HARRIS HEALTH SYSTEM

CODE OF CONDUCT

What we do, every day, must support our mission

to improve the health status and quality of life
for citizens of our community.

We are committed to achieving this

in an ethical and professional manner
and in full compliance with our values; federal, state, and
local rules and regulations; third party payor requirements;
and our own policies and procedures.
Harris Health System
P.O. Box 66769, Houston, Texas 77266-6769

May 2015

Dear Employees and Colleagues,

Harris Health System (Harris Health) is committed to providing outstanding quality service to our patients.
Everything we do, every day, must support our mission to improve the health status and quality of life for the
citizens of our community. We are committed to achieving this in an ethical and professional manner and in
full compliance with our values. We will also comply with all federal, state and local rules and regulations, third
party payor requirements, and our own policies and procedures. While we operate in a complex and highly
regulated environment, we have a Corporate Compliance Program (Compliance Program) to ensure that we
fulfill this commitment. The Compliance Program was established to prevent and timely detect the occurrence
of any accidental and intentional violations and to prevent any future noncompliance. Harris Health’s Code of
Conduct (Code) and policies and procedures fully support the Compliance Program.

A critical element of the Compliance Program is our Code. The Code is consistent with our mission, vision, and
values, and it affirms the principles and professional standards that already exist among our staff. Failure to
observe the Code can result in serious consequences for Harris Health and you, including regulatory sanctions,
fines and penalties, and disciplinary action, up to and including termination.

Our success requires the active participation of everyone associated with our organization. If you know or
suspect that a law, regulation, policy or our Code is not being followed, you must report this information.
To assist you in doing this, a toll-free confidential Compliance Hotline (Hotline) is available for your use twenty-
four hours a day. Calls to the Hotline can be made anonymously. Harris Health will not tolerate retaliation
for reporting Compliance issues.

I am asking you to pledge your full commitment to upholding the Code and the Compliance Program.
Our compliance activities are a critical component in our effort to provide the highest possible quality services
to our community.

Sincerely,

George V. Masi
President & Chief Executive Officer
Harris Health System
 Table of Contents
Introduction to the Code of Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Mission, Vision, Values and Promise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Responsibilities Under the Code. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
STANDARD OF CONDUCT: We are committed to providing outstanding quality of care and services.

Compliance with Laws and Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

STANDARD OF CONDUCT: We are committed to high standards of business and professional ethics and
integrity. We will provide patient care and conduct business while following applicable federal, state and
local laws, regulations, and Harris Health policies.

Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
STANDARD OF CONDUCT: We are committed to creating a work place where employees are treated
with respect and fairness while being empowered to get the job done at or above expectations. Harris
Health strives to attract and retain employees who share a personal commitment to our Mission, Vision,
and Values.

Billing and Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

STANDARD OF CONDUCT: We are committed to fair and accurate billing that is in accordance with all
federal and state laws, regulations, related administrative remedies, similar state statutes, and Harris
Health’s policies and procedures.

Federal and State False Claims Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

STANDARD OF CONDUCT: We are committed to maintaining fair and accurate billing procedures in
accordance with the federal False Claims Act and state False Claims Act.

Protection and Use of Information, Property and Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

STANDARD OF CONDUCT: We are committed to protecting Harris Health’s property and information
against loss, theft, destruction and misuse

Conflicts of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
STANDARD OF CONDUCT: We are committed to acting in good faith in all aspects of our work. We will
avoid conflicts of interest or the appearance of conflicts between the private interests of any employee
and his or her work duties.

Health and Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

STANDARD OF CONDUCT: We are committed to maintaining a work place that protects the health and safety
of our patients and employees.

Reporting Process and Non-Retaliation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

4-Step Process
Compliance Hotline
Non-Retaliation Policy

When in Doubt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Warning signs and a Quick Quiz

Certification and Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

 Introduction to the Code of Conduct
Harris Health System (Harris Health) is committed to the goal of serving our patients, Medical Staff,
employees and the community in an ethical, professional and responsible manner.
Further, Harris Health is committed to providing quality treatment and services in an ethical and
professional manner and in compliance with all applicable laws, regulations and guidelines,
as well as our own policies and procedures. We are particularly sensitive to those requirements
applicable to federal health care programs and the submission of accurate claims.

The Code of Conduct (Code) provides guidelines for everyone, regardless of position, to conduct business
ethically and in a law abiding manner. The Code, as well as all statutes, regulations, guidelines, and Harris Health
policies, must be observed by everyone: Harris Health’s Board of Managers, employees, Medical Staff, trainees,
contractors, volunteers and vendors (Workforce).

If there are any questions about the Code or about any policies or practices of Harris Health, you should raise
the questions with your supervisor, our Human Resources staff, or the Corporate Compliance Officer. Our
supervisory staff have a special obligation to be available and responsive to employees when questions arise
about adherence to the Code. If you are not satisfied with the response received from the supervisory staff
concerning applications of the Code, you should raise your concerns to the next level of management or to the
Corporate Compliance Officer.

Further, the Code adopted by Harris Health is intended to ensure that we meet our compliance goals in a highly
regulated business environment. The Code is designed to provide general guidance and does not replace
the policies and procedures of Harris Health. If there is no specific policy, the standard set forth in the Code
becomes the policy. If a policy and a standard conflict, the standard becomes the policy. The Code is a “living
document,” which will be updated periodically to respond to changing conditions. Thus, Harris Health reserves
the right to modify or terminate any or all of these provisions at any time.

1
 Mission, Vision, Values and Promise
Mission:

We improve our community’s health by delivering high-quality health care to Harris County residents and
by training the next generation of health professionals.

Vision:

We will create a healthier community and be recognized as one of America’s best community-owned
healthcare systems.

We Value:

• Our Patients, Staff and Partners

• Diversity and Inclusion
• Compassionate Care
• Trust
• Integrity
• Mutual Respect
• Communication
• Education, Research and Innovation

Our Promise:

To provide high-quality health care by knowledgeable and highly trained staff;

To provide prompt, friendly and courteous services;
To be sensitive and responsive to your needs and concerns as well as those of your family; and
To provide a clean, comfortable and safe environment, in all of our settings.

2
 Responsibilities Under the Code
Who must comply with Harris Health’s Code of Conduct?

This Code is the foundation of our Compliance Program and applies to all Workforce members. Harris Health’s
Workforce includes the Board of Managers, employees, medical staff, trainees, contractors, volunteers and vendors.

What are the responsibilities of each Workforce member with regard to the Code?

• Understand how the Compliance Program applies to your job and seek assistance and clarification from
your supervisor, the Corporate Compliance Officer, or other Harris Health resources when you have
questions about the application of the standards and other Harris Health policies to your work.
• Report any conduct that you think may be in violation of the Code.
• Listen and respond to questions, complaints or concerns expressed by patients, family members, visitors
or co-workers.
• Complete all required compliance training.
•

What are the responsibilities of Harris Health’s managers and other supervisors?

Build and maintain a culture of compliance:

• Personally lead compliance efforts through regular meetings and proactive steps that include
compliance reports and regular monitoring of compliance matters.
• Know, understand, and follow the statutes, rules and regulations that govern your area(s) of responsibility.
• Encourage Workforce members to raise conduct and ethical questions and concerns.
• Consider a Workforce member’s actions and judgments in promoting and complying with Harris Health’s
Code and other policies when evaluating a Workforce member.
• Ensure that you and all Workforce members you supervise complete all required compliance training.
• Cooperate with the Office of Corporate Compliance to ensure that a culture promoting compliance is
engrained at Harris Health.

Prevent compliance problems:

• Identify compliance risks and propose appropriate policies and procedures addressing such risks.
• Provide education and counseling to assist Workforce members to understand the Code, Harris Health’s
policies and procedures, as well as any applicable law.

Detect compliance problems:

• Implement and maintain appropriate controls to monitor compliance and mechanisms that foster the
effective reporting of potential compliance issues.
• Promote an environment that permits Workforce members to raise concerns without fear of retaliation.

3
 Responsibilities Under the Code
Respond to compliance problems:

• Pursue prompt corrective action to address weaknesses in compliance measures.

• Apply appropriate disciplinary action when necessary.
• Consult with the Corporate Compliance Officer so that compliance issues are promptly and effectively
addressed.

What are the responsibilities of Harris Health’s Board of Managers?

• Lead by example.
• Set the mission for Harris Health’s Compliance Program and exercise oversight through the Corporate
Compliance Committee of the Board of Managers.
• Make decisions that are in the best interest of Harris Health and not affected by conflicts of interest.
• Receive appropriate reports from the Corporate Compliance Officer concerning the status of Harris
Health’s Compliance Program and ensure the provision of the resources required to maintain its vitality
and Harris Health’s response to identified compliance deficiencies.
• Seek and act upon advice received from management, including Harris Health’s President/Chief
Executive Officer, Chief Financial Officer, Harris County Attorney’s Office, and Corporate Compliance
Officer.
• Maintain the confidentiality of all compliance-related information provided, subject to the requirements
of applicable law.
• Complete required compliance training.

4
 Quality of Care
STANDARD OF CONDUCT:
We are committed to providing outstanding quality of care and services.

• We will provide care and services that are based on current standards of practice.
• We will monitor the clinical quality of our services and strive to improve the quality of the services
provided.
• We have a duty at every level of the organization to maintain our integrity and the quality of our job
performance.
• We have a duty and responsibility to address any deficiency or error by reporting it to a supervisor who
can assess the problem, take appropriate action and follow the problem to resolution.
• We will encourage each Workforce member to continually evaluate existing methods of delivering
services in order to discover more effective ways of serving our Medical Staff and patients.
• We will respect the human dignity of each patient and family by responding to all patient questions,
concerns, and needs in a timely and sensitive manner.
• We will effectively communicate to patients in a clear, professional, informed, and understandable
manner.
• We will treat all patients, families, Medical Staff, co-workers, and all outside contacts with courtesy,
dignity, respect, and professionalism.
• We will periodically assess and evaluate the goals and objectives established for medical care and
related services to assure delivery of services according to current standards of practice, and the most
current knowledge in the field.
• We will work to ensure that admissions, transfers, and discharges are medically appropriate and in
accordance with all legal requirements.
• We will engage only fully licensed and properly credentialed providers with proper expertise and
experience to care for our patients.
• We will not discriminate against any patient for any reason including race, color, sex, national origin,
age, religion, marital status, disability, ethnicity, familial status, military status, sexual orientation, genetic
information, gender identity, pregnancy, as well as any other classifications as required by law.

5
 Compliance with Laws and Regulations
STANDARD OF CONDUCT:
We are committed to high standards of business and professional ethics and integrity.
We will provide patient care and conduct business while following applicable federal,
state and local laws, regulations, and Harris Health policies.

• We will promptly report to management, the Corporate Compliance Officer or Compliance Hotline when
any possible violation of law, regulation or Harris Health policy has occurred.
• We will act upon any reported compliance issues or concerns in a fair and truthful manner. Any retaliation
against any Workforce member who in good faith reports a suspected violation will not be tolerated.
• We will not offer, provide, solicit, or receive kickbacks, bribes, rebates, or anything else of value in order
to influence the referrals of patients, or services payable by a government health care program.
• We will accept patients based on the patient’s clinical needs and our capacity to render the needed services.
• We will ensure that all compensation arrangements and other agreements, including but not limited to
financial arrangements and joint ventures, with individuals or organizations that may be possible referral
sources are in writing, reviewed and approved by appropriate management and legal counsel prior to
execution (consistent with the Anti-kickback statute and Stark laws).
• We will exercise due care including implementing controls to prevent, detect, and correct violations
of applicable federal and state laws and internal policies and procedures, to ensure that billings to
government and to private insurance payors are complete and accurate.
• We will not engage in anti-competitive conduct in violation of antitrust laws.
• We will bill payors and patients according to all applicable laws, regulations, and policies.
• We will maintain complete and accurate patient medical records and will maintain such records in
accordance with federal and state privacy and security laws, regulations and policies.
• We will ensure that confidential patient information is accessible only by health care personnel involved
in the patient’s care, payors and others authorized to review patient information.
• We will not hire or contract with individuals who have been sanctioned by the Office of Inspector
General of the U.S. Department of Health and Human Services (OIG) or barred from federal and/or state
procurement programs.
• We will validate that Workforce members who are providers of patient medical services are properly
licensed and trained prior to administering patient care.
• Drugs or other controlled substances used in treatment are maintained, dispensed, and transported in
compliance with applicable laws and regulations.
• We will comply with the requirements of the Emergency Medical Treatment and Active Labor Act
(EMTALA), including providing a medical screening examination to all who seek emergency treatment.

6
 Human Resources
STANDARD OF CONDUCT:
We are committed to creating a work place where employees are treated with respect
and fairness while being empowered to get the job done at or above expectations.
Harris Health strives to attract and retain employees who share a personal
commitment to our Mission, Vision, and Values.

• We recognize that our employees are our most valuable assets.

• We will treat everyone with fairness, consistency, dignity, and respect, regardless of status or position.
• We will promote a work environment that is free from harassment.
• We will review and evaluate each employee’s performance periodically in an objective, consistent, and
uniform manner.
• We will continually strive to build confidence and professionalism in every employee.
• We will work to maintain open lines of communication so that the views of each employee may be
considered and their opinions given proper respect.
• We will maintain the confidentiality of personal employee information, subject to the Texas Public
Information Act.
• We will apply the Code and personnel policies and procedures equally to all employees regardless of
position in the workplace.
• We will provide equal employment opportunities and ensure that our employees are hired, trained,
promoted, and compensated on the basis of personal competence and potential for advancement
without regard for race, color, sex, national origin, age, religion, marital status, disability, ethnicity,
familial status, military status, sexual orientation, genetic information, gender identity, or pregnancy, as
well as any other classifications as required by law.
• We will encourage employees to continually evaluate existing methods of delivering services in order to
discover more effective ways of allocating the resources for patient care and support services.
• We will make promotion decisions based on employee performance, skill, and abilities.
• We will validate that all employees in a position requiring licensure/certification are properly licensed/
certified by federal, state, local and professional agencies.
• We will not permit employees to use work hours for any political activities.
• We will comply with all applicable federal and state laws regulating employment and payment of wages.

7
 Billing and Coding
STANDARD OF CONDUCT:
We are committed to fair and accurate billing that is in accordance with all federal
and state laws, regulations, related administrative remedies, similar state statutes, and
Harris Health’s policies and procedures.

• We will bill only for services or items that are medically necessary, actually provided and documented in
the patient’s medical record.
• We will not knowingly submit for payment or reimbursement a claim that is false, fraudulent, or fictitious.
• We will ensure that claims for services are accurate and identify the services rendered.
• We will assign diagnostic, procedural and billing codes that accurately reflect the services that were
provided. Upcoding, unbundling or any other means of artificially enhancing reimbursement is unlawful
and strictly prohibited.
• We will periodically perform reviews of coding practices and policies, including software edits, to ensure
they are consistent with applicable federal, state and private payor health care program requirements.
• We will determine the cause and scope of identified problems based on our internal reviews and
implement corrective action plans.
• We will follow up on the implementation of corrective action plans to validate the appropriateness of the
monitoring activities and the effectiveness of the corrective action plan.
• We will regularly review our records for credit balances and promptly refund any overpayments.
• We will not routinely waive insurance co-payments or deductibles.
• We will intentionally work to ensure that claims for services submitted to Medicare and Medicaid or
other federally funded health care programs are accurate and correctly identify the services ordered and
performed.
• We will comply with laws and regulations related to government cost reports. All questions or
issues related to cost reports will be promptly reported to the Chief Financial Officer or Corporate
Compliance Officer.
• We will maintain records in a secure location for the period of time required by law. The premature
destruction or alteration of any document in response to, or in anticipation of, a request for those
documents by any government agency or court is strictly prohibited.
• We will conduct general collection/credit procedures according to the Fair Debt Collection Practices Act
to the extent it applies to Harris Health.
• We will respond to questions and complaints related to a patient’s bill in a timely, direct, and
honest manner.

8
 Federal and State False Claims Act
STANDARD OF CONDUCT:
We are committed to maintaining fair and accurate billing procedures in accordance
with the federal False Claims Act and state False Claims Act.

Federal False Claims Act

• We will maintain policies for Workforce members (including management), pertaining to the federal
False Claims Act (FCA), including the administrative remedies for false claims and statements, any
state laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower
protections under such laws.
• We will not knowingly present or cause to be submitted a false or fraudulent claim to the government.
“Knowingly” is a broad term meaning:
– Actually knowing that a claim is false;
– Deliberately ignoring whether the claim is true or false; or
– Recklessly disregarding whether the claim is true or false.
• We will not knowingly make or use a false record or statement to obtain payment by the government of a claim.
• We will not engage in a conspiracy to defraud the government by the improper submission of a false
claim for payment.
• We will not knowingly make, use, or cause to be made or use false records or statements to conceal,
avoid, or decrease an obligation to pay or transmit money or property to the government.
• We understand that damages and penalties for violating the FCA include:
– Civil penalties of not less than $5,500 and not more than $11,000 per violation, plus
– Three times the amount of damages which the government sustains because of the violation.
• We understand that Qui Tam Provisions (whistleblower rights) of the FCA allow a person to bring an action
under the FCA on behalf of the federal government and share in any recovered amount by the government.
• We will train Workforce members on these false claims policies, as well as preventing, detecting and
reporting fraud, waste and abuse.
• We will not engage in retaliatory conduct against employees exercising their rights under the FCA.
• We will timely report and return all identified overpayments to the government.
• We understand that the Medicaid Fraud Prevention Law (FPL) of the Texas Human Resources Code
is substantially similar to the federal False Claims Act, and the actions that trigger civil and criminal
penalties under the Texas FPL generally mirror those of the federal FCA.
• We will not knowingly make or cause to be made false statements or misrepresentations to permit
someone to receive benefits or payments that are unauthorized or are greater than the authorized
benefit or payment.
• We will not knowingly conceal or withhold information to permit a person to receive a benefit or
payment that is unauthorized or is greater than that authorized.

9
State False Claims Act

• We will not knowingly apply for and receive a benefit or payment on behalf of another person and use
any part of it for something other than the benefit of the person on whose behalf it was received.
• We will not knowingly make, cause to be made, encourage, or seek to encourage the making of false
statements or misrepresentations concerning the condition of operations of a facility so that the facility
may qualify for Medicaid certification; or, information required by federal, state law, rule, regulation, or
provider agreement pertaining to the Medicaid program.
• We will not knowingly pay, charge, solicit, accept, or receive, in addition to any amount paid under the
Medicaid program, a gift, money, donation, or other consideration as a condition to the provision or
continued provision of a service or product if the cost of the service or product is paid for, in whole or in
part, under the Medicaid program; except as authorized under the Medicaid program.
• We will not knowingly submit or cause to be submitted a claim for payment for a product provided
or service rendered by a person who is not licensed to provide the product or perform the service, if a
license is required; or is not licensed in the manner claimed.
• We will not knowingly make a claim for payment for (a.) service or product that has not been approved
or accepted by a treating physician or health care practitioner, (b.) a service or product that is
substantially inadequate or inappropriate when compared to generally recognized standards within
the particular discipline or within the health care industry, or (c.) a product that has been adulterated,
debased, mislabeled, or that is otherwise inappropriate.
• We will not knowingly fail to indicate the type of license and the identification number of the licensed
health care provider who actually provided the service on a claim.
• We will not knowingly enter into an agreement, combination, or conspiracy to defraud the state by
obtaining or aiding another person in obtaining an unauthorized payment or benefit from the Medicaid
program or fiscal agent.
• We will not knowingly obstruct an investigation by the Attorney General of Texas.
• We will not knowingly make, use, or cause the making or use of a false record or statement to conceal,
avoid, or decrease an obligation to pay or transmit money or property to the state.
• We understand that damages and penalties for violating the FPL include:
– Payback to the state with interest,
– Civil penalties of not less than $5,000 or more than $15,000 per violation, plus
– Two times the amount of the payment or the value of benefit received.
• We will not engage in retaliatory conduct against Workforce members exercising their rights under
the FPL.

10
 Protection and Use of Information, Property and Assets
STANDARD OF CONDUCT:
We are committed to protecting Harris Health’s property and information against loss,
theft, destruction and misuse.

• We will honor the privacy of patients and not reveal or discuss patient-related information except with the health
care personnel involved in the patient’s care, payors, and others authorized by law to review patient information.
• We will release patient records in accordance with Harris Health’s policies and applicable federal and state
laws and regulations.
• We will maintain the confidentiality of quality assurance, peer review, and health care services information
in accordance with laws and regulations.
• We will maintain all medical business records in accordance with laws and our record retention policies.
• We will not alter or falsify information on any record or document.
• We will correctly use and care for all property and equipment entrusted to us.
• We will protect confidential Harris Health information and not use or reveal such information except in
the proper performance of duties and in accordance with the Texas Public Information Act. Harris Health’s
Corporate Compliance Officer serves as Harris Health’s Public Information Officer and all Public Information
Act requests should be forwarded to him or her immediately.
• We will maintain, inventory, and keep all supplies secure.
• We will dispose of surplus or obsolete property and equipment according to established policies and procedures.
• We will not permit making unauthorized copies of computer software or using personal software on Harris
Health’s computer equipment.
• We will not knowingly communicate or transfer any information or documents to any unauthorized persons.
• We will not use Harris Health owned vehicles, equipment, materials, or other property for personal gain,
convenience or financial benefit.
• We will use computers, the e-mail system, the internet, Harris Health’s intranet and other technology
primarily for work-related purposes.
• We will not use computers, e-mail, instant and/or text messaging, facsimile machines and other technology
to communicate information to unauthorized people. Further, the use of technology to send offensive,
discriminatory, or harassing messages is prohibited.
• We understand that all information created, sent, received, or stored on Harris Health owned devices is the
property of Harris Health and may be subject to disclosure pursuant to the Texas Public Information Act.
• We understand that Harris Health business conducted using personal computers, electronic devices,
e-mail accounts, instant and/or text messaging, facsimile machines and other technology may be subject to
disclosure pursuant to the Texas Public Information Act.
• We will safeguard the use and disclosure of protected health information, including information related to
treatment, medical history, current health status, payment for treatment and other information contained in patient
records, in accordance with HIPAA privacy and security regulations, state law, and our policies and procedures.

11
 Conflicts of Interest
STANDARD OF CONDUCT:
We are committed to acting in good faith in all aspects of our work. We will avoid
conflicts of interest or the appearance of conflicts between the private interests of any
employee and his or her work duties.

• We will not offer, accept, or provide gifts or favors, such as meals, transportation, or entertainment that
might be interpreted as a conflict of interest.
• We will request that all Medical Staff and Workforce members disclose any ownership interest and/or
other relationships that are, or may appear to be, in conflict with their responsibilities to Harris Health.
• All Harris Health Board members shall comply with state and federal laws, rules, and regulations
governing the ethical conduct of public officials, including the disclosure of conflicts of interest.
• We will avoid instances where the actions or activities of an individual acting on behalf of, or with Harris
Health involve: obtaining an improper personal gain or advantage by such individual or a member of
his or her family; or a potentially adverse effect on Harris Health’s interests.
• We will avoid conflicts of interest that may exist whenever a Workforce member or a related party (e.g.,
family member, friend, or business associate) receives a benefit from any decision or action taken by the
Workforce member.
• We will maintain professional relationships with actual and potential vendors and contractors.
• We will exercise good faith and fair dealing in all transactions that involve our responsibilities to Harris
Health. Workforce members will not misuse their position with Harris Health for personal gain.
• Workforce members will not allow outside employment to conflict with their position with Harris Health.
• We will not hire or permit a Workforce member to have a business relationship with a relative that
creates a conflict of interest.
• Workforce members will report actual or perceived conflicts to the Corporate Compliance Officer.
• We will not accept a gift that violates Harris Health’s Gift Policy.
• We will not hire a family member to be supervised by or to supervise another family member, or where a
conflict of interest may occur between the family member’s duties.
• Medical Staff members should avoid conflicts of interest related to their Medical Staff duties.
Unavoidable conflicts should be disclosed and the Medical Staff member should not participate in any
discussion, decision or activity connected with the conflict.

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 Health and Safety
STANDARD OF CONDUCT:
We are committed to maintaining a work place that protects the health and safety of
our patients and employees.

• We will comply with applicable environmental, health, and safety requirements whether established by
management, federal, state or local laws, or our accrediting organizations.
• We will take reasonable precautions and follow safety rules and regulations to maintain a safe
environment for our patients, visitors, and Workforce members.
• We will strive to provide an environment that is free from violence.
• Unauthorized weapons of any kind are strictly prohibited.
• We will follow applicable laws and regulations regarding the disposal of medical waste and hazardous
material.
• We will promptly report to a supervisor any accidents involving injury to a Workforce member or visitor.
• We will promptly report spills or accidents involving medical waste or hazardous materials to a
supervisor and take appropriate action to help prevent harm.
• We will provide training regarding healthy and safe work practices to reduce hazards to the health and
safety of Workforce members and others.
• Supervisors are responsible for inspecting the work areas under their control for health and safety risks,
eliminating or reporting risks to management, being familiar with health and safety procedures, and
training their employees in health and safety precautions.
• Reporting to work while impaired by drugs (prescription or otherwise) or alcohol will not be tolerated.
• We will safely store, secure, and count all drugs and pharmaceuticals. Missing or diverted drugs will be
promptly reported to supervisors.

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 Reporting Process and Non-Retaliation
4-Step Process

If you have a question or concern about an activity being unethical, illegal, or wrong, use the following
4-step reporting process to answer questions and report concerns. Workforce members have an affirmative
duty to report any violations. Throughout this process your identity will be kept confidential to the extent
possible.

1. Talk to your supervisor. He or she is most familiar with the laws, regulations, and policies that relate to
your work and most problems can be resolved at this level.
2. If you are not comfortable contacting your supervisor, if you do not receive an adequate response from
your supervisor, if it is otherwise not possible, or if both you and your supervisor have questions or
concerns, talk to another member of the management team.
3. If you still have questions, contact our Corporate Compliance Officer at 713-566-6461.
4. If for any reason you feel you cannot follow the above steps, call Harris Health’s confidential Compliance
Hotline at 1-800-500-0333. Harris Health‘s Compliance Officer will review and address all reports to the
Compliance Hotline or the Office of Corporate Compliance.
Throughout this process, each problem will be taken seriously and each person involved will be treated with
dignity and respect. Harris Health will conduct a thorough investigation and when appropriate, provide a
response to the Workforce member.

Compliance Hotline

We recognize that there are times when questions or problems cannot be addressed through the normal
communication and reporting process. When this happens, you should use Harris Health’s Compliance Hotline.
The Compliance Hotline is available 24 hours a day at 1-800-500-0333.

You will remain anonymous, unless you choose to identify yourself. If you do give your name, your identity will
be protected to the extent allowed by law. No disciplinary action or retaliation will be taken against you for
calling the Compliance Hotline in good faith.

All calls made to the Compliance Hotline will be reviewed by Harris Health’s Corporate Compliance Officer and
will be responded to fairly. All calls will be investigated before any action is taken. The rights of all Workforce
members, including anyone who is the subject of the Compliance Hotline call, will be respected and protected.

Non-Retaliation Policy

Harris Health will not tolerate retaliation against Workforce members who, in good faith, report fraud, abuse or
wrongdoing, non-compliance with Harris Health policy or the law, or situations that have a negative impact on
patient care.

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 When in Doubt
Warning signs and a Quick Quiz

There may be times when you are unsure whether an activity or a situation is unethical or illegal. If you are not
sure, pursue it until you are confident that it is either resolved, or that the right person at Harris Health knows
the facts and has taken action. A delay on your part could be serious for you, for others, and for Harris Health.

There are words and phrases that raise “red flags” about potential problems, and should send a warning signal
to you. The following are examples of such words and phrases:

“Well, maybe just this once.”

“Everyone does it.”
“No one will ever know.”
“Shred that document – no problem.”
“No one will get hurt.”
“Do not talk to the Compliance Office.”

If you hear comments like these or you are being asked to say or do things like this, then the following “quick
quiz” could be helpful as a guide for what needs to be done next.

“Does this break a law, regulation, policy or our Code?”

“How will I feel about myself afterwards?”
“What would my family, friends, or Medical Staff or patients think?”
“How would this look if it were in the newspaper tomorrow?”
“Am I being fair and honest?”
“Why would my supervisor not want me to talk to the Compliance Office?”

If you are not comfortable with any of your answers to the above questions, or if you are still not sure whether
an activity is wrong, contact your supervisor, another trusted manager of Harris Health, the Corporate
Compliance Officer, or the Harris County Attorney’s Office. The 4-step communication and reporting process
outlined in the previous section should be a helpful guide.

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 Certification and Acknowledgement
I acknowledge and certify that I have received and read Harris Health’s Code of Conduct (Code), understand my
obligations to comply with the Code, and have an affirmative duty to report compliance violations.

I agree to comply with the Code.

Print your name here:

Carolyn Fan

Please sign here:

1/11/2021
ID # Date:

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