Code of Professional Conduct
The Washington Hospital Healthcare System (WHHS) is committed to excellence in:
1. Patient care
2. Education and training
4. Stewardship of district resources
WHHS follows the Patient First Ethic; all decisions made and actions taken
are based on what is in the best interest of the patient.
To further the goal of excellence and the Patient First Ethic, all at WHHS
are expected to adhere to the Code of Professional Conduct in their interactions
with patients, colleagues, other health professionals, students and the public.
For the Code, there is reference to "staff." In this context,
the term staff includes, the board of directors, employees, members of
the medical staff, volunteers, contracted workers, students and instructors.
The Code of Professional Conduct is a series of principles that govern
professional interactions. The Code consists of two complementary sections:
professional obligations and professional ideals. "Obligations"
refer to professional behaviors that are required by the ethical foundation
of the WHHS Ethics Statement. "Ideals" refer to professional
behaviors that professionals at all levels should attempt to acquire because
they enhance professional excellence.
The Code applies to all staff at WHHS involved in the clinical, teaching,
research and administrative activities of the Center. Because of its broad
reach, certain portions of the Code will be more directly applicable to
some disciplines than to others. For example, the clinical portions apply
to physicians, nurses, technicians and all other professionals engaged
in patient care. Similarly, those portions pertaining to teaching and
research apply to all professionals engaged in teaching and research regardless
of discipline or level of training. The portions pertaining to students
apply to trainees at all levels. The general portions of the Code, which
discuss confidentiality, conflicts of interest, interpersonal relations
and the professional ideals apply to all WHHS staff.
Failure to meet the professional obligations described below represents
a violation of the WHHS Code of Professional Conduct. Infractions of the
professional obligations of the Code will be dealt with by the appropriate
WHHS disciplinary committees and processes. Failure to meet the professional
ideals, although less serious, also may be grounds for disciplinary review.
A. Professional Obligations
Respect for Persons
* Maintain the Patient First Ethic.
* Treat patients and staff with the same degree of respect you would wish
them to show you.
* Treat patients with kindness, gentleness and dignity.
* Respect the privacy and modesty of patients.
* Do not use offensive language, verbally or in writing, when referring
to patients or their illnesses.
* Do not harass others physically, verbally, psychologically or sexually.
* Do not discriminate on the basis of sex, religion, race, disability,
age or sexual orientation.
* Refrain from behavior that includes intimidation, foul language, threats
of violence or retaliation.
* Refer to patients by their name, not by their diagnosis or location.
* Avoid the use of first names without permission in addressing adult patients.
* Respect with tolerance, the religion, culture and customs of patients,
visitors and staff.
* Realize that patients and their visitors are in an environment that
can be unfamiliar and frightening. Communicate frequently in language
that a layperson can understand.
Respect for Patient Confidentiality
* Do not share medical information with anyone except those health care
professionals integral to the care of the patient or within the context
of Hospital operations.
* Do not discuss patients or their illnesses in public places where the
conversation may be overheard.
* Do not publicly identify patients, in spoken words or in writing, without
* Do not invite or permit unauthorized persons into patient care areas
of the institution.
* Do not share your confidential computer system passwords.
* Do not access confidential patient information without a professional
"need to know."
* Do not misuse electronic mail.
* Do not remove confidential patient information from the premises. Staff
that must do this in the scope of their job must assure appropriate safeguards
are in place to protect the information.
* Be truthful in verbal and in written communications.
* Do not cheat, plagiarize, or otherwise act dishonestly.
* Maintain accurate, honest records of patient care and business activities,
which include following procedures to correct and amend records and to
make late entries in medical records.
Integrity means strict adherence to a code or set of values such as this
Code of Professional Conduct, the American Nurse's Association's
Code of Ethics for Nurses, or the American Medical Association's Code
* Acknowledge your errors of omission and commission to colleagues, supervisors
* Make patient care decisions based on patients' needs and desires
not on financial preferences or compensation.
* Do not knowingly mislead others.
* Do not abuse special privileges, e.g., making unauthorized long-distance
Responsibility for Patient Care
* Obtain the patient's informed consent for diagnostic tests or therapies
and respect the patient's right to refuse care or procedures.
* Assume responsibility for the patients under your care until you have
handed off (transferred) the care to another professional and that professional
has acknowledged the transfer of care.
* Follow up on ordered laboratory tests and complete patient record documentation
promptly and conscientiously.
* Assure that all patients' tests and treatments are completed and
followed up appropriately.
* Coordinate with your team the timing of information sharing with patients
and their families to present a coherent and consistent treatment plan.
* Do not abuse alcohol or drugs that could diminish the quality of patient
care or your professional performance.
* Do not develop romantic or sexual relationships with patients; if such
a relationship seems to be developing, seek guidance and terminate the
* Do not abandon a patient. If you are unable/unwilling to continue care,
you have an obligation to assist in making a referral to another competent
practitioner willing to care for the patient.
Professional Growth & Awareness of Limitations
* Be aware of your personal limitations and deficiencies in knowledge
and abilities and know when and whom to ask for supervision, assistance
* Know when and for whom to provide appropriate supervision.
* Students and other trainees should have all patient workups and orders
reviewed and countersigned by the appropriate supervisor.
* Do not involve patients in personal issues or solicit for personal gain.
* Do not engage in unsupervised involvement in areas or situations where
you are not adequately trained.
Deportment as a Professional
* Clearly identify yourself and your professional level to patients and
staff; wear your name badge at all times above the waist and in plain view.
* Always maintain the confidentiality of business information and trade secrets.
* Dress in a neat, clean, professionally appropriate manner. Maintain
professional composure despite the stresses of fatigue, professional pressures,
or personal problems.
* Do not make offensive or judgmental comments about patients or staff,
verbally or in writing.
* Do not criticize the medical decisions of colleagues in the presence
of patients or staff or in the medical record.
* Do not access confidential staff information without a professional
need to know.
* Do not abuse alcohol or drugs that could diminish the quality of patient
care or professional performance.
* Do not participate in political campaigns including the wearing of political
buttons and discussion of political issues while on WHHS premises.
Avoiding Conflicts of Interest
* Resolve clinical conflicts of interest in favor of the patient.
* While on the premises do not accept gifts of value from drug companies
or vendors or suppliers.
* Do not participate in vendor incentive programs without disclosure.
* Do not refer patients to laboratories or other healthcare facilities
in which you have a direct financial stake without disclosure.
* Do not accept a "kickback" (any payment intended to influence
decisions) for any patient referral.
* For staff in decision-making positions, disclose any outside financial
interests or commercial activities, including those of immediate family
members, domestic partners or others with a significant personal relationship,
that may represent a conflict of interest and affect professional performance.
Responsibility for Peer Behavior
* Take the initiative to identify and help impaired staff with the assistance
of the Employee Assistance Program, Employee Health Services, Physicians'
Well-Being Committee or other appropriate referrals. (Impairment includes,
but is not limited to, alcohol and/or drug abuse, depression, other physical
or mental illness).
* Report serious breaches of the Code of Professional Conduct to the appropriate
person, if unsure, discuss the situation with your supervisor or department
chair. You may report directly to the Compliance Officer.
* Indicate disapproval or seek appropriate intervention if you observe
less serious breaches.
* No action of retaliation or reprisal shall be taken against anyone who
reports suspected fraud or improper conduct.
* Anyone who attempts to or encourages others to retaliate against an
individual who has reported a violation will be subject to disciplinary action.
Respect for Personal Ethics
* You are not required to perform procedures (e.g., elective abortions,
termination of medical treatment) that you, personally, believe are unethical,
illegal, or may be detrimental to patients.
* Should a patient request a treatment contrary to your personal values
but consistent with current standards of care, you have a duty to refer
the patient to another practitioner or facility for such treatment.
Respect for Property and Laws
* Adhere to the regulations and policies of WHHS, e.g., policies governing
fire safety, hazardous waste disposal and universal precautions.
* Adhere to local, state and federal laws and regulatory standards.
* Do not misappropriate, destroy, damage, or misuse property of WHHS.
Integrity in Research
* Report research results honestly in scientific and scholarly presentations
* When publishing and presenting reports, give proper credit and responsibility
to colleagues and others who participated in the research.
* Report research findings to the public and press honestly and without
* Avoid potential conflicts of interest in research; disclose funding
sources, company ownership and other potential conflicts of interest in
written and spoken research presentations.
* Adhere to WHHS policies and procedures that govern research using human subjects.
Use of WHHS' Computer Systems
* Obtain proper authorization before using WHHS computing resources.
* Do not use WHHS computing resources for purposes beyond those for which
you are authorized.
* Do not share access privileges (account numbers and/or passwords).
* Do not electronically transmit or distribute material that would be
in violation of existing WHHS policies or guidelines.
* Respect the privacy of other users. More specifically, do not read,
delete, copy, or modify another user's data, information, files, e-mail
or programs (collectively, "electronic files") without the other
user's expressed permission.
* Do not intentionally introduce any program or data intended to disrupt
normal operations (e.g., a computer "virus" or "worm")
into WHHS computer systems.
* Do not perform forgery or attempt forgery of e-mail messages.
* Do not circumvent or attempt to circumvent normal resources limits,
log-on procedures, or security regulations.
* Do not use WHHS information technology resources for any private activity.
Do not export WHHS systems for personal use.
* Endeavor to use WHHS information computing resources in an efficient
and productive manner. Avoid game playing, use of streaming video or audio,
printing excessive copies of documents, files, data, or programs; or attempting
to crash or tie-up computer resources.
Respect for Business Ethics
* Charge patients for all and only clinical services provided at the appropriate
level as defined by WHHS policy.
* Ensure that payment requests from vendors, employees and other payees
are processed promptly, accurately and with the appropriate level of documentation.
* Do not promise payments to vendors or other payees or sign contracts
that are beyond the scope of your authority.
* Report all and only hours worked on employee timecards.
* Submit authorized employee timecards that follow the rules and regulations
of the bargaining unit, WHHS, the State of California and the Federal
* Do not take or borrow property or cash from patients, visitors or WHHS.
* Do not use WHHS supplies for personal use.
* Record all financial transactions accurately and promptly.
* Provide reports and other information that is accurate, complete, relevant,
timely and understandable.
* Do not offer patients discounts or write/offs without proper approval.
* Maintain the confidentiality of employee information.
* Maintain the confidentiality of WHHS' financial information.
* Code medical records accurately, consistent with industry guidelines.
Do not upcode to improve reimbursement.
B. Professional Ideals
* Cultivate and practice clinical virtues, such as caring, empathy and
* Fulfill your professional responsibilities conscientiously.
* Notify the responsible supervisor if something interferes with your
ability to perform tasks effectively.
* Learn from experience and grow from the knowledge gained from errors
to avoid repeating them.
* Dedicate yourself to lifelong learning and self-improvement by implementing
a personal program of continuing learning and continuous quality improvement.
* Complete all tasks accurately, thoroughly, legibly and in a timely manner,
this may include attending and participating in meetings and conferences.
* Follow through on whatever you have agreed to do.
* Avoid patient involvement when you are ill, distraught or overcome with
* Cooperate with all other members of the Health Care System.
* Teach others.
* Be generous with your time when answering questions from staff, patients
* Shoulder your fair share of the institutional burden by adopting a spirit
of volunteerism and altruism.
* Use communal resources (equipment, supplies and funds) responsibly and
* Avoid providing professional care to members of your family or to persons
with whom you have a close, personal relationship.
Responsibility to Community
* Avoid unnecessary patient or societal health care monetary expenditures.
* Provide appropriate emergency services to all patients regardless of
their ability to pay.
* Avoid behaviors that impair the community's confidence in the Healthcare System.
* Demonstrate behavior that ensures the future viability of the Healthcare
System for the residents of the District.
Additional guidelines regarding Professional Conduct exist in some departments
and affiliated organizations of WHHS including, but not limited to, the
Medical Staff, Volunteer Services and Information Services.