Exemplary Professional Practice

Policy Title

Location

Purpose

Areas Addressed

BHSF Employee Handbook

BHSF Corporate HR Intranet page

Informs employees about Baptist Health’s history, philosophy, employment policies and practices, benefits and expectations for conduct. (OO15 01 Employee Handbook)

C, S, P

Code of Ethics Policy

BHSF
Corporate Policies Intranet

Delineates employee responsibility and access to Code of Ethics which is a key component of the Corporate Compliance Program (OO15 02 BHSF-819 Code of Ethics Policy and brochure)

        P

Non-Retaliation for Reporting of Potential or Actual Violations of the Code of Ethics

BHSF
Corporate Policies Intranet

Outlines organizational philosophy against retaliation or retribution on staff who in good faith reports Code of Ethics violations   (OO15 03 BHSF-822 Non-Retaliation for Reporting of Potential or Actual Violations of the Code of Ethics)

P

Compliance Hotline

BHSF
Corporate Policies Intranet

Describes the purpose of the Compliance Hotline and the procedures for handling reports received (OO15 04 BHSF-823 Compliance Hotline)

P

Preventing Workplace Violence

BHSF
Corporate Policies Intranet

Sets expectation for zero tolerance of workplace violence and describes signs of violent behaviors and management  (OO15 05 BHSF-HR-5100 Preventing Workplace Violence)

S, P

Compliance Training

BHSF
Corporate Policies Intranet

Describes the nature of training provided to staff on the Corporate Compliance program during new employee orientation, annual required education and yearly management training. (OO15 06 BHSF-825 Compliance Training)

P

Compliance Liaison

BHSF
Corporate Policies Intranet

Delineates duties and responsibilities of the Compliance Liaison designated at each hospital. (OO15 07 BHSF- 838 Compliance Liaison)

P

Communicating Corporate Compliance Program Standards

BHSF
Corporate Policies Intranet

Describes the various methods for communicating the Corporate Compliance standards to employees, physicians, and vendors. (OO15 08 BHSF 826 Communicating Corporate Compliance Program Standards)

P

Incident Reporting

BHSF
Corporate Policies Intranet

Delineates employee expectation and procedure for reporting incidents at work. (OO15 09 BHSF-1402  Incident Reporting)

C, S, P

Drug-Free Workplace Program

BHSF
Corporate Policies Intranet

Outlines the procedure for maintaining a drug-free work environment including follow-up referral process for healthcare practitioners to Intervention Project for Nurses (IPN) or Professionals Resource Network (PRN) and non-healthcare practitioners to Employee Assistance Program (EAP) or addiction treatment program (OO15 10 BHSF-6150 Drug-Free Workplace Program)

C, S, P

Policy Title

Location

Purpose

Areas Addressed

Nursing Peer Review

Homestead Hospital
Policy
Intranet

Outlines the process of  reviewing nursing care quality by RN peers and the council membership (OO15 11 HH-100-12  Nursing Peer Review)

C, S, P

Medical Staff Quality Committee Charter

Organizations and Functions Manual – Medical Staff office

Describes the process of  reviewing quality of medical care by physician peers and council membership (OO15 12 Medical Staff Quality Committee charter, highlighted)

C, S, P

Employee Violence Communication Plan

Homestead Hospital
Policy
Intranet

Describes the procedure to follow when a verbal interaction between employees escalates to a physical altercation.
(OO15 13 HH-1030.05  Employee Violence Communication Plan)

S, P

BHSF 5250 Employee Conduct

BHSF
Corporate Policies Intranet

Outlines expectations of employee conduct and describes unacceptable behaviors that may lead to corrective action.  (OO15 14 BHSF-HR 5250 Employee Conduct)

C, S, P

BHSF 5300 Corrective Action

BHSF
Corporate Policies Intranet

Establishes guidelines for correcting deficiencies in employee performance and behavior (OO15 15 BHSF 5300 Corrective Action)

C, S, P

Policy Prohibiting Harassment and Discrimination

BHSF
Corporate Policies Intranet

Sets out expectation to ensure all employees are treated with dignity and respect (OO15 16 BHSF-HR 5075 Policy Prohibiting Harassment and Discrimination)

S, P

Distribution of Audit Reports

BHSF
Corporate Policies Intranet

Serves as guide for the Corporate Vice President and Chief Compliance Officer on the dissemination of audit results to the appropriate individuals within and outside of the organization. (OO15 17 BHSF 806 Distribution of Audit Reports)

P

Compliance Audits and Investigations

BHSF
Corporate Policies Intranet

Describes the responsibility and procedure for conducting audits and investigations independent of management that the Compliance and Audit department undertakes for any suspected fraud involving management and employees. (OO15 18 BHSF 807 Compliance Audits and Investigations)

P

Management's Response to Audit Findings

BHSF
Corporate Policies Intranet

Illustrates how final audit reports are communicated to parties within Baptist Health who can ensure that an action plan will be developed and implemented in response to the findings. (OO15 19 BHSF 811 Management's Response to Audit Findings)

P

Appropriate Discipline for Compliance Program Violations

BHSF
Corporate Policies Intranet

Outlines the factors considered when determining corrective action for employees who engage in wrongful conduct and violate applicable laws, regulations, Code of Ethics and other Corporate Compliance standards. (OO15 20 BHSF 820 Appropriate Discipline for Compliance Program Violations)

P

Compliance Advisory Committee

BHSF
Corporate Policies Intranet

Delineates responsibilities and activities of the Compliance Advisory Committee which serves as an additional resource in identifying and evaluating organizational risk and recommending internal controls that will further enhance compliance to applicable law, rules and regulations. (OO15 21 BHSF 839 Compliance Advisory Committee)

P