Center for the Study of Ethics in the Professions at IIT

Preface

The Code of Ethics is administered by the Ethics Committee, which is appointed by the Board of Governors upon nomination by the Chairman. It is composed of at least nine Fellows of the College, each of whom serves a three-year term on a staggered basis, with three members retiring each year.

The Ethics Committee shall:

• Review and evaluate annually the Code of Ethics, and make any necessary recommendations for updating the Code.

• Review and recommend action to the Board of Governors on allegations brought forth regarding breaches of the Code of Ethics.

• Develop ethical policy statements to serve as guidelines of ethical conduct for healthcare executives and their professional relationships.

• Prepare an annual report of observations, accomplishments, and recommendations to the Board of governors, and such other periodic reports as required.

The Ethics Committee invokes the Code of Ethics under authority of the ACHE Bylaws, Article II, Membership, Section 6, Resignation and Termination of Membership; Transfer to Inactive Status, subsection (b), as follows:

Membership may be terminated or rendered inactive by action of the Board of Governors as a result of violation of the Code of Ethics; nonconformity with the Bylaws or Regulations Governing Admission, Advancement, Recertification, and Reappointment; conviction of a felony; or conviction of a crime of moral turpitude or a crime relating to the healthcare management profession. No such termination of membership or imposition of inactive status shall be effected without affording a reasonable opportunity for the member to consider the charges and to appear in his or her own defense before the Board of Governors or its designated hearing committee, as outlined in the "Grievance Procedure," Appendix I of the College's Code of Ethics.

Preamble

The purpose of the Code of Ethics of the American College of Healthcare Executives is to serve as a guide to conduct for members. It contains standards of ethical behavior for healthcare executives in their professional relationships. These relationships include members of the healthcare executive's organization and other organizations. Also included are patients or others served, colleagues, the community and society as a whole. The Code of Ethics also incorporates standards of ethical behavior governing personal behavior, particularly when that conduct directly relates to the role and identity of the healthcare executive.

The fundamental objectives of the healthcare management profession are to enhance overall quality of life, dignity and well-being of every individual needing healthcare services; and to create a more equitable, accessible, effective and efficient healthcare system.

Healthcare executives have an obligation to act in ways that will merit the trust, confidence and respect of healthcare professionals and the general public. Therefore, healthcare executives should lead lives that embody an exemplary system of values and ethics.

In fulfilling their commitments and obligations to patients or others served, healthcare executives function as moral advocates. Since every management decision affects the health and well-being of both individuals and communities, healthcare executives must carefully evaluate the possible outcomes of their decisions. In organizations that deliver healthcare services, they must work to safeguard and foster the rights, interests and prerogatives of patients or others served. The role of moral advocate requires that healthcare executives speak out and take actions necessary to promote such rights, interests and prerogatives if they are threatened.

I. The Healthcare Executive's Responsibilities to the Profession of Healthcare Management

The healthcare executive shall:

1. Uphold the values, ethics and mission of the healthcare management profession;

2. Conduct all personal and professional activities with honesty, integrity, respect, fairness and good faith in a manner that will reflect well upon the profession;

3. Comply with all laws pertaining to healthcare management in the jurisdictions in which the healthcare executive is located, or conducts professional activities;

4. Maintain competence and proficiency in healthcare management by implementing a personal program of assessment and continuing professional education;

5. Avoid the exploitation of professional relationships for personal gain;

6. Use this Code to further the interests of the profession and not for selfish reasons;

7. Respect professional confidences;

8. Enhance the dignity and image of the healthcare management profession through positive public information programs; and

9. Refrain from participating in any activity that demeans the credibility and dignity of the healthcare management profession.

   II. The Healthcare Executive's Responsibilities to Patients or Others Served, to the Organization and to Employees

   A. Responsibilities to Patients or Others Served

   The healthcare executive shall, within the scope of his or her authority:

   1. Work to ensure the existence of a process to evaluate the quality of care or service rendered;

   2. Avoid practicing or facilitating discrimination and institute safeguards to prevent discriminatory organizational practices;

   3. Work to ensure the existence of a process that will advise patients or others served of the rights, opportunities, responsibilities and risks regarding available healthcare services;

   4. Work to provide a process that ensures the autonomy and self-determination of patients or others served; and

   5. Work to ensure the existence of procedures that will safe-guard the confidentiality and privacy of patients or others served.

   B. Responsibilities to the Organization

   The healthcare executive shall, within the scope of his or her authority:

   1. Provide healthcare services consistent with available resources and work to ensure the existence of a resource allocation process that considers ethical ramifications;

   2. Conduct both competitive and cooperative activities in ways that improve community healthcare services;

   3. Lead the organization in the use and improvement of standards of management and sound business practices;

   4. Respect the customs and practices of patients or others served, consistent with the organization's philosophy; and

   5. Be truthful in all forms of professional and organizational communication, and avoid disseminating information that is false, misleading, or deceptive.

   C. Responsibilities to Employees

   Healthcare executives have an ethical and professional obligation to employees of the organizations they manage that encompass but are not limited to:
   

   1. Working to create a working environment conducive for underscoring employee ethical conduct and behavior.

   2. Working to ensure that individuals may freely express ethical concerns and providing mechanisms for discussing and addressing such concerns.

   3. Working to ensure a working environment that is free from harassment, sexual and other; coercion of any kind, especially to perform illegal or unethical acts; and discrimination on the basis of race, creed, color, sex, ethnic origin, age or disability.

   4. Working to ensure a working environment that is conducive to proper utilization of employees' skills and abilities.

   5. Paying particular attention to the employee's work environment and job safety.

   6. Working to establish appropriate grievance and appeals mechanisms.

   III. Conflicts of Interest

   A conflict of interest may be only a matter of degree, but exists when the healthcare executive:

   1. Acts to benefit directly or indirectly by using authority or inside information, or allows a friend, relative or associate to benefit from such authority or information.

   2. Uses authority or information to make a decision to intentionally affect the organization in an adverse manner. The healthcare executive shall:

      1. Conduct all personal and professional relationships in such a way that all those affected are assured that management decisions are made in the best interests of the organization and the individuals served by it;

      2. Disclose to the appropriate authority any direct or indirect financial or personal interests that pose potential or actual conflicts of interest;

      3. Accept no gifts or benefits offered with the express or implied expectation of influencing a management decision; and

      4. Inform the appropriate authority and other involved parties of potential or actual conflicts of interest related to appointments or elections to boards or committees inside or outside the healthcare executive's organization.

   IV. The Healthcare Executive's Responsibilities to Community and Society

   The healthcare executive shall:

   1. Work to identify and meet the healthcare needs of the community;

   2. Work to ensure that all people have reasonable access to healthcare services;

   3. Participate in public dialogue on healthcare policy issues and advocate solutions that will improve health status and promote quality healthcare;

   4. Consider the short-term and long-term impact of management decisions on both the community and on society; and

   5. Provide prospective consumers with adequate and accurate information, enabling them to make enlightened judgments and decisions regarding services.

   V. The Healthcare Executive's Responsibility to Report Violations of the Code

   A member of the College who has reasonable grounds to believe that another member has violated this Code has a duty to communicate such facts to the Ethics Committee.

   Appendix I

   American College of Healthcare Executives Grievance Procedure

   1. In order to be processed by the College, a complaint must be filed in writing to the Ethics Committee of the College within three years of the date of discovery of the alleged violation; and the Committee has the responsibility to look into incidents brought to its attention regardless of the informality of the information, provided the information can be documented or supported or may be a matter of public record. The three-year period within which a complaint must be filed shall temporarily cease to run during intervals when the accused member is in inactive status, or when the accused member resigns from the College.

   2. The Committee chairman initially will determine whether the complaint falls within the purview of the Ethics Committee and whether immediate investigation is necessary. However, all letters of complaint that are filed with the Ethics Committee will appear on the agenda of the next committee meeting. The Ethics Committee shall have the final discretion to determine whether a complaint falls within the purview of the Ethics Committee.

   3. If a grievance proceeding is initiated by the Ethics Committee:

   1. Specifics of the complaint will be sent to the respondent by certified mail. In such mailing, committee staff will inform the respondent that the grievance proceeding has been initiated, and that the respondent may respond directly to the Ethics Committee; the respondent also will be asked to cooperate with the Regent investigating the complaint.

   2. The Ethics Committee shall refer the matter to the appropriate Regent who is deemed best able to investigate the alleged infraction. The Regent shall make inquiry into the matter, and in the process the respondent shall be given an opportunity to be heard.

   3. Upon completion of the inquiry, the Regent shall present a complete report and recommended disposition of the matter in writing to the Ethics Committee. Absent unusual circumstances, the Regent is expected to complete his or her report and recommended disposition, and provide them to the Committee, within 60 days.

   1. Upon the Committee's receipt of the Regent's report and recommended disposition, the Committee shall review them and make its written recommendation to the Board of Governors as to what action shall be taken and the reason or reasons therefore. A copy of the Committee's recommended decision along with the Regent's report and recommended disposition to the Board will be mailed to the respondent by certified mail. In such mailing, the respondent will be notified that within 30 days after his or her receipt of the Ethics Committee's recommended decision, the respondent may file a written appeal of the recommended decision with the Board of Governors.

   2. Any written appeal submitted by the respondent must be received by the Board of Governors within 30 days after the recommended decision of the Ethics Committee is received by the respondent. The Board of Governors shall not take action on the Ethics Committee's recommended decision until the 30-day appeal period has elapsed. If no appeal to the Board of Governors is filed in a timely fashion, the Board shall review the recommended decision and determine action to be taken.

   3. If an appeal to the Board of Governors is timely filed, the College Chairman shall appoint an ad hoc committee consisting of three Fellows to hear the matter. At least 30 days' notice of the formation of this committee, and of the hearing date, time and place, with an opportunity for representation, shall be mailed to the respondent. Reasonable requests for postponement shall be given consideration.

   4. This ad hoc committee shall give the respondent adequate opportunity to present his or her case at the hearing, including the opportunity to submit a written statement and other documents deemed relevant by the respondent, and to be represented if so desired. Within a reasonable period of time following the hearing, the ad hoc committee shall write a detailed report with recommendations to the Board of Governors.

   5. The Board of Governors shall decide what action to take after reviewing the report of the ad hoc committee. The Board shall provide the respondent with a copy of its decision. The decision of the Board of Governors shall be final. The Board of Governors shall have the authority to accept or reject any of the findings or recommended decisions of the Regent, the Ethics Committee or the ad hoc committee, and to order whatever level of discipline it feels is justified.

   6. At each level of the grievance proceeding, the Board of Governors shall have the sole discretion to notify or contact the complainant relating to the grievance proceeding; provided, however, that the complainant shall be notified as to whether the complaint was reviewed by the Ethics Committee and whether the Ethics Committee or the Board of Governors has taken final action with respect to the complaint.

   7. No individual shall serve on the ad hoc committee described above, or otherwise participate in these grievance proceedings on behalf of the College, if he or she is in direct economic competition with the respondent or otherwise has a financial conflict of interest in the matter, unless such conflict is disclosed to and waived in writing by the respondent.

   8. All information obtained, reviewed, discussed and otherwise used or developed in a grievance proceeding that is not otherwise publicly known, publicly available, or part of the public domain is considered to be privileged and strictly confidential information of the College, and is not to be disclosed to anyone outside of the grievance proceeding except as determined by the Board of Governors or as required by law; provided, however, that an individual's membership status is not confidential and may be made available to the public upon request.

   Appendix II

   Ethics Committee Action

   Once the grievance proceeding has been initiated, the Ethics Committee may take any of the following actions based upon its findings:

   1. Determine the grievance complaint to be invalid.

   2. Dismiss the grievance complaint.

   3. Recommend censure.

   4. Recommend transfer to inactive status for a specified minimum period of time.

   5. Recommend expulsion