St. Jude Children’s Research Hospital
Code of Conduct
Dear Colleague:
As a global leader in the research and treatment of pediatric catastrophic diseases, St. Jude Children’s Research Hospital has a reputation for defining excellence in all that we do. Our Code of Conduct (Code) outlines the high standards of professional conduct that guide us as we pursue our mission of finding cures and saving children. The Code provides guidance to each of us as we apply its principles to our daily decision-making processes. These standards of integrity apply to all employees, contractors, vendors, trainees, students, volunteers, Board members and others who conduct work on behalf of the hospital. We encourage you to educate yourself about this Code and to comply with all policies, laws and regulations that affect your St. Jude responsibilities.
As you familiarize yourself with the Code, I encourage you to reflect upon the ways you can embody its principles in all that you do. Ultimately, it is the responsibility of each of us—as well as our business partners—to abide by these high ethical standards. Together, we can continue to strengthen the hospital’s worldwide reputation by upholding the standards set forth within this Code.
James R. Downing, MD President and Chief Executive Officer
Our Mission
To advance cures, and means of prevention, for pediatric catastrophic diseases through research and treatment. Consistent with the vision of our founder, Danny Thomas, no child is denied treatment based on race, religion or a family’s ability to pay.
Our Code
Outlines the principles for how we conduct ourselves toward others and perform our duties. Our Code applies to all researchers, physicians, employees, volunteers, Board members and anyone who is conducting work on behalf of St. Jude. Following our Code ensures that we pursue the mission with the highest standards of integrity and that we continually earn and maintain the trust of our donors and those who look to us for providing care and discovering cures. Together, we are St. Jude.
Our Core Values
We are united by one mission: finding cures, saving children. We are driven by a set of core values. These principles help guide us in our behaviors and decisions –ultimately empowering every employee to deliver on our mission..
This includes: Always recognize that advancing treatment for children with catastrophic diseases is at the center of everything we do. This is why we exist. It’s what we do.
Do what is right; take ownership of what you do. We know what is right. It’s up to us to own our actions-and do what is right.
Work with purpose and urgency—your efforts matter. Every role in our institution contributes to our mission. Every moment, every decision and every idea matter.
Embrace the challenge to create a new tomorrow. Every person on our campus has something to contribute to our mission. Even during change and growth, keep sight of the power you have to influence and ignite the work around you.
Work collaboratively and help others to succeed. True success doesn’t happen on an individual basis. It requires all of us supporting and inspiring one another to reach new heights.
Always be respectful of your coworkers, our patients and their families, and visitors to our campus.
We share St. Jude with the world. This includes the diversity of backgrounds, perspectives and journey of every person who is a part of our campus. We are inclusive and we realize that we are stronger when all are valued.
Make the most of St. Jude resources, and be mindful of those who provided them.
The support for our institution is incredible. It allows us to charge into frontiers that others can only imagine. And it’s possible because of tens of thousands of people who trust us to be good stewards of their donations. We must be diligent to make their contributions count in every way possible.
The Code supplements policies and procedures that provide detailed guidance. The Code is not intended to address every issue that might arise in our daily activities, but rather serves to document and foster our commitment to ethical conduct and compliance throughout the institution. Our formal Compliance Program is the foundation upon which we conduct all aspects of our work in full compliance with all rules and regulations. Ultimate responsibility and oversight of the Compliance Program belongs to senior leadership (Chief Executive Officer) and the Board of Governors; however, the day-to-day responsibility for operation and oversight rests with the Chief Compliance Officer who is assisted by the Compliance Steering Committee.
How We Care For Our Patients
We treat our patients and their families with respect, ensuring dignity and provide each patient with quality care. Patients and their families are involved in decisions regarding their care. We inform patients about therapeutic alternatives and the risks associated with the recommended interventions.
We strive to provide the best patient centered care and support to our patients and their families in every encounter and do not discriminate in doing so, always acting in accordance with St. Jude values, our policies and applicable civil rights laws. We ensure an effective process exists to meet the written and verbal communication needs of each limitedEnglish proficient (LEP) patient and family.
We recognize that patients have the right to privacy in treatment and to confidential medical records, according to laws that govern privacy and medical records, except required reporting and permitted disclosures.
We maintain appropriate professional boundaries with our patients, understanding that they trust us for their care. We are guided by policy and the codes of ethics of our professional disciplines. We promote the well-being of our patients. However, staff should not engage in one-on-one interactions with minor patients outside of their job duties. This includes social media chatting instant messaging, text messaging and any other communications that are not aligned with professional job responsibilities. Every employee is mandated by Tennessee law and St. Jude Policies to report actual, suspected, or threatened mistreatment, neglect, abuse, or misappropriation of patient property.
How We Conduct Our Research
St. Jude research makes vital contributions to the development of new and better therapies for the treatment of children with cancer and other catastrophic diseases, and informs the global research community of our findings. We follow the highest professional standards for conducting research, whether basic science, translational research or clinical investigations.
We comply with all relevant statutes and regulations. Consistent with St. Jude policies, we pursue research with uncompromising honesty and persistence and publish our findings for the benefit of others.
We are committed to protecting the rights of research participants who take part in our research. Our research is monitored by St. Jude committees to ensure safety and protection of research participants.
The medical and scientific communities depend on the reputation and integrity of our investigators. Everyone involved in research must comply with guidelines for responsible conduct of research.
Intellectual Property and Proprietary Information
St. Jude is committed to ensuring that information gained as a result of research on the causes of pediatric catastrophic diseases will be shared with other healthcare centers and researchers world-wide, and will be utilized for the greatest possible public benefit. The Hospital recognizes that certain activities of its employees, students and trainees may produce inventions and discoveries which further support these goals. The development and dissemination of discoveries and inventions owned by the Hospital may often be best accomplished through patent protection and/or licensing of inventions.
Our Commitment To Ethical Business Practices
Appropriate Behavior
We embrace diversity and inclusion, treat everyone with respect and dignity, and act accordingly in our relationships. We have a right to work in an inclusive, professional atmosphere free from harassment, discrimination, and violence. Our actions align with our Core Values. Relationships between managers and subordinates and peers must be professional. This includes avoiding potential conflicts of interest, perceptions of unfairness, favoritism and inappropriate relationships.
Billing
Background and Exclusion Checks
We check government databases to confirm whether an applicant, employee, agent, a volunteer, vendor, or Board member has been excluded from taking part in federal or state health care or research programs. We also conduct comprehensive screenings on all final candidates with the applicants’ written permission. The Compliance Office is informed if an individual becomes excluded while working at St. Jude.
We are committed to ensuring that our billing, coding and reimbursement practices comply with all federal and state laws and regulations, as well as our institutional guidelines and policies. While our patients never receive a bill from St. Jude, we do bill third party payors if a patient has insurance. St. Jude bills only for
services that are provided and documented, and are medically necessary and appropriately ordered. We do not knowingly cause or present claims which are untrue and return any payments we identify that were received in error. Those who have knowledge of a false claim must report it to a manager, the Compliance Office or to EthicsPoint. Anyone reporting a false claim in good faith is protected from retaliation to the furthest extent possible under both federal and state laws, and St. Jude policy.
Confidentiality
We maintain the confidentiality of patients, employees and other proprietary information. We do not share confidential information with other employees or others outside the organization unless there is a legitimate St. Jude business purpose.
We understand the importance of maintaining confidentiality by limiting access to information, keeping all computer passwords or access codes secret, and preventing unauthorized access to and release of confidential information.
Conflicts of Interest and Commitment
Our staff is encouraged to participate in activities outside of the organization that further our mission, provide productive collaborations and promote the practical application of scientific discoveries.
At the same time, outside activities can create conflicts of interest and/or conflicts of commitment that may compromise or appear to compromise our work. We disclose, for review and management, those outside activities that may create conflicts of interest or commitment in order to safeguard the integrity and objectivity of our research, education, clinical judgment and business decisions.
Drug-Free Workplace
All St. Jude employees must be able to safely and effectively perform their jobs. We prohibit the unauthorized manufacture, possession, use, sale or distribution of illegal substances in the workplace.
We also acknowledge that the use of a legal medication may pose a safety risk for employees, patients or others.
Duty to Report Drug Diversion
We have a duty to report any theft, tampering, or misuse of any prescription drug or controlled substance for any purpose, including use, sale, or gift.
Equal Employment Opportunity
St. Jude ensures that employment-related decisions are based on relevant qualifications, merit, performance and other job-related factors.
Fraud, Waste and Abuse
We are fully committed to complying with the laws and regulations designed to prevent fraud, waste and abuse in government health care programs. Individuals may be found guilty of fraud or abuse if they knew or should have known something was wrong. Both situations carry significant civil and/ or criminal penalties, including exclusion from participating in federal health care programs like Medicare or Medicaid.
• Fraud is knowingly submitting an incorrect claim or using or making a false statement to obtain payment from a federal or state health care program or a private insurer.
• Waste means misuse of resources causing unnecessary costs that are wasteful to a federal or state health care program.
• Abuse describes practices that directly or indirectly results in unnecessary costs that are wasteful to a federal or state health care program.
Gifts
We seek to ensure that interactions with vendor representatives do not have the real or perceived potential to improperly influence purchasing decisions, research, clinical decision-making, or create patient safety or quality care concerns.
Government Investigations
We cooperate fully and promptly with government investigations and answer all questions in government interviews truthfully.
False reporting to governmental agencies is strictly prohibited. We also protect St. Jude’s legal rights in any government investigation by referring any governmental inquiries or requests for information, documents or interviews to the Office of Legal Services.
Health and Safety
We follow all federal, state, and local safety and environmental protection regulations. We participate in special training for handling and storing hazardous materials, disposing of hazardous wastes, fire prevention, and response to accidents, disasters and emergencies.
Legal and Regulatory Compliance
We follow all applicable laws, rules, regulations, professional standards and St. Jude policies and procedures when conducting business and operations. For example, we observe antitrust laws when entering into agreements with competitors. We are committed to complying with all applicable international laws.
Management Responsibility
Leadership requires that managers and supervisors set personal examples of integrity and set the right tone for the people who report to them. We expect our leaders to assure that everyone on the team has sufficient information and training to comply with this Code. Leaders are accountable for educating their staff about the Compliance Program, taking steps to prevent violations, taking prompt action if a violation occurs and preventing retaliation against employees for reporting good-faith concerns. We expect leaders and their staff to fully participate with external regulatory auditors or inspectors as well as with internal audits or assessments.
Political Activity
As a 501(c)(3) organization, we do not endorse or oppose any politician or candidate, allow campaign literature to be distributed on hospital premises, or participate in any campaign fundraising. It is important for politicians and candidates for elective office to better understand catastrophic pediatric diseases and biomedical research. We wish to promote such better understanding among public officials of these critical medical and scientific issues.
Referrals
We accept and make patient referrals and admissions based on the patient’s health care needs, and our resources and expertise. We do not give or receive anything of value in exchange for the referral of patients to other health care providers or suppliers. Our decisions are based solely on the well-being of patients and the expediency of their treatments.
Work Place Conduct
As members of the St. Jude team, we behave in a professional and cooperative manner while at work or when involved in St. Jude business. We observe and follow the ethical standards of our profession, exemplifying compassion, collaboration, ethical behavior and a sense of urgency to advance cure rates.
Our Commitment To Effective Resource Utilization
Financial Reporting
We are responsible for ensuring the integrity of our financial information. Our institutional policies provide guidance for properly authorizing and accurately reporting payments and transactions. We cooperate fully with internal and external auditors and any regulatory agencies that examine our records. We maintain high standards of accuracy and documentation by following industry best business practices, and by meeting external reporting requirements.
Purchasing and Contracting Practices
We enter into fair and equitable contractual arrangements with reputable vendors and individuals who meet the needs of the hospital. We comply with all applicable federal and state laws, and hospital policy. We seek opportunities to do business with small businesses, and women and minority owned businesses. We perform background and exclusion checks and do not knowingly enter into contracts with vendors, suppliers or subcontractors who are
excluded from participation in any government program.
Stewardship of Resources
We are grateful for the generous donations made to St. Jude via ALSAC and are strong stewards of donor dollars. We protect the hospital’s assets and ensure their efficient use. St. Jude resources, such as time, materials, supplies, equipment and information are for St. Jude business purposes only.
Speak Up And Report Concerns
Responsibility to Report Compliance Concerns
We are expected to report any issue or practice that we believe, in good faith, may be a violation of law, regulatory requirement, the Code or St. Jude policies. All reports are treated as confidential. St. Jude policies prohibit any negative consequences or retaliation for good-faith reporting of potential misconduct.
Reports may be submitted to:
• Supervisor or manager
• EthicsPoint Hotline (www. Ethicspoint.com or by phone at 1-800-433-1847)
• Online reporting via the Compliance intranet page
• Compliance Office (595-5563)
St. Jude policies prohibit any negative consequences or retaliation for good-faith reporting of potential misconduct.
Consequences for Non-Compliance
Any St. Jude employee who fails to comply with the Code and St. Jude policies and procedures may be subject to disciplinary action up to and including termination of employment.
Supervisors or managers who knew or should have known about a violation and failed to take reasonable actions to prevent or promptly report and correct the situation are subject to disciplinary action up to and including termination of employment.
Any St. Jude employee who fails to comply with applicable laws, rules, and regulations may be subject to disciplinary action up to and including termination of employment, personal fines, imprisonment, and exclusion from participation in Medicaid and other federal health care programs.
Failure to comply with applicable laws, rules and regulations affects all of us. St. Jude may be subject to fines and loss of confidence and trust of our patients, donors and community.
SUMMARY
Our Code of Conduct is not intended to define every aspect of our daily behavior; rather, it provides broad guidance for how we provide care to our patients, conduct research and carry out business transactions. Ultimately, it is the responsibility of everyone working at St. Jude and our business partners to abide by the highest ethical standards, while performing our work in compliance with all applicable laws, rules and regulations. This is essential if we are to further elevate our role as a national resource with a global mission of finding cures and saving children.
YOUR COMMITMENT
St. Jude espouses a culture of strong ethics and compliance, which must be supported by all employees. Our commitment to uphold this culture in our daily work is an essential characteristic for a world leader in combating childhood catastrophic diseases. Above all, we value the trust placed in us by our patients and our community. We realize that this trust will disappear if it is not continuously earned.
If you feel that our Code of Conduct is being violated, please report it to your supervisor, the Compliance Office or EthicsPoint EthicsPoints is available at www.ethicspoint.com or 1-800-433-1847.
If you have any questions about the Code of Conduct, please call Compliance at ext. 5563
I certify that I have received, read, and agree to abide by the St. Jude Children’s Research Hospital Code of Conduct. I understand that the Code of Conduct represents laws, policies, rules and regulations applicable to St. Jude Children’s Research Hospital. I understand that compliance with these laws, policies, rules and regulations is mandatory. Signature