Professional Documents
Culture Documents
Code of Conduct
Code of Conduct
Table of Contents
Purpose Statement.....................................................................................................................3
Mission, Vision and Values........................................................................................................3
Introduction and Definitions ....................................................................................................3
Letter from the President...........................................................................................................4
Principle 1 Legal Compliance....................................................................................................5
Principle 2 Business Ethics ........................................................................................................7
Principle 3 Confidentiality ........................................................................................................9
Principle 4 Conflict and Duality of Interest ..............................................................................12
Principle 5 Core Activity and Relationships ..............................................................................14
Principle 6 Protection of Assets .................................................................................................16
Administration and Application ................................................................................................17
Getting Help and Reporting .....................................................................................................17
2
PURPOSE Courtesy We affirm that courtesy is essential in all
This Code of Conduct has been adopted by the Board of relationships
Commissioners of The Joint Commission, the Board of Integrity We pledge that honesty and ethical behavior
the Joint Commission Center for Transforming will characterize all of our transactions
Healthcare and the Board of Directors of Joint Empowerment We believe that each employee should
Commission Resources to provide standards to guide have the authority and support necessary to contribute
Joint Commission Personnel (as defined below) in effectively to continuous improvement in organization
conducting themselves to protect and promote performance
organization-wide integrity and to enhance The Joint Responsiveness We seek to understand and be
Commissions ability to achieve its declared mission. responsive to the needs of one another and the needs
of those who use our products and services
VISION STATEMENT Recognition We believe that effective performance
should be recognized
All people always experience the safest, highest Improvement We seek to continually improve our
quality, best-value health care across all settings. performance
The ability of The Joint Commission to achieve its mission requires that we continually strive to maintain the
remarkable reputation for integrity that this organization has earned throughout its long history. This means
that all of us are called upon to:
conduct all our activities in a way that is truly compliant with our professional, legal, and ethical
responsibilities, and
observe the principles and adopt the behaviors of a safety culture.
That is why, every year, we review and agree to follow the Code of Conduct. The code sets forth the basic
principles we hold dear in conducting our business and it recognizes our responsibilities to our peers, partners
and the health care community that we serve. Because we are The Joint Commission, our every action is
closely scrutinized by our stakeholders and other interested parties. I think you will agree that one of our most
valuable assets is our reputation.
The enclosed Code of Conduct is intended to guide responsible decision-making with the goals to promote
organization-wide integrity and to demonstrate that complying with our legal and ethical obligations is a natu-
ral extension of what we do every day. The Code of Conduct is our map toward these goals; it orients and
directs us in our day-to-day work and in our dealings with others. Our work is not easy; but it is also both pro-
fessionally and personally rewarding. I thank you for the pride you take in your work and I encourage you to
be mindful of the Code of Conduct and of your role in keeping The Joint Commissions reputation one that
others strive to emulate. Thank you.
Sincerely,
4
PRINCIPLES AND STANDARDS
The Joint Commission shall strive to ensure that all provide accurate reports to appropriate taxing author-
activities by or on behalf of the organization are in ities, shall file all tax and information returns in a
compliance with applicable laws and regulations. manner consistent with applicable laws and shall avoid
the appearance of impropriety as well as actual impro-
The following standards provide guidance to all Joint
priety. (See Principle 4: Conflicts and Dualities of
Commission Personnel to support their compliance
Interest.)
with applicable laws. These standards are neither
exclusive nor complete. Joint Commission Personnel
Lobbying/Political Activity
are required to comply with all applicable laws,
Joint Commission Personnel shall not engage in
whether or not specifically addressed in these policies.
lobbying on behalf of The Joint Commission unless
If questions regarding the existence, interpretation, or
authorized. Political campaign activity on behalf of
application of any law arise, they should be directed to
The Joint Commission is prohibited because it jeop-
The Joint Commissions Corporate Compliance
ardizes the tax-exempt status of the organization.
Officer who, as appropriate, will consult The Joint
Political Activity No individual shall contribute
Commissions Compliance Council and/or legal staff.
or make any agreement to contribute any money,
Standard 1.1. Antitrust property, or services of any Joint Commission
Personnel at The Joint Commissions expense to
All Joint Commission Personnel shall comply with any political candidate, party, organization, or com-
applicable antitrust and similar laws that promote mittee. Joint Commission Personnel may personally
competition. Examples of conduct prohibited by the contribute money, time, or service to political
antitrust laws include agreements to fix prices, rig organizations or campaigns, but they must do so as
bids, or other collusion with competitors intended to individuals, and not as a representative of The Joint
reduce competition for purchases of goods or services; Commission.
boycotts; certain kinds of exclusive dealing; in certain Lobbying The Joint Commission may participate
circumstances, the tying of the sale of one product or in designated lobbying activities:
service to a requirement to purchase another product The Joint Commission may engage in advocacy
or service; and unfair trade practices that may include when consistent with its mission, and may
L e g a l
bribery, misappropriation of trade secrets, deception, analyze and take positions on issues that have a
intimidation, or similar unfair business activity. relationship to the operations or interests of The
Joint Commission and/or the quality and safety
Standard 1.2. Tax Exemption of care;
As a tax-exempt, not-for-profit entity, The Joint The Joint Commission may offer recommenda-
Commission has a legal and ethical obligation to act tions through written or oral testimony and
in compliance with applicable tax laws, to engage in statements concerning legislation, regulations or
activities in furtherance of its charitable purpose, and policy decisions being considered by
to ensure that its resources are used in a manner which governmental agencies; and
furthers the public good rather than the private or The Joint Commission can comment on existing
personal interests of any individuals or groups of indi- federal or state law and administrative
viduals. Consequently, The Joint Commission and all procedures.
Joint Commission Personnel shall avoid compensation
arrangements in excess of fair market value, shall
5
The Joint Commission lobbying activities are coordi- In addition, no form of harassment or discrimina-
nated through Department of State & External tion on the basis of sex, sexual orientation, race,
Relations or The Joint Commissions Washington, color, disability, age, religion or ethnic origin, and
DC office. any other classification prohibited by law shall be
permitted. Each allegation of harassment or discrimi-
The Joint Commission has many contacts and nation shall be promptly investigated in accordance
dealings with governmental bodies and officials. All with applicable Joint Commission policies. Joint
such contacts and transactions shall be conducted in Commission Personnel are to contact Human
an honest and ethical manner. Any attempt to influ- Resources to report any incident of harassment or
ence the decision-making process of governmental discrimination, or with any questions relating to
representatives or officials by an improper offer of this issue.
any benefit is absolutely prohibited. Any requests or
demands by any governmental representative for any Standard 1.5. Safety
improper benefit shall immediately be reported to The Joint Commission is committed to providing a
the Corporate Compliance Officer. safe work environment for all Joint Commission
Personnel. As an employer, The Joint Commission
Standard 1.3. Protecting the shall adhere to applicable laws, regulations, rules, and
Environment guidelines to ensure an environment free from
The Joint Commission shall manage and operate its recognized hazards that might cause harm to Joint
businesses in a manner that respects its environment Commission employees. Employees are responsible
and conserves natural resources. All Joint for carrying out their duties in a safe and efficient
Commission Personnel shall strive to utilize resources manner. Safety consciousness must be a key part of
appropriately and efficiently, to recycle where possi- all Personnel thinking and planning. All Personnel
ble and otherwise dispose of all waste in accordance must report any unsafe conditions immediately,
with applicable laws and regulations, and work coop- including any suspicious, or unauthorized person
eratively with the appropriate authorities to remedy found on the premises.
any environmental contamination for which The
Joint Commission may be responsible. Standard 1.6 Intellectual Property
The Joint Commission complies with the laws and
Standard 1.4. Equal Employment regulations that govern the rights to and protection
Opportunity of our own and others copyrights, trademarks,
The Joint Commission believes that fair and equi- patents, trade secrets, and other forms of intellectual
table treatment of Joint Commission employees and property.
all who deal with The Joint Commission is critical to
fulfilling its mission, vision, and values. To further
this policy, Joint Commission employees will be
recruited, hired, trained, promoted, assigned, trans-
ferred, laid-off, recalled, and terminated based on
their own abilities in balance with corporate needs,
achievements, experience, and conduct without
regard to race, color, religion, sex, sexual orientation,
ethnic origin, age or disability, genetic information
and any other classification prohibited by law.
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Principle 2. Business Ethics
In furtherance of The Joint Commissions commit- grants or performing research of any type are respon-
ment to the highest standards of business ethics sible for maintaining high ethical standards in any
E t h i c s
and integrity, all Joint Commission Personnel written or oral communications regarding their
shall accurately and honestly represent The Joint research projects as well as for following appropriate
Commission and shall not engage in any activity research guidelines and Joint Commission policies.
or scheme intended to defraud anyone of money,
property or honest services. Further, all Joint (b) Misappropriation or Inappropriate Use
Commission Personnel shall conduct themselves of Proprietary Information
consistent with The Joint Commission Safety Joint Commission Personnel shall not misappropri-
Culture. ate confidential or proprietary information belonging
to any other person or entity or utilize any publica-
The standards set forth below provide guidance to
tion, document, computer program, information, or
ensure that The Joint Commissions business activi-
product in violation of a third partys interest in such
ties reflect the high standards of business ethics and
product. All Joint Commission Personnel shall
remain consistent with the corporate value of
ensure that they do not improperly copy for their
integrity. Leadership will inspire others to be
own use or for The Joint Commissions use any
accountable to deliver results with integrity, and all
documents or computer programs in violation of
staff will use teamwork and the sharing of informa-
applicable copyright laws or licensing agreements.
tion to foster ethical decision-making. Joint
B u s i n e s s
8
Principle 3. Confidentiality
In accordance with applicable legal and ethical stan- organization-specific information in accordance with
dards, Joint Commission Personnel shall maintain applicable laws and Joint Commission policies.
the confidentiality of The Joint Commissions intellec-
Standard 3.2. Protected Health
C o n f i d e n t i a l i t y
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Standard 3.3. Proprietary Information Standard 3.5. Certain Financial
Information, ideas, and intellectual property assets of Information
The Joint Commission are important to organiza- The Joint Commission believes in transparency of
tional success. Confidential information pertaining certain financial information. Therefore, IRS Form
to The Joint Commissions competitive position or 990 is available to the public upon request and is
strategies to accomplish its mission and information posted on The Joint Commissions web site, and the
relating to negotiations with Joint Commission Accreditation fee schedule is posted on the accredit-
Personnel or third parties shall be protected and ed organizations extranet site and is available to
shared only with Joint Commission Personnel hav- potential customers. However, the following speci-
ing a need to know such information in order to fied financial information shall be treated as confi-
perform their job responsibilities. Joint Commission dential and limited to those persons with a business
Personnel shall exercise care to ensure that The Joint need-to-know: insurance claim information; busi-
Commissions intellectual property rights, including ness rules; internal audit reports; survey contract
patents, trademarks, copyrights and software are information; customer financial information; vendor
carefully maintained and managed to preserve and bids; certain business contract information such as
protect their value. Joint Commission Personnel also negotiated discounts; tax analyses and assessments;
have an obligation to maintain the confidentiality of government approved contract rates, including cal-
any outside organizations proprietary information culations and methodology; corporate credit card
that is of a sensitive and confidential nature when information; credit card information submitted with
such is acquired in the course of providing services expense reports for employees or guest travelers; and
to that organization. When Joint Commission JCR consulting and JCI Accreditation pricing infor-
Personnel obtain knowledge of a health care organi- mation. Joint Commission Personnel shall exercise
zations intellectual property or confidential propri- due care to prevent the release or sharing of such
etary information in the course of the provision of information beyond those persons who may need
services, such knowledge shall be treated with the such information to fulfill their job functions.
same degree of confidentiality that is given to such
Joint Commission information. Standard 3.6. Information Security
The Joint Commission is committed to providing
safeguards for all confidential information. Joint
Standard 3.4. Personnel Commission Personnel are provided access to The
Actions/Decisions Joint Commissions IT network when authorized for
Salary, benefit, and other personal information relat- business purposes. Joint Commission Personnel are
ing to Joint Commission employees shall be treated responsible for ensuring that their behavior will
as confidential. Personnel files, payroll information, maintain administrative, physical and technical safe-
disciplinary matters, and similar information shall be guards. This includes but is not limited to protecting
maintained in a manner designed to ensure confi- their passwords, not accessing information to which
dentiality in accordance with applicable laws. Joint they are not authorized, not installing unauthorized
Commission Personnel shall exercise due care to pre- material on their PCs, and reporting any vulnerabili-
vent the release or sharing of information beyond ties to or breaches of security to the Joint
those persons who may need such information to Commission Security Officer.
fulfill their job functions.
10
Standard 3.7. Firewall Policies
It is of the utmost importance to The Joint
Commission to maintain the integrity and independ-
ence of The Joint Commissions Accreditation process
and the integrity of JCR consultative activities. To
prevent improper sharing of information, The Joint
Commission has created the Firewall Policy which is
designed to ensure that no confidential organization-
specific information is shared between The Joint
Commissions Accreditation functions and the consul-
tative functions of JCR. Joint Commission Personnel
are responsible for ensuring that their actions are con-
sistent with the Firewall Policy, procedures, protocols,
and guidelines that have been established. All viola-
tions to the policy must be reported to the Corporate
Compliance Officer, and all Personnel are encouraged
to raise concerns or to ask questions to clarify their
understandings of the operations of the firewall.
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Principle 4. Conflicts and
Dualities of Interest
Joint Commission employees and Board members owe organization other than The Joint Commission.
Conflicts and Dualities of Interest
a duty of undivided and unqualified loyalty to the Conflict of interest means more than individual bias.
organization. Persons holding such positions may not There must be a financial interest that could directly
use their positions to profit personally or to assist affect the work or services of Personnel to be considered
others in profiting in any way at the expense of the a conflict.
organization. Conflicts and dualities of
Commissioners and JCR Directors are more
specifically addressed in Policies and Procedures on Standard 4.1. Outside Financial Interests
Fiduciary and Confidentiality Requirements and While not all-inclusive, the following is a general
Conflicts and Dualities of Interest. Additional description of the types of activities by any Joint
provisions regarding conflicts that apply to The Joint Commission Personnel, or household member of such
Commission and JCR employees and Personnel are person, which would create a conflict or duality of
set forth in the conflicts policies of these interest:
organizations. Competition for Opportunities. Competition with The
Joint Commission by any Joint Commission employ-
ees or Board members, directly or indirectly, through
All Joint Commission Commissioners, JCR Directors,
the purchase, sale, or ownership of property or prop-
Center Directors and employees shall regulate their
erty rights or interests or business investment oppor-
activities to avoid actual impropriety and/or the appear-
tunities.
ance of impropriety that might arise from their activities
Ownership or Employment Interests. Ownership in,
or involvement with other persons or entities that, if not
employment by, or engagement in another business
disclosed, have the potential to influence the
relationship with any outside concern which does
Accreditation activities, business affairs, or plans of The
business with The Joint Commission. This does not
Joint Commission Accreditation. Joint Commission
apply to stock or other investments held in a publicly
Personnel shall not make public statements with regard
held corporation, provided that the value of the stock
to Joint Commission matters unless authorized to make
or other investments does not exceed 5% of the cor-
such statements as a representative of The Joint
porations stock. The Joint Commission may, follow-
Commission. Should a conflict or duality be identified,
ing a review of the relevant facts, permit ownership
it must be disclosed. All Personnel are encouraged to
interests which exceed these amounts if management
refer to the relevant Conflict of Interest Policy for more
concludes such ownership interests will not adversely
detail. All Personnel are encouraged to call the
impact The Joint Commissions business interests or
Corporate Compliance and Privacy Officer with any
the judgment of the affected person.
questions on whether a particular situation presents a
Conduct of Outside Business. Conduct of any business
conflict of interest.
not on behalf of The Joint Commission with any
Definition: Joint Commission vendor, supplier, contractor, or
Conflict of Interest A conflict of interest occurs when agency, or any of their officers or employees.
an interested person has a financial interest individually
or as it relates to a family member, which is disclosed as
or found to (a) impair the individuals objectivity or (b)
create an unfair competitive advantage for any person or
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Interested Transactions. Representation of The Joint All fees and/or compensation (other than reim-
Commission by any Joint Commission Personnel bursement for expenses arising from Board
in any transaction in which he or she or a house- participation) that are received for Board services
hold member has a substantial personal interest. provided during normal work hours shall be paid
Non-Financial Interests. Involvement in the man- directly to The Joint Commission.
agement or oversight of a business or charity, The Joint Commission retains the right to
whether or not competitive to The Joint prohibit membership on any Board of
Commission, which may divide the loyalty of Directors/Trustees where such membership might
Joint Commission Personnel to The Joint conflict with the best interests of The
Commission. Joint Commission or JCR.
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Principle 5. Core Activity and
Relationships
Core Activity and Relationships
Joint Commission transactions with organizations Accreditation Process Decision-Making and Gifts.
seeking to obtain or retain Accreditation, vendors, Joint Commission employees, specifically including
contractors, and other third parties shall be conduct- surveyors, directly involved in the Accreditation
ed free from offers or solicitation of gifts and favors process may not accept any form of gift from a sur-
or other improper inducements in exchange for veyed organization. A modest onsite lunch provided
influence or assistance in a transaction. by the surveyed organization may enhance the effi-
ciency of the survey and is not considered a gratuity
The standards set forth below are intended to guide key or gift. In those organizations where it is culturally
Joint Commission Personnel in determining the unacceptable to refuse a gift, such as the Indian
appropriateness of certain activities or behaviors in the Health Service and international organizations, the
context of The Joint Commissions core activities and judgment to accept a nominal gift
relationships, including relationships with organizations rests with the survey team leader.
seeking to obtain or retain Accreditation, vendors, Gifts From Existing Vendors. Joint Commission
contractors, and government entities. This policy shall Personnel may retain gifts from vendors which have
be construed broadly to avoid even the appearance of a nominal value. The Joint Commission does not
improper activity. If there is any doubt or concern as to define nominal as a specific dollar value, but
whether specific conduct or activities are ethical or expects Joint Commission Personnel to exercise good
otherwise appropriate, the Corporate Compliance judgment and discretion in accepting gifts.
Officer should be consulted. Vendor Sponsored Meals. At a vendors invitation,
Joint Commission Personnel may accept meals that
are business-related at the vendors expense, as long
Standard 5.1. Gifts and Gratuities as the amount of which falls within Joint
The Joint Commission needs to preserve and protect its Commission reimbursement guidelines. For more
reputation at all times and to avoid even the appearance detailed information, Joint Commission employees
of impropriety. Consequently, the following situations should refer to the Gift Policy.
are some examples where gift exchanges may require
additional guidance: Standard 5.2. Contracting
Gifts Influencing Decision-Making. Unless otherwise Joint Commission Personnel may not utilize insider
authorized, Joint Commission Personnel shall not information from any business activity conducted by or
accept gifts, favors, services, entertainment or other on behalf of The Joint Commission for their own
things of value to the extent that decision-making or benefit. All business relations with contractors must be
actions affecting The Joint Commission may be conducted at arms length both in fact and in appear-
influenced. Similarly, the offer or giving of money, ance and in compliance with Joint Commission policies
services, or other things of value with the expectation and procedures. Joint Commission Personnel must
of influencing the judgment or decision-making disclose personal relationships and business activities
process of any purchaser, supplier, customer, with contractor Personnel that could be construed by
government official, or other person by The Joint an impartial observer as improper with reference to the
Commission is absolutely prohibited. Any such Joint Commission Personnels performance or duties.
conduct must be reported immediately to the Joint Commission Personnel have a responsibility to
Corporate Compliance Officer.
14
obtain clarification from management on questionable state, municipal, and foreign governmental agencies, such
practices that may arise and to comply, where applicable, as the Government Accountability Office, the
with The Joint Commissions conflict of interest policies. Department of Health and Human Services, the Office of
All non-governmental grant support or sponsorship must Inspector General, the Centers for Medicare and
be approved by the Corporate Sponsorship Committee Medicaid Services, and various state agencies. However,
and formalized in an approved written agreement. when non-routine requests from government agencies are
received, employees should consult with senior manage-
Standard 5.3. Business Inducements ment, the Department of State & External Relations (for
Joint Commission Personnel shall not seek to gain any state agency requests), The Joint Commissions
advantage through the improper use of payments, busi- Washington, DC office (for federal agency requests), or
ness courtesies or other inducements. Offering, giving, the Legal Department prior to responding to such
soliciting or receiving any form of bribe or other improper requests.
payment is prohibited. Appropriate commissions, rebates,
discounts, and allowances are customary and acceptable Standard 5.5. International Business
business inducements provided that they are approved by Practices
Joint Commission management, or the CFO or his or her The policy of The Joint Commission is to abide by all
designee, and that they do not constitute illegal or unethi- laws applicable to the jurisdictions in which it operates,
cal payments. Any such payments must be reasonable in and it expects anyone doing business on its behalf to also
value, competitively justified, properly documented, and comply with those laws. All Joint Commission Personnel,
made to the business entity to whom the original agree- joint-venture partners, or anyone else doing business in
ment or invoice was made or issued. Such payments are The Joint Commissions name are required to comply
not to be made to individual employees or agents of busi- strictly with the International Business Practices Policy, the
ness entities. In addition, Joint Commission Personnel Foreign Corrupt Practices Act, and all other applicable
may provide gifts, entertainment, and meals of nominal laws.
value to Joint Commission customers, current and
prospective business partners, and other persons when
such activities have a legitimate business purpose, are
reasonable, and are consistent with all applicable laws.
15
Principle 6. Protection of Assets
All Joint Commission Personnel shall strive to Standard 6.3. Use of Corporate
preserve and protect The Joint Commissions Assets
assets by making prudent and effective use of All Joint Commission Personnel are expected to
Joint Commission resources and properly and
Assets
are protected and properly used and that financial with copyright laws as it applies to print and elec-
records and reports are accurate and reliable. All tronic materials. Prior to engaging in any activity
Joint Commission Personnel share responsibility on company time which will result in remunera-
for maintaining and complying with required tion to Joint Commission Personnel or the use of
internal controls. The Joint Commissions equipment, supplies,
materials, or services for personal or non-work
Standard 6.2. Travel and related purposes, Joint Commission Personnel shall
Entertainment obtain the approval of an appropriate manager.
Travel and entertainment expenses should be con-
sistent with each Joint Commission employees job
responsibility and the organizations needs and
resources. It is Joint Commission policy that Joint
Commission employees should not suffer financial
loss or experience financial gain as a result of busi-
ness travel and entertainment. Joint Commission
employees shall exercise reasonable judgment in the
use of Joint Commission assets and spend the
organizations assets as carefully as they would
spend their own. Joint Commission Personnel also
shall comply with Joint Commission policies relat-
ing to travel and entertainment expenses.
16
ADMINISTRATION AND APPLICATION Note: Nothing in this Code of Conduct or in other
The Joint Commission expects each person to whom policies referred to herein is intended to or shall be
this Code of Conduct applies to abide by the princi- construed as providing any additional employment or
ples and standards set forth herein and to conduct the contract rights to Joint Commission Personnel or
Accreditation activities, business, and affairs of The other persons. While it generally attempts to commu-
Joint Commission in a manner consistent with the nicate policy changes concurrent with or prior to the
general statement of principles set forth herein and in implementation of such changes, The Joint
all Joint Commission Policies and Procedures and in Commission reserves the right to modify, amend or
The Joint Commission Employee Handbook. alter this Code of Conduct and its related policies at
any time it deems necessary.
Employee Responsibilities:
Understand and comply with the Code of GETTING HELP
Conduct. When a question arises over the ethics of a particular
Prevent compliance violations and protect the rep- scenario, all Joint Commission Personnel are encour-
utation of the company. aged to make decisions consistent with the Code and
Report if you believe or suspect a violation has with maintaining the integrity of The Joint
occurred. Commission. The Joint Commissions reputation
rests on the strength of each individuals business
Leadership Responsibilities: conduct. Should any questions about this Code of
1. Officers and Managers will assume a leadership Conduct arise, the Corporate Compliance and
role in the promotion of ethical conduct and Privacy Officer should be contacted at
ensuring all employees are familiar with the Code (630) 792-5627.
of Conduct.
2. Create an open environment to support staff in REPORTING OF POTENTIAL
asking questions and making ethical decisions. VIOLATIONS
All Personnel are expected to report potential viola-
Failure to abide by this Code of Conduct, the tions of this Code of Conduct as follows:
guidelines for behavior that the Code of Conduct To your supervisor, who will report up as neces-
stipulates, or the other policies referenced herein sary;
may lead to disciplinary action. For alleged viola- If it is an HR related issue to the VP of HR at
tions, The Joint Commission shall weigh relevant #5621;
facts and circumstances, including, but not limited If the matter is related to a security breach, to the
to, the extent to which the behavior was contrary Security Officer thru the IT HELP Desk;
to the express language or general intent of the All other compliance related matters to the
Code of Conduct or other relevant policies, the Corporate Compliance and Privacy Officer at
egregiousness of the behavior, the Joint #5627;
Commission Personnels history with the organiza- If anonymity is desired to the HOTLINE at 1-
tion, and other factors which The Joint 800-750-4972.
Commission deems relevant. Discipline may, at The Joint Commission has a non-retaliation policy
The Joint Commissions discretion, range from which prohibits any punishment from good faith
verbal counseling to termination. In the event that reporting of a concern about compliance with policy
any Joint Commission Personnel are covered by or legal requirements.
the terms of a collective bargaining agreement,
discipline shall be in accordance with the
provisions of that agreement.
17
!
HIERARCHY OF JOINT COMMISSION ETHICAL PRINCIPLES
& Values,
The Joint Commission, Mission, Vision and & & of Conduct, Employee
Code & Manual and
& Policies and Procedures.
&
Definitions and Relationships with each other
Mission/Vision/Values
!
Employee Handbook
!
Summarizes key HR policies which pertain to employees.
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