36C24218R0169-039.pdf

RFP 36C24218R0169

D.11 NETWORK 2 STATEMENT OF ORGANIZATIONAL ETHICS (NETWORK

MEMORANDUM 10N2-71-13, JULY 30, 2013)

NETWORK 2 STATEMENT OF ORGANIZATIONAL ETHICS

1. PURPOSE: To establish and implement a code of behavior for employees who provide a consistent, ethical framework for patient care and business operations.

2. POLICY: The VA Health Care Upstate New York has established this Statement of Organizational Ethics in recognition of the ethical responsibility a health care organization has to the patients and the community it serves. In keeping with the principles found in the Standards of Ethical Conduct for Federal Employees and the VHA Integrated Ethics Methodology, it is the responsibility of every employee and volunteer to act in a manner that is consistent with this organizational statement and its supporting policies.

3. RESPONSIBILITY: All employees within the Network, its facilities and clinics will adhere to the principles and practices detailed in this policy.

4. PROCEDURES:

A. Principles: Our behavior is, and will be, guided by a dedication to the principle that all patients, employees, volunteers, and visitors deserve to be treated with dignity and courtesy which will be demonstrated through a standardized, comprehensive and systematic integrated approach to ethics in health care.

1. Respect for Patients:

A. VA Health Care Upstate New York is committed to providing quality medical care in an atmosphere in which the human needs and concerns of the patient are met and his/her individual rights and interests are protected.

B. This atmosphere must be based on care that is provided in a courteous, concerned, and compassionate manner in conjunction with the principles of Integrated Ethics, to support, maintain and improve ethics quality. The scope of Integrated Ethics at both the VISN and facility level includes three core functions:

1. Ethics Consultation. The consultation service at each facility must respond to both requests for consultation about ethical questions pertaining to an active clinical case and requests for general information, policy clarification, document review, discussion of hypothetical or historical cases, and ethical analysis of organizational ethics questions.

2. Preventive Ethics (PE). The PE team at each facility must use a systematic approach for proactively identifying, prioritizing, and addressing ethics quality gaps on a systems level. The goal of the preventive ethics function is to reduce disparities between actual practices and best or preferred practices by implementing systems-level changes.

3. Ethical Leadership. The ethical leadership function requires that leaders make clear through their words and actions that ethics is a priority; and to communicate clear expectations for ethical practice, practice ethical decision making, and support of their organization’s ethics program.

C. Ethics in health care encompasses the following domains:

1. Shared decision making with patients.

2. Ethical practices in end-of-life care.

3. Patient privacy and confidentiality.

4. Professionalism in patient care.

5. Ethical practices in business and management.

6. Ethical practices in government service.

7. Ethical practices in the everyday workplace.

8. Ethical practices in research.

9. Ethical practices in resource allocation.

D. VISN and facility procedures for utilizing the CASES and ISSUES approach to resolving ethical quality gaps can be accessed at http://vaww.ethics.va.gov/integratedethics.

1. Patients and their surrogate(s), or significant others will be informed about the known therapeutic alternatives as well as the benefits and risks associated with them and be involved in decisions regarding their care, that we deliver to the maximum extent practicable.

2. We will constantly strive to understand and respect their objectives and competent decisions for care.

3. In all circumstances we will treat patients in a manner giving reasonable thought to their background, culture, religion, heritage, and personal beliefs.

2. Informed Consent:

A. It is this VA Network’s policy that every patient has the right to as much information as needed, or available to make informed decision regarding his/her care.

Except in emergency situations, practitioners must inform patients of the purpose and description of any diagnostic/therapeutic procedures, expected results of both consenting to and forgoing proposed procedures, significant risks, and alternative treatments in language that is understandable to the patient.

B. All patients involved in Research Protocols will be accorded the informed consent procedures as outlined by Appendix 9c, M-3, Part 1, Procedures for Obtaining Informed Consent; Requirements for the Protection of Human Subjects and VHA Handbook Directive 1004.1, Informed Consent.

3. Conflict of Interest: VA Health Care Upstate New York staff may not: hold financial interests that conflict with the conscientious performance of duty; use public office for private gain; or engage in outside employment or activities that conflict with official government duties and responsibilities. It is noted that unresolved conflicts amongst and between leaders and organizational units within VISN facilities undermines communication and cooperation among members of healthcare teams and jeopardizes patient safety. Staff must disclose potential conflicts; VISN 2 facilities will have defined processes to resolve any conflict that, if not managed, could adversely affect patient safety or quality of care.

NOTE: Any concerns that involve criminal conflict of interest law or Standards of Conduct are matters for the Designated Agency Ethics Official (DAEO). The DAEO, the Assistant General Counsel for Professional Staff Group III, addresses issues involving the application of criminal conflict of interest laws, Title 18 United States Code (U.S.C.) Chapter 11 and the Standards of Conduct for Executive Branch Employees 5 CFR., Part 2635. The DAEO and the Deputy Ethics Officials in the Regional Counsel offices and in Professional Staff Group III are the only source of authoritative advice on criminal conflicts of interest and the legal questions relating to Standards of Conduct. Following the good-faith advice of such ethics officials provides the employee with meaningful protection from criminal or administrative sanctions.

http://vaww.ethics.va.gov/integratedethics

4. Confidentiality/Privacy: VA Health Care Upstate New York recognizes a responsibility to respect patient privacy and maintain patient and other information in a confidential manner. Patient information will not be shared in an unauthorized manner. Information from patient files and computerized files will only be released when proper authorization by the appropriate staff has been received. Patient privacy is to be respected in conducting physical examinations and interviews; professional discussion of patients in public places (e g. elevators, lobbies) is to be avoided.

Sensitive information concerning personnel, patient and management issues will be maintained in strict confidence and utilized only by those individuals authorized to review and act upon such information.

5. Patient Care Services and Technology: The Network provides services compatible with our mission and values.

New services and technologies implemented within the Network shall be consistent with the mission and objectives defined in the VISN 2 Strategic Plan. Implementation strategies are based on safety, efficacy, efficiency, costs, known experience, availability from other sources, number of Veterans who benefit and the effect on the institutional ability to provide other needed services as well as staff competence and qualifications.

6. Other rights: VA Health Care Upstate New York management supports the right of patients to inquire about and be informed of the existence of business relationships among the network, its facilities, affiliated educational institutions, other health care providers, third party payers or networks that may influence the patient’s treatment or care. This philosophy is guided by the following mechanisms:

A. Mission Statement.

B. Value Statement.

C. Strategic Plan.

D. Employee Orientation.

E. Publication and distribution of Patient Rights and Responsibilities.

F. Patient Representative Program.

G. Regular Employee Newsletter Articles.

H. Posting of Patients’ Rights in Common Areas.

I. Corporate culture that encourages and nurtures concepts of ethical behavior.

J. Compassionate and concerned patient care.

K. Education about Advance Directives.

L. Education about patient abuse.

M. VISN 2 Integrated Ethics Board/ facility Integrated Ethics Councils.

7. Employee Practices:

A. Standards of Ethical Conduct for Federal Employees require:

1. All employees must place loyalty to the public trust above personal or organizational private gain in order to prevent a conflict of interest or the appearance of a conflict of interest.

2. All employees must abide by all federal rules and regulations governing the acceptance of or giving of gifts (see 5 C.F.R., Part 2635).

3. An employee must not use his or her position, including official time, information, property or endorsements, for personal gain or the private gain of anyone.

4. An employee must comply with all laws and regulations governing federal employees.

5. VA employees will not solicit or recruit VA patients into their private practices or businesses for treatment, services, or supplies that can be provided to the Veteran at or by the VA.

8. Resolution of Conflicts: From time to time conflicts will arise among those who participate in Network and patient care decisions. This Network supports the patient’s right to present concerns, needs or complaints without fear of reprisal or access to care being compromised. Whether the conflict is between members of administration, medical staff, employees, or between patient caregivers and the patient (or the patient's family/significant other), we will strive to resolve conflicts fairly, objectively, and at the level most directly involved with the conflict. In cases where mutual satisfaction cannot be achieved, it is the policy of this Network to involve the Patient Advocate or the facility Executive Leadership Official/ Designee on call to oversee the resolution of the conflict. Other staff and second options will be sought as needed to pursue a utility satisfactory resolution. The Network seeks to resolve disputes at the lowest level within the organization. The Network Integrated Ethics Board will serve as a committee of last resort.

9. Eligibility/Admission/Transfer/Discharge/Protective Services: All eligible Veterans (including TriCare patients) requiring hospital care may be admitted to Network facilities or will be transferred to another hospital for appropriate care. Any individual requiring emergency hospitalization will be admitted regardless of eligibility to pay. Ineligible Veterans and non-Veteran patients who require non-emergency hospitalization may be referred to another hospital for that care. Any individual being transferred to another hospital will first be treated to stabilize his/her medical condition and to minimize further compromise of that condition.

The individual will not be transferred until accepted by the receiving facility. The sending facility is responsible for transfer of the individual. The sending facility remains responsible during transport if a staff member is sent with the individual. Otherwise, EMS assumes responsibility during transport. All pertinent medical information will accompany the individual. Individuals may be discharged upon completion of acute medical care or on stabilization of a chronic medical condition. Discharge planning will be coordinated with the individual and families to ensure appropriate provisions are made prior to discharge in order to meet the individual’s biopsychosocial continuing care needs.

Arrangements for any needed medical care will be made at the time of discharge. Individuals considered to be vulnerable adults (those unable to care for or advocate for themselves due to neglect, abuse or exploitation), shall be accorded access to protective services.

10. Fair Billing Practices: In compliance with existing federal regulations and public law, VA Health Care Upstate New York will bill co-pay required Veterans and/or third parties for non-service connected treatment provided to the Veterans and will provide assistance to Veterans seeking to understand the cost relative to their care. The North East Consolidated Patient Account Center (CPAC) has designated staffing to assist patients with billing concerns. VHA and CPAC staff will ensure effort is made to resolve questions and/or complaints in a timely fashion in the best interests of both the patient and the Network.

11. Ethical Business Practices: Government business shall be conducted in a manner above reproach, except as authorized by statute or regulation, with complete impartiality and with preferential treatment for none. Transactions relating to the expenditure of public funds require the highest degree of public trust and an impeccable standard of conduct. The general rule is to strictly avoid any conflict of interest in Government-contractor relationships. As a rule, no Government employee may solicit or accept, directly or indirectly, any gratuity, gift favor, entertainment, loan, or anything of monetary value from anyone who:

A. Has or is seeking to obtain Government business with the employees' agency.

B. Conducts activities that are regulated by the employee's agency.

C. Has interests that may be substantially affected by the performance or non-performance of the employee's official duties.

12. Outreach/Public Information: It is the policy of the VA Health Care Upstate New York to promote, assist and support both the flow of, and access to, information that will serve to communicate an understanding of the Network’s mission and the services it provides. The Network communicates policy with the public in an honest and forthright manner that minimizes confusion and broadens both individual and public understanding.

5. REFERENCES:

A. Standards of Ethical Conduct for Employees of the Executive Branch at 5 CFR Part 2635.

B. Commission on Accreditation of Rehabilitation Facilities, Behavioral Health Standards Manual, Section 4, A., “Rights of Persons Served”.

C. Commission on Accreditation of Rehabilitation Facilities, Employment and Community Services Standards Manual, Section 3, C., “Rights”.

D. Joint Commission on Accreditation of Healthcare Organizations, Comprehensive Accreditation Manual for Hospitals (HAP), “Patient Rights and Organizational Ethics”.

E. Joint Commission on Accreditation of Healthcare Organizations, Comprehensive Accreditation Manual for Long Term Care, “Resident Rights and Organizational Ethics”.

F. Joint Commission on Accreditation of Healthcare Organizations, Comprehensive Accreditation Manual for Behavioral Health, “Rights, Responsibilities and Ethics”.

G. VHA Handbook 1004.06, Integrated Ethics.

6. RESCISSIONS: Network Memorandum 10N2-71-03, dated July 23, 2003.

7. FOLLOW-UP RESPONSIBILITY: Author, Chaplain Richard D. Brown, VISN 2 Integrated Ethics Board.

8. AUTOMATIC RESCISSION DATE: July 30, 2016.

// Signed 7/30/13 //

JAMES CODY, FACHE

Interim Network Director

DISTRIBUTION: Medical Center Directors

Network Care Line Managers

VISN 2 Network Web Site