TRINIT Y HEALTH
Code of Conduct
OUR MISSION
We, Trinity Health, serve together
in the spirit of the Gospel
as a compassionate and
transforming healing presence
within our communities.
OUR CORE VALUES
Reverence
Commitment to Those
Experiencing Poverty
Safety
Justice
Stewardship
Integrity
TABLE OF CONTENTS
A Message from Mike Slubowski............................................................................... 1
Introduction..................................................................................................................... 2
Code Of Conduct: Supporting Right Relationships.............................................. 4
Relationships with Those We Serve.......................................................................... 4
Relationships with Coworkers and Others That Serve with Us........................ 9
Relationships with Suppliers and Other Business Partners............................. 12
Relationships with Regulators and Those Who Pay for Our Services............ 16
Where to Find Help....................................................................................................... 21
Resources to Assist You............................................................................................. 21
OUR VISION
As a mission-driven innovative
health organization, we will
become the national leader
in improving the health of our
communities and each person
we serve. We will be the most
trusted health partner for life.
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Introduction
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Supporting Right Relationships
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Those We Serve
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Coworkers & Others
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Suppliers & Business Partners
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Regulators & Payers
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Resources
Dear Trinity Health Colleagues and Service Provider:
Our Mission calls us to serve together in the spirit of the Gospel
as a compassionate and transforming healing presence in our
communities. Guided by our Core Values, we create trusting
relationships with colleagues, patients, physicians, service partners
and our communities as we care for the whole person – body,
mind, and spirit.
Our health care ministry began over 160 years ago through the
dedication of our founding religious congregations. We have a long,
rich history of providing excellent service and compassionate care.
Those we serve place enormous trust in us. To earn and keep this
trust we need to make every effort to avoid even the appearance
of illegal or unethical conduct.
Trinity Health has an Integrity and Compliance Program that guides
us in understanding and following laws, regulations, professional
standards, and ethical commitments. This Code of Conduct is an
important resource to help us meet these obligations.
The Code of Conduct describes expected behaviors and addresses
more common issues and questions you may encounter in your
work. It includes resource information to assist you when you have
questions or need further assistance. The Code also explains your
duty to speak up and report, without fear of retaliation, any matters
you believe may be a violation.
Each of us is personally responsible for living our Trinity Health
Core Values, which require compliance with the law as well as
acting with integrity. We all have an active role in making honesty,
transparency, and ethical behavior a part of our culture.
Thank you for your dedication and commitment to this very
important effort.
Michael A. Slubowski
President and CEO
Trinity Health
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Introduction
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Supporting Right Relationships
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Those We Serve
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Coworkers & Others
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Suppliers & Business Partners
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Regulators & Payers
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Resources
Introduction
Responsibilities of All Who Serve in Trinity Health
1
This Code of Conduct outlines responsibilities expected at Trinity Health.
It provides guidance on behavior expectations. By following the Code
of Conduct, we can contribute to achieving Trinity Health’s Mission.
The Code of Conduct applies to all:
• Trinity Health organizations
• Colleagues
• Volunteers
• Medical staff members
We all have an important role in supporting our Code of Conduct. We must:
• Behave in an ethical manner.
• Review and follow the Code of Conduct.
• Ask questions and seek guidance when needed. See Resources to Assist You on Page 21
for a listing of resources available.
• Speak up and report concerns about actions or behaviors that may conict with the Code of
Conduct. See Resources to Assist You on Page 21 for more information.
• Participate in periodic training programs to further your Code of Conduct understanding, and
how it applies to your Trinity Health role.
Nothing in this Code of Conduct or the policies that support the Code is intended to prevent any
of us from engaging in or declining to engage in lawful conduct protected by the National Labor
Relations Board.
Leader Responsibilities
Trinity Health leaders must set the example and serve as a role model for our
Code of Conduct. Leaders also serve an important role when receiving and
responding to questions and concerns. They are expected to respond with proper
urgency and transparency. Leaders should reach out for guidance and assistance
when needed. See Resources to Assist You on Page 21 for more information.
Leaders in Trinity Health must:
• Serve as a role model supporting our Mission and Core Values.
• Conduct their work with high ethical standards.
• Promote a culture of trust, open communication, and respect.
• Lead their teams in knowing and applying the Code of Conduct.
• Encourage questions and issues and concern reporting.
• Respond timely and appropriately when matters are brought to their attention.
• Comply with Trinity Health’s non-retaliation policies.
1 Throughout this document, references to Trinity Health refer to the System Ofce and all ministries and subsidiaries.
• Suppliers
• Independent contractors
• Consultants
• Other service providers
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Those We Serve
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Regulators & Payers
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Resources
Code of Conduct Violations
Our Mission and Values are extremely important to Trinity Health. Following
this Code of Conduct supports us in making good decisions every day.
The Code of Conduct standards are mandatory and must be followed. We are expected to use
common sense and good judgment when completing Trinity Health work activities. And we are
responsible for our behaviors and actions.
Non-compliance with this Code or other Trinity Health policies will be investigated. Colleagues
and Service Providers who violate the Code may be subject to disciplinary measures, including
warnings, suspension or possible termination of employment, hospital privileges and business
relationships. The discipline action taken will depend on the violation’s nature, seriousness,
and frequency.
The following are examples of behaviors and conduct that can result
in disciplinary actions:
• Knowingly authorizing or participating in a violation of law and regulations.
• Refusing to provide information or failing to report violations.
• Intentionally falsifying business record documentation.
• Retaliating against individuals who report issues and concerns in good faith.
• Deliberately ling false or frivolous reports of violations.
• Actions that are discriminatory or rise to the level of harassment.
• Reckless actions or behaviors that threaten the privacy and security of personal health
and other condential business information.
• Leaders who fail to appropriately understand and monitor processes in their area of
responsibility to assure compliance with law, regulation, policy, or the Code of Conduct.
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Supporting Right Relationships
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Those We Serve
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Coworkers & Others
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Suppliers & Business Partners
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Regulators & Payers
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Resources
Code Of Conduct: Supporting Right Relationships
Maintaining relationships is essential to fullling Trinity Health’s Mission.
Virtually everything we do in Trinity Health is dependent on a relationship with:
• Patients, residents, family members and our communities;
• Co-workers and others who serve with us;
• Suppliers and other service providers;
• Government regulators; and
• Government payers, commercial insurers and others that pay for the services we deliver.
Our Core Value of Reverence calls us to honor the sacredness and dignity of every person.
Successful, long-term relationships are built on trust. Acting with integrity, being honest, and
following all laws and regulations are behaviors and actions that build and maintain trust. Our
Core Value of Integrity- we are faithful to who we say we are - provides clear guidance for
how we carry out Trinity Health’s Mission.
Relationships with Those We Serve
Trinity Health strives to be a transforming healing presence in our communities. Our
Core Value of Reverence reminds us to honor the sacredness and dignity of every person.
Patients, residents, their family members and loved ones, and others who entrust their
care to us are our priority. We are all expected to:
• Deliver people-centered, quality services with compassion, dignity, and respect.
• Commit to safety for every person, every time.
• Speak up when there is a quality or safety issue and participate in our TogetherSafe program.
• Support health equity and deliver services consistent with Trinity Health’s Non-Discrimination
Policy.
• Maintain a positive and courteous customer service orientation.
• Conduct our work with the highest levels of ethical and professional conduct.
• Do not engage in romantic or sexual interactions with patients during the patient’s treatment.
Such interactions detract from the goals of the clinical relationship and may exploit the
vulnerability of the patient, compromise your ability to make objective judgments about the
patient’s health care, and ultimately be detrimental to the patient’s well-being.
• Speak professionally.
• Respond to requests for information or assistance in a timely and supportive manner.
• Provide comfort for our patients and residents, including prompt response to their needs.
• Discuss available treatment options openly with patients, residents, or their families and
involve them in care decisions.
• Create and maintain complete, timely and accurate medical records.Protect the privacy and
condentiality of all personal health information.
• Clearly explain the outcome of any treatment or procedure to patients, residents, or their
designees, especially when outcomes differ signicantly from expected results.
• Respect patient or resident advance directives.
• Address ethical conicts that may arise in patient or resident care, including end-of-life issues.
• Provide care that is consistent with the Ethical and Religious Directives for Catholic Health
Care Services.
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Regulators & Payers
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Resources
Quality of Care and Patient Safety
Safety is an important Trinity Health value. We are committed to providing
compassionate, high-quality care that is safe, effective and efcient. We do
everything we can to make sure the care we provide is safe. And we design
the systems we use with safety rst in mind.
Trinity Health is committed to a Just Culture by creating and sustaining a culture
of safety. Trinity Health supports an open, fair and just culture by:
• proactively managing risks and behavior choices.
• designing safe systems.
• responding to adverse events in a fair and consistent manner.
• through open discussion, learning about risks and safety expectations.
We are all expected to report safety issues, incidents and “near misses” so they can be
addressed timely through changes to systems and processes without fear or blame. Concerns
about the safety or quality of care can be reported internally or directly to The Joint Commission.
See Resources to Assist You on Page 21. Trinity Health does not take disciplinary or punitive
action against anyone making a safety or quality of care report in good faith. This includes
reports made to The Joint Commission.
Medically Necessary and Appropriate Care
No matter what our role or where we work at Trinity Health, all of us serve our
patients and families. It’s our common purpose. We treat all patients and others
in our care with respect and dignity. We provide care that is both necessary and
appropriate. We assist patients and others in making informed care decisions
and we respect and honor those choices.
We are committed to keeping patients and families at the center of all we do. We also support
the health and wellness of our communities through education, outreach and programs.
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Resources
Protecting Personal Health Information (PHI)
We collect personal health information (PHI) from patients, residents, members
and others in our care. This information might include current and past medical
conditions, medications, and family histories. We are strongly committed to
maintaining the condentiality of personal and protected health information.
PHI is collected in many ways - paper and electronic records, lms and digital
images, and even in verbal discussions. All PHI should be protected and treated
condentially. This supports our Core Value of Reverence and compliance with
federal and state data protection laws.
Be sure you:
• Access, review and use PHI only as necessary to perform your job.
• Safeguard PHI (electronic or paper) and do not leave it unattended or available to others.
• Be aware and do not discuss PHI in public areas e.g., cafeterias, restrooms, or elevators.
• Store PHI only on Trinity Health approved laptops or tablets.
• Only release PHI to others or remove PHI from your facility when you have authorization from
your immediate leader.
• Never discuss or post PHI on any social media site such as Facebook or Twitter whether using
those sites at work or at home.
• Immediately notify your leader or the Privacy Center of Expertise if you believe PHI has been
lost, stolen or accessed inappropriately.
Trinity Health has implemented specic policies and procedures to protect PHI privacy and
security. Consult your organization’s policies and procedures for more information.
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Gifts From or To Patients and Residents
We do not request personal gifts from patients, residents, or their family
members. The receipt of such gifts is subject to Trinity Health policy. Occasional
perishable gifts, like a fruit basket, given to a department may be accepted.
Patients who want to express their appreciation with a gift of money (including
but not limited to gift cards) should be referred to your organization’s fundraising
department. Only foundation or fundraising department colleagues can solicit
gifts from patients and their families.
Trinity Health can give free or discounted items or services to patients or residents only
in limited situations. Any gifts or other items of value provided to Medicare or Medicaid
beneciaries may not exceed $15 per item with $75 per year maximum. Always discuss
with your leader or consult your organization’s policies before giving any gifts to a Medicare
or Medicaid patient or resident.
In some cases, Trinity Health may provide patients with items and services that support
preventive care or advance a patient’s clinical goal. For example, items that support a treatment
or medication plan or for chronic disease management may be allowed. Programs to provide
these types of patient items must be approved by Trinity Health senior management with
compliance and legal advice from Trinity Health’s Integrity and Compliance Ofce and
Legal Counsel.
Emergency Medical Treatment and Active Labor Act (EMTALA)
Trinity Health hospitals with a dedicated emergency department follow
the Emergency Medical Treatment and Active Labor Act. EMTALA requires
medical screening exams and stabilization care for individuals who come to
the emergency department.
This care must be provided before asking questions about the person’s ability to pay for
services. Trinity Health is committed to providing emergency medical care when we have the
capacity and capability. We follow EMTALA. We do not delay medical screening or necessary
stabilizing treatment when a patient is in an emergency or in labor. We do not admit, discharge,
or transfer patients with emergency medical conditions simply based on their ability to pay or
any other discriminatory factor.
Ethical and Religious Directives (ERDs) for Catholic Health Care Services
The ERDs provide ofcial church guidance and teachings on issues central to
Trinity Health as a Catholic health care ministry. Colleagues, medical staff and
others working in Trinity Health are required to follow the ERDs. Consult your
organization’s Mission Leader if you have questions regarding how the ERDs
apply to your work.
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Coworkers & Others
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Suppliers & Business Partners
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Regulators & Payers
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Resources
Questions & Answers
Q What should I do if I see that a patient is not being treated with proper respect and courtesy?
A All colleagues are expected to provide care to patients with compassion, dignity, and respect.
First, act right away if the patient is at risk of harm. Then discuss what you saw with your
direct leader. If your leader can’t or doesn’t help, contact a higher-level manager in your unit.
You can also contact one of the resources listed on on Page 21.
Q What should I do if I know that a medical error has occurred? Should I tell the resident
or the resident’s family?
A First, report the medical error using your organization’s safety event reporting system (see
Page 21). Trinity Health supports timely and compassionate disclosure of medical errors.
This discussion should include thoughtful communication and coordination with all caregivers.
Follow your organization’s safety event reporting processes so the resident and family
communication is handled properly.
Q A patient told me he doesn’t want to receive aggressive treatment. He wants to be made
comfortable and be allowed to die. My patient doesn’t think we are listening to him. What
should I do?
A People-centered care is listening to the patient and considering their wants - even if the
decision conicts with your own values. You should advise the clinical team of the patient’s
wishes. The clinical team can work with the patient and their family on the best ways to
honor his wishes, for example, providing palliative care services. Patients and residents
should be presented with appropriate options so they can make informed decisions. Please
contact your organization’s Mission Leader or ethics committee with questions or concerns.
Q I work in a hospital and have access to the patient registration system. Recently my friend
was seen in the emergency room and later admitted to the hospital. I’m concerned and
would like to check the patient registration system to see how she’s doing or at least locate
which room she’s in so I can visit her. Is that okay?
A Since you are not involved in your friend’s care, you do not have a business reason to access
her medical information or location. You may only access this type of information when you
need it to do your job. Trinity Health has monitoring systems in place to review colleague
system access privileges use. Improper use of access privileges is a violation and could
include discipline steps up to termination. It is important to respect our patients’ privacy.
Our patients have the right not to share their health status with others. It is not appropriate
to call or visit patients if you become aware of their admission only through your job role in
your ministry.
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Regulators & Payers
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Resources
Q My doctor uses a patient portal where I can look up information, like lab results, in my
medical records. Why can’t I access my own health information directly through the
electronic health record where I work?
A All patients are encouraged to use the patient portal to review their medical information and
partner with clinicians involved in their care. Colleagues and others given access to Trinity
Health’s electronic medical record systems are restricted and should only access information
needed to do their job. Accessing your own medical records in Trinity Health information
systems is a policy violation. The Privacy Center of Expertise monitors access and use of
medical records systems. Improper use of access privileges is a violation and could include
discipline steps.
Q I am a nurse and one of the patients on my oor has asked that her same-sex life partner
be included in her discharge planning meeting. This meeting is typically only attended by
family members. How should I respond?
A Since the patient has asked that her partner be recognized as a member of her family for
discharge planning purposes, you should invite the patient’s partner to attend. We support
patients, residents, their family members and loved ones in receiving compassionate care
that respects their dignity, diversity and specic wishes, when possible.
Relationships with Coworkers and Others That Serve with Us
The delivery of high-quality, safe and compassionate care requires effective
teamwork. Studies note a positive relationship between the workplace environment
and the quality and safety of care delivered. Trust and respect are important
behaviors to support effective work environments. We are all expected to:
• Treat others with honesty and dignity.
• Maintain a positive and courteous customer service orientation.
• Speak professionally to colleagues and others.
• Take actions to support cooperation and trust.
• Respond to requests for information or assistance timely.
• Communicate with others clearly, openly, and honestly.
• Provide and accept appropriate feedback.
• If possible, attempt to address differences you may have with colleagues directly.
• Respect the diversity of others and follow Trinity Health’s Non Discrimination Policy.
• Respect personal boundaries, refrain from inappropriate physical contact and report any
workplace harassment, intimidation, or violence of any kind.
• Promptly report any serious workplace injury or any situation that could present a potential
health and safety hazard.
• Protect the condentiality of colleague health information, social security numbers, medical
information, and banking information.
• Perform your duties and responsibilities free from the inuence of drugs or alcohol.
• Protect the condentiality of all medical peer review information.
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Harassment and Workplace Violence
Trinity Health does not tolerate behaviors that undermine a culture of safety. Colleagues can
expect to work in an environment free of harassment and disruptive behavior. Behavior that
is not tolerated, includes but is not limited to the following:
• unwelcomed comments, remarks, gestures, or physical contact.
• offensive, degrading or humiliating jokes, slurs, or comments (explicit or suggestive).
• the display or circulation (including email or the internet) of offensive, derogatory or sexually
explicit pictures or other materials.
• verbal or physical abuse or threats.
Workplace violence is any act or threat of physical violence, intimidation, or other disruptive
behavior that impacts work related activities. It may be intentional or unintentional. It may
affect and involve colleagues, patients, residents, physicians, contractors, suppliers, and visitors.
Colleagues who see or experience harassment or workplace violence should immediately report
the incident. See Resources to Assist You on Page 21.
Workplace Safety
Trinity Health is committed to a safe work environment. Each Trinity Health organization has
developed policies to protect workplace health and safety. These policies comply with applicable
government regulations. You should be familiar with and understand how these policies apply to
your specic job duties. Seek advice if you have a question or concern. See Resources to Assist
You on Page 21.
Inclusion and Belonging
Demographics in our nation are rapidly changing. With the growing evidence that a diverse
workforce improves healthcare outcomes and helps to reduce health disparities, there is an
urgent need to address persistent barriers such as systemic racism, biases, and stereotypes.
Built on the foundation of Trinity Health's Mission and Core Values, we seek to integrate
diversity, equity, and inclusion in all that we do. We all have different lived experiences,
customs, abilities, and talents. Together, we can become our best selves by embracing all
dimensions of diversity and providing accessible, inclusive, and equitable care for those we
serve. Trinity Health is committed to providing an inclusive work environment where everyone
is treated with fairness, dignity and respect. Trinity Health is an equal opportunity employer
and prohibits discrimination against any individual with regard to race, color, religion, sex,
sexual orientation, and gender identity, pregnancy (including childbirth, lactation and related
medical conditions), national origin, ancestry, age, physical or mental disability, genetic
information (including testing and characteristics), veteran status, uniformed service member
status, or any other status protected by applicable local, state and federal laws and regulations.
Consistent with applicable law, Trinity Health will provide a reasonable accommodation for the
known physical or mental limitations of an otherwise qualied individual with a disability who
is an applicant or an Employee, unless undue hardship or a direct threat to the health or safety
of the individual or others would result. Consistent with applicable law, Trinity Health will also
provide a reasonable accommodation for an individual’s sincerely held religious beliefs,
observances, and practices unless doing so would pose an undue hardship.
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Regulators & Payers
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Resources
Questions & Answers
Q I overheard a colleague making jokes about people of certain ethnic backgrounds. It made
me feel uncomfortable. What should I do?
A All of us must respect others. Colleagues cannot make jokes based on ethnic or
discriminatory characteristics. Even if no harm was intended this behavior can contribute to
an uncomfortable environment and possibly harassment. You should discuss this matter
with your leader or contact your organization’s Human Resources department. You can also
contact the Ofce of Diversity, Equity, and Inclusion.
Q My leader told me I must start work an hour earlier on scheduled workdays because we
need coverage in the department. Can she do that? I’ve worked the same schedule of
hours for ve years.
A Yes. Your leader can change your work schedule to meet the department’s operating needs.
If you are unable to comply with your new work schedule, discuss the matter with your
leader or Human Resources.
Q A male colleague has been very “friendly” with several female coworkers in my department.
There’s a lot of hugging and touching, even when other people are in the room. I don’t think
this is right even if the female coworkers involved don’t seem to mind. What should I do?
A You should discuss the situation with your leader. If you are comfortable, you could also
discuss your feelings directly with the male colleague. He may not be aware that his
behavior makes you or others feel uneasy. If you remain concerned, contact a higher-level
manager or leader, Human Resources, or the Integrity and Compliance Line. This situation
will be handled the same if it is a female colleague that initiates touching with male
colleagues or if both parties are of the same gender.
Q One of my coworkers returned from a break and appears to be under the inuence of
alcohol or drugs. How should I respond?
A First, if you work in a clinical area, act immediately if patients or residents are at risk of harm.
Then notify your leader, a higher-level manager or Human Resources immediately and report
the situation. There may be a medical condition causing your colleague’s behavior rather than
alcohol or drugs, but your leader or a higher-level manager will need to evaluate the situation.
Q I saw a physician yell at a colleague in front of a patient. I was very bothered by the
physician’s behavior and feel terrible for the colleague. Is there anything I can do?
A Trinity Health is committed to a safe and welcoming work environment. Behavior that is
rude, embarrassing, threatening, or intimidating, including the use of profane or abusive
language, is not acceptable. You should discuss the matter with your leader, a higher-level
manager, or medical staff ofce. You could also contact Human Resources or the Integrity
and Compliance Line.
Controlled Substances
Many Trinity Health colleagues have access to prescription drugs, controlled substances and
other medical supplies as part of their work duties. These substances may be governed by laws
that strictly limit their use to minimize potential risks to both patients and health care workers.
Unauthorized access, use, or diversion (e.g., theft) of controlled substances is prohibited.
Immediately report to your leader or a higher-level manager any potential issues or concerns
you have about controlled substances security or diversion.
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Q I have a problem with one of my colleagues. She and I share assignments in my department,
but I feel like I carry most of the workload and she slacks off. I really don’t want to work with
her anymore. What should I do?
A When you have a conict with a colleague, it is best to rst discuss it privately with the
person. Explain what you have observed and how it affects your work. You can also share
your concerns with your leader. You should also discuss the issue with your leader if you
believe the colleague’s behavior may violate our Code of Conduct.
Q I work in the Human Resources department. Lately I’ve been nding condential colleague
information, including payroll data and other personal information, left behind in the copy
room. What should I do?
A Protecting the privacy and security of colleague information is very important. Take the
documents you’ve found to your leader or a higher-level manager in your department so
they can determine the best way to follow-up.
Relationships with Suppliers and Other Business Partners
Trinity Health conducts business ethically and compliantly. All colleagues and
service providers must maintain appropriate business relationships. Accepting
gifts or entertainment from a business contact, such as a supplier, could cloud
judgment when making business decisions. It might also give the impression
that the vendor is buying favorable treatment.
Health care is a highly regulated industry. Giving and receiving gifts, meals, entertainment and
travel may create a real or perceived conict of interest. In some cases, those expenses could
also be viewed as a kickback in violation of the law. You must obtain any required approval
before accepting gifts, meals, entertainment or travel from a supplier, service partner, or
industry stakeholder.
Our Core Value of Stewardship requires us to be faithful stewards of the human, nancial, and
natural resources entrusted to us. Ultimately Trinity Health bears the cost of supplier provided
gifts, entertainment, and meals. The following guidelines apply to everyone (check with your
leader as your department may follow more restrictive policies).
• Do not accept gifts, entertainment, meals, or other incentives that inuence a purchasing
or contracting decision, or could appear to improperly inuence Trinity Health decisions.
• Do not accept gifts, entertainment, meals, or other incentives that encourage or reward
patient referrals.
• Do not offer, accept, or solicit gifts, meals, entertainment, or other incentives that could
be perceived as a bribe, payoff, deal or any other attempt to gain a competitive advantage.
• Do not accept cash or items redeemable for cash such as checks, gift cards, etc.
• Occasional non-cash items of nominal value (e.g., pens, note pads, coffee mugs) may
be accepted, but are generally discouraged. Additionally, occasional consumable and
perishable goods (e.g., fruit basket, owers, cookie trays) shared with co-workers in
a department or unit may be accepted but are generally discouraged.
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• You should politely decline supplier and other service partner entertainment or social
invitations. This includes activities like free or discounted tickets to sporting, theater or concert
events, golf outings, travel, and lodging, etc. You may attend an entertainment or social event
with a supplier or other service partner so long as you, not the supplier, pay your own cost
to attend. Any exceptions require the advance approval of your leader and your organization’s
Integrity and Compliance Ofcer.
• Suppliers and other service providers may occasionally donate to charitable fundraising events
that benet Trinity Health and afliated organizations. These events may include social or
entertainment activities (e.g., golf or dinner) where Trinity Health colleagues are invited to
participate. You can accept these invitations provided you have the advance approval of your
leader. Trinity Health colleagues are encouraged (but not required) to make a personal donation
to the fundraiser equal to the value of an individual attendee to the event.
• You may accept invitations to attend local or out-of-town programs, workshops, seminars, and
conferences sponsored by a supplier or other business partner. These must have a legitimate
educational purpose or otherwise support a Trinity Health business objective (e.g., product
training). Acceptance of the invitation must also:
(1) Be infrequent (e.g., no more than once annually);
(2) With your leader’s advance approval; and
(3) Where Trinity Health, not the supplier, pays for any related travel expenses. Any exceptions
to this policy require your leader’s advance approval and review by your organization’s
Integrity and Compliance Ofcer.
Trinity Health discourages colleagues from accepting meals and refreshments paid by suppliers
or other service providers. An occasional meal or refreshment may be accepted when these
requirements are met:
• Such events are infrequent (generally 1-2 times per year).
• The meal is immediately before or after a legitimate business meeting.
• The setting for the meal is proper for discussing business (e.g., ofce or restaurant) and the
host attends.
• The cost of the meal is modest (generally this means it does not exceed $50).
• Trinity Health does not incur additional travel or overnight lodging costs because of your
participation in the meal.
The above requirements do not apply to meals and refreshments provided in connection with a
conference or other educational program sponsored by a supplier, consultant or service partner
for the benet of all attendees.
All gifts accepted that are greater than $25 in value must be disclosed during the annual Conicts
of Interest Disclosure Survey process. Contact your Integrity and Compliance Ofcer for more
information.
Fundraising
As a tax-exempt charitable organization, Trinity Health may solicit charitable contributions
to support our health care ministry. Only colleagues who work in foundations or specic
fundraising departments are permitted to solicit gifts from suppliers and other service providers.
Fundraising requests to suppliers are not to be made in exchange for promises of Trinity Health
business or to inuence current or future business decisions.
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Conicts of Interest
Conicts of interest may arise. We seek to ensure these conicts do not have impacts on
business decisions or operations. You are expected to avoid situations that could place you
in conict with Trinity Health interests. A conict of interest may exist when your outside
activities, personal nancial interests or relationships interfere, or could appear to interfere,
with your judgment or decision-making. In addition to gifts, entertainment and meals, be
aware of these potential conicts of interest:
• Outside Employment: You should discuss and obtain your leader’s approval before accepting
an offer to work for any organization that conducts business or competes with Trinity Health.
• Endorsements and Testimonials: Obtain your marketing department and leader’s advance
approval before making any endorsements or testimonials for suppliers, vendors, trade or
professional organizations.
• Financial Interests: Generally it is a conict of interest for Trinity Health to do business with
a company in which you or a family member has a nancial interest. It might also be a conict
for you to recommend a company in which you or a family member has a nancial interest.
Financial interests may include employment, compensation arrangements, and ownership
or investment interests. Discuss with your leader any nancial interests you or a family
member have that might impact your Trinity Health job responsibilities.
• Service on Outside Boards: Trinity Health colleagues are encouraged to actively participate
in charitable and civic organizations that benet our communities. Obtain your leader’s
approval before accepting an invitation to join a board of any organization that may create
a conict of interest with your Trinity Health job duties.
When considering conicts of interest, remember that appearances count! Discuss any
questions you have regarding potential conicts of interest with your leader or contact your
organization’s Integrity and Compliance Ofcer.
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Questions & Answers
Q Suppliers frequently visit our ofce and bring in new products for us to sample. They always
want to provide lunches for the ofce staff. Can we accept free supplier paid lunches?
A In general, Trinity Health discourages acceptance of supplier paid meals. Only accept these
occasionally and when they are connected to a legitimate business purpose like a product
demonstration. Take out food (“dine and dash”) delivered to ofce staff are not allowed.
Additionally, the cost of any supplier paid meals provided must be modest. Also consult
your organization’s local policies which may be more restrictive.
Q The rm my organization uses for marketing and advertising services offered me two suite
tickets to a professional basketball game. Can I accept the tickets?
A You should politely decline the acceptance of gifts that involve social or entertainment
activities such as free or discounted tickets to sporting events. You may accept the tickets
only if you personally pay the supplier for the cost of the tickets.
Q A supplier recently called seeking my input on a new product under development. The
supplier is holding an out-of-town meeting and asked me to attend. The supplier is willing
to pay my airfare, hotel and meals for two days, as well as pay for my time to attend the
meeting. Can I accept the invitation?
A Trinity Health policy prohibits acceptance of supplier-paid compensation, travel, lodging,
and meal expenses. If your role includes making recommendations or decisions about
the supplier’s products, your acceptance of this offer could improperly inuence your
future decision-making. You and your leader should discuss the meeting’s purpose, the
supplier’s expectations and the benet to Trinity Health. Your leader and organization
Integrity and Compliance Ofcer may approve your participation at the meeting so long
as Trinity Health covers the expenses.
Q Suppliers frequently send gifts of fruit or candies to our department during the holidays.
Can we accept these gifts or must they be returned?
A Although discouraged, you may accept occasional gifts (e.g., no more than 1-2 times a year)
of perishable or consumable gifts that are shared with co-workers.
Q I work full-time, 12-hour shifts and would like to get some extra work hours at another
health care provider in the community. Do I have to discuss with my leader before I accept
another position?
A Before you consider an offer to work for a potential Trinity Health competitor, discuss
the situation with your leader to make sure there are no potential issues. This issue is
especially important for full-time colleagues.
Q I was asked by a professional organization to speak at an upcoming educational event.
The organization has offered to pay my travel expenses and lodging for the day I am
scheduled to speak. May I accept the offer?
A Yes, Trinity Health colleagues may accept travel expenses and lodging in exchange for
professional speaking engagements. The expenses should be reimbursed only for the
day you are asked to speak. For example, if it’s a ve-day educational conference and you
will only be speaking on the rst day, the reimbursed expenses should be for one night’s
lodging and related travel expenses.
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Q My sister-in-law is a health care industry consultant. Is it okay if I recommend her to work
on a consulting project?
A Yes, however you should fully disclose your relationship. You should not participate in the
hiring decision, nor use your position to inuence the hiring decision outcome. Also, you
must not share any information with your sister-in-law that is condential or that has not
been provided to other prospective consultants.
Q I am the point of contact for a Trinity Health supplier. Our organization is conducting a major
capital campaign and the supplier recently asked me what amount they should donate. They
said they want to keep their Trinity Health contract. What should I say?
A You should refer the supplier to your organization’s Foundation or fundraising department
to discuss capital campaign contribution options. You should also advise the supplier that
their decision to donate (and how much to donate) to the capital campaign is not a factor
in current or future contracting decisions.
Relationships with Regulators and Those Who Pay for Our Services
Trinity Health receives payments for patient care and services from federal and
state health care programs like Medicare and Medicaid. Trinity also has contracts
with commercial insurance and other third parties for payment of services.
There are many Medicare and Medicaid laws and regulations that apply to our operations. Our
contracts with insurance companies also include certain requirements we must follow. These
laws and other obligations are complex and can be challenging to apply in a rapidly changing
environment. Trinity Health is committed to complying with all applicable laws and regulations.
We must:
• Always act with honesty and integrity.
• Follow all laws, regulations and policies that apply to our work. Ask for assistance if you have
questions. See Resources to Assist You on Page 21.
• Follow all Medicare, Medicaid, and other federal and state health care programs requirements.
Also follow all commercial insurance companies and other third-party payer requirements.
This includes:
- Delivering high-quality, medically necessary, and appropriate services.
- Creating and maintaining complete and accurate medical records.
- Submitting complete and accurate claims for services provided.
- Protecting the privacy and security of health information we collect.
• Respond to accrediting (or other external agency) surveys with honesty, openness and
accurate information. Do not take actions that obstruct or mislead an accrediting or external
agency survey team.
• Submit accurate and complete reports to federal and state regulatory agencies. This includes
cost, quality, safety, tax and other reports.
• Be mindful of antitrust requirements. Do not discuss or share pricing, market strategies, payer
strategies, or wages and benets information with competitors. Consult with Legal counsel on
any matters that involve antitrust laws.
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• Screen colleagues, board members, vendors, and other parties to conrm they can
participate in federal health care programs. We do not do business with, employ or bill for
services rendered by individuals or entities that are excluded or ineligible to participate in
federal health care programs. You must notify your leader if you become excluded, debarred,
or ineligible to participate in federal or state health care programs.
• Present only truthful and non-deceptive marketing and advertising information.
• Conduct all medical research activities consistent with all laws and regulations, Institutional
Review Board and Trinity Health policies.
• Participate in Trinity Health training and education programs. These assist you in knowing
the laws, regulations, and Trinity Health policies that apply to your work.
• Cooperate with any government investigation. Never destroy or alter documents or
information. This includes electronic documents, records, or messages. Never lie or make
false statements to a government investigator.
• Do not offer gifts or other items of value to a government representative.
• Do not contribute − or direct the contribution of − Trinity Health funds to any political
candidate, political party, or political campaign.
Trinity Health’s Commitment to Compliance with the Law
You should be aware of some key laws and regulations and how they affect Trinity.
Listed below are some key regulatory areas that impact our daily job responsibilities.
Fraud and Abuse
Trinity Health is always looking for ways to improve our fraud, waste and abuse
prevention and detection. Our fraud, waste, and abuse prevention program includes
multiple management controls and oversight across multiple departments. Fraud
and abuse laws generally prohibit:
• direct, indirect or disguised payments in exchange for patient referrals.
• submission of false, fraudulent or misleading claims or bills, including claims for services
not rendered or claims which do not comply with payer requirements.
• making false representations to any person or entity to participate in a program or obtain
payment for any service.
Fraud and abuse laws are designed to protect government health care programs, like Medicare
and Medicaid, and other third parties that pay for the health care services we deliver. To support
compliance, we must:
• submit accurate and truthful claims for services provided.
• submit claims only for services provided.
• provide only medically necessary services.
• not submit claims for services not covered by the payer.
• never make false statements or representations to get claims paid.
• make repayment to a health care program or payer when required.
• not offer or pay money, goods, or anything of value to encourage or reward patient referrals.
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Relationships with Physicians and Other Referral Sources
You may work with physicians or other persons or entities that refer patients
or residents to Trinity Health facilities. You must be aware of the laws and
regulations that apply to these relationships. These laws include the federal
Anti-Kickback Law, Stark Law, laws that apply to tax-exempt organizations, and
similar state laws. The intent of these laws is to ensure medical decisions and
actions are in the patient’s best interest. The goals are to prevent over-utilization
and protect federal health care program funds.
Trinity Health has specic policies and procedures for nancial relationships with physicians
and other referral sources. There are two key principles that apply to all such relationships:
1. We do not pay for referrals. Patient and resident referrals and admissions are based on
an individual’s medical needs and our ability to render the needed services. Trinity Health
does not pay or offer payment to anyone for patient or resident referrals.
2. We do not accept payments for referrals. Trinity Health does not ask or receive anything
of value, directly or indirectly, in exchange for patient or resident referrals to a Trinity Health
facility. We do not take into account the value or volume of referrals made to us when
making referrals to other health care providers.
Physician and other referral source nancial relationship laws are complex. There can be
unintended violations of the law, which could result in signicant legal and nancial
consequences. Always contact Legal counsel or your Integrity and Compliance Ofcer if you
have questions about these laws.
Tax-Exemption
Most Trinity Health organizations are not-for-prot, tax-exempt organizations
operated exclusively for religious or charitable purposes. Activities that support
our charitable purpose include care of those who are poor, benets provided
to our communities, and medical education programs. Trinity Health is required
to follow a number of tax laws and regulations. These laws generally prohibit:
• Using Trinity Health assets to benet individuals who are in a position of substantial inuence.
• Paying more than “fair market value” for goods and services. Also providing goods and
services to others at less than fair market value unless allowed by law.
• Campaigning (including indirect activities) for or against the election of any public ofce
candidate. Trinity Health funds may not be donated to any political candidate, party
organization, or committee.
• Engagement in substantial lobbying activities. Trinity Health may comment on legislation
or regulations under consideration. We may also take public positions on issues relating
to our operations and mission.
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The False Claims Act
The False Claims Act protects the federal government from being overcharged
or sold substandard goods or services. This federal law makes it a crime for any
person or organization to knowingly make a false record or le a false claim to a
federal health care program. “Knowingly” includes having actual knowledge that
a claim or record is false. It also includes acting with “reckless disregard” as to
whether a claim is false. Most states have adopted similar state false claims laws.
False Claims Act penalties are signicant. Financial penalties can be as high as three times the
claims amount plus nes of $11,000 - $22,000 per claim. Willful violations of the False Claims Act
can also result in criminal penalties.
The federal False Claims Act and most similar state laws allow individuals with original informa-
tion about fraudulent activities in government programs to le a lawsuit on behalf of the gov-
ernment. If these individuals are successful with their cases, they can receive a portion of the
government recoveries.
All Trinity Health colleagues, volunteers, physicians, suppliers and service providers are protected
from being red, demoted, threatened or harassed for ling a False Claims Act lawsuit. This is
called non-retaliation.
You are encouraged to contract your organization’s Integrity and Compliance Ofcer or the
Integrity and Compliance Line if you have questions or suspect fraudulent activity.
Questions & Answers
Q My colleague regularly uses the work Internet for personal activities. I am not their leader,
but this seems wrong. What should I do?
A You should discuss this matter with your leader or a higher-level manager. We all must
ensure that resources and assets are used each day to primarily support Trinity Health
activities. These resources include supplies, materials, equipment, and colleague work time.
The occasional personal use of technology resources, like the Internet, is allowed if it doesn’t
interfere with the colleague’s work or violate any Trinity Health policies.
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Q I used to work for a competitor organization. I have information from that organization
that could help Trinity Health in negotiating more favorable supplier contracts. Can I share
this information?
A No. Do not disclose condential information you obtained from another job. We may not use
this information in any business dealings. Further, it would be unethical for you to share any
condential information you may learn from your Trinity Health job with a future employer.
Q A colleague I work with frequently posts updates on Facebook. Sometimes he makes
references to his day at work. He never mentions any patient or long-term care resident
names. He does sometimes discuss unusual cases in detail. Should I be concerned?
A Yes. Just because there is no patient or long-term care resident’s name does not make it
“okay” to discuss on a social media site. Patients or residents can still be identied based
on the uniqueness of the situation. Disclosure of condential information via social media
could put our patients and residents at risk. It might also be a violation of federal privacy
laws. This can result in hefty nes and criminal penalties for both the organization and the
colleague who made the posting. You should discuss this matter with your leader or contact
Trinity Health’s Privacy Center of Expertise for assistance.
Q I recently witnessed some unusual activity occurring at my organization’s loading dock.
Several shipments of expensive computer equipment were picked up by another company
and taken away. I questioned my leader who gave me an explanation, but the more I think
about it, the answer just doesn’t seem to make sense. What should I do?
A You should discuss the issue with a higher-level manager in your department or contact
your Integrity and Compliance Ofcer. The explanation may be correct and there may be
nothing wrong occurring. However, when there is something about an answer you receive
that bothers you, or just doesn’t feel right, it’s best to discuss the issue with another
member of your organization’s management or your Integrity and Compliance Ofcer.
Q I assist my boss in preparing her expense reimbursement reports. She often submits
receipts for meals and entertainment expenses without specifying who attended and
without a description of the meeting’s business purpose. My boss is extremely busy,
and I don’t like to bother her with questions or make it seem like I don’t trust her. What
should I do?
A First, make sure you clearly understand your organization’s specic expense reimbursement
policy documentation requirements. Share these requirements with your boss. Explain you
want to assist her in providing all the required expense reimbursement documentation.
Ultimately, she is responsible for the expense reimbursements submitted on her behalf.
If this approach does not work, you should contact a higher-level manager in your
organization or your organization’s Integrity and Compliance Ofcer for assistance.
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This Code of Conduct addresses common issues and questions. Working in
the health care industry can be challenging. There are complex and frequently
changing rules and regulations. There may be times when the answer to a
particular issue or question is not clearly addressed in the Code. You are
responsible for seeking answers to your questions or concerns. There are
many resources to assist you.
Where to Find Help
Direct Leader This is usually the best place to start in getting answers. Your leader knows the
work you do. They may already have the information you need or can direct you to the right
resource. If your issue or concern involves your direct leader, seek help from one of the other
resources listed below.
A Higher-Level Manager or Leader If you are not comfortable discussing the issue with your
leader or do not agree or are uncomfortable with the answer you receive, discuss the issue with
a higher-level leader in your organization.
Human Resources Your organization’s human resources staff can likely answer many of your
questions and assist you in addressing workplace issues and concerns.
Integrity and Compliance Ofcer Your Integrity and Compliance Ofcer is responsible for the
Integrity and Compliance Program operations in your organization. They are available to assist
you in obtaining answers to your questions and concerns.
Resources to Assist You
Your Organization’s Integrity and Compliance Ofcer
Dawn Geisert
Senior Vice President, Chief Compliance & Integrity Ofcer, Integrity and Audit Services
734-343-3010
dawn.geisert@trinity-health.org
Integrity and Compliance Line - You are encouraged to use one of the resources listed here
to address your questions and concerns. You are always welcome to contact the Trinity
Health Integrity and Compliance Line at 866-477-4661. You may also le a report online at
www.mycompliancereport.com using THO as the access code. You may choose to remain
anonymous. All reports are treated as condential as possible. See further information on
the Integrity and Compliance Line in the information box.
Legal - Contact the legal department when you need legal advice or guidance.
Mission Department and Local Ethics Committee - Guidance on matters relating to Mission
and Core Values, Ethical and Religious Directives for Catholic Health Care Services, pastoral
care, advance directives, end of life issues and patient rights are best addressed with your local
mission department and/or local ethics committees.
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Medical Staff Ofce - If you are a privileged practitioner, you are encouraged to contact your
organization’s medical staff ofce to discuss any issues or concerns.
Privacy and Security Ofcials - Contact the Privacy Center of Expertise if you have questions
or concerns related to the use or protection of personal health information or condential
business information: privacyofcer@trinity-health.org or 833-718-1043.
Risk Management and Safety - If you have questions or concerns related to patient care or
workplace safety or are seeking guidance regarding the disclosure of medical errors or adverse
events, please contact your local risk management and/or safety departments.
Patient and Colleague Safety Event Reporting Systems - We have reporting systems
designed to assist colleagues, medical staff, and others in reporting “near misses’; errors and
other events involving patient care or safety. Reports can be made anonymously. You should
be familiar with your organization’s system to report patient safety events.
This could be the Voice Organization Incidents, Complaints and Events (VOICE) system or the
MIDAS system. All colleague injuries, threats or “near misses” should be reported promptly
to the colleague’s leader and to the workers’ compensation claims coordinator. If it is available
at your organization, use the Trinity Health Employee Incident Report (THEIR) system. If the
THEIR system is not available at your organization, use your organization’s standard workers’
compensation injury reporting process.
Trinity Health values your opinions, insight and feedback. The most efcient way to resolve
concerns is through the internal resources listed on Page 21. If you feel a patient care concern
has not be effectively addressed, there are also external reporting options available including
The Joint Commission Ofce of Quality and Patient Safety: email complaint@jointcommission.
org, Mail One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181. Individual state survey
agencies may also be contacted with concerns.
Obligation to Speak-Up
Trinity Health supports an environment that encourages all of us to seek answers to questions
and to report issues and concerns. We are all expected to report any activity we believe may
violate applicable laws, regulations, professional standards of practice, or this Code of Conduct.
We should use one or more of the resources listed to make the report. If the matter has
previously been reported and you believe it has not been given sufcient attention, you should
report the matter to a higher level leader, your Integrity and Compliance Ofcer or the Integrity
and Compliance Line.
Non-Retaliation Policy
Trinity Health has a “zero tolerance” policy for any form of retaliation against those who report
issues and concerns in good faith. This includes reports about potential violations of our Code
of Conduct. Retaliation includes direct as well as indirect actions, or the threat of actions, of
leaders, co-workers, or others.
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Integrity and Compliance Line
866-477-4661 or www.mycompliancereport.com Access code = THO
The Integrity and Compliance Line is staffed 24 hours a day, seven days a week by an outside
organization. When you call the Integrity and Compliance Line, you will speak with an individual
trained to listen to your questions and concerns. They will gather as much information from you
as possible. If you prefer, you may submit your issue online at the website address listed above.
When prompted for an access ID, please use THO. We do not trace or record reports, and the
Integrity and Compliance Line does not use caller ID.
When submitting a report, you always have the option to remain anonymous. Trinity Health uses
every effort to maintain, within the limits of the law, the condentiality and identity of any indi-
vidual who reports issues and concerns. Your report will be provided to Trinity Health for review
and investigation. When using the phone system to le a report, you will be provided a report
identication number for you to check back on the status and ultimate resolution of your report.
Trinity Health follows its non-retaliation policies and medical staff bylaws. Retaliation is subject
to discipline, including dismissal from employment, suspension of medical staff privileges, or
termination of Trinity Health business relationships. If you believe you are being retaliated against
for making a report or raising a concern, contact your Integrity and Compliance Ofcer or the
Integrity and Compliance Line.
Acknowledgment Process
All Trinity Health colleagues are required to acknowledge their receipt and review of this Code
of Conduct, conrm they understand it represents the mandatory Trinity Health policies and
agree to abide by it. New colleagues are required to do so as a condition of employment. All
Trinity Health colleagues are required to participate in annual Code of Conduct training designed
to reinforce awareness and understanding.
Adherence to and support of our Code of Conduct and participation in related training
activities is considered in decisions regarding hiring, promotion and compensation for all
Trinity Health colleagues.
THSO W07967-2402-MC ©2024 Trinity Health, All Rights Reserved
TRINIT Y HEALTH
Code of Conduct