URMC Compliance Program Policy Manual:
General Policy

It is the Policy of URMC and its affiliates, The University of Rochester Medical Center (Strong Memorial Hospital, School of Medicine and Dentistry, School of Nursing, Eastman Dental Center and URMFG), Strong Partners Health System, Inc., Highland Hospital, Highland Living Center, The Highlands at Pittsford, the Meadows at Westfall, and Visiting Nurse Service (collectively, "URMC" or the "System") to provide services in compliance with all state and federal laws governing its operations, and consistent with the highest standards of business and professional ethics. This Manual is a statement of that policy and sets forth the code of conduct and ethical behavior expected from all employees and staff. In order to ensure that the URMC compliance policies are consistently applied, the System has established a legal and regulatory Compliance Program. The program is directed by a Compliance Committee, a Compliance Program Medical Director and a Compliance Officer, who are charged with reviewing our compliance policies and specific compliance situations that may arise.

All URMC employees, as well as those professionals who enjoy professional staff membership or deliver care to its patients, must carry out their duties in accordance with this policy. Any violation of applicable law, or deviation from appropriate ethical standards, will subject an employee or independent professional to disciplinary action, which may include oral or written warning, disciplinary probation, suspension, reduction in salary, demotion, dismissal from employment, tenure revocation proceedings or revocation of medical staff privileges. These disciplinary actions also may apply to a supervisor (or a staff member's department chief) who directs or approves the person's improper actions, or is aware of those actions but does not act appropriately to correct them; or who otherwise fails to exercise appropriate supervision or detect non-compliance with this policy.

This Manual includes statements of URMC policy in a number of specific areas. All employees and professional staff members must comply with these policies, which define the scope of employment and professional staff membership. Conduct that does not comply with these statements is not authorized by the URMC entities, is outside the scope of employment and professional staff membership, and may subject employees and professional staff members to disciplinary action. If an employee or professional is unsure whether any action complies with the URMC policies or applicable law, he or she should present that question to that employee's supervisor, or, if appropriate, directly to the Compliance Officer. All employees or professionals should review this Manual from time to time to make sure that these policies guide their actions.

If, at any time, any employee or professional staff member becomes aware of any apparent violation of these policies, he or she must report it to his or her supervisor (in the case of an employee), Department Chair, Department Compliance Liaison or to the Compliance Officer. All persons making such reports are assured that such reports will be treated as confidential except as required by law; such reports will be shared only on a bona fide need-to-know basis. No adverse action will be taken against persons making such reports in good faith, whether or not the report ultimately proves to be well-founded. If an employee or professional staff member does not report conduct violating URMC policies, of which (s)he is or should be aware, that employee or professional staff member may be subject to disciplinary action, up to and including termination of employment or revocation of tenure or privileges.

The laws discussed in this Policy Manual are complex and many of the concepts are developed in case-by-case determinations. In addition, this Manual deals only generally with some of the more important legal principles. Their mention is not intended to minimize the importance of other applicable laws, professional standards, or ethical principles, which may be covered in other institutional policies. Where appropriate, reference is made to specific policies that have been in place at the various URMC entities and which are an integral part of the URMC Compliance Program. Any person who is in doubt as to the propriety of a course of action or concerned about whether a stated policy applies, must promptly communicate with his or her supervisor, Chair, or compliance liaison, or with the Compliance Officer, before taking action.

Finally, all employees and professionals with privileges should recognize that this Code of Conduct may be amended from time-to-time, to reflect changes in applicable laws and policies. All are expected to familiarize themselves with such changes and to abide by them.