2017 Standards For Business Conduct

Standards for Business Conduct
9th Edition
i | Sutter Health Confidential Message Line 1-800-500-1950

Message from Sutter Healths President and CEO
Dear Colleague,
For more than a decade, Sutter Health has been proud to demonstrate its
commitment to honesty and integrity through our Standards for Business Conduct
which are outlined in this document. This document was created with the goal of
ensuring our employees, aligned physicians, vendors and contractors understand the
importance of their role in conducting business with the highest levels of honesty
and integrity.
The examples found in this document will help guide you through the complex
policies, laws, rules and regulations that you may face in your everyday job. As Sutter
Healths President and CEO, I can assure you that we will continue to treat honesty
and integrity as our highest priorities. It is important to remember that despite the
difficult and ever-changing environment in which we work, each of us has a duty to
uphold the highest ethical standards in the way we deal with our patients, customers
and coworkers.
Please take the time to read through this important information and learn more
about the resources available to you and how you make a difference in Sutter Health.
Thank you for doing your part in continuing to make Sutter Health an organization
of which we can all be proud.
Sarah Krevans
President and CEO
Message from Sutter Healths Chief Compliance Officer
The responsibility for maintaining an ethical and legally compliant Ethics & Compliance - Everyones
environment rests with each and every one of us. We have a duty to make Responsibility
compliance part of our daily operations and to operate with integrity.
If you find yourself asking What is the
The Sutter Health Ethics & Compliance Program and the Standards
right thing to do in this situation?, the
for Business Conduct are designed to foster an environment in which
Standards for Business Conduct is a good
employees, physicians, vendors and contractors are given the tools they
place to begin your search for the answer. The Standards for Business
need to build and maintain a culture of compliance.
Conduct provides an overview of the most significant standards and
We work in one of the most highly regulated industries in the United requirements that apply to your daily work. Remember, each of us has
States. Comprehensive legal and regulatory requirements control an obligation to ask questions and to seek to understand requirements
nearly every aspect of our operations, from protecting the privacy and that apply in our day to day work for Sutter Health. Thank you for taking
security of patient information, to how we provide and bill for services the time to read through and acknowledge Sutter Healths Standards for
to our patients and how we manage our relationships. The burden of Business Conduct and for your commitment to an ethical and compliant
understanding and correctly applying legal and regulatory requirements environment.
in our health care organization is significant. At Sutter Health, our goal
is to maintain a patient care, business and workplace environment that
is consistent with the highest ethical standards and applicable legal and
regulatory requirements.
We all strive to do the right thing. However, working in this complex Ginger Chappell
environment means that making legal and ethical decisions is not always Vice President, Ethics & Compliance Services
easy or intuitive. You may, therefore, become aware of activities or and Chief Compliance Officer
behaviors that appear to be inconsistent with the Standards for Business
Conduct or other Sutter Health policies or legal requirements. If so,
it is your responsibility to report the suspected misconduct to your
manager, another supervisor, or compliance, privacy, or information
security officer. You may reach out to our officers directly, by calling the
Confidential Message Line, or by reporting online. Every Sutter Health
employee has a duty to report suspected illegal or unethical conduct.
Sutter Health has a strict policy prohibiting any form of retaliation against
a person who, in good faith, reports a concern about possible non-
compliance.
Contents
Sutter Health Mission, Vision and Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Patient Billing Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Ethical Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Accuracy of Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Confidentiality and Proprietary Information . . . . . . . . . . . . . . . . . . . . . . . . 3 Coding and Billing Practices: Accurately Bill for Services Rendered to
Our Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Conflict of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Coding and Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Gifts, Loans, and Entertainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Reporting Improper Coding/Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Solicitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
False Claims Act (FCA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Advertising, Marketing and Communications . . . . . . . . . . . . . . . . . . . . . . . . . 6
California FCA: Medi-Cal Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Financial Relationships with Physicians and Other Providers. . . . . . . . . . . . . 25
Graphic Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Anti-kickback Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
News Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Physician Financial Relationships: Stark Law Essentials. . . . . . . . . . . . 26
Social Networking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
California Anti-Kickback and Anti-Referral law. . . . . . . . . . . . . . . . . . . . . 27
Third-Party Use of the Sutter Health or Affiliate Names and Logos . . . . . . 8
Payments to Physicians to Reduce or Limit Care . . . . . . . . . . . . . . . . . . 27
Patient Care and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Patient Inducement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Patient Confidentiality and Privacy Rights. . . . . . . . . . . . . . . . . . . . . . . . 10
Tax-Exempt Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Employee Use of Computer Systems and Equipment . . . . . . . . . . . . . . 11
Prohibition of Private Benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Emergency Medical Treatment and Labor Act (EMTALA) . . . . . . . . . . . . 12
Sanctions of Private Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Charity Care: Our Commitment to Low Income Uninsured Patients . . . . 12
Government Investigations/Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Patients with Disabilities: Our Commitment to Equal Access. . . . . . . . . . 13
Responding to Government Investigations/Audits . . . . . . . . . . . . . . . . . 32
Caring for Patients with Communication Challenges . . . . . . . . . . . . . . . 13
Obstruction of a Federal Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Communicating Patient Care Concerns to Joint Commission . . . . . . . . 14
Exclusion Checks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Workplace Conduct and Employment Practices. . . . . . . . . . . . . . . . . . . . . . 15
Individual Culpability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Prohibition Against Discrimination, Harassment and Retaliation. . . . . . . . 16
Health, Safety and Environmental Concerns. . . . . . . . . . . . . . . . . . . . . . . . . 34
Confidential Employee Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Research and Research Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Financial Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Human Subjects Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Employee Use of Charitable Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Political Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Research Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Anti-Trust Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Acknowledgement of Standards for Business Conduct Handbook. . . . . . . . 40
Sutter Health Mission, Vision and Values
Mission Values
We enhance the well-being of people in the
communities we serve through a not-for-profit Honesty and Integrity
commitment to compassion and excellence in We act openly and truthfully in everything we do.
health care services.
Excellence and Quality
Vision We exceed customer expectations by delivering premier clinical quality and
Sutter Health leads the transformation of health maintaining the highest levels of safety.
care to achieve the highest levels of quality,
access and affordability. Compassion and Caring
We treat those we serve, and one another, with concern, kindness and respect.
Community
We work to understand and best serve the diverse needs of our community.
Teamwork and Trust

We recognize that the power of our combined efforts exceeds what we can accomplish
individually, and we are accountable to each other and to our customers.
Innovation
We continually create, seek out and adopt new ways of providing value to our
customers, rapidly moving from idea to execution.
Affordability
We deliver health care efficiently by using resources responsibly.
1 | Sutter Health Confidential Message Line 1-800-500-1950

ETHICAL CONDUCT

Ethical Conduct
Conduct business with honesty and integrity. Honesty & Integrity are at the center of Sutter Affordability: You recognize your departments
These qualities are demonstrated through Healths values. The following situations processes use a considerable amount of
truthfulness, the absence of deception or demonstrate how ethics ties to each of our supplies unnecessarily. Although youre not
fraud, and respect for the laws that apply to values. aware of a policy against the current practices,
Sutter Health and Affiliates. Every member of you suggest new processes to your supervisor
Teamwork: A co-worker asks you for
the Sutter Health workforce is responsible for which minimizes the waste.
assistance with a clinical procedure but you are
acting with integrity.
not qualified to do so. Rather than declining Compassion & Caring: You observe someone
Being ethical and having integrity is more than to assist or violating a policy by assisting, you struggling to navigate a hospital because they
just following laws, regulations and policies. find someone else who is qualified to help your cant read. Rather than just pointing them in
These qualities require strong moral principles co-worker. the right direction, you guide them to their
which govern behavior. The ethical behavior destination and introduce them to someone
Community: A patient asks if they can leave
of each individual at Sutter Health supports the who can help them.
the hospital (against medical advice) because
organizations integrity. If there is any doubt
they worry they cannot pay for hospital Q. How do I know whether something is
in the appropriateness of any behavior, stop
expenses. You explain Sutter Healths not-for- ethical?
and seek guidance from a supervisor or your
profit mission and offer to put them in contact
Compliance, Privacy or Information Security
with the hospital Community Benefits Liaison
Officer. A. If a policy, standard or law doesnt answer
to assist with applying for financial assistance.
your question, consider asking yourself how
Q. My supervisor asked me to do something Excellence & Quality: The deadline for you would feel if you saw your words or
but I dont feel comfortable doing it. Im not a software upgrade project is quickly actions in social media or in the news. Or,
aware of a policy or law which prohibits the approaching. You become aware of a glitch that ask yourself how it would look to your family,
behavior, but it doesnt feel right. What do may adversely affect some patient records. You friends, patients or community.
I do? report the concern even though it postpones
project completion and requires rework and
A. There are many actions and behaviors overtime.
Confidentiality and Proprietary
which are legal but may not be ethical (i.e.
Innovation: A patient expresses dissatisfaction Information
not doing what you say youll do). Trust your
about the response time she experiences when
instincts. If you feel uncomfortable doing Employees must not use or share Sutter Health
leaving a message for her doctor. You suggest
something, talk to your supervisor or another confidential and proprietary information with
that she submit her questions through the
leader. Remember that Sutter Health prohibits anyone outside the organization (including
MyHealthOnline mobile app. The patient has
retaliation and retribution for reporting friends, relatives, acquaintances, customers
the app on her phone but she doesnt know how
concerns in good faith. and others). Proprietary information is
to send a question in a message. You sit next
any information used in the operation of
to her and teach her how to send a message,
Sutter Health and Affiliate business that is
lookup results and schedule appointments.
sufficiently valuable and secret to afford an

actual or potential economic advantage over 6. P
rotected Health Information (PHI) any influenced, in part or in whole, by your other
others and is not available to the general information about health status, provision interests.
public. Confidential information means any of care or payment for healthcare about
Officers, directors and certain other employees
information that is intended strictly for use a patient or member
must complete a Conflict of Interest Disclosure
within, by or on behalf of, Sutter Health, as 7. Personally Identifiable Information Statement annually. In any event, if you
required by law or as required or permitted
All employees are required to abide by the are unsure whether you have an actual or
by Sutter Health policies, including but not
Workforce Confidentiality and Privacy Policy, potential conflict of interest, promptly notify
limited to any information created, received,
Use of Internet, E-Mail and Instant Messaging your supervisor so that you may discuss the
maintained, or transmitted by or on behalf
Policy, and all other Privacy, Information circumstances. Generally, a conflict of interest
of Sutter Health that identifies, or could
Security Policies and Procedures. All can be avoided or resolved if it is disclosed
identify, a patient or health plan member.
employees will be asked to sign a Workforce in advance. If there is an actual or potential
Unauthorized use or disclosure of confidential
Confidentiality Agreement annually and to conflict of interest, you may be asked to
information could seriously adversely impact
acknowledge the Privacy and Information complete a Conflict of Interest Disclosure
the organization, our patients and members,
Security Policies and Procedures. Statement if not already required to do so.
employees, and business partners.
Without specific authorization, do not disclose Q. Our hospital is holding a seminar for the
Conflict of Interest
this information to other Sutter Health public on womens health. A pharmaceutical
Avoid conflicts of interest and even the company wishes to help sponsor the event
employees except on a need-to-know basis
appearance of conflicts of interest. and to provide educational materials about
(i.e. the disclosure is necessary to accomplish a
job function) and the recipient agrees to treat A conflict of interest occurs if an outside its newest drugs. Can we accept its support
the information as confidential. interest or activity may influence or appear to and list it as a co-sponsor?
influence your ability to exercise objectivity or
Some examples of confidential or proprietary
meet your job responsibilities to Sutter Health. A. Donations from pharmaceutical companies
information include, but are not limited to, the
Participation in activities that conflict with your to support educational forums can be
following:
employment responsibilities at Sutter Health is accepted in some circumstances, but
1. Financial Data/Projected Earnings not acceptable and it is your responsibility to subject to limits on the type and amount
2. Provider Contracts discuss any suspected conflict of interest with of donations. See the Conflict of Interest
your supervisor, as discussed below. policy and Attachment A to the Supplier
3. Information Systems/Technical Designs Registration and Facility Access Policy.
A reasonable guideline to follow is that a
4. Marketing Plans/Strategies Educational materials produced by a
potential conflict of interest exists any time
pharmaceutical firm may be distributed
5. Business Forecasts/Strategies an objective observer of your actions might
if they help to inform patients about
wonder whether you are motivated solely by
a condition or disease and suggest a
your responsibilities to Sutter Health or are

consultation with the patients physician or cash equivalent (such as gift cards) from a Q. My two children attend a private school.
regarding options for treatment. However, patient or a vendor. The school desperately needs funds for
in these public situations, neither Sutter playground equipment and field trip
Sutter Health employees also may not offer or
Health nor any Affiliated individual should activities. They are having a Jog-A-Thon to
give a gift of substantial value that may appear
endorse, or be perceived as endorsing raise money. Is it okay if I ask my coworkers
to be intended to influence anyone outside of
any particular commercial product. In if they would be willing to support my kids
Sutter Health.
any event, no patients protected health in this event?
information, including, but not limited Q. A vendor with whom we have done business
to, a patients picture, and no employees in the past offered to pay for an all-inclusive A. E
mployees are prohibited during work time,
protected identifiable information, seminar at a resort hotel. Can a Sutter or at any time in an immediate patient care
including, but not limited to, an employees Health employee accept the offer? area, from soliciting coworkers or patients
picture, may be used or disclosed in relation relating to a personal, non-Sutter Health
to the seminar without the express written related activity. An employee may engage in
authorization of the patient or employee, A. No, Sutter Health employees must not
accept gifts, particularly ones that have such activities on an employees own time
as applicable. Consult your local Privacy outside of immediate patient care areas
Officer if you have questions. substantial value, from individuals or
from companies that do business, or may provided that the employee complies with
want to do business, with Sutter Health Sutter Healths policies regarding solicitation
Gifts, Loans, and Entertainment or any Affiliate. This type of activity and conflict of interest. If you have any
should be reported to your supervisor and questions about the solicitation or conflict
Sutter Health employees and their families
Compliance Officer to resolve the current of interest policies, your supervisor or
are prohibited from soliciting or receiving
gift and assure this does not happen in Human Resources professional are available
substantial gifts, loans, entertainment or
the future. to assist you.
anything else of value from a person or
organization that does business, or may want
to do business, with Sutter Health. This applies
Solicitation
to all employees of Sutter Health and its
Affiliates, including senior management. If a Sutter Health employees may not solicit their
Sutter Health employee receives any substantial co-workers or patients on behalf of their
gift, it must be returned and the employees personal business or any third party during
supervisor notified. Below are some general work time or in any immediate patient care
examples of gifts that are not permitted. Please areas. Limited fundraising or solicitation in
see the Sutter Health Conflict of Interest Policy furtherance of Sutter Healths mission and in
for additional guidance on what gifts are and support of various health-related not-for-profit
are not permitted. programs may be permitted with management
approval (e.g., United Way, March of Dimes).
Sutter Health employees may not accept a gift
of more than nominal value or any gift of cash
ADVERTISING, MARKETING
AND COMMUNICATIONS

Advertising, Marketing and Communications
Sutter Health is viewed as a reliable, News Media Q. After I finished work, a reporter and camera
authoritative source of information about It is Sutter Healths systemwide policy to person approached me in the parking lot.
health care and about issues relating to the identify, train and authorize spokespeople to They said they had some questions about
delivery of health care. We want to maintain talk with representatives of the news media our organization and wanted an employees
public trust by providing accurate, balanced about official Sutter Health information. perspective. They were just asking for my
and consistent information. Approved spokespersons of Sutter Health opinion, so is it OK to go on camera?
All advertising, communications and other shall work cooperatively with news media
promotions should enhance the positive representatives to provide official news A. Although the media may seem to only be
reputation of Sutter Health and its Affiliates by announcements, releases, statements, reports, interested in your personal opinion, your
communicating a clear, consistent, high-quality reactions, responses, etc., to requests for comments may come across as a response
image of the organization and its services. information. from Sutter Health, especially if you are still
in uniform, wearing an ID badge or in front
The Communications Department of Sutter
Advertising of a company building. Also, they may ask
Health and its Affiliates serves as the first
questions you are not prepared to answer
All advertising should be produced by or in point of contact with representatives of
on camera. If you are ever approached by
coordination with representatives of the Sutter the news media regarding all inquiries
a reporter, politely decline the request and
Health Marketing Department to ensure it related to the organization and its services.
direct him or her to the Communications
complies with Sutter Healths brand guidelines Communications will follow established
Department, where official Sutter Health
and graphic standards. Advertising that processes when engaging with the news
spokespeople will respond.
includes photographs and/or names of patients, media, including the identification of
their family members, physicians or employees appropriate subject matter experts and
must also comply with our policies requiring spokespersons throughout the network. Social Networking
signed individual consent.
Employees should refer all media inquiries to Employees should follow the Sutter Health
the Communications Department. Standards for Business Conduct, as well
Graphic Standards as Sutter Health or Affiliate Employee
All Sutter Health departments and Affiliates Handbooks, values and applicable laws in all
must conform to Sutter Healths graphic online communications. This includes knowing
standards to maintain a consistent and and adhering to Sutter Healths systemwide
recognizable image. For information about Social Networking Policy.
our graphic standards, please refer to the
Never share information in online communities
Sutter Health Brand Center at http://brand.
about a patients identity or health condition
sutterhealth.org. In addition, all logos should
in any way, or Sutter Health or Affiliate
be obtained through the Brand Center. To
confidential, proprietary or trade-secret
request access, please contact brandcenter@
information.
sutterhealth.org.

Q. My friends and family are interested in Q. I was disappointed to see a number of
seeing what I do at work on a regular basis. negative online reviews about my employer.
I started a blog to document my days as a Theres nothing wrong with posting a positive
nurse, and I also post a lot on Facebook and review under an anonymous account on Yelp,
Twitter as a way to stay connected. Today, right? I just want to create a more accurate
I encountered a patient with a very rare reflection of my organization.
condition that I think my followers will be
interested in learning more about. Can I A. There are serious implications for ghost
write about this experience? blogging, which is when an individual
posts an endorsement or review about his
A. Any employee can start his or her own or her company without sharing his or her
blog or be active in social networking, connection to, or role in, the organization.
but participation in such activities Be transparent and state your connection
requires following Sutter Healths Social to Sutter Health or a Sutter Affiliate in any
Networking Policy and Commenting online forums or postings from online
Guidelines. Employees cannot discuss any comments on news stories to discussion
patient information in person or in online boards and more.
communities and forums per Privacy
regulations. This includes videos, text,
photos or any other communication that Third-Party Use of the Sutter Health
identifies a patient or in any way discusses a or Affiliate Names and Logos
patients health condition or an image. Even Sutter Health believes that vendor or other
if you do not identify a patient by name, a third-party use of our organizations names
description of the patients condition might and logos requires special scrutiny. It is our
reveal his or her identity. systemwide policy that employees cannot
approve, permit, originate, edit or otherwise
Employees are encouraged to follow or produce communications and marketing
fan official Sutter Health social media materials related to or referencing Sutter
accounts, and share information posted Health on behalf of a Vendor, Other Third-
there to help promote the good works of Party Vendor or Private Individual without
our organization. prior review and approval by the Sutter Health
Marketing/Communications Department
before use or distribution. Never promise,
in writing or in conversation, that our
organization or its employees will endorse a
particular third-party product or service.

PATIENT CARE
AND TREATMENT

Patient Care and Treatment
Deliver appropriate, effective, and quality All employees are required to abide by the A. No. There are specified procedures and legal
care with compassion. Deliver care to patients Workforce Confidentiality and Privacy Policy, requirements that must be followed to gain
without regard to race, creed, gender, age, Use of Internet, E-Mail and Instant Messaging access to records of family members. Your
illness, disability status, sexual orientation, Policy, and all other Privacy, Information local Privacy Officer can assist you.
national origin or ability to pay. Security Policies and Procedures. All
employees will be asked to sign a Workforce Q. I am a clinical assistant and I am
Patients must always be treated with sensitivity,
Confidentiality Agreement annually and to often asked to fax confidential patient
respect and professionalism. A patients
acknowledge the Privacy and Information information to a physicians office, per
care plan must be appropriate to meet the
Security Policies and Procedures. the physicians request, without a signed
intended medical and psychological outcomes.
Protective measures must be in place to authorization form from the patient. I feel
Q. I am concerned about a co-worker who
safeguard patients from harm. uncomfortable doing this, and I could not
was recently admitted to the hospital.
find a policy dealing with this issue. Is this
Can I access her information in our
permitted?
Patient and Member Confidentiality electronic medical record system to see
and Privacy Rights how she is doing?
A. Yes, state and Federal privacy laws and
Information about our patients and members
regulations generally allow for the release of
is considered Protected Health Information A. No. While you have the best interests of
health information to a treating physician
(PHI) and must only be accessed, used or your co-worker at heart and assuming you
without the patients authorization for
disclosed for legitimate business purposes and are not one of the patients caregivers, you
continuing care of the patient. If you feel
as required to perform job related duties. State may not access her health information
that you need further explanation regarding
and Federal laws govern the use, disclosure without her specific written authorization
the purpose for the release of information,
and safeguarding of health information and to do so. This would be a violation of
it is your responsibility to ask the resources
give patients and members rights related Privacy regulations and Sutter Health and
available to you until you are satisfied that
to access, restrictions, amendment, and Affiliate Policy would require disciplinary
you are following correct procedures. Please
confidential communication of their health action, up to and including termination of
see the Electronic and Fax Transmittal of
information. The disclosure of sensitive patient employment.
Protected Health Information Policy for
information such as information regarding
more details.
HIV test results, alcohol or drug use, and Q. How can I access records of members of my
mental health treatment is generally subject immediate family including my childrens
to additional restrictions. Unlawful access, use Q. I accidentally faxed a document that
records? I know they are stored in our
or disclosure of patient or member information contained patient information to the wrong
computer system. Can I just go in and look
may be reportable to the patient or member, person. What should I do?
at them?
government agencies and, in some cases, the
media. Contact your local Privacy Officer to
report a privacy incident or if you have any
questions about privacy.

A. If you have accidentally faxed sensitive regarding patients within the Sutter Health Healths information:
or confidential information to the wrong network of care, that may compromise
Choose strong passwords that differ from
recipient(s), you should inform your a patients personal dignity or otherwise
your personal accounts.
supervisor, manager or director and the make them question the confidentiality of
local Privacy Officer immediately. You the services provided by the network, are Protect your passwords and never share
should also follow up with the recipient(s) prohibited. them with others.
to inform them that the fax was sent in Use a screensaver when stepping
error and, obtain their full name and Q. Im not sure what to do with these away from your computer
contact information, and ask them to retain prescription bottles with patient names on ( +L or ctrl+alt+delete).
the information until the Privacy Officer them. Can I just throw them in the trash?
contacts them to make arrangements for the Type [encrypt] or [confidential] in the
return of the documents. subject line to securely send a message
A. No. You should check with your department outside of Sutter Health (be sure to include
to confirm the process for properly the square brackets). Always use this
Q. I had an interesting patient case that I want disposing of the bottles. The bottles will function when sending PHI.
to post on my various social media sites, likely be processed by a disposal vendor to
including my Facebook page. Is it ok to post Store confidential information on a
pick up and shred or otherwise destroy the
information about the case if I dont include network drive. Do not save on your local
PHI. Sutter Health is not allowed to dispose
the patient name? computers hard drive (c:).
of any PHI in dumpsters or other containers
that are accessible by the public or other Place portable computing devices in a
A. Individuals may not use or disclose any unauthorized persons. secure location when unattended or not
patient identifiable information of any in use.
kind, including patient images, on any Question any email you receive with
social media platform. Even if an Individual
Employee Use of Computer Systems
and Equipment links or attachments requiring immediate
is not identified by name within the attention. Validate the message by calling
information at issue, if there is a reasonable Sutter Health is expanding its use of
or initiating a new message by looking up
basis to believe that the person could still computer systems and portable devices (i.e.,
the address.
be identified from that information, then laptops, smartphones, etc.) to better manage
information about patients, employees and Inquire if unfamiliar individuals are in
its use or disclosure could constitute a
the organization. Employees and third party your area to prevent unauthorized access
violation of the federal or state privacy
contractors who are granted access to our to our systems.
regulations. Information of any kind,
including patient images, on any social systems must familiarize themselves with the Practicing good security often takes extra steps,
media platform cannot be shared or posted Sutter Health Privacy and Information Security but they are well worth the time to protect
without the express written authorization policies. Policies are in place to protect both our patients information. More detailed
of the patient. Additionally, online activities you and Sutter Health. information is available on the Security
Please follow these steps to protect Sutter Awareness and Training intranet website.

Q. I have been asked to share my password with Emergency Medical Treatment and Charity Care: Our Commitment to
another employee. Is this okay? Labor Act (EMTALA) Low Income Uninsured Patients
EMTALA is, in effect, a national safety net It is the policy of Sutter Health to provide
A. No, never share your password with anyone. that requires hospitals to provide a clinical income based Financial Assistance (charity
You are responsible for all actions associated evaluation by a physician or other qualified care) to qualified individuals and to provide
with your user ID and password. Indicate hospital staff member to any individual who uninsured and insured patients with the
that you are uncomfortable with the request comes to the facility and requests an assessment information required by law regarding
and that sharing your password would or treatment of a possible emergency financial assistance. Charity care is based
violate the Sutter Health Passwords policy. If medical condition. Hospitals are required to on the individuals ability to pay, as defined
your supervisor or manager approaches you use whatever resources they have available by Federal Poverty Income Guidelines, and
to share a password, you can contact your to provide such evaluation. If the patients available in the form of free or discounted care
compliance, privacy or security officer for condition is determined to be an emergency, to eligible low-income uninsured patients, and
guidance. the hospital is further required to provide insured patients with high medical costs.
whatever care may be necessary to stabilize
Charity Care is generally not available for
Q. If I receive a suspicious looking email the condition and prevent worsening of the
elective procedures, or applicable to charges
message that includes a link in the message patients condition. If, however, the complexity
for services rendered by physicians or other
or an attachment, should I be skeptical? of the patients needs exceed the hospitals
medical providers charges not included on the
resources or capacity to provide the required
hospital bill.
assessment and treatment, the patient must be
A. Yes. Phishing is a fraudulent email attempt
promptly transferred to a facility that has such Information about financial assistance is
to trick you into revealing confidential
resources available. All services mandated by provided through notices that are posted
information or providing access to your
EMTALA must be provided without regard to in the primary languages of the hospital
computer and our information systems. Health
the patients ability to pay, pre-existing medical or foundation service areas in a variety of
information is valuable, so its safer to be
condition, age or citizenship. Compliance with locations, such as admitting, emergency
skeptical of unsolicited email messages with
EMTALA is a condition of a hospitals Medicare departments, billing offices and other
links and/or attachments. Be extra cautious
provider agreement. Additional information outpatient settings. Information about financial
of messages requesting immediate action.
about EMTALA may be found in Sutter Health assistance is also provided on the Sutter Health
Validate whether the message is legitimate by
Risk Services EMTALA Snake Bite Kit website and on patient bills.
calling the sender or by sending a separate
publication or in your hospital policies.
email directly to the individual.

Patients with Disabilities: Caring for Patients with print, audio recordings, or computer disks
Our Commitment to Equal Access Communication Challenges pictographs. Contact information can be found
Communication is an important part of patient in your Affiliates policy entitled Patients/
Sutter Health partners with patients by assuring
care. If our patients cannot understand us Visitors with Disabilities: Communication
patients with disabilities can come into our
due to language barriers or hearing or visual Assistance. This website lists contracted
facilities, get services and participate during care.
issues, it could negatively impact the patient language assistance vendors.
Specific steps facilitating full access to care may
require scheduling physically accessible spaces experience and health outcomes. Resources: http://mysutter/Resources/
or equipment, communicating in ways that allow Therefore, Sutter Health provides, at no cost CulturalCompetence/Pages/default.aspx
effective participation by patients with hearing to the patient, language assistance to Limited
or vision loss or changing ways of positioning on English Proficient (LEP) patients and effective
equipment during care. Sutter Health is proud to communication tools for persons with hearing
be a leader in disability access in the health care or visual impairments.
industry. All patient care entities have a set of
policies that guide you in how to care for patients Interpreting services are available through
with disabilities. bilingual staff members who have
demonstrated competency as an interpreter,
Q. Who can I ask if I have questions about or through telephone or in-person interpreter
patients with disabilities? vendors.
Family members should not be used as
A. Each care facility has an ADA Coordinator interpreters except in an emergency, or when
trained to help you understand your the patient refuses the offer of an interpreter
responsibilities to patients with disabilities. and insists the family member provide this
You may also consult the set of policies service. In this case, refusal of the interpreter
with the captioned Patients/Visitors with should be documented in the patient record.
Disabilities. Additional resources may be Minors should NEVER be used as interpreters.
found on the Disability Access Compliance
page on the MySutter site. Effective communication tools for persons
with visual, hearing, speech or cognitive issues
may include the use of an assistive listening
system, a qualified American Sign Language
interpreter, a qualified oral interpreter,
computer-assisted real time transcription,
or alternative formats such as Braille, large

Q. I was taking care of a non-English speaking Q. I have concerns about one of the surgeons concerned that a patient is really going to
female patient who was being treated for at my hospital. His patients never do as get hurt. What should I do?
issues related to her reproductive system. I well after surgery as patients who have the
had to ask many personal questions related same surgery performed by other doctors. I A. Ensuring patient safety is a cornerstone of
to her sexual history. Her 15-year old son know I am not a doctor, but I am concerned our mission. Be certain that your supervisor
was serving as an interpreter for her, and I about the quality of care that this surgeon understands your concerns. Complete and
felt very uncomfortable asking such personal gives his patients. Is there anything I can do submit an Incident Report (also known as
information about his mother in front of about this? a QAR or Unusual Occurrence Report).
him. Could I have insisted she use a hospital Contact your Risk Manager immediately
provided interpreter? A. Yes. Each time there is an unfavorable if you believe that patient safety may be
patient outcome complete an Incident in immediate jeopardy or if a patient is
A. Minors should never be utilized as Report (example: Quality Assessment actually injured as a result of defective
interpreters due to the sensitive nature Report (QAR) or Unusual Occurrence equipment or supplies.
of many health issues and patient Report). Use the report to describe
confidentiality. Every Sutter Health Affiliate problems experienced by your surgical
has language assistance services for patients patients. The information will be provided
with limited English speaking ability. If a to Medical Staff leadership, and peer review
patient insists on using a family member as will be conducted, if warranted. Without
an interpreter, it should be documented in your reports, it is difficult for the hospital to
the patient record and the patient should be recognize and correct problems. You should
advised that the family member must be 18 also consult with your Risk Manager.
years of age or older.
Q. I am a unit clerk in an acute care hospital.
Communicating Patient Care I know that the side rails on one of the
Concerns to Joint Commission patient beds on the unit where I work
sometimes fail to lock in the up position.
Any hospital employee who has concerns about
Just today, I heard that a patient fell out
the safety or quality of care provided in the
of bed because the rail was down. My
hospital may report these concerns to the Joint
supervisor knows about this incident, and
Commission. Sutter Health hospitals should
he said, because of the high census, we do
take no disciplinary action against an employee
not have enough beds to go around right
who reports safety or quality of care concerns
now, and this bed must remain in use. I am
to the Joint Commission.

WORKPLACE CONDUCT AND
EMPLOYMENT PRACTICES

Workplace Conduct and Employment Practices
All employees deserve to be treated with respect, confidential message line at 1-800-500-1950 to Sexual Orientation
dignity and fairness. Sutter Health strives to report the concern. Registered Domestic Partner Status
create and maintain a work environment in
which employees are treated with respect, where Sex
Q. I have worked at Sutter Health for about a
diversity is valued, and where opportunities are year. Yesterday, my supervisor terminated Gender
provided for development. my employment on the grounds that I was Gender Identity or Expression
If an employee of any Sutter Health Affiliate not performing at the level he expected
Ancestry
perceives that inappropriate or unfair conduct of me. My last review stated that I was
is occurring in the workplace, the employee mostly meeting expectations, and I have not National Origin (including possession
is encouraged to discuss this with his or her received any disciplinary actions, just a few of a drivers license issued to individuals
supervisor, his or her chain of command, coaching sessions. Can he do that? who did not present proof of authorized
Human Resources, his or her Compliance presence in the U.S.)
Officer or use the confidential message line at A. Maybe. Introductory periods, conditions Age
1-800-500-1950 to resolve the issue. of employment, disciplinary policies
Medical Condition
and grievance procedures vary among
Q. I have reason to believe a co-worker may be Sutter Affiliates. If you disagree with the Physical or Mental Disability
falsifying his timecard. He always comes in termination, contact Human Resources Military or Protected Veteran Status
late but documents that he is on time. I am to find out what the grievance or appeal
certain our supervisor knows about it, but Political Affiliation
process is for your Affiliate.
he has not done anything. I do not think it Pregnancy or Preceived Pregnancy
is fair that my co-worker is allowed to get
Prohibition Against Discrimination, Childbirth
away with this. What can I do?
Harassment and Retaliation Breast feeding or Related Medical
Discrimination, harassment and retaliation Condition
A. Timecards are legal documents that
should accurately reflect the hours worked. are examples of inappropriate conduct that Genetic Information
You should inform your supervisor if undermine our work environment. Sutter
or any other characteristic made unlawful
you believe any employee is improperly Health does not tolerate discrimination or
by local, state or federal law, ordinance or
recording his/her work hours. If you do harassment on the basis of
regulation. Sutter Health also prohibits
not believe your supervisor is handling the Race retaliation against anyone who, in good faith,
matter in the best interest of the Affiliate, objects to or reports perceived discrimination
you have an obligation to report your Color
or harassment, participates in an investigation
concern by notifying your department Creed of discrimination, harassment or retaliation,
director, Human Resources or the Religion or engages in other legally protected activity.
Compliance Officer. You can also use the Employees who are found to have engaged
M
arital Status
in discrimination, harassment, or retaliation,

regardless of their level in the organization, U
nwanted sexual advances Confidential Employee Information
are subject to discipline up to and including O
ffering employment benefits in exchange All employees are required to abide by the
termination of employment. for sexual favors Workforce Confidentiality and Privacy
Employees who feel that they are subjected to M
aking or threatening reprisals after a Policy, Use of Internet, E-Mail and Instant
or have witnessed discrimination, harassment negative response to sexual advances Messaging Policy, and other Privacy
or retaliation of any nature must report the and Information Security policies and
V
isual conduct: leering, making sexual Procedures. Employees will be asked to
conduct. Employees are encouraged, when
gestures, displaying of suggestive objects or sign a Workforce Confidentiality
appropriate, to firmly and promptly notify
pictures, cartoon or posters Agreement annually and acknowledge the
the offender that his or her behavior is
inappropriate and unwelcome. It may at times Verbal conduct: making or using derogatory Privacy and Information Security policies.
be difficult to initiate such a communication comments, epithets, slurs, and jokes
and employees should use their judgment and V
erbal sexual advances or propositions
discretion in deciding whether to confront the
offender. Additionally, employees must report V
erbal abuse of a sexual nature, graphic
the incident immediately to their supervisor, verbal commentaries about an individuals
somebody in their chain of command, Human body, sexually degrading words used
Resources, or the Sutter Health Confidential to describe an individual, suggestive or
Message Line at 1-800-500-1950. obscene letters, notes or invitations
P
hysical conduct: touching, assault,
Q. My new boss is overly friendly. He likes to impeding or blocking movements
shake my hand every shift and I feel like he
Even if your new bosss conduct is not sexual
lingers in that handshake. It makes me very
harassment, if it makes you uncomfortable, you
uncomfortable. Is this sexual harassment?
should find a way to communicate this, either
How can I get him to stop?
directly to your supervisor, somebody in their
chain of command, Human Resources, or the
A. Sexual harassment is any unwanted sexual Sutter Health Confidential Message Line at
advances, or visual, verbal or physical 1-800-500-1950.
conduct of a sexual nature. This definition
includes many forms of offensive behavior
and includes gender-based harassment of a
person of the same sex as the harasser. The
following is a partial list of conduct that
may be considered sexual harassment:

FINANCIAL INTEGRITY

Financial Integrity
Employee Use of Charitable Assets Q. It has come to my attention that a co-worker A. In addition to general criminal laws
All Sutter Health employees are expected to in the accounting department regularly prohibiting the taking of other peoples
be good stewards of Sutter Healths charitable stays after work and comes in on weekends property, we have an additional reason to
assets. Specifically, they are expected to maintain to do billing and bookkeeping for his wifes guard against the personal use of Sutter
and properly care for Sutter Healths and any janitorial business. This has been going on Health property. Sutter Health and many of
Affiliates charitable assets for the benefit of for a long time and it doesnt seem right its Affiliates are not-for-profit corporations.
those communities that Sutter Health serves. to me. Am I being overly reactive to As not-for-profits, assets are held in trust
this practice? for the benefit of the communities Sutter
Sutter Health and its not-for-profit Affiliates Health and its not-for-profit Affiliates
hold charitable assets in trust for the benefit A. No. Personal use of your Sutter Healths serve. Assets include items like pens,
of the communities they serve. Sutter Health computer, software, copier, paper and flashlights, batteries, copy paper and
charitable assets, including monies, must not printer by your co-worker on a long-term, other office supplies. If we take business
be used for improper or illegal activities and continuous basis is prohibited. You should property home for personal use, we are not
should be used with care solely for authorized report this conduct to your supervisor, only stealing from the hospital or medical
purposes. Personal use of Sutter Health Human Resources or Compliance Officer. or philanthropic foundation, but we are
property is generally prohibited, including, stealing from our neighbors who are the
but not limited to, the use of Sutter Health individuals who make up the communities
resources or facilities to support an employees Q. I know for a fact that one of my co-workers
we serve. In this case, you should report
own outside business activities or those of takes home a lot of pens, flashlights,
the misuse of property to your supervisor,
another organization. This applies to physical batteries, copy paper and other office
the Human Resources Department, or
assets such as office equipment, computers, supplies. Ive told him I think this is wrong
your Compliance Officer. You may request
software and supplies, including medical and that he should stop doing it, but he just
that the investigation be done in such a
supplies, as well as other types of property laughs at me, saying the hospital is rich and
way to protect your identity. For example,
such as business records, patient information can afford the losses. Im the only one who
the investigation could focus on property
and customer lists. Employees having access knows about it, so if I report it, he will know
controls throughout the department rather
to e-mail and the Internet should follow all I told on him.
than focusing specifically on the conduct of
policies relating to its proper usage. Sutter your co-worker.
Health property should not be removed from
Sutter Health facilities unless it is necessary
to do so to perform your job and you must
return the property to its proper location
as soon as it is no longer needed off-site for
business purposes.

Political Contributions Anti-Trust Laws
Sutter Health may not use company monies Sutter Health values require that we compete
to contribute to a political party, committee, fairly and be in compliance with all antitrust
organization or candidate in connection with laws. In order to succeed in todays health
a federal, state or local campaign. You may, of care marketplace, each of us must be
course, make personal contributions of your committed to competing vigorously on behalf
own funds to the campaigns of candidates of of Sutter Health. But Sutter Health draws
your own choice. Such contributions are not a line between competing vigorously and
reimbursable by Sutter Health. competing unfairly and we must never cross
that line.
Q. I heard that Sutter Health gives large
contributions for political activities that are It is unlawful to agree, or attempt to agree,
sponsored through organizations such as the with competitors to share price information,
California Healthcare Association and the fix prices, divide geographic markets by
American Hospital Association. Is this true? agreeing to limit services or otherwise
make any agreement that raises, or is
likely to raise, the price of our services or
A. While Sutter Health does not make
improperly reduce, or is likely to reduce
contributions to candidates for political
competition. Particular care should be taken
offices, it often does make contributions
in pursuing joint ventures or alliances with
to organizations that advocate issues that
other health care providers. Seek advice
relate to the delivery of health care.
from your supervisor or manager before
taking any action that may compromise fair
competition or compliance with antitrust
laws. A supervisor or manager who is
contacted regarding antitrust matters should
immediately contact hospital administration
who will contact the appropriate individual at
Sutter Health.

PATIENT BILLING
PRACTICES

Patient Billing Practices
Accuracy of Records A. You have an obligation to report potential documents should be retained for periods
Sutter Health policies outline the legal billing errors or suspected misconduct. prescribed by law and by Sutter Health and
requirements for preparing and maintaining Generally, you should discuss these Affiliate record retention policies.
accurate patient and business records, concerns with your supervisor first, but if
Sutter Health Affiliates have policies relating
including their retention and confidential no action is taken, you should discuss this
to the timely completion of medical record
destruction. with your Revenue Cycle Liaison or with
documentation by physicians to support
your Compliance Officer.
Medical records may be amended in order billing. Affiliates should ensure all physicians
to complete the documentation or to correct are aware of policies on completing and
Q. My supervisor asked me to alter some nurse authenticating medical records.
an error.
staffing records prior to a Joint Commission
Correction of an electronic medical record Survey. He told me it was important for Q. I am working on a claim and noticed that
should be done in a way that records the our department to get a good grade on the the physician did not include a diagnosis
initial entry, the change, the date of the change survey. I want our department to look good, with his order for several tests. Can I use a
and the person making the change. Medical but I do not think this is the right thing to diagnosis from an earlier encounter or the
record information may not be deleted or do. What should I do? patients problem list as the reason for
inappropriately corrected. Changes in the these tests?
medical record made more than 30 days from A. Altering any type of documentation is not
the date of service should not be used for permitted. You have an obligation to report A. No. Only a physician (or non-physician
reimbursement purposes. suspected misconduct. Generally, you practitioner) can state the reason for the
Affiliate financial and billing records shall discuss these concerns with your supervisor test or procedure. However there are
not contain false or misleading information. first, but if no action is taken, you should times when it is permissible to review the
Financial transactions will be recorded discuss this with another supervisor or encounter from where the order generated
in accordance with Generally Accepted with your Compliance Officer. to clarify or obtain a diagnosis. Please
Accounting Principles (GAAP) and Sutter check with your Compliance Officer for
Health policies and standards. additional guidelines.
Coding and Billing Practices:
Accurately Bill for Services Rendered
Q. I noticed what looks like duplicate charges
to Our Patients
for the same services posted to the patients
account. My manager says not to worry Correct coding and billing is essential to any
about it as the problem belongs to someone compliance program. Each Sutter Health
else. What should I do? Affiliate should submit accurate claims that are
supported by documentation in the medical
record. Services must be accurately and
completely coded to ensure proper billing.
Medical record documentation should support
all services billed. Medical record and billing
Q. As a coder, I sometimes see lab values in the Coding practices should conform to Official would conflict with coding guidelines. Any
medical record that indicate the patient has Coding Guidelines, the American Hospital time you feel pressured to change codes,
gram-negative pneumonia, yet the physician Association Coding Clinic, and the American discuss this with your supervisor or follow
has not documented this specific type of Medical Association CPT Assistant. Accurate your chain of command.
pneumonia in the chart. If I code gram- billing is largely based upon correct coding.
negative pneumonia (instead of unspecified Billing procedures must comply with the Q. I am working on an outpatient radiology
pneumonia), the insurance company might requirements of state and federal laws and claim for a Medicare patient who received a
reimburse at a higher rate. Should I code regulations. Employees who enter charges chest X-ray. When I looked at the diagnosis
this diagnosis? should be trained on how to select charges on the claim, I discovered that the only
that accurately reflect the services provided. diagnosis was written as routine chest
A. No, Diagnosis codes must be fully Billing and coding professionals should not X-ray. I realized Medicare does not pay for
supported by physician documentation change codes, sequencing of codes, or the routine tests. Can I select a diagnosis from
in the medical record. Lab results by description of codes on the bill itself for the patients problem list so Medicare will
themselves do not support a diagnosis; the reimbursement purposes unless the medical pay for the x-ray?
physician must state the type of pneumonia record documentation supports the change.
in the chart for you to code it. Follow A. No. There needs to be medical justification
Q: A patient is admitted with pneumonia
your departments coding guidelines for for this test based upon a physicians order.
and my principal diagnosis selection
physician query. You should never pick a diagnosis from
is pneumonia based on physician
documentation. The data abstractor the problem list to get a claim paid. You
Coding and Billing has asked me to resequence the codes so may look at the encounter from which the
pneumonia will not be principal. Should I order originated to see if a diagnosis can
Coding and billing policies and procedures
change the codes? be re-linked or re-assigned prior to the
must be written, approved by management
test performed. You can also query the
and approved by Ethics & Compliance
physician about the reason for the test. The
Services. These documents must also be A. No. Coding professionals should select the
next question may be, Can this test be
routinely reviewed, updated and maintained principal diagnosis based on the specific
billed to the beneficiary? The answer is: it
in PolicyStat. These policies and procedures guidelines for the conditions documented
depends. If you accepted the beneficiarys
should be made available to all employees by the attending physician and/or
Medicare card and did not provide the
involved with the coding, billing or auditing of physicians involved the care of the
patient an Advance Beneficiary Notice
medical records or accounts receivable. patient. A coder should never feel pressured
(ABN), you are not permitted to charge the
to change a code or resequence a code if it
patient for the x-ray.

Q. I transmitted a claim to Medicare. The A. No. You can only bill based on documentation receive a percentage of the money recovered
claim was edited out for an incorrect CPT-4 in the medical record or transcribed report. as a reward and the False Claims Act protects
code. How should I proceed? The biller should refer the claim to a trained individuals who report concerns in good faith.
coder who can review the documentation
A. There are many reasons why a code may be to determine if another diagonosis code is California FCA: Medi-Cal Fraud
edited out. You should review the patients appropriate or query the physician. California was the first state to enact a state
medical record and coding guidelines to False Claims Act similar to the federal law
ensure that the CPT initially submitted is Reporting Improper Coding/Billing with whistleblower provisions, but with greater
correct. If the initial CPT code is incorrect, financial incentives to whistleblowers. The state
If you suspect that improper coding and billing
resubmit the claim with the corrected can file California false claims cases against
are occurring, you should discuss the issue
CPT code. If the initial CPT was correct, providers who are alleged to have defrauded
with your immediate supervisor and give your
you will need to follow the instructions of Medi-Cal (Californias Medicaid program).
supervisor a chance to solve the problem. If
the edit. This may include writing off the California also has specific criminal statutes
you are not comfortable discussing the issue
charge or appending a modifier if required for knowingly making or causing to be made a
with your supervisor, you should continue
and supported by documentation. If you false or fraudulent claim for payment to non-
up the chain of command in reporting your
have any questions, notify your supervisor governmental insurers recovered as a reward
concern. If you are not comfortable doing this,
who will review the CPT code, and take and the False Claims Act protects individuals
go to another resource where you work, such as
appropriate steps to determine the cause of who report concerns in good faith.
the Compliance Officer, Risk Manager,
the edit. It is not appropriate to change the
Human Resources representative, or call the For additional resources see Guidelines on
code until the cause of the edit is identified.
Sutter Health Confidential Message Line at Non-Retaliation/Non-Retribution Policy and
1-800-500-1950. the Deficit Reduction Act Policy.
Q. I am working on a claim and know that if
I submit this claim with the procedure that
False Claims Act (FCA)
was performed and the diagnosis that was
provided, the claim will be denied. However, The False Claims Act is a federal law that
I do know of a payable diagnosis, somewhat prohibits submission of false claims to
similar to the one on the claim form. May I government and payers (e.g., Medicare). A
substitute the payable diagnosis for the one false claim is an attempt to obtain payment by
already on the claim form? presenting false or misleading information.
Criminal penalties for submitting false claims
include imprisonment and criminal fines.
The government may decide to pursue civil
remedies and collect up to three times the
amount lost, plus penalties ranging from $5,500
to $11,000 for each false claim. Whistleblowers
who alert the government to false claims may

FINANCIAL RELATIONSHIPS WITH
PHYSICIANS AND OTHER PROVIDERS

Financial Relationships with Physicians and Other Providers
The Anti-kickback Laws programs; potential Civil Monetary Penalties compensation for goods or services
Physicians and health care providers (and the up to $50,000 per violation; as well as potential support services, such as services that
individuals who work for them) cannot pay False Claims Act liability with monetary support a physicians private medical
or accept any remuneration (which you can penalties that could include three times practice
generally think of as money, gifts or other amount of the kickback.
gifts (such as wine or flowers)
benefits) if it is intended to influence patient
referrals and recommendations. Physician Financial Relationships: meals and entertainment (such as tickets to
Stark Law Essentials a culture or sporting event)
The laws are intended to protect patients from
the potential harms that could result from a The Stark law prohibits a physician from information technology items or services
referral or recommendation that is based on referring patients for certain services payable
health care services (sometimes known as
economic motives, rather than whats best by Medicare if that physician has a financial
professional courtesy)
for the patient. The laws are also intended to relationship with the referral recipient (such as
a hospital, medical foundation or home health office space, equipment or supplies
protect government programs (like Medicare)
from getting billed for more services than company) unless a specific legal exception recruitment support
necessarycosts that we as taxpayers will bear. applies. The Stark Law also prohibits the entity
marketing or promotional support
that gets the patient referral from submitting
No payment or benefit should ever be claims to Medicare for services resulting continuing medical education (CME)
requested or accepted from someone who from an illegitimate referral. A financial services such as laboratory or imaging
sells us services or supplies, or from post- relationship can be either an ownership or services to be purchased by physicians,
discharge providers such as SNFs, home health compensation arrangement, and includes group practices or Independent Physician
companies, DME companies and pharmacies, almost any type of remuneration in cash Association (IPAs)
because it could be potentially linked to or in kind, direct or indirect. Thus, any time
referrals or recommendations. Similarly no anything of value is passed to a physician from Note that these are examples only. This is not a
payments or benefits should be made, given a hospital or medical foundation to which that complete list.
or offered to physicians for their referrals. For physician refers services, the Stark Law may be
physician financial relationships, see also the implicated.
Stark Law section, below.
It is critical to consult the Office of the General
Potential Consequences of Noncompliance Counsel (OGC) before offering, providing, or
entering into an arrangement to provide, any of
Possible consequences of a violation under
the following to a physician or physician group:
the Anti-Kickback law include a fine of up to
$25,000 per violation; imprisonment up to
five years; exclusion from federal health care

Q: How do we comply with the Stark Law? the physician has nothing to do with For additional resources see:
Medicare patients.
The OGCs website: http://mysutter/Resources/
A: Review applicable Sutter Health policies. Potential Consequences of Noncompliance: SystemDepartments/GeneralCounsel/Pages/
Work with the OGC Legal Services Contract Possible consequences include denial of or default.aspx
Service Team for new and renewing physician repayment of claims; and additional monetary
agreements and for amending and/or penalties of thousands of dollars per service; Q. There is an independent physician on our
extending any existing physician agreements. potential exclusion from participation in medical staff who practices in a building
For compliance questions about existing federal health care programs; potential that is connected to the hospital. Recently,
agreements, and questions about providing overpayment liability; potential for False my supervisor asked me to assist this
gifts or other items to physicians, contact your Claims Act liability. physician with scheduling his patients
Compliance Officer. For physician offices for office visits. My supervisor also told
leases or space use arrangements, contact this physician that he can help himself to
California Anti-Kickback and Anti-
Sutter Health Facility and Property Services. excess supplies that the hospital is not
Referral Law
using. Are these activities okay?
Some arrangements with physicians may be There are also state anti-kickback and anti-
okay, but only if a number of conditions or referral laws that are similar to the Federal
Anti-Kickback Statute and the Stark law. Again, A. No. The Stark Law prohibits giving items
requirements are met. Sutter Health has policies
it is important to consult with the OGC Legal and services to a physician without charge,
and procedures that apply to:
Services or your Compliance Officer before and this conduct potentially conflicts with
Physician Office Leases entering into any financial relationship with a other laws.
Physician Administrative Services Contracts physician or before providing anything of value
(such as medical director agreements, to a physician. Q. An independent cardiologist on our medical
medical staff leadership agreements, staff sometimes uses an office in the hospital
physician champion agreements, speaking Payments to Physicians to Reduce or to see his private patients. Is this okay?
services agreements, etc.) Limit Care
Physician Recruitment Agreements Federal law prohibits hospitals from knowingly A. Maybe. The cardiologists use of space
making a payment directly or indirectly to a would create a financial relationship that
Physician Call Coverage Agreements implicates Stark. If the space use is pursuant
physician as an inducement to reduce or limit
Gifts and Incidental Benefits (Non- medically necessary items or services furnished to a written lease and otherwise meets
Monetary Compensation) to Medicare and Medi-Cal patients who are the requirements of the rental of office
under the physicians direct care. In addition, space exception to the Stark Law, it may be
There is no requirement of bad intent under
a physician cannot knowingly accept such a appropriate. However, physicians offices are
the Stark law: Good or bad intent does not
payment. Any proposed incentive arrangement usually located in medical office buildings,
matter; if there is a financial relationship with
with a physician must be reviewed by the OGC so if there is a concern about a space use
a referring physician, the relationship must
and, if it is appropriate, would need to be set arrangement, talk to your supervisor or
satisfy an exception even if the arrangement
forth in a written agreement. Compliance Officer.
with
Q. An independent psychiatrist on our medical Hawaii would be considered remuneration). Q: We have an inpatient who is ready for
staff came to Grand Rounds at the hospital As such, the arrangement would trigger discharge, but she doesnt have enough
yesterday and gave a lecture. Wed like to the Stark Law and would need to meet a money to pay for taxi fare to get home from
now pay her for her time. Is this okay? Stark exception. While the Non-Monetary the hospital and she has no one to drive
Compensation exception would permit you her. She also mentioned that her heat was
A. Maybe. The provision of compensation to a to give a gift to a physician, there is a cap on turned off by the utility company when she
physician who serves as a referral source to the the value of the aggregate gift(s) you can give. couldnt pay her bill. Can we help?
hospital would create a financial relationship A trip to Hawaii would exceed that cap.
that implicates Stark. The compensation A: In most cases we can provide some
relationship would have to meet all of the Patient Inducement assistance to patients to facilitate a safe
requirements of a Stark exception. Sutter discharge, after there has been a good faith
Federal law strictly limits the circumstances in
Health policy requires that you contact the determination of financial need. While the
which a gift, waiver of fees or other benefit can
OGC before administrative services are patient cannot be given cash, we can pay
be given to a Medicare or Medicaid (Medi-Cal)
rendered by a physician if you do want to the vendor such as the taxi company or
patient. In addition, cash payments cannot be
compensate the physician for the services. utility company. There are limitations on
given to patients. The laws stem from a concern
the amount and types of assistance that can
that a patient could select a provider based on
Q. The medical director of our emergency be provided. Consult your supervisor before
the reward given or promised by the provider,
department is retiring from this leadership providing assistance.
and a concern that unnecessary services will be
position after several years of service at our billed to government programs.
hospital. As a retirement gift, wed like to Q: I think certain lab services are a good source
give him and his wife a trip to Hawaii. Is The laws permit some assistance to be provided of revenue. Could we offer a financial
that okay? to financial needy patients, but the assistance reward to patients who choose us over our
must be unadvertised, and is usually limited to competitors for laboratory services?
those who are existing patients. Sutter Health
A. No. Even though you are not paying
has Charity Care policies that address free
compensation to the physician, you would A: No, in general, gifts or benefits cannot be
and discounted health care to patients with a
be giving him something of value (the trip to provided to patients as part of a marketing
financial need, and we also have guidelines that
campaign. Some very low value items (such
describe when other forms of non-healthcare
as a refrigerator magnet) can be provided
assistance may be given to patients. Consult
to patients as part of a health promotion
your Compliance Officer, Discharge Planning
effort or to encourage patients to obtain
Lead or Finance Leadership before giving
preventive care services. There are often
assistance or anything else to a patient.
dollar limits on what can be provided,
so consult your supervisor before giving
anything to patients.

TAX-EXEMPT STATUS

Tax-Exempt Status
Sutter Health and most Affiliates operate as 2. P

urchasing supplies, equipment or influence include, but are not limited to,
tax-exempt charities under both California and services from a vendor where the vendors current and former:
federal law. A charitable organization must be relationship with management resulted in
Officers
operated primarily to conduct its stated exempt a price that was known to exceed the fair
purpose, as it serves a public rather than a market value. Key Employees (defined as managing 10%
private interest. As charitable organizations, of the organizations assets or expenses)
3. C
harging rental space that is below fair
any money that we make must primarily market value to physicians or businesses. Board, Directors or Trustees
be used to advance our charitable mission.
Generally, Sutter Healths monies are used Physicians, in certain instances (e.g., when
Sanctions of Private Benefit acting as Director, as medical staff leader,
for patient care, but we also fund a variety of
Providing a significant inappropriate or a physician who exerts substantial
purposes, including charity care, maintaining
private benefit may result in a tax-exempt influence in performing administrative
and upgrading facilities, and developing
organization losing its exempt status. services)
new programs to make a difference in the
Less significant violations of the private
communities we serve. Substantial contributors
benefit rules may result in an intermediate
sanction, such as fines and penalties, on the In addition, family members of, or businesses
Prohibition of Private Benefit owned by, the above referenced persons are
organization and individuals receiving and
Our organization needs to be aware of any approving the transaction. The private benefit also considered to have substantial influence.
transaction, arrangement, practice, or policy will need to be paid back to the organization,
that may potentially or actually provide a applicable contracts/policies/agreements
private benefit that unjustly enriches any modified to prevent any further excess
individual, entity, or business. We need to benefit, and organization managers may be
enter into contracts and arrangements that personally liable for penalties and held jointly
are based on commercially reasonable terms and severally liable.
that bear a proper relationship to our exempt
purpose. Some examples of arrangements that If the private benefit is received by an
would violate the prohibition against private individual that can exert substantial influence
benefit include: over the exempt organization, the individual is
personally subject to an increased penalty on
1. P
ayments to physicians for services if the the excess benefit plus an additional penalty
payments exceed the fair market value of if the excess benefit is not repaid in a timely
the services. manner. Typically persons with substantial

GOVERNMENT
INVESTIGATIONS/AUDITS

Government Investigations/Audits
Responding to Government 2. N
otify your supervisor and Compliance If a Sutter Health employee receives a subpoena
Investigations/Audits Officer. or other written request for information (such
If a law enforcement agency arrives at your 3. Y
our Compliance Officer will notify as a Civil Investigative Demand) regarding
facility what a search warrant or to do an Administration if appropriate. Sutter Health, the employee should immediately
investigation you should first, notify the most contact an Administrator. The Administrator
Posters which identify the many government will contact OGCs Legal Services and the
senior-level individual at your location. They
agencies are in every mailroom of every Affiliate. Compliance Officer before responding.
will contact your affiliates Compliance Officer.
These posters contain the name and phone
The Compliance Officer may contact the Office
number of each Affiliates Compliance Officer. Q. I understand that Noridian (our Medicare
of the General Counsel or other individuals,
as necessary. Next, ask to see the lead law Administrative Contractor MAC) is
In some cases, government investigators, or
enforcement officers credentials and request a requesting patient records for review. If I
persons presenting themselves as government
business card or contact information. If theres receive a letter/request, what should I do?
investigators, may contact employees outside
a search warrant, request a copy of it to provide of the workplace, during non-work hours, or
to your Compliance Officer. Request that, as a at home. While you have the right to speak to A. Noridian has been given authority by the
courtesy, the officers delay initiating their search such a person, do not feel pressured to do so. Centers for Medicare and Medicaid Services
in order for counsel to be contacted. You may first want to contact Administration, (CMS) to audit Medicare patient records for
OGCs Legal Services, or your Compliance services provided, documented, and billed
Law enforcement officers presenting a valid to Medicare. When a request for records is
Officer. Employees have the right to not talk to
warrant have a legal right to search the premises received, as a result of a Noridian review,
the person and the right to have an attorney or
and to seize what is designated in the warrant as follow your Affiliate policy, or notify your
a representative of the Affiliate present if they
evidence. Always be courteous. Do not obstruct Affiliate Compliance Officer. These requests
do choose to speak.
the search and do not volunteer information are time sensitive, and documents must be
that is not necessary. The search warrant entitles Sutter Health employees must never: submitted to Noridian within the specified
officers to search for physical evidence, but you time period.
D
estroy, alter or amend any Affiliate
are under no legal obligation to be interrogated
document or record in anticipation of a
or interviewed. If you choose to be interviewed,
request for the document or record by a Q. Can the government auditors look at my
you must first contact Sutter Health legal
government agency or court computer files for information relevant to
counsel.
L
ie or make false or misleading statements an audit?
Many government audits begin with a letter
to any government investigator
or fax, rather than an in-person visit by an
A
ttempt to persuade any other Affiliate A. In some circumstances, government
auditor. If your department receives a letter
employee, or any other person, to auditors are entitled to review your hard
from state or federal agency requesting
provide false or misleading information drive. However, before you give anyone
information for an audit, follow these steps:
to a government investigator or to fail to access to your computer, alert your Affiliate
1. D
ate stamp the letter with the date cooperate with a government investigation Administration, OGCs Legal Services and
received. or audit the Compliance Officer.

Obstruction of a Federal Audit Individual Culpability
Federal law prohibits anyone from intentionally The health care industry is regulated by many
deceiving or defrauding the United States. laws. It is important that we follow these
laws to protect our patients and to maintain
The law prohibits anyone from attempting
good business practices. Following these laws
to influence, obstruct or impede a federal
also protects us individually. Government
auditor in the performance of his official duties.
enforcement agencies investigate and
Routine government audits, as well as any other
prosecute companies and individuals for
government investigation, are subject to this law.
legal misconduct. In 2015 the Department of
Anyone in violation of this law is subject to Justice emphasized its focus on investigating
fines and imprisonment of up to five years. individuals in corporate wrongdoing and
holding these individuals accountable for their
Exclusion Checks actions.
Federal and State Government agencies

maintain lists of individuals who are generally
ineligible to work for organizations which
receive government payments, such as Sutter
Health. If you become aware of someone at
Sutter Health who is on one of these lists,
contact your Compliance Officer immediately.
This includes employees, temporary agency
workers, travelers, independent contractors,
students, volunteers, physicians or job
candidates for any of these roles regardless of
the reason why the individual is on a list.

HEALTH, SAFETY AND
ENVIRONMENTAL CONCERNS

Health, Safety and Environmental Concerns
Sutter Health and its Affiliates require Q. I work in the Shipping and Receiving
compliance with all applicable workplace health, Department. Many of the boxes we receive
safety and environmental laws, regulations and are heavy, and we are constantly moving
standards. We constantly strive to find sound them. The other day, I felt a sharp pain
and innovative methods to reduce the impact of in my back. It went away, so I did not say
our activities on the environment. anything about it. I am now wondering if I
should have reported it.
Sutter Health employees are responsible
for maintaining a safe environment by
participating in training and drills, prompt A. Yes. Every employee has a responsibility to
reporting of identified hazards, utilizing safe report any workplace injury to his or her
work practices and adhering to all safety supervisor. Every Sutter Health Affiliate has
policies and procedures. If you have a question a policy regarding employee work-related
regarding unsafe work practices in your work injuries that explains what is required when
area promptly contact your supervisor, Safety accidents or injuries occur. Even though an
Officer or Risk Manager. employee may not feel pain immediately,
pain and other complications may develop
Q. I am a new employee in the Environmental later. Reporting the incident will facilitate
Services Department. A co-worker is prompt medical care and a review of work
training me on how to properly clean patient practices to avoid future injuries.
rooms and public areas. Yesterday, we found
a syringe in one of the public bathrooms. My
co-worker picked it up and threw it in the
regular garbage, saying that this happens all
the time. I think it is unsafe to be picking up
these used syringes, but I am afraid that if I
say anything about this, I will be considered
a troublemaker. What should I do?
A. Every employee is responsible for safety

in the workplace. If you do not feel
comfortable discussing this concern with
the employee, you should go to your
supervisor, Safety Officer, Risk Manager or
Compliance Officer. Reporting this incident
will ensure corrective action is taken.

RESEARCH AND
RESEARCH OVERSIGHT
36 | Sutter Health Confidential Message Line 1-800-500-1950 Clinical Research

Research and Research Oversight
Research related to health care has been Informed consent is the hallmark of human of information. The HIPAA privacy rule also
performed at Sutter Health for many decades. subjects protection. Both a document and covers the protected health information (PHI)
From prestigious National Institutes of a process, informed consent is intended to of all patients who are enrolled in clinical trials.
Health projects to data coordination of assure that potential participants understand In some situations, the IRB/Privacy Board
research conducted internationally to classic study procedures, potential risks and benefits, must approve researchers use of PHI.
drug treatment trials and innovative clinical any treatments that provide an alternative to
care analysis, researchers and research participation, any costs or compensation of Research Oversight
administrators must meet numerous federal participation, and other information crucial Sutter Health Policy requires that all
and state laws and regulations as well as to an informed determination of whether or researchers who make use of Sutter Health
systemwide institutional policies. These rules not to participate. Before consent is given, the resources e.g. labs, images, clinics, hospitals,
are intended to protect the rights and well investigator or a research staff member reviews providers, staff, and data must collaborate
being of patients who enroll in clinical trials the content of the consent form, answers with the designated research institute to ensure
as research subjects, to assure fair treatment of questions, and monitors the consent interview that all rules and other requirements are met.
government and private payers; and to uphold for sufficient evidence that a potential No research may be initiated without the
the privacy and integrity of data. participant is equipped to provide informed approval of the research institute; some studies
consent and understands that withdrawal will also require the approval of the centralized
Human Subjects Protection from participation is always an option. If the administration office. Any employee who
Research involving human participants is participants native language is not English, believes that research is being conducted or is
subject to Institutional Review Board (IRB) translation assistance is available. planning to be conducted without institutional
regulations. The IRB acts as proxy to the Food A copy of the signed informed consent oversight is required by policy to inform the
and Drug Administration (FDA) in matters document is provided to the participant and researcher of the requirement and to report the
pertaining to drug, device, and biologics the original is retained by the investigator for research to the designated research institute.
research, but also oversees any other research the requisite number of years required by the Research oversight is intended to facilitate
that poses more than minimal risk to its human FDA or the study sponsor. If a studys design and assure the meeting of all applicable
subjects. The Sutter Health IRB approves or other regulated information changes, an requirements while minimizing unnecessary
new studies, reviews continuing studies, updated consent form and a new informed delay of study initiation. It also serves to
and provides IRB exemptions as applicable. consent process are required. standardize research practices and to support
Multiple committees whose members include researchers in satisfying their many compliance
physicians, scientists, and community advocates Privacy requirements.
meet monthly to ensure that clinical trials are
The Food and Drug Administrations human Examples of federal, state, or institutional rules
ethical and that the rights and safety of study
subject protection regulations, which apply that govern research include:
participants are protected. The IRB office
to federally funded and privately funded
collaborates with researchers, operational Human subjects protection (see above)
research, include protections to help ensure
leaders, and privacy, legal, and compliance
the privacy of subjects and the confidentiality FDA regulations and other requirements,
officers to support the research enterprise.
stipulating protocol standards and the

reporting of findings, deviations, and A. The study that you mention is subject Q. I am a nurse who assists medical staff in
serious adverse events, and other to federal, state, and institutional conducting device research. We plan to bill
study details requirements. You should call a research all routine care related to the study to the
Financial conflict of interest, limiting institute that is assigned to your area patients who consent to be in the study. Is
actual or perceived conflicts that might (Bay or Valley) and provide any materials this allowed?
unduly influence research outcomes that the academic institute gave to you,
as required by Sutter Health policy. The A. Yes, under certain circumstances, billing
Federal grants management requirements, research institute will review the materials, research-related services to patients and
specifying appropriate use of funding and determine compliance requirements, and their insurers is allowed. However, extreme
reporting of that use contact the applicable officers, which would caution must be used to ensure that
Research integrity and scientific include the Research Privacy Officer and patients are not billed for services that are
misconduct, prohibiting falsification or the Research Attorney and may include not medically necessary, are prohibited
fabrication of data and plagiarism the Research Compliance Officer and the by Medicare, or have been promised by
Institutional Review Board manager. The the study sponsor or the consent form. To
Research billing compliance, requiring
patients whose PHI is being collected prevent misbilling, Sutter Health policy
insurance coverage analysis, adherence to
are not providing consent and no waiver requires healthcare coverage analysis and
Medicare rules, determination of clinical
of Health Information Portability and the use of special research billing functions.
services that must be billed to the study
Accountability Act authorization appears In addition, studies of devices assigned an
sponsor, and research-related modification
to be involved. These privacy issues Investigational Device Exemption by the
of claims to federal payers
must be addressed. In addition, written FDA are subject to additional requirements.
The Animal Welfare Act, protecting agreements are generally required whenever Please contact a research institute that is
animals that are involved in research sharing Sutter Health data to an external assigned to your area (Bay or Valley). All
projects party to ensure that recipients of data are research projects must be overseen by the
accountable for proper data governance, centralized research administration office
Q. I am a physician who has been approached
including but not limited to safeguarding and the designated research institute.
by an academic institute to collaborate in
the information, limiting uses, and agreeing
a research study. If I agree, I would ask my
not to attempt to re-identify the data. The
patients certain questions and record the
institute will also make sure that the Sutter
answers in the electronic medical record.
Health research site(s) to be involved have
Every month or so, a research staff member
provided permission for study activities to
would come to the clinic and would review
occur at their location.
the data. He or she records certain data
on a spreadsheet but would not record
any information that would identify the
patients. What should I do?

Notes
1. A
dditional information about the Sutter Health Ethics and
Compliance Program and Health Insurance Portability and
Accountability Act (HIPAA) Security and Privacy resources
can be found at http://mysutter/Resources/ SystemDepartments/
GeneralCounsel/EthicsCompliance/Pages/default.aspx.
2. Th
e Compliance Program does not affect the employment at will
status of employees or replace the provisions of any collective
bargaining agreement. The Program does not create any contractual
obligation between Sutter Health or any Affiliate and any employee.
3. S utter Healths Ethics and Compliance Program does not replace
policies governing employee grievance procedures, employee
benefits or other Sutter Health or Affiliate employment and Human
Resource policies.
4. Th
e term supervisor is used throughout the Standards to include
any person who directly supervises an employee, whether that
persons actual title is supervisor, manager, director, vice president,
senior vice president, executive vice president or other officer of
Sutter Health or Affiliates.
5. A
ll references to Sutter Health or Sutter in the Standards for Business
Conduct refer to Sutter Health and its Affiliates.
6. W
herever the terms Sutter Health employees, employees, we, or
us are used in the Standards, such terms refer to all members of the
workforce at Sutter Health and at each Sutter Health Affiliate.

Acknowledgement of
Standards for Business Conduct Handbook
9th Edition

My signature on this form or my acknowledgement online acknowledges NAME (PLEASE PRINT)
that I have received and agree to read the Sutter Health Standards for
Business Conduct handbook.

I agree to comply fully with the standards contained in this book. I
SIGNATURE
understand that compliance with these standards, policies and procedures
is a condition of my continued employment or association with Sutter

Health. I also understand that Sutter Health reserves the right to
DATE
occasionally amend, modify and update the Standards for Business

Conduct handbook and principles contained in the handbook.
I acknowledge that I have a duty and ethical obligation to report
any concerns about possible improper conduct to a supervisor or a DEPARTMENT
compliance officer or to the Confidential Message Line so that my
concerns can be investigated and resolved.
I also acknowledge that the handbook is only a statement of principles for
individual and business conduct and does not, in any way, constitute an
employment contract or an assurance of continued employment.
Ethics Compliance Services

2200 River Plaza Drive
Sacramento, CA 95833

Ethics & Compliance Services
2200 River Plaza Drive
Sacramento, CA 95833
www.sutterhealth.org
15-SHSO-0003529

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Standards for Business Conduct

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Teamwork and Trust

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Sutter Health and most Affiliates operate as 2. P

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Federal and State Government agencies

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A. Every employee is responsible for safety

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Ethics Compliance Services

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A. Every employee is responsible for safety