Our Code of Conduct

Woodlawn Hospital’s physicians and employees are obligated to follow this Code of Conduct. The physicians and employees of Woodlawn Hospital must help to create a culture, which promotes the highest standards of ethics and compliance. This culture must encourage everyone in the organization to raise concerns when they arise.


Patient Care

Our mission is to provide quality healthcare to all of our patients. We treat all patients with respect and dignity and provide care that is both necessary and appropriate. We make no distinction in the admission, transfer or discharge of patients or in the care we provide based on race, color, religion, or national origin. Clinical care is based on identified patient healthcare needs, not on patient or organization economics.

Patient Information

We realize the sensitive nature of health information and are committed to maintaining its confidentiality as required by state and federal regulation. Woodlawn Hospital’s employees must never disclose confidential information and/or violate the privacy rights of our patients unless required by state or federal law. Patient information will be released only when necessary to serve the patient’s needs or if required by law, including, but not limited to, the Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Regulations.

Third-Party Payors

We will take great care to ensure that all billings to government and to private insurance payors reflect truth and accuracy and conform to all pertinent federal and state laws and regulations. We prohibit any employee or agent of Woodlawn Hospital from knowingly presenting or causing to be presented claims for payment which are false or fraudulent. We will operate oversight systems designed to verify that claims are submitted only for services actually provided and that services are billed as provided. These systems will emphasize the critical nature of complete and accurate documentation of services provided. As part of our documentation effort, we will maintain current and accurate medical records.

Regulatory Compliance

All physicians and employees must ensure compliance with all laws and regulations. Any suspected violation should be immediately reported to a supervisor, Woodlawn Hospital’s Corporate Compliance Officer, or Compliance Committee member. Woodlawn Hospital will be forthright in dealing with any billing inquiries. Requests for information will be answered with complete, factual, and accurate information. We will cooperate with and be courteous to all government inspectors and provide them with the information to which they are entitled during an inspection.

Business Information and Information Systems

Accuracy, Retention, and Disposal of Documents and Records

Each Woodlawn Hospital employee is responsible for the integrity and accuracy of the organization’s documents and records. No one may alter or falsify information on any record or document. Medical and business documents and records are retained in accordance with the law and the record retention policy. Medical and business documents include paper documents such as letters and memos, computer-based information such as e-mail or computer files on disk or tape, and any other medium that contains information about the organization or its business activities. It is important to retain and destroy records appropriately according to policy. Physicians and employees must not tamper with records, or remove or destroy them prior to the specified date.

Confidential Information

Confidential information about our organization’s strategies and operations is a valuable asset. Although you may use confidential information to perform your job, it must not be shared with others outside of Woodlawn Hospital unless the individuals have a legitimate need to know this information and have agreed to maintain the confidentiality of the information. Confidential information includes personnel data maintained by the organization, patient lists and clinical information, pricing data, information pertaining to acquisitions, divestitures, affiliations and mergers, financial data, research data, strategic plans, marketing strategies, employee lists and data maintained by the organization, supplier and subcontractor information, and proprietary computer software.

Electronic Media

All communications systems, electronic mail, intranet, internet access, or voice mail are the property of the organization and are to be primarily used for business purposes. Patient or confidential information should not be sent through the internet until such time that its confidentiality can be assured. Woodlawn Hospital reserves the right to periodically access, monitor, and disclose the contents of all communications systems, electronic mail, intranet and internet access or voice mail. Access and disclosure of individual employee actions through electronic media may only be done with the approval of the Chief Executive Officer or Corporate Compliance Officer on the advice of legal counsel. Employees may not use internal communication channels or access to the internet at work to post, store, transmit, download, or distribute any threatening; knowingly, recklessly, or maliciously false; or obscene materials including anything constituting or encouraging a criminal offense, giving rise to civil liability, or otherwise violating any laws. Additionally, these channels of communication may not be used to send chain letters, personal broadcast messages, or copyrighted documents that are not authorized for reproduction; nor are they to be used to conduct a job search or open misaddressed mail. Employees who abuse our communications systems or use them excessively for non-business purposes may lose these privileges and be subject to disciplinary action.

Financial Reporting and Records

We have established and maintained a high standard of accuracy and completeness in the documentation and reporting of all financial records. These records serve as a basis for managing our business and are important in meeting our obligations to patients, employees, members, suppliers, and others. They are also necessary for compliance with tax and financial reporting requirements. All financial information must reflect actual transactions and conform to generally accepted accounting principles. No undisclosed or unrecorded funds or assets may be established.

Workplace Conduct and Employment Practices

Conflict of Interest

A conflict of interest may occur if your outside activities or personal interests influence or appear to influence, based upon what a reasonable and disinterested third party observer might perceive when viewing the activity, your ability to make objective decisions in the course of your job responsibilities. A conflict of interest may also exist if the demands of any outside activities hinder or distract you from the performance of your job or cause you to use Woodlawn Hospital resources for other than Woodlawn Hospital purposes. It is your obligation to ensure that you remain free of conflicts of interest in the performance of your responsibilities at Woodlawn Hospital. If you have any question about whether an outside activity might constitute a conflict of interest, you must obtain the approval of your supervisor or the Corporate Compliance officer before pursuing the activity.

Diversity and Equal Employment Opportunity

We are committed to providing an equal opportunity work environment where everyone is treated with fairness, dignity, and respect. We will comply with all laws, regulations, and policies related to non-discrimination in all of our personnel actions. Such actions include hiring, employee reductions, transfers, terminations, evaluations, recruiting, compensation, corrective action, discipline, and promotions. No one shall discriminate against any individual with a disability with respect to any offer, or term or condition, of employment. We will make reasonable accommodations to the known physical and mental limitations of otherwise qualified individuals with disabilities.

Harassment and Workplace Violence

Woodlawn Hospital’s employees have the right to work in an environment free of harassment. We will not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work with us. Degrading or humiliating jokes, slurs, intimidation, or other harassing conduct is not acceptable in our workplace. Any form of sexual harassment is strictly prohibited. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions. Moreover, verbal or physical conduct of a sexual nature that interferes with an individual’s work performance or creates an intimidating, hostile, or offensive work environment has no place at Woodlawn Hospital. Harassment also includes incidents of workplace violence. As part of our commitment to a safe workplace for our employees, we prohibit employees from possessing firearms, other weapons, explosive devices, or other dangerous materials on Woodlawn Hospital’s premises. Employees with prior permission from the Chief Executive Officer keep certain weapons in their vehicles with certain restrictions as outlined in HR Policy #896 – Violence in the Workplace. Employees who observe or experience any form of harassment or violence should report the incident to their supervisor or the Human Resources Director.

License and Certification Renewals

Employees and individuals in positions which require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials and shall comply at all times with federal and state requirements applicable to their respective disciplines. To assure compliance, Woodlawn Hospital may require evidence of the individual having a current license or credential status. Woodlawn Hospital will not allow any employee or independent contractor to work without valid, current licenses or credentials.

Relationships with Subcontractors and Suppliers

Our selection of subcontractors, suppliers, and vendors will be made on the basis of objective criteria including quality, technical excellence, price, delivery, adherence to schedules, service, and maintenance of adequate sources of supply. Our purchasing decisions will be made on the supplier’s ability to meet our needs, and not on personal relationships and friendships. We will always employ the highest ethical standards in business practices in source selection, negotiation, determination of contract awards, and the administration of all purchasing activities.


We follow high ethical standards, as well as applicable state and federal laws, in any research conducted by our physicians and professional employees. We do not tolerate intentional research misconduct. Research misconduct includes making up or changing results or copying results from other studies without performing the research. All patients asked to participate in a research project are given a full explanation of alternative services that might prove beneficial to them. They are also fully informed of potential discomforts and are given a full explanation of the risks, expected benefits, and alternatives. The patients are fully informed of the procedures to be followed, especially those that are experimental in nature. Refusal of a patient to participate in a research study will not compromise their access to services. All personnel applying for or performing research of any type are responsible for maintaining the highest ethical standards in any written or oral communications regarding their research projects as well as following appropriate research guidelines. As in all accounting and financial record keeping, our policy is to submit only true, accurate, and complete costs related to research grants.

Substance Abuse

To protect the interests of our employees and patients, we are committed to an alcohol and drug-free work environment. All employees must report for work free of the influence of alcohol and illegal drugs.

Marketing Practices

We may use marketing and advertising activities to educate the public, provide information to the community, increase awareness of our services, and to recruit employees. We will present only truthful, fully informative, and non-deceptive information in these materials and announcements. All marketing materials will reflect services available and the level of licensure and certification.

Business Courtesies

Extending Business Courtesies to Non-Referral Sources

It is critical to avoid impropriety, or the impression of impropriety, based upon what a reasonable and disinterested third party observer might perceive, when giving gifts to individuals who do business or are seeking to do business with Woodlawn Hospital. We will never use gifts or other incentives to improperly influence relationships or business outcomes. Gifts to business associates who are not government employees must not exceed $200.00 per year per recipient.

Extending Business Courtesies to Possible Referral Sources

Any entertainment or gift involving physicians or other persons who are in a position to refer patients to our healthcare facility must be undertaken in accordance with all Federal laws, regulations, and rules regarding these practices. Gifts of significant monetary value must receive Board approval.

The Corporate Compliance Program

Program Structure

Woodlawn Hospital’s Compliance Program is intended to demonstrate the commitment of the organization to the highest standard of ethics and compliance. There is a Corporate Compliance Officer, Privacy Officer, Information Security Officer and a Compliance Committee. These individuals are prepared to support you in meeting the standards set for in this code.

Resources for Guidance and Reporting Violations

To report a suspected violation, you may choose from several options. You may speak with the Corporate Compliance Officer or any member of the Compliance Committee, or utilize the anonymous hotline. The Compliance Hotline is 1-888-893-8981. It is posted on the employee bulletin boards throughout the facility and is located on the cover of the Code of Conduct handbook. Each employee receives a Code of Conduct handbook at orientation and also can be obtained in the Human Resources Office. Woodlawn Hospital will make every effort to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports possible misconduct. There will be no retribution or discipline for anyone who reports a possible violation in good faith. Any employee who deliberately makes a false accusation with the purpose of harming or retaliating against another employee will be subject to discipline.

Personal Obligation to Report

We are committed to ethical and legal conduct that is compliant with all relevant laws and regulations and to correcting wrongdoing wherever it may occur in the organization. Each employee has an individual responsibility for reporting any activity by a fellow employee, physician, subcontractor, or vendor that appears to violate applicable laws, rules, regulations, or this Code.

Internal Investigations of Reports

We are committed to investigate all reported concerns promptly and confidentially to the extent possible. The Corporate Compliance Officer will coordinate any findings from the investigations and immediately recommend corrective action or changes that need to be made. We expect all employees to cooperate with investigation efforts.

Corrective Action

Where an internal investigation substantiates a reported violation, it is the policy of the organization to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting whatever disciplinary action is necessary, and implementing systemic changes to prevent a similar violation from recurring in the future. Woodlawn Hospital will consult legal council, if necessary, prior to any corrective action.


All violators of the Code will be subject to disciplinary action. The precise discipline utilized will depend on the nature, severity, and frequency of the violation and may result in any of the following disciplinary actions: Verbal warning; Written warning; Suspension; Termination; and/or Restitution.

Internal Audit and Other Monitoring

Woodlawn Hospital is committed to the aggressive monitoring of compliance with its policies. The monitoring effort is conducted by various departments within Woodlawn Hospital, which routinely conducts internal audits of issues that have regulatory or compliance implications.
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