Standard: All efforts will be made to protect personal and confidential or privileged information about UCSD patients and our health care and health sciences practices.  UCSD abides by Federal HIPAA Privacy and Security Regulations and applicable state laws.

Policy:

a.   The UCSD Healthcare Notice of Privacy Practices informs our patients how we will treat their confidential health information.  UCSD personnel shall not disclose confidential patient information unless at the patient’s request and/or authorized by law.  Approval for use of patient information for research purposes must be obtained from the Institutional Review Board.

b.   UCSD personnel are trained about privacy and security regulations as these apply to their duties.  Confidential patient information should be discussed with or disclosed to UCSD personnel on a limited, “need to know only” basis and only in response to a legal or authorized request.  The HIPAA “minimum necessary standard” is enforced.  At no time should confidential patient information be discussed with or disclosed to non-UCSD personnel, including the family or business and social acquaintances of the patient or of UCSD personnel or students, customers, suppliers or others, except as authorized by law.  Personnel and students who have questions regarding patient confidentiality should refer to UCSD policies or consult with the Health Information Management Services (HIMS) or the Compliance Office.  Breach of patient confidentiality calls for corrective or disciplinary action including, if indicated, termination of employment. UCSD policies should be updated as necessary to reflect changes to federal and state laws regarding medical records privacy.

e.        Some information may be sought under the California Public Records Act, the Information Practices Act, or other statutes requiring the release of information.  University personnel should review any such information request with a supervisor, CCO, University General Counsel or campus Administrative Records Office which handles Information Practices Act requests.

f.         Personnel shall not reveal or disclose proprietary or trade secret information to unauthorized or non-UCSD persons.  Such proprietary information may relate to UCSD business affairs or the affairs of a vendor or contractor.

g.       UCSD personnel should not reveal or disclose confidential medical staff or peer review information.  California and federal law bestows certain privileges and provides for confidentiality of certain records including the proceedings and records of organized committees of medical staff and peer review bodies.

h.       Personnel records are considered confidential.  Access to personnel files is limited to management, the human resources department staff, and internal auditors, and these individuals are held accountable for protecting the privacy of personnel records.

Question:  I discovered that a fellow employee is looking at laboratory reports on other employees and telling his friends about them.  Is this proper?

 Answer:  This is a serious problem which calls for discipline of that employee, including possible termination of employment.  The employee could be fined by the government under HIPAA regulations.  Such violation may require modification of policies, procedures or computer systems.  Immediately report the problem to your supervisor.  If you are reluctant to do that, the Compliance Office or Confidential Message line should be notified.

 Question:  Our office occasionally receives calls from patients wanting copies of their medical records.  Can we provide this information?

 Answer:   Generally, patients are entitled to receive copies or summaries of their records.  There may be exceptions to this rule (for example, minors, mental health patients).  The patient must make the request in writing.  Release of medical record information is best handled by Health Information Management Services.

 Question:  A resident physician retains copies of patient reports, claiming these are needed to qualify for specialty certification.  Is this proper?

 Question:  I received a call from the new employer of a former UCSD employee asking questions about the employee's performance while at UCSD.  Should I give out this information?

 Answer:  Information concerning employee performance is sensitive and may be confidential.  Refer all such calls to a Human Resources department at UCSD (Campus or Healthcare).

 Question:  A co-worker who developed training materials (such as a software program) for UCSD is marketing these materials on his own time to other companies.  He intends to keep the proceeds for his own use.  Is this proper or ethical?

 Answer:  Generally, UCSD owns information including  ”intellectual property” (computer programs, training materials, processes, marketing strategies) created by employees while on the job or while using UCSD resources.  Proceeds may be shared with the employee or his department.  This is a complex area and you should raise this issue with your supervisor, the Dean’s Office or Technology Transfer Office, the Compliance Officer or Confidential Message Line.

 Question:  A writer from the local paper called and asked me about details of the UCSD Medical Center’s Strategic Plan.  He is reporting on how local hospitals are reacting to the difficult health care environment.  Can I answer his questions?

 Answer:  We may have released our Plan to the press.  On the other hand, the Plan may include trade secrets.  Release of details could jeopardize the success of the Plan.  Refer the call to UCSD Health Sciences Communications at 619-543-6163.  They will know what to release.

1. The complete and accurate preparation and maintenance of all records (medical, professional, electronic, paper and institutional) by UCSD physicians, clinicians, nurses and others are important for providing quality care and conducting the business of the UCSD clinical enterprise. Accurate records are required in order for the UCSD hospital or clinic to retain licensure and accreditation.
2. UCSD personnel will not knowingly create records that contain any false, fraudulent, fictitious, deceptive or misleading information. It is unlawful to knowingly make false entries in medical records.
3. UCSD personnel must not delete any entry from a record. Medical records can be amended and material added to ensure the accuracy of the record in accordance with UCSD Medical Center and Medical Staff policies and procedures. Whenever personnel amend a record, they must indicate that the notation is an addition or correction and record the actual date that the additional entry has been made.
4. Personnel must not sign someone else’s signature or initials on a record. Electronic signatures and signature stamps may be utilized, according to UCSD and Medical Staff policies. Use of these devices is limited to the individual whose signature is so recorded. Access to these devices must be secured.
5. UCSD records shall be maintained in accordance with accepted standards and principles of the particular profession and applicable UCSD policies and procedures.
6. Unless authorized according to UCSD policy, at no time shall records be destroyed, altered after the fact or removed from the premises. The UCSD record retention and record destruction policies and procedures must be consistent with Federal and state requirements regarding the appropriate time periods for maintenance and location of records. The premature destruction of records could be misinterpreted as an effort to destroy evidence or hide information.

Question: I am an RN. A fellow RN called me from home after she completed her shift. She told me that she forgot to enter an order for a change in medication for a patient that had been phoned in at 9:00 a.m. by the patient’s physician. The nurse asked me to log the change into the patient's chart at the appropriate time, 9:00 a.m., and to use her initials. She said charts are often updated in this way and no harm is done. Is this okay?

Question: A physician writes notes in the chart of patients after she returns from a trip out of town. I know she talked to the resident on those out of town days and the notes reflect those conversations. She places the notes in the chart next to a note written on those days and does not indicate the date the notes were actually written.

Answer: Such notes may appear to an outside party to be an attempt to show a patient visit (and generate a charge) when one is not justified. It is proper to add this kind of information to the chart. However, the note should be dated when written and explain that it reflects a prior date’s conversation rather than a personal visit with the patient. This may be an innocent mistake on the part of the physician and should be immediately reported to her or by means of reporting your concern to your supervisor.

1. The UCSD Corporate Compliance Program Management Manual, available to your department office, contains detailed instructions as to how to respond to requests for information or records. If you receive such a request you should delay any response until these requirements have been reviewed.
2. If an investigator from a federal or state agency wants to talk to an individual during or after work hours, the investigator should first contact the individual's supervisor, the CCO or Risk Management. Before consenting to an interview, UCSD personnel must obtain positive identification of the investigator and ask the investigator to identify the nature and subject of the interview. If a request is made over the phone, UCSD personnel should first obtain call-back information so that we can ensure that the identification of the requestor is correct.
3. Before answering any questions, UCSD personnel have the legal right to consult with a supervisor, the CCO, Risk Management or University General Counsel. Consulting with General Counsel or retaining a personal attorney does not mean that the individual is unwilling to cooperate with the government. UCSD personnel are entitled and encouraged to have someone with them during any interview. This can be arranged through a supervisor, senior manager or the CCO. Notes should be made of interviews.
4. If the government representative wants to search UCSD facilities, UCSD personnel should ask for the legal authorization for such search, notify their supervisor and direct the government representative to the Office of the Dean, Medical Center Director or other appropriate member of senior management.
5. It may be difficult to determine what legally can or cannot be released. Prior to providing an investigator with any confidential patient, personnel, student information, or other UCSD records--either in written or verbal form--UCSD personnel must consult with a supervisor, Risk Management, Administrative Services Office, the CCO, Audit Management Advisory Services, or the General Counsel. UCSD has a responsibility to protect patient, personnel and student confidentiality.
6. UCSD personnel must never destroy or alter UCSD records in anticipation of a government request for a document or record.
7. UCSD personnel must not attempt to persuade other employees to lie or make misleading statements to a government investigator or to destroy records.

Question: The local district attorney called and asked me to give a statement regarding treatment of a particular UCSD patient. Should I respond?

Answer: We have a responsibility to protect patient confidentiality. Do not provide confidential patient information to the person who identifies himself or herself as a district attorney. Obtain the person's name and phone number and indicate he/she will be contacted by Risk Management or the Office of the General Counsel.

Question: What should I do if an FBI agent comes to my home and asks to talk to me about the activities of my department?

Answer: UCSD cannot prohibit you from talking to a government investigator if you wish to do so. However, you may consult with the UCSD General Counsel or your personal attorney before answering any questions. Asking to speak with legal counsel before answering questions is your right, is always prudent and in no way indicates that you are not cooperating fully. If you speak with the investigator, you should make notes summarizing the conversation and immediately notify your supervisor, manager or the CCO.

Question: I work in the payroll/accounts payable department and every month I process a check for a medical director. Recently I learned that the physician never performs services as a medical director. What should I do?

Answer: These are questionable circumstances. Bring this information to the attention of your supervisor, a higher level manager or another UCSD resource such as the Compliance Office.

Question: I am aware that a Home Health Agency has paid a UCSD manager to conduct an educational session. That manager helps to arrange home care for UCSD patients. Was this an improper transaction? What should I do?

Answer: This situation raises the appearance of a payment in return for referrals and must be examined. The manager may have disclosed this situation. The complex issues involved may have been examined and approval granted. You should raise this issue with your manager or an administrator or the CCO or the Confidential Message Line.

UCSD personnel should be knowledgeable about those activities that could be a violation of the antitrust laws. Examples of such activities may include, but are not limited to, the following:

i. agree, or attempt to agree, with a competitor to artificially set prices or salaries;

ii. divide markets, restrict output, or block new competitors from the market;

iii. share pricing information with competitors that is not normally available to the public;

iv. deny staff privileges to physicians or allied practitioners, individually or as a group when there is no clinical, quality or academic programming basis to do so and when such decisions should be based on individual qualifications; and

v. agree to or participate with competitors in a boycott of government programs, insurance companies, or particular drugs or products.

Agreements which expose UCSD to potential antitrust liability must be approved by senior management and General Counsel.

Question: I have a friend in the managed care department of one of our competitors. She has been asked by her company to survey managed care prices in the region. Can I give her copies of price lists and bids?

Answer: No. Any sharing with competitors of pricing information not normally available to the public could be perceived as, or be legally treated as, an effort to fix fees or limit competition.

Question: I sometimes attend trade shows or professional meetings at which I run into old friends who work for competitors of UCSD. Are there subjects that I should avoid?

1. UCSD personnel shall not use their official positions to influence a UCSD decision in which they know, or have reason to know, that they have a financial interest.
2. Personnel should follow the Compendium of University of California Specialized Policies, Guidelines, and Regulations Related to Conflict of Interest and be knowledgeable about activities that may be an actual or potential conflict of interest. Examples of such activities may include, but are not limited to, the following:

3. As a general rule, UCSD personnel should avoid contracting for goods or services with family members of other UCSD personnel. However, if family members are not directly involved in the purchasing decision and UCSD personnel disclose the relationship, General Counsel may conclude that, according to UCSD conflict of interest policy, a specific activity may not pose a conflict. In all such cases, senior and executive management, the Campus Conflict of Interest Coordinator and University General Counsel, where appropriate, should be consulted prior to engaging in any such contract or other activities that could pose a conflict of interest.
4. Personnel cannot use UCSD funds to contribute to a political party, committee, organization or candidate in connection with a federal campaign. You may, of course, make personal contributions of your own funds to the campaigns of candidates of your own choice. Such contributions are not reimbursable by UCSD.

Question: My supervisor is about to contract with a coffee vendor for a new coffee kiosk. My wife owns a coffee kiosk business. Would it be a conflict of interest if I recommend my wife's company?

Answer: Generally, UCSD avoids contracting for goods or services with family members of employees. Do not take any action that may create the impression that you are attempting to influence a UCSD purchasing decision in favor of a family member. As long as you and your wife stay out of the purchasing decision and disclose the relationship and UCSD can reach an objective decision, such arrangements may be acceptable.

Question: Many airlines, hotels and rental car companies have frequent traveler programs through which I can receive free trips, car rentals or hotel stays for my personal use. Does UCSD allow me to accumulate these points for my personal use?

Answer: Yes, you may use these credits as long as you are aware of certain responsibilities. You must be sure that you haven’t subjected UCSD or a government grant to additional expenses by scheduling a particular routing, carrier or trip simply to pursue these credits. The trip should be clearly necessary and use the most cost-effective carrier, routing and services. Personnel should be able to clearly explain their choices of timing, routing, location and carrier.

Question: In appreciation for our business, suppliers to UCSD occasionally invite me out to dinner or sports events or sponsor educational activities. Is this acceptable?

Answer: You may accept these types of invitations if they are within the bounds of the law, good taste, moderation and common sense. Your activities must not only be acceptable according to UCSD policy but must also avoid creating an appearance of impropriety. If this activity will influence (or appear to influence) a purchasing decision, it is prohibited.

Question:   I am a member of the UCSD committee which selects drugs for our formulary.  A pharmaceutical manufacturer uses me as an expert advisor for their cancer drug development.  Is this a conflict of interest?

 Answer:  It could be.  You should excuse yourself from decision about that company’s drugs.  Their payment to you should be reasonable in relation to the services you provide, avoiding the appearance of excess payment to influence your opinions on the formulary committee.

In some cases, the patient's health care program may place limits on the patient's choice of provider if the patient expects the program to cover some or all of the costs of care. The patient has the freedom to choose providers not in his or her health program or insurance panel, provided the patient is willing to pay for non-covered care.

Question: A doctor I work with always arranges for her patients to go to one skilled nursing facility (SNF) even if it is distant from where the patient's family lives.

Answer: This doctor may have had particularly favorable experiences at that SNF. On the other hand, it is proper for you to raise a question about any possible improper financial arrangements between the SNF and the doctor. Ask the doctor or your supervisor. Keep asking until you are satisfied with the answer.

UCSD will make reasonable accommodations to the known physical and mental limitations of otherwise qualified individuals with disabilities. If an individual requires accommodations or needs assistance, he/she should contact the campus Employee Assistance Program or a UCSD Human Resources Department (Campus or Healthcare).

UCSD will not tolerate harassment or discrimination by anyone based on the diverse characteristics or cultural backgrounds of those who work for the UCSD’s health centers and health systems pursuant to the University of California Nondiscrimination and Affirmative Action Policy Regarding Academic and Staff Employment.

Personnel who observe or experience any form of discrimination, harassment or violence should report the incident to their supervisor, Human Resources Department, the campus Office of Equal Opportunity & Diversity, the CCO, the Compliance Confidential Message Line, appropriate Academic Senate committee, or General Counsel. Reports of suspected violations by faculty should also be reported to the Academic Senate through the Faculty Council or Dean for Academic Affairs.

Question: My supervisor is a member of a minority ethnic group. I am not. He seems to give the best assignments and promotions to minority workers in our department.

Answer: Promotions and assignments should be based on your ability compared to your fellow workers. If your supervisor cannot explain his decisions to your satisfaction, ask his supervisor or Human Resources. You should not be harassed because you ask questions. On the other hand, when you have received a proper explanation, you have an obligation to accept these supervisory decisions and work to improve your performance so that you will be selected next time.

Question: I have a disability. My supervisor and most of my fellow workers have been fair and helpful in their interactions with me, but one worker tries to make me feel uncomfortable, implying that I am receiving favorable treatment.

Answer: Ask your supervisor to deal with this employee. Managers need to treat you fairly and make sure that others in your workplace do the same.

VI. REPORTING POTENTIAL ERRORS OR SUSPECTED VIOLATIONS

VII. REMEDIAL OR CORRECTIVE ACTION AND DISCIPLINARY PROCEDURES

CORPORATE COMPLIANCE HANDBOOK

My signature on this form acknowledges that I have received and agree to read the UCSD Health Sciences Corporate Compliance Handbook and Code of Conduct.

I confirm that I have not been excluded by the federal government from participation in any governmental program, nor to the best of my knowledge, have I been proposed for exclusion. I agree to notify the Corporate Compliance Officer or the University's Office of the General Counsel immediately upon my receiving written or verbal notification that I am proposed for exclusion from any governmental health care program.

___________________________________________ __________

Name (Please Print) Signature

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Date and Department/Division