can I hire her?

If the position reports directly to you, then you cannot fill the position with your niece. The human resources hiring process and applicable policies should be followed when you hire for the position.

I heard that Kaiser Permanente has been asked by the government to turn over documents for a grand jury investigation. I’d prefer not to provide them with my personal notes, which I always save just for my own reference. Would it be okay to destroy them?

No. Deliberate destruction of documents that may be relevant in an investigation is illegal and against Kaiser Permanente policy. Never alter, conceal, or destroy documents or records if they have been requested by a government agency or if they are likely to be requested in connection with an investigation.

I think my boss has some stake in a side business that contracts with Kaiser Permanente for skilled nursing care. I’m not sure about it, though. I don’t want to report it in case I am wrong. What should I do?

You should go ahead and report the issue to your compliance officer. If you prefer to make the report anonymously, you can call the Kaiser Permanente Compliance Hotline at 1-888-774-9100. Representatives from Kaiser Permanente’s National Compliance, Ethics & Integrity Office would rather follow up on this situation and discover that all relationships are legitimate than learn about a real conflict of interest situation through public criticism or other external sources.