1 St. Jude Children s Research Hospital Code of Conduct
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Dear Colleague: As a global leader in the research and treatment of pediatric catastrophic diseases, St. Jude Children s Research Hospital has a reputation for defining excellence in all that we do. Our Code of Conduct (Code) outlines the high standards of professional conduct that guide us as we pursue our mission of finding cures and saving children. The Code provides guidance to each of us as we apply its principles to our daily decision-making processes. These standards of integrity apply to all employees, contract staff, vendors, trainees, students, volunteers, Board members and others who conduct work on behalf of the hospital. We encourage you to educate yourself about this Code and to comply with all policies, laws and regulations that affect your St. Jude responsibilities. As you familiarize yourself with the Code, I encourage you to reflect upon the ways you can embody its principles in all that you do. Ultimately, it is the responsibility of each of us as well as our business partners to abide by these high ethical standards. Together, we can continue to strengthen the hospital s worldwide reputation by upholding the standards set forth within this Code. James R. Downing, MD President and Chief Executive Officer
Contents 7 Our Mission Our Code 9 Our Values 13 How We Care For Our Patients 15 How We Conduct Our Research Intellectual Property and Proprietary Information 17 Our Commitment to Ethical Business Practices Appropriate Behavior Background and Exclusion Checks Billing Confidentiality Conflicts of Interest and Commitment Drug-Free Workplace Legal and Regulatory Compliance Management Responsibility Political Activity Referrals Work Place Conduct 25 Our Commitment To Effective Resource Utilization Financial Reporting Purchasing and Contracting Practices Stewardship of Resources 27 Speak Up And Report Concerns Responsibility to Report Compliance Concerns Consequences for Non-Compliance 29 Summary Your Commitment Equal Employment Opportunity Fraud, Waste and Abuse Gifts Government Investigations Health and Safety
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Our Mission To advance cures, and means of prevention, for pediatric catastrophic diseases through research and treatment. Consistent with the vision of our founder Danny Thomas, no child is denied treatment based on race, religion or a family s ability to pay. 7 Our Code Outlines the principles for how we conduct ourselves toward others and perform our duties. Our Code applies to all researchers, physicians, employees, volunteers, Board members and anyone who is conducting work on behalf of St. Jude. Following our Code ensures that we pursue the mission with the highest standards of integrity and that we continually earn and maintain the trust of those who look to us for providing care and discovering cures. Together, we are St. Jude.
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Our Values Ethical behavior is essential in achieving the mission of St. Jude. We believe that we are only as strong as our reputations, both as individuals and as an institution. This includes: A commitment to provide our patients with the highest quality of medical and supportive care, and their families with the level of information and support necessary for them to make informed decisions and become active participants in the care of their children. A commitment to respect the ethnic, cultural, religious and lifestyle differences of patients, their families, our colleagues and our supporters. A commitment to our donors that every dollar donated will be wisely spent toward achieving our mission of advancing cures, and means of prevention, for pediatric catastrophic disease through research and treatment. A commitment to a culture of excellence, innovation and creativity, not only in our research, but in everything we do. 9 A drive and a sense of urgency to succeed. Honesty, integrity and accountability in our actions and decisions. A culture of trust and teamwork. Respect for the employees under our supervision. A commitment to the continual development of our employees. A commitment to diversity. A commitment to social responsibility and institutional citizenship on a local, state, national and global level.
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The Code supplements policies and procedures that provide more detailed guidance. It is not intended to address every issue that might arise in our daily activities, but rather serves to document and foster our commitment to ethical conduct and compliance throughout the institution. Our formal Compliance Program is the foundation upon which we conduct all aspects of our work in full compliance with all rules and regulations. Ultimate responsibility and oversight of the Compliance Program belongs to senior leadership (Chief Executive Officer) and the Board of Governors; however, the day-to-day responsibility for operation and oversight rests with the Chief Compliance Officer who is assisted by the Compliance Steering Committee. 11
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How We Care For Our Patients We treat our patients and their families with respect, ensuring dignity and providing each patient with quality care. Patients and their families are involved in decisions regarding their care. We inform patients about therapeutic alternatives and the risks associated with the recommended interventions. We make no distinctions in the admission, transfer or discharge of patients or in the care we provide based on race, color, national origin, ancestry, religion, sex, sexual orientation, marital status or actual or perceived disability. We maintain appropriate professional boundaries with our patients, understanding that they trust us for their care. We are guided by policy and the codes of ethics of our professional disciplines. We safeguard the privacy of our patients and protect the confidentiality of their health information and confidential information from inappropriate use or disclosure. 13
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How We Conduct Our Research St. Jude research makes vital contributions to the development of new and better therapies for the treatment of children with cancer and other catastrophic diseases, and informs the global research community of our findings. We follow the highest professional standards for conducting research, whether basic science, translational research or clinical investigations. We comply with all relevant statutes and regulations. Consistent with St. Jude policies, we pursue research with uncompromising honesty and persistence and publish our findings for the benefit of others. We are committed to protecting the rights of research participants who take part in our research. Our research is monitored by St. Jude committees to ensure safety and protection of research participants. The medical and scientific communities depend on the reputation and integrity of our investigators. Everyone involved in research must comply with guidelines on responsible conduct of research. Intellectual Property and Proprietary Information St. Jude is a not-for-profit organization and does not undertake research or developmental work with profit as a motive; however, sometimes patentable inventions may result from our work. In these cases we comply with the laws and regulations that govern our own and others copyrights, trademarks, patents, trade secrets and other forms of intellectual property. 15
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Our Commitment To Ethical Business Practices Appropriate Behavior We treat everyone with respect and dignity and act appropriately in our relationships. We have a right to work in a professional atmosphere free from harassment, discrimination, violence, and inappropriate conduct and relationships. Sexual misconduct and sexual harassment are unprofessional behaviors. Relationships between managers and subordinates and peers must be professional. This includes avoiding potential conflicts of interest, perceptions of unfairness, favoritism and inappropriate relationships. Background and Exclusion Checks We check government databases to confirm whether an applicant or employee has been excluded from taking part in federal or state health care or research programs. We also conduct criminal background checks on all final candidates with the applicants written permission. The Compliance Office is informed if an individual becomes excluded while working at St. Jude. Billing We are committed to ensuring that our billing, coding and reimbursement practices comply with all federal and state laws and regulations, as well as our institutional guidelines and policies. St. Jude bills only for services that are provided and documented, and are medically necessary and appropriately ordered. We do not knowingly cause or present claims for payment which 17
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are untrue. Those who have knowledge of a false claim must report it to a manager, the Compliance Office or to EthicsPoint. Anyone reporting a false claim in good faith is protected from retaliation to the furthest extent possible under both federal and state laws. Confidentiality We maintain the confidentiality of patients, employees and other proprietary information. We do not share confidential information with other employees or others outside the organization unless there is a legitimate St. Jude business purpose. We understand the importance of maintaining confidentiality by limiting access to information, keeping all computer passwords or access codes secret, and preventing unauthorized access to and release of confidential information. Conflicts of Interest and Commitment Our staff is encouraged to participate in activities outside of the organization that further our mission, provide productive collaborations and promote the practical application of scientific discoveries. At the same time, outside activities can create conflicts of interest and/or conflicts of commitment that may compromise or appear to compromise our work. We disclose, for review and management, those outside activities that may create conflicts of interest or commitment in order to safeguard the integrity and objectivity of our research, education, clinical judgment and business decisions. Drug-Free Workplace All St. Jude employees must be able to safely and effectively perform their jobs. We prohibit the unauthorized manufacture, possession, use, sale or distribution of illegal substances in the workplace, or the use of a legal medication that may pose a safety risk for employees, patients or others. Equal Employment Opportunity St. Jude ensures that employment-related decisions are based on relevant qualifications, merit, performance and other job-related factors. 19
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Fraud, Waste and Abuse We are fully committed to complying with the laws and regulations designed to prevent fraud, waste and abuse in government health care programs. Individuals may be found guilty of fraud or abuse if they knew or should have known something was wrong. Both situations carry significant civil and/ or criminal penalties, including exclusion from participating in federal health care programs like Medicare or Medicaid. Fraud is knowingly submitting an incorrect claim or using or making a false statement to obtain payment from a federal health care program or a private insurer. Waste means misuse of resources causing unnecessary costs that are wasteful to a federal health care program. Abuse describes practices that directly or indirectly results in unnecessary costs that are wasteful to a federal health care program. Gifts We do not accept gifts or business courtesies from vendors that may improperly influence our purchasing and business decisions. Government Investigations We cooperate fully and promptly with government investigations and answer all questions in government interviews truthfully. False reporting to governmental agencies is strictly prohibited. We also protect St. Jude s legal rights in any government investigation by referring any governmental inquiries or requests for information, documents or interviews to the Office of Legal Services. Health and Safety We follow all federal, state, and local safety and environmental protection regulations. We participate in special training for handling and storing hazardous materials, disposing of hazardous wastes, fire prevention, and response to accidents and emergencies. 21
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Legal and Regulatory Compliance We follow all applicable laws, rules, regulations, professional standards and St. Jude policies and procedures when conducting business and operations. For example, we observe antitrust laws when entering into agreements with competitors. We screen recipients of our exports and obtain export licenses when required. Management Responsibility Leadership requires that managers and supervisors set personal examples of integrity and set the right tone for the people who report to them. We expect our leaders to assure that everyone on the team has sufficient information and training to comply with this Code. Leaders are accountable for educating their staff about the Compliance Program, taking steps to prevent violations, taking prompt action if a violation occurs and preventing retaliation against employees for reporting good-faith concerns. 23 Political Activity As a 501(c)(3) organization, we do not endorse or oppose any politician or candidate, allow campaign literature to be distributed on hospital premises, or participate in any campaign fundraising. Referrals We accept and make patient referrals and admissions based on the patient s health care needs, and our resources and expertise. We do not give or receive anything of value in exchange for the referral of patients to other health care providers or suppliers. Our decisions are based solely on the well-being of patients and the expediency of their treatments. Work Place Conduct As members of the St. Jude team, we behave in a professional and cooperative manner while at work or when involved in St. Jude business. We observe and follow the ethical standards of our profession, exemplifying compassion, collaboration, ethical behavior and a sense of urgency to advance cure rates.
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Financial Reporting Our Commitment To Effective Resource Utilization We are responsible for ensuring the integrity of our financial information. Our institutional policies provide guidance for properly authorizing and accurately reporting payments and transactions. We cooperate fully with internal and external auditors and any regulatory agencies that examine our records. We maintain high standards of accuracy and documentation by following industry best business practices, and by meeting external reporting requirements. Purchasing and Contracting Practices We enter into fair and equitable contractual arrangements with reputable vendors and individuals who meet the needs of the hospital. We comply with all applicable federal and state laws, and hospital policy. We seek opportunities to do business with small businesses, and women and minority owned businesses. We do not knowingly enter into contracts with vendors, suppliers or subcontractors who are excluded from participation in any government program. Stewardship of Resources We are grateful for the generous donations made to St. Jude via ALSAC and are strong stewards of donor dollars. We protect the hospital s assets and ensure their efficient use. St. Jude resources, such as time, materials, supplies, equipment and information are for St. Jude business purposes only. 25
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Speak Up And Report Concerns Responsibility to Report Compliance Concerns We are expected to report any issue or practice that we believe, in good faith, may be a violation of law, regulatory requirement, the Code or St. Jude policies. All reports are treated as confidential. Reports may be submitted to: Supervisor or manager EthicsPoint Hotline (800-433-1847) Online reporting via the Compliance intranet page Compliance Office (595-5563) St. Jude policies prohibit any negative consequences or retaliation for good-faith reporting of potential misconduct. Consequences for Non-Compliance Any St. Jude employee who fails to comply with the Code and St. Jude policies and procedures may be subject to disciplinary action up to and including termination of employment. 27 Supervisors or managers who knew or should have known about a violation and failed to take reasonable actions to prevent or promptly report and correct the situation are subject to disciplinary action up to and including termination of employment. Any St. Jude employee who fails to comply with applicable laws, rules, and regulations may be subject to disciplinary action up to and including termination of employment, personal fines, imprisonment, and exclusion from participation in Medicaid and other federal health care programs. Our failure to comply with applicable laws, rules and regulations affects all of us. St. Jude may be subject to fines and loss of confidence and trust of our patients, donors and community.
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SUMMARY Our Code of Conduct is not intended to define every aspect of our daily behavior; rather, it provides broad guidance for how we provide care to our patients, conduct research and carry out business transactions. Ultimately, it is the responsibility of everyone working at St. Jude and our business partners to abide by the highest ethical standards, while performing our work in compliance with all applicable laws, rules and regulations. This is essential if we are to further elevate our role as a national resource with a global mission of finding cures and saving children. YOUR COMMITMENT St. Jude espouses a culture of strong ethics and compliance, which must be supported by all employees. Our commitment to uphold this culture in our daily work is an essential characteristic for a world leader in combating childhood catastrophic diseases. Above all, we value the trust placed in us by our patients and our community. We realize that this trust will disappear if it is not continuously earned. 29
If you feel that our Code of Conduct is being violated, please report it to your supervisor or Ethics Point at 1-800-433-1847. If you have any questions about the Code of Conduct, please call Compliance at ext. 5563
I certify that I have received, read, and agree to abide by the St. Jude Children s Research Hospital Code of Conduct. I understand that the Code of Conduct represents laws, policies, rules and regulations applicable to St. Jude Children s Research Hospital. I understand that compliance with these laws, policies, rules and regulations is mandatory. Signature Date Title Print Name
262 Danny Thomas Place Memphis, TN 38105-3678 www.stjude.org Designed and Printed by BMC 3/14