CHOP Vendor Guide The Children’s of

The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
CHOP Vendor Guide
Supply Chain Mgmt | Vendor Guide
Page 1
The Children’s Hospital of Philadelphia
th
Table of Contents
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Doing Business with CHOP ............................................................................................................................................................ 4
Hospital Background ...................................................................................................................................................... 4
Mission statement ......................................................................................................................................................... 4
Supply Chain Department .............................................................................................................................................. 4
Diversity ......................................................................................................................................................................... 5
Hospital Policies ........................................................................................................................................................................... 6
Vendor Policies .............................................................................................................................................................. 6
Business Associate Agreements..................................................................................................................................... 7
Standard Vendor Terms and Conditions........................................................................................................................ 8
Confidentiality of patient and institutional information ............................................................................................... 9
Medication Samples and Vouchers ............................................................................................................................... 9
Safety ............................................................................................................................................................................. 9
Use of wireless RF Transmitting Devices ................................................................................................................... 9
Fire and Emergency plans ............................................................................................................................................10
New Product Introduction / Evaluation .......................................................................................................................11
Vendor Requirements .................................................................................................................................................................. 11
Vendor Criteria.............................................................................................................................................................11
Vendor Credentialing ...................................................................................................................................................12
Vendor Credentialing ...................................................................................................................................................13
Registration ..................................................................................................................................................................15
Vendor Recertification .................................................................................................................................................15
Visits .............................................................................................................................................................................18
Appointment Guidelines ..............................................................................................................................................18
Check-in Procedures ....................................................................................................................................................18
Main Hospital Campus .................................................................................................................................................18
Abramson Building/Colket Translational Research Building .......................................................................................18
Wanamaker Building and 3535 Market Street ............................................................................................................19
Kids First, Primary & Specialty Care Centers, and Ambulatory Surgical Centers ........................................................19
Hospital and Parking Maps ..........................................................................................................................................19
Financials .................................................................................................................................................................................... 20
Procurement ................................................................................................................................................................20
Accounts Payable Shared Services Center ...................................................................................................................21
CHOP Accounts Payable changes.................................................................................................................................21
Change to bill address ..............................................................................................................................................21
Supply Chain Mgmt | Vendor Guide
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The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Change AP Contact Information ..............................................................................................................................21
Use Purchase Orders ................................................................................................................................................21
Electronic Invoicing ......................................................................................................................................................22
Support Contact/Resources .........................................................................................................................................22
Appendix ..................................................................................................................................................................................... 23
FAQs .............................................................................................................................................................................24
Vendormate Approach ................................................................................................................................................26
Security and Badging Policy .........................................................................................................................................27
Supply Chain Mgmt | Vendor Guide
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The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Doing Business with CHOP
Hospital Background
Since its start in 1855 as the nation's first hospital devoted exclusively to caring for children, The Children's Hospital
of Philadelphia has been the birthplace for many dramatic firsts in pediatric medicine. The Hospital has fostered
medical discoveries and innovations that have improved pediatric healthcare and saved countless children’s lives.
Over 150 years of innovation and service to our patients, their families and our community, reflect an ongoing
commitment to exceptional patient care.
The Children’s Hospital of Philadelphia was ranked No. 1 in more specialties than any other pediatric hospital in the
nation, earning it top honors in U.S. News & World Report’s 2012-13 survey of Best Children's Hospitals.
Today, the Hospital has 430 beds and had more than 1 million outpatient and inpatient visits last year.
Mission statement
The Children's Hospital of Philadelphia, the oldest hospital in the United States dedicated exclusively to pediatrics,
strives to be the world leader in the advancement of healthcare for children by integrating excellent patient care,
innovative research and quality professional education into all of its programs.
Supply Chain Department
Supply Chain is responsible for the contracting, procurement and storage of supplies, equipment and services, as
well as managing supply expenses across the organization
Value
Analysis
Manage the
introduction of
new products
Contracting
Procurement
Materials
Distribution
Acquisition of goods Provide central location
Develop sourcing
for receiving and
and services
strategies, facilitate
distributing products
RFX process and offer
ongoing support
Process and Technology
Supply Chain Mgmt | Vendor Guide
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The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Diversity
At The Children’s Hospital of Philadelphia, we believe that each person brings a special worldview that contributes to
the high quality of patient care, research and education for which we’re renowned.
We respect, value and honor the differences that our employees bring to CHOP. Different cultures. Different
backgrounds. Those differences may include race and ethnicity, gender, age, sexual orientation, physical ability, and
national origin or ancestry.
We believe that these very differences help us to remain innovators at the forefront of pediatric care. Every person
that we employ — whether performing direct patient care, conducting research, or providing clinical or
administrative support — plays an essential part in ensuring our continued excellence.
“I would like to see a multicultural workforce where all employees can contribute their best and work
effectively together without regard to race or ethnicity, physical ability, sexual orientation, religion, gender,
job position or educational level. In order to do this, we need to interweave diversity into all aspects of the
Hospital's systems and operations. Diversity needs to be a part of our recruitment and retention strategies,
promotional considerations, training and internal and external communications, just to name a few. By
ensuring that diversity is a part of all of our processes then we also ensure that we have a culture that is
inclusive and not exclusive for both our staff and patients alike.”
Steven M. Altschuler, MD
President and Chief Executive Officer
Supply Chain Mgmt | Vendor Guide
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The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Hospital Policies
Vendor Policies
Supply Chain Mgmt | Vendor Guide
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THE CHILDREN’S HOSPITAL OF PHILADELPHIA
No. A-3-7
Title:
Page 1 of 20
ADMINISTRATIVE
POLICY MANUAL
INTERACTIONS WITH VENDORS
Effective Date:
7/1/2009
POLICY
It is the policy of the Hospital that interactions with Vendors comply with applicable law, meet
ethical standards, avoid or minimize conflicts of interest, protect patient and research subject
confidentiality, and promote fair and open dealings.
PURPOSE
The purposes of this Policy are to: provide guidance regarding appropriate interactions of Hospital
healthcare and research professionals and administrative staff with Vendors; minimize the undue
influence or perceived undue influence of Vendors on the business decisions of Hospital
professionals and administrative staff and the practice patterns of Hospital professionals; and
support safety and privacy of patients and research subjects.
SCOPE
This Policy applies to all Trustees, Officers, employees and members of the Medical and
Research Staffs of The Children’s Hospital of Philadelphia, including The Children's Hospital
of Philadelphia Research Institute, the CHOPPA Practice Plans (currently Children’s
Anesthesiology Associates, Children’s Health Care Associates, Children’s Surgical
Associates, Radiology Associates of Children’s Hospital, and their New Jersey Affiliates) and
entities controlling, controlled by or under common control with The Children's Hospital of
Philadelphia, including, without limitation, The Children’s Hospital of Philadelphia Foundation
(together, the ”Hospital”), as well as any others who are providing services or conducting
research at facilities owned or operated by the Hospital or otherwise on behalf of the Hospital
or whose presence at or affiliation with the Hospital may place them in a position to interact
with Vendors on behalf of the Hospital (all such persons referenced under Scope, “Hospital
Personnel”).
All Vendors are expected to abide by this Policy with respect to their interactions with Hospital
Personnel or while in Hospital Facilities, including not engaging or attempting to engage in any
conduct that could cause Hospital Personnel to violate this Policy.
RELATED POLICIES
Administrative Policy Manual
Administrative Policy Manual
Administrative Policy Manual
Administrative Policy Manual
Administrative Policy Manual
Administrative Policy Manual
Patient Care Manual
No. A-3-1 Conflicts of Interest
No. A-1-4 Organizational Ethics Statement
No. A-1-5 Compliance Standards of Conduct
No. A-4-17 Gifts to Employees
No. A-3-8 Control of On-Site Activity by Vendors
No. A-4-3 Introduction of New Medical Devices,
Products and Equipment
No. TX-7-05 Medication Samples and Vouchers
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
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ADMINISTRATIVE
POLICY MANUAL
INTERACTIONS WITH VENDORS
Effective Date:
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DEFINITIONS
A. “Hospital” means The Children’s Hospital of Philadelphia, including The Children's
Hospital of Philadelphia Research Institute, the CHOPPA Practice Plans (currently
Children’s Anesthesiology Associates, Children’s Health Care Associates, Children’s
Surgical Associates, Radiology Associates of Children’s Hospital, and their New Jersey
Affiliates) and entities controlling, controlled by or under common control with The
Children's Hospital of Philadelphia, including, without limitation, The Children’s Hospital of
Philadelphia Foundation.
B. “Hospital Facilities” means any facility owned, leased, licensed or otherwise in the
possession of the Hospital.
C. “Hospital Personnel” means Trustees, Officers, employees and members of the Medical
and Research Staffs of the Hospital, and others who are providing services or conducting
research at facilities owned or operated by the Hospital or otherwise on behalf of the
Hospital or whose presence at or affiliation with the Hospital may place them in a position
to interact with Vendors on behalf of the Hospital. 1
D. “Vendors” means entities and persons that have or are seeking to enter into business
relationships with the Hospital (e.g., to provide any equipment, product, supply, facility,
item or service for which payment may be made, including but not limited to a
pharmaceutical product, medical device, or other clinical equipment, product or supply), as
well as the representatives and agents of such entities or persons. 2
IMPLEMENTATION
I.
GENERAL PRINCIPLES
A. The selection of and conduct of business with a Vendor should be solely on the basis of
arm’s length (i.e., free from improper or inappropriate influence) and appropriate business,
medical, clinical and/or research criteria, as applicable, such as cost effectiveness and
quality. The selection and conduct of business should not be made on the basis of, or be
influenced by, past, present or future gifts to or for the benefit of Hospital Personnel,
1
This Policy is not intended to apply to Hospital Trustees to the extent they are not involved in decision
making with respect to the recommendation, use or purchase by the Hospital of particular equipment,
products, supplies, facilities, items or services.
2
A Hospital Trustee who owns, works for or has another business relationship with a Vendor is not
considered a Vendor for purposes of this Policy when (1) acting only in his/her capacity as a Trustee
and (2) there are no discussions of the Vendor’s business relationship with the Hospital. For example,
a Trustee who is an executive with a company that provides services to the Hospital may host a
Hospital executive at an entertainment event to the same extent as any other Trustee, provided the
Trustee does not discuss the company’s dealings with the Hospital.
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INTERACTIONS WITH VENDORS
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donations to the Hospital, support to the Hospital or Hospital Personnel such as clinical,
research or educational support, or factors other than fair and open dealings based on
appropriate business, medical, clinical and/or research criteria.
B. Hospital Personnel should conduct business with Vendors in a way that maximizes the
ability of the Hospital to carry out its patient care, research and educational missions, and in
accordance with legal and ethical standards and Hospital policies aimed at preventing
conduct that may inappropriately influence purchasing decisions or be perceived as doing
so.
C. Vendors may not offer or provide, and neither Hospital Personnel nor the Hospital may
solicit or accept from a Vendor, any gift, compensation or payment of any kind or in any
amount that is:
1. given to influence, or could be perceived as being given to influence, Hospital
Personnel or the Hospital with respect to prescribing, recommending, using or
purchasing pharmaceutical, medical device, clinical equipment, products or
supplies, or any other equipment, products, supplies, facilities, items or services.
2. given based on considerations such as the value or volume of patient referrals,
purchases or other business generated; or
3. intended to induce patient referrals.
D. Vendors have no right of access to Hospital Personnel or the Hospital. Vendors may, in the
discretion of the Hospital, have access to Hospital Personnel and the Hospital to promote
their products or business if based solely on arm’s length and appropriate business,
medical, clinical and/or research criteria, as applicable; provided, however, that such
access may not be influenced by the receipt, or expectation of receipt, of any gift,
compensation or payment of any kind from or on behalf of a Vendor to the Hospital or
Hospital Personnel.
E. The Hospital and Hospital Personnel are held to high standards with respect to appropriate
dealings with third parties. Many practices that are common in other industries are illegal or
prohibited in the case of a health care organization, physicians, other health care providers,
and companies engaged in the manufacture, distribution, marketing or sale of
pharmaceuticals, medical devices, and other clinical equipment, products and supplies.
Federal and state laws set strict standards for relationships between providers and
Vendors. In all interactions with or on behalf of Vendors, Hospital Personnel will endeavor
to adhere to all relevant legal standards and the highest standards of ethics and integrity.
F. The Hospital and Hospital Personnel should avoid conflicts of interest, including the
appearance that decisions with respect to the use of pharmaceuticals, medical devices, or
other equipment, products, supplies, facilities or services are influenced by benefits
expected or received from or on behalf of a Vendor.
ADMINISTRATIVE
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INTERACTIONS WITH VENDORS
Effective Date:
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G. Although this Policy is intended to address a broad spectrum of situations that arise
involving the interactions between Vendors and the Hospital or Hospital Personnel,
questions may arise about situations that do not appear to be covered by this Policy or
the Hospital’s Conflicts of Interest Policy (A-3-1). In those circumstances, Hospital
Personnel should seek advice from their Department Chair or applicable Senior
Manager, the Office of General Counsel, or the Office of Compliance and Privacy.
H. Even where interactions with Vendors are not prohibited under this Policy, they may be
prohibited or circumscribed by other agreements, guidelines or policies. For example,
they may be prohibited under the Hospital’s Conflicts of Interest Policy (A-3-1) or
require advance approval and/or disclosure under the Hospital’s Conflicts of Interest
Policy (A-3-1). In addition, there may be other restrictions. For example, outside
activities (e.g., permissible consulting activities) generally are required to be performed
on a person’s own time (e.g., vacation day, weekend or evening when not providing
services for the Hospital) and in the person’s personal capacity and not as a
representative of the Hospital.
II. GIFTS, MEALS AND COMPENSATION
A. Personal Gifts (Gifts to or for the Benefit of Hospital Personnel)
1.
Hospital Personnel are deemed to have received a “gift” where an item of value is
given to them or for their benefit and something of equal value is not provided in
exchange. It includes the receipt of free or discounted items that are given to or for
the benefit of Hospital Personnel.
a. Gifts include cash in any form, cash equivalents such as gift certificates,
property or the use of something of value. Gifts can include goods,
hospitality, services, travel and travel expenses, use of something of value
such as a vacation home, tickets or admissions to events or functions,
including but not limited to sporting events, cultural events, and social
entertainment, payment of obligations, and any other items of value.
b. Gifts also include the payment, subsidy or reimbursement of any travel or
lodging expenses for a spouse, family member or guest accompanying
Hospital Personnel to any meeting or conference unless such person is
participating in a professional capacity.
c. Hospital Personnel are deemed to have received a gift where the item of
value is given to them personally, or to their designee, or as a result of their
actions or expected actions to a member of their family, person with whom
they live or another person, where such person’s receipt of the gift is valued
by the Hospital Personnel.
d. Meals are discussed separately in II. C below.
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INTERACTIONS WITH VENDORS
Effective Date:
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e. Honoraria or other payment for the provision of specific permissible
substantive services rendered (e.g., speakers fees), including the provision or
reimbursement of reasonable travel and food, is not considered a gift
provided the compensation is reasonable for the services rendered and
treated as compensation (e.g., reported as compensation for tax purposes to
the extent required). See also the Conflicts of Interest Policy (A-3-1)
regarding outside compensated activities and, with regard to consulting
arrangements, additional requirements such as advance review and
approval.
f.
Gifts do not include attendance at an event or function with a Vendor where
the expense of attending the event or function is borne by Hospital Personnel
personally or by the Hospital (where appropriate).
i.
If a Vendor offers to host Hospital Personnel at an event or function, it
does not violate this Policy if Hospital Personnel attends if: (1)
Hospital Personnel pays the cost for the Hospital Personnel to attend
either personally or the Hospital pays if appropriate (either by directly
purchasing a ticket or paying an admission charge, or paying the
Vendor for its cost of Hospital Personnel’s attendance); and (2)
attendance is approved by the Hospital Personnel’s supervisor at
least at the Department manager or division chief level (or a
designee).
ii. In special cases, however, where the cost for the Hospital Personnel
to attend an event or function hosted by a Vendor varies significantly
from the fair market value of the attendance (e.g., a sold out playoff
football game), the fair market value of the attendance may be the
more appropriate measure of the payment for the attendance, and
should be considered by the Hospital’s supervisor (or a designee)
along with the decision on whether to approve the attendance, in
consultation with the Office of General Counsel or Office of
Compliance and Privacy if appropriate. See also II. F. for exception
process.
2. Gifts may not be offered by or on behalf of a Vendor to Hospital Personnel and
Hospital Personnel may not accept gifts offered to them by or on behalf of
Vendors. Hospital Personnel may not solicit gifts from Vendors.
a. A Vendor purchasing sponsorship or tickets to a Hospital fundraising event
(e.g., Daisy Day, Carousel Ball, an auxiliary golf outing) may not give tickets
to a Hospital Department or program, or to individual Hospital Personnel, to
be used by Hospital Personnel and/or their guests to attend the event at the
Vendor’s expense. If a Vendor has tickets that it does not intend to use and
wishes to donate them to the Hospital, the Vendor may return the tickets to
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INTERACTIONS WITH VENDORS
Effective Date:
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The Children’s Hospital of Philadelphia Foundation, which may distribute
the tickets if it chooses to do so, including to Hospital Personnel.
b. Notwithstanding this prohibition on gifts to individuals, Hospital Personnel
are permitted under this Policy to attend, in person or by telephone,
webcast or similar means, Vendor-run educational programs that are
offered for free to all attendees, not just Hospital Personnel, and to accept
books or other written or electronic materials provided to all attendees
regarding the subject matter of the program. This exception applies only to
Hospital Personnel’s attendance at the program and the acceptance of
educational materials provided in connection with the program, but not to
the receipt of other gifts or meals that may be offered by Vendors at the
program, which remain subject to the general restrictions set forth in this
II.A and II.C. 2 below.
i.
See, however, Section V below regarding the consideration to be
given to the decision to attend Vendor-run educational programs that
are not accredited.
3. Hospital Personnel may not accept gifts or compensation for time spent listening
to, meeting with or accessing websites of Vendors or their representatives
promoting or explaining their products.
4. Hospital Personnel may not accept compensation, including payment or
reimbursement of expenses, from Vendors simply for attending a CME or other
activity or conference unless the person is speaking, teaching or otherwise
engaged in a meaningful substantive role and the total compensation, including
payment or reimbursement of expenses, is reasonable given the role. See partial
exception for Trainees at Section IX.
B. Gifts to or for the Benefit of the Hospital or Clinical Departments
1. The Hospital or a Clinical Department may accept non-cash gifts serving a
substantial clinical, research, educational or other mission function, such as
anatomical models, medical textbooks, charts, and products or samples for
evaluation purposes, provided each of the following requirements is met:
a. The gift is not given to, or intended to be for the personal benefit of Hospital
Personnel.
b. In the case of a single gift with a value in excess of $500, or more than one
gift in a July 1 fiscal year with a total value in excess of $1,000 from a single
Vendor, including affiliated entities, to the Hospital or a Clinical Department,
advance approval must be given by a person at the level of Vice President
or higher or the applicable Department Chair, or a designee.
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C. Meals or Other Food
1. On-site
Vendors may not provide or fund and Hospital Personnel may not accept meals
or other types of food or drink at Hospital Facilities. This prohibition includes
holiday gift baskets, trays of cookies or pretzels and sodas sent to a
department or unit.
2. Off-site
a. The position of the Association of American Medical Colleges (AAMC) is
that with the exception of food provided in connection with Accreditation
Council for Continuing Medical Education (ACCME)-accredited
programming and in compliance with ACCME guidelines, food and meals
supplied or paid for by industry are personal gifts that academic medical
center personnel should not accept when off-site, just as when on-site
within academic medical centers. AAMC Report on Industry Funding of
Medical Education (June 2008).
b. The Pharmaceutical Research and Manufacturers of America (PhRMA), in
its Code on Interactions with Healthcare Professionals, prohibits: (i) meals
in connection with informational presentations made by field sales
representatives or their immediate managers at off-site locations, including
restaurants; and (ii) meals provided directly by pharmaceutical companies
at CME events (meals provided by and at the discretion of the CME
provider using financial support provided by a pharmaceutical company are
not prohibited). PhRMA Code on Interactions with Healthcare Professionals
(effective
January 2009).
c. The following guidelines apply to off-site meals for Hospital Personnel:
i.
Vendors may not provide or fund and Hospital Personnel may not
accept meals outside of Hospital Facilities other than at a Vendor’s
office premises (see c.ii below). Examples of prohibited off-site meals
could include a Vendor-hosted meal at a restaurant, catering facility,
or local hotel or conference center for a business meeting or
presentation by the Vendor.
ii. Vendors may provide or fund and Hospital Personnel may accept
meals while at the office premises of Vendors if there is a legitimate
business purpose to the meal, the setting and nature of the meal are
appropriate to the business purpose and are not excessive or
extravagant, the meal does not include the spouse, family member or
guest of Hospital Personnel, and the frequency of such meals is not
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excessive. Examples could include a modest lunch or dinner at a
Vendor’s office during an extended session working on a business
transaction, a modest working lunch at a Vendor’s office, or a modest
lunch during an educational seminar hosted at a Vendor’s office for its
clients or customers.
iii. The principles set forth in II.A.1.f, regarding events or functions
hosted by Vendors and paid for by Hospital Personnel or the Hospital,
apply equally with respect to meals with Vendors paid for by Hospital
Personnel or the Hospital.
iv. This is not intended to preclude Hospital Personnel from partaking of
a meal or social event (e.g., a reception) provided or funded indirectly
with Vendor support, if: (1) the meal or social event is provided in
connection with an ACCME accredited conference or program
attended by Hospital Personnel and in conformity with the ACCME
Standards for Commercial Support; (2) the meal or social event is
provided in connection with a state Nurses Association accredited
continuing education conference or program attended by Hospital
Personnel and in conformity with applicable standards for commercial
support; or (3) the meal or social event is provided by and in
connection with a conference or program conducted by an established
third-party scientific, educational or professional organization or other
company that offers educational conferences and programs, provided,
however, that the organizer may not be affiliated with any Vendor.
For example, if a Vendor sponsors a lunch at an annual meeting
conducted by a professional society, Hospital Personnel attending the
meeting may partake of the meal. If, however, a Vendor invites
attendees of a professional society’s meeting to a dinner at a
restaurant that includes substantive educational presentations,
Hospital Personnel may attend the educational presentation but may
not accept the dinner unless the Hospital Personnel personally pays
for the dinner or, where appropriate, the Hospital pays for the dinner.
D. Sample Medications and Vouchers
The Medication Samples and Vouchers Policy (Patient Care Manual No. TX-7-05)
governs issues relating to obtaining medical samples and vouchers from Vendors.
E. Other Potentially Improper Attempts to Influence
1. Even where a dealing is at fair market value, a conflict can arise because a Vendor
provides a personal opportunity to Hospital Personnel, or a member of their family
or person with whom they maintain a living arrangement approximating a family
relationship, that might not have been provided but for the Vendor’s business
relationship or potential business relationship with the Hospital.
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2. Examples could include a Vendor offering the spouse or child of Hospital
Personnel a job with the Vendor. Even though the spouse or child will be paid fair
market value for the services provided, the opportunity for the job may constitute a
prohibited attempt to influence.
3. In such situations, Hospital Personnel should seek guidance from their Department
Chair, applicable Senior Manager, the Office of General Counsel or the Office of
Compliance and Privacy,
F. Exceptions
1. Personal Friendships. The Hospital recognizes that there are situations in which
Hospital Personnel have personal friendships with employees of Vendors that
developed outside of the business relationship. For example, Hospital Personnel
may be in a tennis group or book club that includes employees of Vendors. This
Policy does not prohibit Hospital Personnel from personal encounters such as
going to dinner at the home of an employee of a Vendor or attending a wedding of
the child of an employee of a Vendor where Hospital Personnel have such a
personal friendship such that, over the long run, there is a mutual reciprocity (e.g.,
the Hospital Personnel alternatively takes the employee of the Vendor to dinner)
and the employee of the Vendor is personally paying for the personal encounter. If
the Vendor company is paying for the encounter, this exception does not apply.
Where there is any question about the appropriateness of the encounter or where
the encounter involves the employee of the Vendor paying for restaurant meals,
entertainment or gifts, Hospital Personnel should seek guidance from their
supervisor at least at the Department manager or division chief level (or a
designee), the Office of General Counsel, or the Office of Compliance and Privacy.
In addition, where Hospital Personnel have a personal friendship with an employee
of a Vendor and will be in a decision-making role with respect to the use or
purchase of equipment, products supplies or services from the Vendor (or a
competitor of the Vendor with respect to the product or services under
consideration), Hospital Personnel must disclose the existence of the personal
friendship to their Department Chair or applicable Senior Manager and a process
should be employed to avoid the potential for the personal friendship to influence
the decision making in question.
2. Hospital Personnel as Guests of Others at Vendor Events. This policy does not
prohibit attendance by Hospital Personnel at a meal or other event paid for or
provided by a Vendor where: (1) the Hospital Personnel attends as a guest of
someone, such as a spouse, who is not Hospital Personnel (“Host”), (2) the Host
works for the Vendor or has another business relationship with the Vendor that is
unrelated to the relationship the Vendor has or hopes to have with the Hospital
Personnel or Hospital, (3) the invitation is extended by the Vendor to the Host
because of the Host’s business relationship with the Vendor and not the
relationship the Vendor has or hopes to have with the Hospital Personnel or the
Hospital, and (4) the invitation from the Vendor to the Host and to all other invitees
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includes an invitation to bring a spouse, guest and/or other family members. For
example, a Hospital employee whose spouse works for a Vendor may accompany
his spouse to an annual holiday party for the Vendor’s employees and their
spouses.
3. Employee Discount Programs. This policy does not prohibit employee discounts
under an established corporate discount program offered by a Vendor to the
Hospital provided: (1) the discounts are made available to all Hospital Personnel,
and (2) the discount program is approved in advance by a member of Senior
Management.
4. Other Exceptions.
a. Exceptions to these restrictions on gifts, meals and compensation may be
granted in limited circumstances with advance approval (see 4.b below).
Requests for exceptions should be evaluated on a case-by-case basis,
considering factors such as:
i.
The value to the Hospital of the associated activity.
ii. The feasibility or appropriateness of the Hospital and/or Hospital
Personnel paying for or reimbursing the Vendor for the gift, meal or
compensation.
iii. The role of the Hospital Personnel in question and the potential for the
receipt of the gift, meal or compensation to influence the Hospital’s
relationship with the Vendor.
iv. The presence or absence of other safeguards to promote fair and
arms-length dealings with the Vendor.
v. The extent to which external standards (e.g., professional societies,
AAMC, PhRMA) provide guidance on the specific situation.
An example of a situation in which it may be appropriate to grant an
exception is where a Vendor is honoring Hospital Personnel with an
established award funded by the Vendor. In such case, Hospital Personnel
and their family may be given permission to attend the dinner at which the
award is given and to accept the award.
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b. The following process applies to the granting of exceptions in accordance
with F.4.a:
i.
In the case of Hospital Personnel (other than a member of Senior
Management at the level of Vice President or Department Chair or
higher), an exception may be granted with advance approval by both:
(1) a member of Senior Management at the level of Vice President or
Department Chair or higher; and (2) the General Counsel or Chief
Compliance Officer, or their designees.
ii. In the case of a member of Senior Management at the level of Vice
President or Department Chair or higher, an exception may be
granted with advance approval by both: (1) the Chief Executive Officer
or a designee; and (2) the General Counsel or Chief Compliance
Officer.
iii. In the case of the Chief Executive Officer, an exception may be
granted with advance approval by the Chair of the Audit &
Compliance Committee of the Boards of Trustees or a designee.
III. SPEAKERS BUREAUS
A. The position of the AAMC is that participation by faculty in industry-sponsored
speakers bureaus should be strongly discouraged. The AAMC excepts situations in
which academic investigators are presenting results of their industry-sponsored
studies to peers and there is opportunity for critical exchange. AAMC Report on
Industry Funding of Medical Education (June 2008). The Hospital supports the
position of the AAMC with respect to Hospital Personnel participation on speakers
bureaus.
B. While the Hospital discourages the participation of Hospital Personnel in speakers
bureaus, it does not prohibit participation in speakers bureaus under all circumstances.
Participation in speakers bureaus is prohibited where conflict issues arise under the
Hospital’s Conflicts of Interest Policy (A-3-1)
C. Speakers bureaus raise particular concerns in the case of clinicians and researchers
who are speaking on professional topics. Clinicians and researchers may not agree to
any restrictions by industry regarding the content of their professional presentations or
related materials, should not allow industry to censor their presentations or related
materials, and should not allow industry to have final approval of their presentations or
related materials (except with respect to limiting disclosure of confidential information
that does not compromise the presentations or related materials). If any materials are
provided by others (such as a graph provided by industry showing study results) and
used in the presentations or related materials, the clinician or researcher must
acknowledge the source of the materials. It is, however, prohibited for a clinician or
researcher to be paid by industry to present materials prepared by the company (even
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though properly acknowledged to have been prepared by the company) where the
person has a clinical or research involvement at the Hospital with a product related to
the materials. In rare situations, exceptions may be granted on approval of the
relevant Chair or the Chief Operating Officer, as applicable (or their designees), and
the Research Review Committee.
IV. GHOSTWRITING
A. Ghostwriting is the provision of written material that is officially credited to someone
other than the writer(s) of the material. It includes unacknowledged, undisclosed
provision of content. Transparent writing collaboration with attribution between
academic and industry investigators, medical writers, and/or technical experts is not
ghostwriting.
B. Hospital Personnel are prohibited from allowing their professional presentations of any
kind, oral or written, to be ghostwritten by any party, industry or otherwise.
V. VENDOR- RUN EDUCATIONAL PROGRAMS
A. The position of the AAMC is that academic medical center faculty and trainees should
not attend industry events billed as continuing medical education that are not
accredited by the ACCME. AAMC Report on Industry Funding of Medical Education
(June 2008). Examples of Vendor events billed as continuing medical education
include Vendor-sponsored seminars at off-site locations and Vendor-sponsored journal
clubs.
B. While the Hospital does not prohibit attendance at Vendor-run educational programs
that are not accredited, all Hospital Personnel should carefully consider the propriety of
attending.
1. See II.A.2.b regarding the exception to the prohibition on gifts to individuals for
attendance at Vendor-run educational programs offered for free to all attendees
and the acceptance of educational materials provided in connection with the
program.
2. The provision by Vendors and receipt by Hospital Personnel of other gifts or meals
that may be offered by Vendors at Vendor-run educational programs remain
subject to the general restrictions set forth in II.A and II.C.2. For example, with
respect to meals, Hospital Personnel attending a Vendor-run educational program
at a Vendor’s office may partake of a modest lunch offered during the program.
However, Hospital Personnel attending a Vendor-run educational program at an
off-site location other than a Vendor’s office (e.g., a restaurant) may not accept a
lunch offered during the program unless the Hospital Personnel personally pays for
the lunch or, where appropriate, the Hospital pays for the lunch.
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VI. VENDOR FUNDING FOR EDUCATIONAL PROGRAMS AT OR SPONSORED BY THE
HOSPITAL
A. ACCME Programs
Vendor funding for any educational program sponsored or organized by the Hospital or
conducted in a Hospital Facility and accredited by the ACCME for continuing medical
education credit is: (i) handled exclusively by the Continuing Medical Education
Department of the Office of Medical Staff Affairs; and (ii) subject to the ACCME
Standards for Commercial Support. The ACCME Standards for Commercial Support
may be found at www.accme.org.
B. Nursing Continuing Education Programs
Vendor funding for any educational program sponsored or organized by the Hospital or
conducted in a Hospital Facility and qualifying for continuing nursing education credit
(contact hours) awarded by a state Nurses Association, an accredited approver by the
American Nurses Credentialing Center’s Commission on Accreditation or equivalent
accrediting entity is: (i) handled exclusively by the Office of Nursing Education; and (ii)
subject to the standards for commercial support required by the state Nurses
Association.
C. Standards for Vendor Funding for Educational Programs
While certain programs such as those that qualify for ACCME or state Nurses
Association credit may be subject to additional or more stringent requirements, Vendor
funding for all educational programs sponsored or organized by the Hospital or
conducted in a Hospital facility is, at a minimum, subject to the following requirements:
1. The funding from the Vendor may not be in consideration of or related to any
business relationship, whether past, present or future, existing or desired.
2. The funding from the Vendor must be provided in the form of a grant to The
Children’s Hospital of Philadelphia or The Children’s Hospital of Philadelphia
Foundation, and may not be made to an individual.
3. The funding must be documented in a written agreement between the Vendor and
The Children’s Hospital of Philadelphia or The Children’s Hospital of Philadelphia
Foundation, in a form approved by the Office of General Counsel.
4. For educational programs involving clinicians or involving researchers engaged in
clinical trials, except for funding for state Nurses Association continuing nursing
education programs as described in VI.B above, the Continuing Medical Education
Department of the Office of Medical Staff Affairs approves all funding and, in
consultation with the Office of General Counsel, approves the written agreement
memorializing the support.
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5. For other educational programs not described in VI.C.4 above, funding should be
approved by a member of Senior Management at the level of Vice President or
Department Chair or higher.
6. The Vendor may not have any role with respect to the educational content of the
program, including with respect to the program topics, objectives, content,
methods, speakers or evaluations.
7. The fact that the Vendor has provided funding for the program must be disclosed to
all participants in the written materials, if any, and, if none, verbally at the outset of
the program or lecture; provided, however, that the acknowledgement must be
limited to the Vendor’s name as a sponsor of the program.
8. If there is any financial or in-kind relationship in any amount within the past 12
months between the Vendor, including affiliated entities, and any presenter, author
whose materials are being presented, researcher whose results are being
presented or a person with control over the content of or speakers at the program,
such relationship must be disclosed to all participants in the written materials, if
any, and, if none, verbally at the outset of the program or lecture. The disclosure
must include the following information: (a) the name of the individual; (b) the name
of the Vendor; and (c) the nature of the relationship the person has with the
Vendor. If there is no financial or in-kind relationship between an individual
presenter, author or researcher and the Vendor, the fact that no such relationship
exists must be disclosed to all participants in the written materials, if any, and, if
none, verbally at the outset of the program or lecture.
9. The content or format of the program and its related materials must be educational
and not for the purpose of promoting a specific proprietary business interest of a
commercial interest. If the educational materials or content includes trade names,
where available trade names from several companies should be used, not just
trade names from a single company. If presentations speak to a therapeutic
option, the presentation must give a balanced view of appropriate therapeutic
options.
10. Product promotion material or product-specific advertisement of any type is
prohibited in or during the educational activity. Live (staffed exhibits,
presentations) or enduring (printed or electronic advertisements) promotional
activities must be kept separate from the educational activity. Educational materials
that are part of the educational activity (such as slides, abstracts and handouts)
may not contain any advertising, trade name or product-group message or
promotion.
11. The funding from the Vendor will be used to pay expenses in connection with the
program (such as payment of honoraria and expenses for outside lecturers, and
provision of modest meals for participants in conjunction with the educational
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program, but the funding may not be used to pay, including payment or
reimbursement of expenses, any person simply for attending the program) in
accordance with Hospital policy in effect from time to time; provided, however, that
if all of the funds are not needed to support the program, then any remaining
monies will be available for other medical education purposes in accordance with
Hospital policy in effect from time to time unless such use was prohibited by the
Vendor when it provided the funding.
12. The intent of this Section VI.C. is to apply key principles of the ACCME Standards
for Commercial Support to Vendor funding of non-ACCME /state Nurses
Association accredited educational programs sponsored or organized by the
Hospital or conducted in a Hospital Facility. For additional guidance in the
interpretation of the standards set forth herein, see the ACCME Standards for
Commercial Support (available at www.accme.org).
VII. PURCHASING DECISION MAKING
A. Hospital Personnel who are involved in decision making with respect to the use or
purchase of equipment, products, supplies or services should avoid the appearance of
a conflict of interest with respect to Vendors.
1. Certain Hospital Personnel, such as employees involved in the Hospital’s Supply
Chain, have such significant Vendor interactions that they are held to a higher
standard in terms of avoiding the appearance of a conflict of interest with respect to
Vendors.
2. Involvement in Decision Making
a. Hospital Personnel serving on the Therapeutic Standards Committee or
Medical Device Committee must disclose any relationship they have with
respect to a Vendor (or competitor of the Vendor with respect to the product
under consideration) whose product is being considered that constitutes an
actual, potential or perceived conflict of interest under the Conflicts of Interest
Policy (A-3-1) and, after any presentation by the conflicted person with respect
to information it is important for such person to present (e.g., the person
uniquely understands certain scientific or clinical information about the product
that is important for the Committee to know), the conflicted person should leave
the Committee meeting while the matter is being discussed and/or voted upon
and the minutes should reflect the fact that the conflicted person was not
present for the discussion or vote.
b. Any Hospital Personnel serving as a member of a Hospital Institutional Review
Board (“IRB”) that has under its review a study in which the product of a
Vendor is being considered for use in human subjects research, must disclose
any relationship they have with respect to the Vendor (or competitor of the
Vendor with respect to the product under consideration) that constitutes an
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actual, potential or perceived conflict of interest under the Conflicts of Interest
Policy (A-3-1), and abide by the procedures set forth in the “Policy on Avoiding
Conflicts of Interest in IRB Actions” (Committees for the Protection of Human
Subjects SOP 904).
c. A process similar to that described in “a” should be employed in other
situations where the decision maker has a relationship with respect to the
Vendor (or competitor of the Vendor with respect to the equipment, product,
supply or services under consideration) that constitutes an actual, potential or
perceived conflict of interest under the Conflicts of Interest Policy (A-3-1).
d. Hospital Personnel who provide input, but are not involved in decision making
with respect to the use or purchase of equipment, products, supplies or
services, must, prior to providing input, disclose any relationship they have with
respect to the Vendor (or competitor of the Vendor with respect to the
equipment, product, supply or services under consideration) whose equipment,
product, supply or service is being considered that constitutes an actual,
potential or perceived conflict of interest under the Conflicts of Interest Policy
(A-3-1), to their Department Chair or applicable Senior Manager, and to the
person(s) or committee(s) to whom the conflicted person expects to provide
input. Disclosure to the Department Chair or applicable Senior Manager
should be made at least annually if the provision of input is ongoing and the
disclosure to the person(s) or committee(s) to whom the conflicted person
expects to provide input should be made at each instance prior to the conflicted
person providing such input.
VIII.
VENDOR SUPPORT FOR RESEARCH
A. All external research support from a Vendor, whether in the form of funding or in-kind
donations such as equipment, must be paid or gifted to The Children’s Hospital of
Philadelphia or The Children’s Hospital of Philadelphia Foundation, and Hospital
Personnel, Departments, divisions and programs may not receive research support
directly from Vendors.
B. All external research support must be documented in a written agreement between the
Vendor and The Children’s Hospital of Philadelphia or The Children’s Hospital of
Philadelphia Foundation.
C. The Office of Technology Transfer approves all Vendor support of research activities
at the Hospital and, in consultation with the Office of General Counsel, approves the
written agreement memorializing the support.
D. All external research funding is accessed through accounts at the Hospital, usually the
The Children's Hospital of Philadelphia Research Institute, and expended in
accordance with policies of the Hospital and, where applicable, the Foundation, in
effect from time to time.
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E. The Hospital accepts funding for research from external sources, including Vendors, in
accordance with policies and practices that are consistent with all legal requirements,
the Hospital’s mission, its status as a nonprofit tax-exempt organization (the funding
may not generate unrelated trade or business income without the consent of the
President & CEO of the Hospital, please see the Office of General Counsel if there are
any issues), and prevailing standards for academic medical centers. Vendors may not
prohibit Hospital Personnel or the Hospital from publishing the results of the Hospital’s
research.
IX. VENDOR FUNDS FOR RESIDENT AND FELLOW TRAINING
A. All external funding from a Vendor for resident and fellow training (including Ruth L.
Kirschstein National Research Service Award (NRSA) and other trainees) must be
paid to The Children’s Hospital of Philadelphia or The Children’s Hospital of
Philadelphia Foundation, and Hospital Personnel, Departments, divisions and
programs may not receive such funding for training directly from Vendors.
B. All external funding for training must be documented in a written agreement between
the Vendor and The Children’s Hospital of Philadelphia or The Children’s Hospital of
Philadelphia Foundation.
C. The Graduate Medical Education Committee, through the Graduate Medical Education
Department of the Office of Medical Staff Affairs, approves all Vendor funding for
resident and fellow training and, in consultation with the Office of General Counsel,
approves the written agreement memorializing the support. The Office of Sponsored
Projects approves all Vendor funding for research fellows and, in consultation with the
Office of General Counsel, approves the written agreement memorializing the support.
D.
All external funding for training is expended in accordance with policies of the Hospital
and, where applicable, the Foundation, in effect from time to time.
E. Vendor support of trainees, in the form of financial assistance or scholarships, may be
provided but should be free of any actual or perceived conflict of interest, must be
specifically for the purpose of education, and each of the following additional
requirements must be met:
1. The Hospital Department, division or program selects the trainee who will receive
the support based on institutional criteria and the Vendor may not recommend or
suggest a candidate.
2. The support is provided to The Children’s Hospital of Philadelphia or The Children’s
Hospital of Philadelphia Foundation, which provides the support directly to the
trainee in accordance with Hospital policies, and not directly by the Vendor to the
student or trainee.
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3. The Department, program or division has determined that the proposed use of the
support (e.g., covering expenses to allow a trainee to attend an educational,
scientific or health care policy conference of a national, regional or specialty
medical association) has educational merit.
4. The proposed use of the support does not benefit the Vendor and there is no
implicit or explicit expectation that the recipient will do something to benefit the
Vendor in return for support.
X. VENDOR GIFTS OR GRANTS FOR OTHER PURPOSES
A. For other situations in which a Vendor seeks to provide support for Hospital programs
(such as funding a position in a clinical division), the matter must be reviewed by the
Office of General Counsel for a determination of the terms under which such support
may, if at all, be accepted.
B. All grants or financial support from Vendors for other purposes must be documented in
a written agreement, approved by the Office of General Counsel, between the Vendor
and The Children’s Hospital of Philadelphia or The Children’s Hospital of Philadelphia
Foundation.
C. All external funding for such other purposes is expended in accordance with policies
of The Children’s Hospital of Philadelphia and, where applicable, the Children’s
Hospital of Philadelphia Foundation, in effect from time to time.
XI. TRAINING AND SITE VISITS BY HOSPITAL PERSONNEL
A. On occasion, it may be appropriate for Hospital Personnel to travel to other locations
to evaluate new systems, to review installations or designs of facilities, to receive
training, to benefit from the experiences of other users or for other legitimate purposes
that require site visits to another location. In such situations, a Vendor may reimburse
the Hospital for the travel expenses for Hospital Personnel to make the site visit
provided each of the following requirements is met:
1. The arrangement has been reviewed and approved in advance by a member of
Senior Management at the level of Vice President or Department Chair or higher.
2. The Senior Manager determines there is a valid business reason for the site visit and
for the participation of the particular Hospital Personnel selected to attend.
3. The expenses paid by the Vendor are paid to The Children’s Hospital of Philadelphia
or The Children’s Hospital of Philadelphia Foundation, which in turn reimburses the
expenses of the Hospital Personnel involved in accordance with the Hospital’s Travel
Policy (A-2-2).
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4. The Vendor may directly provide meals so long as the setting and nature of the
meals are appropriate to the business purpose and are not excessive or extravagant,
and meals are not provided for the spouse, family member or guest of Hospital
Personnel.
5. The Vendor may directly provide lodging only with the advance approval of a
member of Senior Management at the level of Vice President or Department Chair or
higher and the lodging must not be excessive or extravagant.
6. Hospital Personnel are prohibited from attending entertainment events at Vendor’s
expense during site visits. Hospital Personnel who choose to attend entertainment
events offered at Vendor’s expense during site visits must personally pay or
reimburse the Vendor for the cost of attending, and may not seek reimbursement
from the Hospital for the expense.
XII.
OTHER VENDOR ACTIVITY
Supply Chain Management maintains a policy, Control of On-Site Activity by Vendors
(A-3-8), which includes additional provisions pertaining to Vendor activity, such as
requiring Vendors to have appointments and wear identification badges, restricting
areas of Vendor access at Hospital facilities, and placing limits on Vendors’ use of
Hospital Facilities and resources.
XIII.
ENFORCEMENT
A. Vendors who fail to comply with this Policy are subject to appropriate action, up to and
including having their access to Hospital Facilities restricted and losing their business
privileges at the Hospital.
B. Any Hospital Personnel who violate any provision of this Policy may face sanctions up
to and including discharge and/or removal from the Medical and Research Staffs, as
appropriate, depending on the seriousness of the violation.
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RESPONSIBILITY FOR MAINTENANCE OF THIS POLICY
GENERAL COUNSEL
SENIOR VICE-PRESIDENT, AUDIT, COMPLIANCE AND PRIVACY
Approved by:
Supersedes
1/1/2009
Signature:
__________________________________________________________
Madeline Bell, Executive Vice President and Chief Operating Officer
This Administrative Policy is the property of The Children’s Hospital of Philadelphia and is protected by U.S. and
international copyright laws and may not be used or reproduced without the prior written consent of The Children’s Hospital
of Philadelphia. This Policy is to be used solely by employees of the Hospital, the Hospital Medical Staff and those acting
on the Hospital’s behalf in connection with Hospital matters or in their Hospital duties. This Policy may not be copied,
photocopied, reproduced, entered into a computer database or otherwise duplicated, in whole or in part in any format. Any
personal or other use is strictly prohibited.
THE CHILDREN’S HOSPITAL OF PHILADELPHIA © 2009 All Rights Reserved
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POLICY
It is the policy of the Hospital that interactions with Vendors comply with applicable law, meet
ethical standards, avoid or minimize conflicts of interest, protect patient and research subject
confidentiality, and promote fair and open dealings.
PURPOSE
The purpose of this Policy is to establish guidelines and procedures with respect to on-site
activities by Vendors. Such on-site activities subject to this Policy include soliciting,
marketing, providing training or in-service education, servicing or assisting on equipment or
devices, distributing information at Hospital Facilities and any other activity related to the
Vendor’s business.
SCOPE
This Policy applies to all Trustees, Officers, employees and members of the Medical and
Research Staffs of The Children’s Hospital of Philadelphia, including its Joseph Stokes,
Jr. Research Institute, the CHOPPA Practice Plans (currently Children’s Anesthesiology
Associates, Children’s Health Care Associates, Children’s Surgical Associates,
Radiology Associates of Children’s Hospital, and their New Jersey Affiliates) and entities
controlling, controlled by or under common control with The Children's Hospital of
Philadelphia, including, without limitation, The Children’s Hospital Foundation (together,
the ”Hospital”), as well as any others who are providing services or conducting research
at facilities owned or operated by the Hospital or otherwise on behalf of the Hospital or
whose presence at or affiliation with the Hospital may place them in a position to interact
with Vendors on behalf of the Hospital (all such persons referenced under Scope,
“Hospital Personnel”).
All Vendors are expected to abide by this Policy with respect to their interactions with
Hospital Personnel or while in Hospital Facilities, including not engaging or attempting to
engage in any conduct that could cause Hospital Personnel to violate this Policy.
RELATED POLICIES
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No. A-3-7 Interactions with Vendors
No. A-3-1 Conflicts of Interest
No. A-1-4 Organizational Ethics Statement
No. A-1-5 Compliance Standards of Conduct
No. A-4-3 Introduction of New Medical Devices,
Products and Equipment
No. A-3-5 Confidentiality of Patient and Institutional
Information
No. A-4-17 Gifts to Employees
No. TX-7-05 Medication Samples and Vouchers
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DEFINITIONS
A. “Hospital” means The Children’s Hospital of Philadelphia, including its Joseph
Stokes, Jr. Research Institute, the CHOPPA Practice Plans (currently Children’s
Anesthesiology Associates, Children’s Health Care Associates, Children’s Surgical
Associates, Radiology Associates of Children’s Hospital, and their New Jersey
Affiliates) and entities controlling, controlled by or under common control with The
Children's Hospital of Philadelphia, including, without limitation, The Children’s
Hospital Foundation.
B. “Hospital Facilities” means any facility owned, leased, licensed or otherwise in the
possession of the Hospital.
C. “Hospital Personnel” means Trustees, Officers, employees and members of the
Medical and Research Staffs of the Hospital, and others who are providing services
at facilities owned or operated by the Hospital or otherwise on behalf of the Hospital
or whose presence at or affiliation with the Hospital may place them in a position to
interact with Vendors on behalf of the Hospital. 1
D. “Patient care areas” mean any areas in Hospital Facilities where patient care
occurs, including but not limited to inpatient hospital rooms, procedure rooms (e.g.,
perioperative complex, cardiac catheterization lab, interventional radiology), patient
observation rooms, nursing stations, outpatient examination rooms, the emergency
room, and testing areas within the clinical laboratory.
E. “Vendors” means entities and persons that have or are seeking to enter into
business relationships with the Hospital (e.g., to provide any equipment, product,
supply, facility, item or service for which payment may be made, including but not
limited to a pharmaceutical product, medical device, or other clinical equipment,
product or supply), as well as the representatives and agents of such entities or
persons. 2
1
This Policy is not intended to apply to Trustees to the extent they are not involved in decisionmaking with respect to the recommendation, use or purchase by the Hospital of particular
equipment, products, supplies, facilities, items or services.
2
A Hospital Trustee who owns, works for or has another business relationship with a Vendor is
not considered a Vendor for purposes of this Policy when (1) acting only in his/her capacity as a
Trustee and (2) there are no discussions of the Vendor’s business relationship with the Hospital.
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IMPLEMENTATION
I.
ACCESS TO HOSPITAL FACILITIES AND PERSONNEL
A. Appointments Required
Except as provided in A.2 and A.3 below, Vendors must have a scheduled
appointment to have access to Hospital Facilities. This applies to visits for any
purpose relating to the Vendor’s business, including soliciting, marketing,
providing training or in-service education, servicing or providing equipment or
devices, or distributing information relating to equipment, products, supplies,
facilities, items or services. Drop-in visits are not permitted.
1. Vendors appearing at any Hospital Facility without an appointment (but see
A.2 and A.3 below) or not wearing an identification badge (see B below)
should be reported to Supply Chain or Security.
2. Appointments under this Section A are not required for visits for product or
device recalls and emergency deliveries and services.
3. Appointments under this Section A are not required for routine visits made
on a regular recurring basis and that are, by arrangement, for purposes
such as making deliveries or pick-ups or working on-site on on-going
projects. Examples include deliveries of office supplies or food products
used by the food service; pick-ups or deliveries by UPS, Federal Express,
or courier services; maintenance of office plants (e.g., Plant Lady); and onsite consulting or construction work under a long-term engagement.
B. Check-in and Identification Badges
1. Main Hospital Campus. Upon arrival at any of the Hospital Facilities that
are part of the main Hospital campus (the main Hospital building, Wood
Center, Children’s Seashore House, Abramson Pediatric Research Center,
or Colket Translational Research Building), a Vendor must (1) proceed to
and check in at the designated check-in site and (2) obtain a Hospitalissued identification badge (unless the Vendor has previously been issued
a non-expired identification badge for use on a recurring basis). A Vendor
must wear a valid identification badge at all times while at Hospital Facilities
on the main Hospital campus.
2. Other Hospital Facilities. Upon arrival at any of the Hospital Facilities that
are not part of the main Hospital campus, a Vendor is required to comply
with such procedures, if any, as may be established by Supply Chain from
time to time regarding designated check-in sites and Hospital-issued
identification badges at such locations.
ADMINISTRATIVE
POLICY MANUAL
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
No. A-3-8
Title:
CONTROL OF ON-SITE ACTIVITY BY VENDORS
Page 4 of 7
Effective Date:
1/1/2009
C. Authorized and Unauthorized Areas
1. Hospital Personnel should avoid scheduling meetings or other visits with
Vendors at locations other than private offices or conference rooms.
2. Except as provided in C.3 below, to protect patient confidentiality and avoid
disruptions in patient care, Vendors should generally not be present in patient
care areas or other areas where patient information is visible (examples of
the latter could include offices where medical records are stored or where
computer terminals used to access patient information are in use).
3. Vendors may only attend, and Hospital Personnel may only schedule
appointments with or otherwise permit Vendors to attend, meetings or other
visits in patient care areas or other areas where patient information is visible,
in those limited circumstances where there is a clear educational or patient
care benefit requiring a Vendor to be present, such as to service or provide,
or provide assistance, training or in-service education on, devices or other
equipment (e.g., in an operating area).
a. See E.1.e below for additional procedures and requirements that may
apply.
4. Where necessary, Vendors may travel through patient care areas en route to
scheduled appointments in other areas, but are prohibited from lingering or
conducting business in patient care areas (except as provided in C.3 above).
5. Vendors are prohibited from lingering or conducting business in non-patient
care areas where patients or members of the general public are likely to be
present, such as waiting areas, lounges, corridors, lobbies and cafeterias
unless specifically authorized by Hospital Personnel (such as meeting a
physician by pre-arrangement in a cafeteria).
D. Compliance with Hospital Policies and Procedures
Vendors must abide by all applicable Hospital policies and procedures while at
Hospital Facilities.
E. Additional Procedures Relating to Vendor Access
1. Supply Chain may maintain any such additional procedures and
requirements as are appropriate to implement this Policy, on matters
including but not limited to:
a. The designation of Vendor check-in locations and check-in
procedures, if any, at all Hospital Facilities.
ADMINISTRATIVE
POLICY MANUAL
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
No. A-3-8
Title:
CONTROL OF ON-SITE ACTIVITY BY VENDORS
Page 5 of 7
Effective Date:
1/1/2009
b. The process, including applicable charges if any, for issuance of
Vendor identification badges for Vendors who visit the Hospital on a
routine basis, where appropriate.
c. The registration of Vendors (may be applicable to some or all types of
Vendors) as approved Hospital Vendors.
d. The designation of Hospital policies with which Vendors must
familiarize themselves and, where appropriate, a process for their
acknowledgement in writing before being granted access to Hospital
Facilities.
e. Additional procedures and requirements applicable to Vendors before
they may be granted access to procedural or other patient care areas,
including, without limitation, such matters as advance registration as
approved Vendors, process for scheduling and verifying
appointments, orientation and training on Hospital policies and
procedures, required advance departmental or procedural area
approvals, documentation of training on the use of particular
equipment or devices, and documentation of immunizations and
health screenings.
2. Such Supply Chain procedures and requirements are available at
www.chop.edu/vendors.
II. USE OF HOSPITAL FACILITIES OR RESOURCES BY VENDORS
A. Vendors may not use Hospital resources to disseminate information to Hospital
Personnel about scheduled meetings or other events sponsored by Vendors or
otherwise for Vendor’s business purposes (this applies both to events at Hospital
Facilities and events off-site).
B. Departmental and division offices, including residency and fellowship programs,
may not provide e-mail lists or address lists of Hospital Personnel to Vendors for
their own business purposes. This is not intended to preclude individual Hospital
Personnel from providing their own email or mailing address to Vendors.
C. Vendors may not access the Hospital paging system to contact Hospital
Personnel unless specifically requested by the person being paged.
D. Vendors may not display, post or leave any type of printed or handwritten
material, advertisement or signs, or item of any other nature, in patient care
areas or public areas in any Hospital Facilities. (Examples include brochures,
signs announcing Vendor events, promotional items such as pens and sample
consumer products.) Vendors may not display, post or leave any type of printed
ADMINISTRATIVE
POLICY MANUAL
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
No. A-3-8
Title:
CONTROL OF ON-SITE ACTIVITY BY VENDORS
Page 6 of 7
Effective Date:
1/1/2009
or handwritten material, advertisement or sign, or item of any other nature in any
other area of the Hospital Facilities unless it is given to a specific person who has
agreed to accept it and doing so is otherwise in accordance with the Hospital’s
Policy on Interactions with Vendors (A-3-7).
E. Vendor materials that may be useful to patients should be offered to the
appropriate department (for example, materials about pharmaceutical products
should be offered to the Department of Pharmaceutical Services), which will
decide whether it will accept the materials and, if so, the appropriate use of the
materials.
III. OTHER VENDOR ACTIVITY
A. The Medication Samples and Vouchers Policy (Patient Care Manual No. TX-705) governs issues relating to obtaining medical samples and vouchers from
Vendors.
B. The Interactions with Vendors Policy (Administrative Policy A-3-7) governs many
other issues relating to the activities of Vendors and their interactions with the
Hospital and Hospital Personnel.
IV. ENFORCEMENT
A. Hospital Personnel are responsible for reporting to Supply Chain if they identify a
Vendor who fails to adhere to any provision of this Policy.
B. Vendors who violate any provision of this Policy are subject to appropriate action,
up to and including having their access to Hospital Facilities restricted and losing
their business privileges at the Hospital, as appropriate, depending on the
seriousness of the violation.
C. Any Hospital Personnel who violate any provision of this Policy may face
sanctions up to and including discharge and/or removal from the Medical and
Research Staffs, as appropriate, depending on the seriousness of the violation.
ADMINISTRATIVE
POLICY MANUAL
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
No. A-3-8
Title:
CONTROL OF ON-SITE ACTIVITY BY VENDORS
Page 7 of 7
Effective Date:
1/1/2009
RESPONSIBILITY FOR MAINTENANCE OF THIS POLICY
VICE PRESIDENT, SUPPLY CHAIN MANAGEMENT
Approved by:
NEW
Signature:
__________________________________________________________
Madeline Bell, Executive Vice President and Chief Operating Officer
This Administrative Policy is the property of The Children’s Hospital of Philadelphia and is protected by U.S. and international
copyright laws and may not be used or reproduced without the prior written consent of The Children’s Hospital of Philadelphia.
This Policy is to be used solely by employees of the Hospital, the Hospital Medical Staff and those acting on the Hospital’s
behalf either on the premises of the Hospital in connection with Hospital matters or in their Hospital duties involving the care of
Hospital patients. This Policy may not be entered into a computer database or otherwise duplicated, in whole or in part in any
format. Any personal or other use is strictly prohibited.
THE CHILDREN’S HOSPITAL OF PHILADELPHIA © 2008 All Rights Reserved
VENDOR RELATIONS
We have two policies, Interactions With Vendors (A-3-7) and Control of On-Site Activity By Vendors (A-3-8), that apply to relations
between all Hospital personnel and all vendors doing or seeking to do business with the Hospital. The policies apply to vendors who
provide all types of goods and services, including clinical, research and administrative, and to all parts of the Hospital and its affiliates.
The policies are intended to promote integrity in our dealings with vendors. Selected highlights of the policies are listed below. For
details, please review the policies, which are available on the employee Intranet (go to “Policies and Procedures” on the home page).
INTERACTIONS WITH VENDORS
Gifts, Meals and Compensation
• No personal gifts to Hospital personnel (not even token gifts like pens and coffee mugs with vendor l logos). Gifts include tangible items, tickets to entertainment or sporting events, and other things given for free.
• No food from vendors on-site (includes holiday gift baskets, pretzels, meals, etc.).
• No vendor-paid meals in restaurants.
• You may:
–Attend an entertainment event or meal with a vendor, with advance approval, if you or the Hospital (instead of the vendor) pay the cost to attend.
–Have a modest meal in a vendor’s office while working on Hospital business.
–Attend a vendor-run educational program offered free to all attendees, but you may not accept meals/other gifts at the program
unless otherwise permitted under the policy.
• Vendors can provide non-cash gifts to the Hospital or clinical departments, with advance approval, if the gifts serve substantial clinical, research or educational functions (e.g., anatomical models, medical textbooks, charts, products for evaluation purposes).
Speakers Bureaus
• Participation in vendor-sponsored speakers bureaus is discouraged. If you are a clinician or researcher speaking on a professional topic, certain restrictions apply (e.g., the vendor may not restrict or censor the content of your presentation).
Ghostwriting
• You may not allow your professional presentations (oral or written) to be ghostwritten by anyone.
Vendor Funding for Hospital-Run Educational Programs
• All arrangements for vendor funding of educational programs for clinicians or researchers should be handled through the Continuing Medical Education Department (or for nursing education, the Office of Nursing Education). • All vendor funding for education programs must:
–Be made in the form of an educational grant to the Hospital or The Children’s Hospital Foundation and documented in an
approved written agreement.
–Follow the relevant accrediting bodies’ standards for commercial support or, if not accredited, the comparable standards detailed in the policy.
Purchasing Decision Making
• Decision makers with actual, potential or perceived conflicts with respect to a vendor must:
–Disclose the conflict.
–Not participate in the decision about which vendor to select (except to provide any important information to others).
CONTROL OF ON-SITE ACTIVITY BY VENDORS
Appointments, Check-In and ID Badges
• Appointments are required for all vendor visits to Hospital facilities except:
–Product device recalls
–Emergency deliveries
–Routine pre-arranged visits for deliveries, on-site project work and similar purposes
• Vendors must check in and obtain vendor ID badges at designated locations at Main Campus
–Permanent (annual) vendor badges will be issued to reps visiting on regular basis (at least once a week).
Authorized and Unauthorized Areas
• Avoid meeting with vendors in locations other than private offices or conference rooms.
• Vendors are not permitted in patient care areas except:
–Where necessary to travel en route to scheduled appointments
–Where there is a clear educational or patient care benefit requiring their presence (e.g., vendors who service, provide, assist, train or conduct in-service education on devices or other equipment)
Special Requirements for Vendors in Procedural Areas
• Vendors visiting procedural areas (e.g., the perioperative complex, interventional radiology, GI Suite, and cardiac catheterization laboratory) must meet additional requirements established by Supply Chain, including advance registration and orientation, before access will be granted.
Vendors’ Use of Hospital Facilities and Resources
• Vendors may not:
–Use Hospital resources to disseminate information about meetings or other events they sponsor.
–Access the paging system unless requested by the person being paged.
–Display, post or leave written material or any items in patient care or public areas (e.g., signs, brochures, promotional items), and may not do so elsewhere at Hospital facilities without permission.
Administration
• Supply Chain is responsible for administering the vendor access program at the Hospital.
FOR MORE INFORMATION
Visit the vendor relations site on the Intranet:
http://intranet.chop.edu/vendors
To view what your vendors will see on the web, visit:
www.chop.edu/vendors
For questions about vendor interactions:
[email protected]
Janet Holcombe, ext. 66037
For questions about vendor access/on-site activity:
[email protected]
Angela Burkholder, ext. 42492
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Business Associate Agreements
The Hospital works with a variety of individuals and organizations to perform activities on the Hospital’s behalf that
involve the use or disclosure of patient information. Some of these individuals/organizations are considered Business
Associates and the Hospital must enter into a written Business Associate Agreement with them. If you are identified
as a Business Associate, Supply Chain Management will forward an agreement for signature.
Questions about Business Associates, including whether a vendor has a completed Business Associate Agreement on
file at CHOP, can be sent to [email protected]
Supply Chain Mgmt | Vendor Guide
Page 7
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Standard Vendor Terms and Conditions
Supply Chain Mgmt | Vendor Guide
Page 8
PURCHASE ORDER TERMS AND CONDITIONS
A.
PURCHASE ORDER TERMS AND CONDITIONS
1. COMPLETE AGREEMENT
This Purchase Order, which includes any supplementary sheets, schedules, exhibits, riders, and attachments annexed
hereto or any document or writing incorporated by reference by Buyer, contains the complete and entire agreement
between the parties and supersedes any other communications, representations, or agreements, whether verbal or
written, with respect to the subject matter hereof.
2. RISK OF LOSS AND TITLE
Risk of loss of the goods shall pass to Buyer at the time the goods are actually delivered. Title to the goods shall
remain with Seller until Buyer receives the goods.
3. NON-ASSIGNMENT
Assignment of the order or any interest therein or any payment due or to become due thereunder, without the written
consent of Buyer, shall be void.
4. PRICES
The price(s) shall not be higher than that appearing on the face of this Purchase Order, or if no price appears thereon,
then no higher than the last quoted by Seller for the same or substantially similar articles in similar quantities.
5. PACKING, SHIPMENT, AND TRANSPORTATION
No charge will be allowed for boxing, packing, crating, or storage unless stated herein. Materials shall be suitably
packed to secure the lowest transportation cost and to conform with the requirements of common carriers.
Transportation charges on materials sold “delivered destination” must be prepaid whenever possible. If purchase
terms are f.o.b. shipping point, and Seller prepays authorized f.o.b. transportation charges, a copy of the carrier’s bill or
other evidence will be required by Buyer prior to reimbursement to Seller. All drop shipments must reference Buyer’s
Purchase Order number. Failure to include The Children's Hospital of Philadelphia’s P.O. number on packing slips
will result in non-adherence to Seller's Return Policy, penalties to the Seller and/or termination of this Purchase Order.
6. DELIVERY
Delivery shall be made both in full quantities and at time specified, strictly in accordance with Buyer’s delivery
schedule. If Seller’s deliveries fail to meet such schedule, Buyer, without limiting its other remedies, may direct
expedited routing and the difference between the expedited routing and the order routing costs shall be paid by Seller.
Goods fabricated beyond Buyer’s release is at Seller’s risk. Unless otherwise specified herein, no deliveries shall be
made in advance of Buyer’s delivery schedule. Material delivered in excess of the quantity specified will be returned at
no cost to buyer. Buyer shall not be liable for excess costs of deliveries or defaults due to causes beyond its control
and without its fault or negligence, provided, however, that when Seller has reason to believe that deliveries will not be
made as scheduled, written notice setting forth the cause of the anticipated delay will be given immediately to Buyer. If
Seller’s delay or default is caused by the delay or default of a subcontractor, such delay or default shall be excusable
only if it arose out of cause beyond the control of both Seller and subcontractor and without the fault or negligence of
either of them and the supplies or services to be furnished were not obtainable from other sources in sufficient time to
permit Seller to meet the required delivery schedule.
7. TERMINATION FOR DEFAULT
If Seller breaches any of the terms hereof including warranties of Seller or if Seller becomes insolvent or commits an
act of bankruptcy, Buyer shall have the right to terminate by written notice to Seller, without liability, all or any part of
the undelivered portion of this order. In case of such termination, Seller shall continue performance of any nonterminated portion of the order and Buyer may obtain elsewhere the portions of the supplies or services affected by the
termination of supplies or services similar thereto, and charge the Seller with any cost increase caused thereby.
Buyer’s rights under this clause are in addition to, and not in lieu of, any other remedies available under this order or
provided by law.
8. TERMINATION FOR CONVENIENCE
Buyer reserves the right to terminate this order in whole or from time to time in part, even though Seller is not in default
hereunder. In such event there will be made an equitable adjustment of the terms of this order mutually satisfactory to
Buyer and Seller. Upon receipt of written notice of such termination, Seller shall, unless such notice otherwise directs,
immediately discontinue all work on the order.
9. REMEDIES
The remedies herein reserved shall be cumulative and in addition to any other or further remedies provided in law or in
equity. No waiver of a breach of any provision of this order shall constitute a waiver of any other right, remedy, or
provision.
10. CHANGES
Buyer shall have the right by written order to make changes as to destination, specifications, designs, and delivery
schedules. Seller shall not make any changes unless agreed to in writing signed by buyer.
11. INSPECTION AND REVIEW
All purchases will be subject to Buyer’s final inspection. Buyer, at its’ option, may reject any non-conforming
equipment or material and return it to Seller at Seller’s risk and expense at the full invoice price plus all transportation
and other related costs.
12. INSURANCE, INDEMNITY, ETC.
If the order involves operations by Seller on the premises of Buyer or the performance of labor for Buyer, Seller shall
take all necessary precautions to prevent the occurrence of any injury to person or property during the progress of
such work and shall indemnify and protect Buyer against all liabilities, loss, and expenses, including reasonable
attorneys’ fees, claims, or demands for injuries or damages to any person or property resulting from the performance of
this contract or from any act or omission of Seller, its agents, employees, or subcontractors. Seller further agrees to
maintain Workers’ Compensation, Employer’s Liability, and Comprehensive General Liability insurance coverages as
will satisfy Buyer that it is protected from said risks. Seller shall provide Buyer with insurance certificates setting forth
the limits of liability, coverage type, policy number, and expirations date, and naming Buyer as an additional insured on
all policies except Workers’ Compensation, and providing Buyer shall receive a minimum of 30 days’ notice in the
event of cancellation or non-renewal of coverage.
13. INTELLECTUAL PROPERTY
By accepting this order, Seller guarantees that the material hereby ordered and the sale, lease, or use of it will not
infringe any United States or foreign patents, copyrights, trademarks, or other intellectual property rights, and the Seller
agrees to defend, protect, and save harmless the Buyer, its successors, assigns, customers, and users of its products,
against all suits and from all damages for actual or alleged infringements of any patent, copyright, trademark, or other
intellectual property right by reason of the sale, lease, or use of the material hereby ordered.
14. WARRANTIES
Seller warrants the merchantable quality of the goods sold hereunder and that such goods will conform to any
specifications, drawings, samples, or other descriptions furnished or specified by Buyer, will be of good material and
workmanship and free from defect. Seller expressly warrants that the material covered by this order, which is the
product of Seller or is in accordance with Seller’s specifications, will be fit and sufficient for the purpose intended.
15. WARRANTY PRICE
Seller warrants that the prices charged Buyer, as indicated on this Purchase Order, are no higher than prices charged
on orders placed by others for similar quantities on similar conditions subsequent to the latest general announced or
published price change. In the event Seller breaches this warranty, the prices of the Articles shall be reduced
accordingly retroactively to date of such breach.
16. COMPLIANCE WITH LAWS
In filing this order, Seller shall comply with all applicable federal, state, and local laws and government regulations and
orders and Seller warrants that the articles meet all applicable Government specifications and requirements.
(a) While this agreement remains in effect and for a period of four years after the termination of this agreement, Seller
shall maintain, and shall make available upon proper request from proper government authorities, this agreement and
any subcontract under this agreement valued at $10,000 or more in any twelve-month period, and all books,
documents, and records related thereto that are necessary to verify the nature and costs of services provided
hereunder by Seller or any organization related to Seller, in accordance with applicable government regulations in
effect from time to time.
(b) Seller further represents and warrants that neither Seller, nor its officers or directors have been debarred,
suspended, or excluded from providing services under federal or state government programs. Seller further represents
that its business is guided by a compliance program to ensure organizational compliance with laws and regulations.
17. PENNSYLVANIA LAW
This Purchase Order is governed by the laws of the Commonwealth of Pennsylvania as respects contracts made,
accepted, and performed in Pennsylvania.
18. AMENDMENT AND WAIVER
This Purchase Order may be amended only in writing signed by Buyer. No provision of this Purchase Order can be
waived except in writing signed by Buyer and no failure to object to any breach of a provision of this Purchase Order by
Buyer shall waive Buyer’s right to object to a subsequent breach of the same or any other provision.
19. MARKETING APPROVALS
In purchasing a drug or device in interstate commerce Buyer relies upon the distributor and manufacturer to obtain all
necessary marketing approvals. Absent contrary advice from you, Buyer regards your sale of a drug or device as
warranting that FDA premarket approval has been obtained.
20. HIPAA COMPLIANCE
By fulfilling this Purchase Order, Supplier hereby confirms that all products and services are compliant with all aspects
of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), including the provisions related to Privacy,
Security, and Code Sets.
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Confidentiality of patient and institutional information
Confidential Information
All patient information is confidential, regardless of whether it is spoken in a conversation, written on a piece of
paper, contained in an e-mail or stored electronically in a Hospital computer or on a portable storage device.
Vendors and their employees or agents must protect and keep patient information confidential.
Medication Samples and Vouchers
The Hospital no longer accepts medication samples from pharmaceutical representatives or physicians. The Hospital
supports the use of Medication Vouchers for patients as an alternative to samples to assist patients in safely
obtaining prescribed medications.
Safety
Use of wireless RF Transmitting Devices
Cellular phones


AT&T, Verizon, and Sprint/Nextel serviced cellular phones are permitted throughout the hospital, unless
otherwise posted.
Cell phones must be kept a minimum of three feet away from medical devices.
Walkie talkie/Radio


Prohibited from use in procedural rooms and inpatient rooms.
Prohibited from use in all departments utilizing physiological monitoring by Telemetry.
Use of computers
Laptop computers can be used in patient care areas in the electrical or battery mode. The Hospital provides free
wireless access to all visitors in the Main Hospital, Wood Center, Seashore House, Abramson Center and Wanamaker
Building.
Supply Chain Mgmt | Vendor Guide
Page 9
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Fire and Emergency plans
Vendor representatives are responsible for being familiar with the emergency procedures for any CHOP facility they
are visiting.
Supply Chain Mgmt | Vendor Guide
Page 10
Mandator y Education: Bloodborne Pathogens
Rev. 10/2010
Imagine this…
You’re a nurse working the evening shift, when a co-worker asks
for your help because they are having trouble drawing blood from
a sick Core
child. You
insert a butterfly needle
and haveSeek
a successful
Curriculum:
Operation
stick. You then remove the needle, and while applying pressure
on the patient’s hand to stop any bleeding, you accidentally stick
your co-worker with the needle. Reasoning that because the
needle has been exposed to air and there was a low risk of
contracting any infectious virus like HIV, your colleague decides
to wait until the end of the shift to report the needlestick.
 What could you have done differently?
 What is HIV?
 How could this exposure have been prevented?
 What should your colleague have done immediately?
The answers to these questions and others like it are contained
within this learning module.
How could this exposure have been prevented?
In the previous scenario, the exposure could have been
prevented.
 Needlestick injuries,
 Cuts from scalpels, sutures or other sharp objects
contaminated with blood,
 Splashes to the eyes, nose or mouth,
 Contact with broken, chapped or cut skin.
Facts about Bloodborne Illness
The most common germs or diseases presenting a risk to people
working in a hospital or healthcare facility are bloodborne
pathogens such as Hepatitis B, Hepatitis C, and Human
Immunodeficiency Virus (HIV). Other less common diseases are
listed in CHOP’s Bloodborne Pathogens Exposure Control Plan,
which will discussed later.
Some of you are potentially exposed to blood in your daily work e.g. phlebotomists, surgeons, and lab techs. Others could come
into contact with blood accidentally. For example, if a
contaminated needle isn’t disposed of properly, or someone
doesn’t clean up a blood spill.
Hepatitis B Virus (HBV)
Objectives
What is Hepatitis B?
Hepatitis B is an infection of the liver caused by the hepatitis B
virus (HBV). It can lead to serious problems with your liver and
may cause liver cancer or chronic liver disease.
This learning module covers the use of Standard Precautions
and reviews the procedure for exposure to Bloodborne
Pathogens. After completing this learning module, our patients
and colleagues need you to be able to:
How is it spread?
HBV is spread by direct contact with infected blood and body
fluids. HBV can survive in dried blood on a counter or other
surface up to 7 days.
The butterfly device inserted has a safety feature that should
have been engaged prior to removing the device from the patient.
 Define Standard Precautions and how to apply them in
practice,
 Describe 4 ways that a bloodborne pathogen can be
transmitted,
 Describe bloodborne diseases/pathogens,
 Outline the procedure to follow when you are exposed to a
bloodborne pathogen.
Definition of Bloodborne Pathogens
Bloodborne Pathogens is a term that is used to describe germs
that may be found in human blood and in some other human
bodily fluids (referred to as “other potentially infectious fluids” OPIF). Occupational exposure to such bloodborne germs can
occur through:
What are its symptoms?
Many people infected with HBV have no symptoms. Others may
have symptoms that include fatigue, poor appetite, fever,
vomiting, dark urine or jaundice — a yellowing of the skin and
whites of the eyes.
Is there a Vaccine?
The Hepatitis B vaccine is a safe, effective series of 3 shots and
is recommended for all Health Care Workers who have the risk of
coming in contact with blood and bodily fluids. The vaccine is
available free of charge through the Occupational Health
Department (OHD), ext. 41928.
Mandator y Education: Bloodborne Pathogens
Hepatitis C Virus (HCV)
What is Hepatitis C?
Hepatitis
C is aCurriculum:
liver disease caused
by infection with
the
Core
Operation
Seek
hepatitis C virus (HCV). It can lead to serious problems, such as
liver disease and liver failure.
How is it spread?
HCV is spread by direct contact with infected blood and bodily
fluids. This occurs most commonly through needle-sticks. The
risk of getting HCV is no greater in healthcare workers than in the
general population.
What are its symptoms?
The most common symptom of HCV infection is extreme fatigue
(tiredness), although many people have no symptoms.
 Always be alert to any work activity that may put you at
risk of exposure to blood or Other Potentially Infectious
Fluids (OPIF).
 Let your supervisor know if you think any changes need to
be made to protect you.
 Standard Precautions protect both healthcare personnel
and patients from contact with infectious agents.
Practicing Hand Hygiene
Alcohol-Based Hand Rubs (foam and gel)
1.
Apply to palm of one hand (the amount used depends
on specific hand rub product).
2.
Rub hands together, covering all surfaces, focusing in
particular on the fingertips and fingernails, until dry. Use
enough rub to require at least 15 seconds to dry.
Is there a vaccine? How is it treated?
There is no vaccine to prevent HCV infection.
HIV (AIDS)
What is HIV?
The Human Immunodeficiency Virus (HIV) is the virus that
causes Acquired Immunodeficiency Syndrome (AIDS). The virus
attacks the body's immune system, eventually leaving it unable to
fight infection.
How does HIV spread?
HIV is spread by direct contact with infected blood and body
fluids or through sexual intercourse. Babies born to an HIV
infected mom can contract HIV during birth or through infected
breast mild.
What are its symptoms?
When first infected with HIV, there may be symptoms of fever,
headache, fatigue, muscle aches, rash or swollen glands.
Is there a vaccine? How is it treated?
There is no vaccine to prevent HIV infection. However, potent
drug therapy has been successful in preventing progression or
prolonging the time it takes to develop AIDS.
Preventing Disease Transmission: Standard
Precautions
Standard Precautions are a set of infection control practices that
healthcare personnel use to reduce transmission of
microorganisms in healthcare settings.
Hand hygiene, use of personal protective equipment, engineering
controls, and safe work practices help protect you from exposure
while on the job. In addition:
Rev. 10/2010
Hand washing
1.
Wet hands with water.
2.
Apply soap. Rub hands together for at least 15 seconds,
covering all surfaces, focusing on fingertips and
fingernails.
Don’t have a timer? Sing Happy Birthday to yourself
twice.
3.
Rinse under running water and dry with disposable
towel.
4.
Use the towel to turn off the faucet.
Personal Protective Equipment (PPE)
Personal protective equipment (PPE) helps you practice
Standard Precautions. It includes gowns, gloves, facemasks
and eye protective wear. Select these items based on your
expected contact to blood and bodily fluids.
Gloves must be worn any time there is even a possibility
that your hands may come in contact with blood or other
bodily fluids. Never reuse disposable gloves.
Gowns must be worn to protect your skin and prevent
soiling of your clothing during work or activities that might
cause splashes or sprays of blood and bodily fluids.
Masks and eye protection must be worn to protect the
mucous membranes of your eyes, nose and mouth during
work or activities that might cause splashes or a spray of
blood or bodily fluids.
Mandator y Education: Bloodborne Pathogens
Rev. 10/2010
Engineering Controls
Risk of Exposure
To reduce the risk of infection, certain engineering controls have
been introduced at CHOP. The following devices are used at
CHOP:
Your risk of exposure is determined by many factors including:
Core Curriculum: Operation Seek
 Sharps Containers - Always dispose of sharp items in the
rigid sharps containers provided in your work area.
 Bio-Safety Cabinets - These cabinets protect users from
droplets and aerosols from contaminated specimens.
CHOP’s Bio-safety Manual on the CHOP intranet provides
more detail.
 Needle-less systems and safety devices - Safety
devices available at CHOP include:
 How well you adhere to Standard Precautions,
 The types of devices you use for high risk procedures,
 How often you are exposed to blood and bodily fluids,
 What type of fluids you are exposed to.
Bodily fluids that generally do not carry these germs unless
mixed with blood are: Sweat, tears, urine, vomit, stool, saliva*and
sputum.
* Saliva can transmit hepatitis B through deep penetrating bites.
o Safety Push Button Butterfly Device
Bodily fluids that may put you at risk are: Semen, vaginal
secretions, fluid around a joint, fluid in the sac of the heart and
amniotic fluid.
o Blood transfer devices
CHOP’s Bloodborne Pathogens Exposure Control Plan
o Angel Wing devices
The Hospital's Bloodborne Pathogen Exposure Control Plan
(ECP) outlines the steps taken at CHOP to eliminate or minimize
occupational exposure to bloodborne pathogens. As noted earlier
in the lesson, a copy of the plan can be found on the CHOP
intranet in the Infection Prevention & Control Manual, on the
Occupational Health website under the Forms Library.
o Insyte safety IV catheters
o Safety lancets
o Safety scalpels
Work Practice Controls
Housekeeping: Should follow proper procedures for cleaning
and disinfection using our hospital approved
detergent/disinfectant.
Linen: Place soiled linen in a leak-proof bag in a covered
hamper.
Infectious waste: Place infectious waste in red bag trash. All
items saturated with blood and bodily fluids including bloody
diapers and certain waste coming from isolation rooms are
classified as infectious waste. Some laboratory waste will need to
be autoclaved before disposal.
Spills of blood and bodily fluids: Clean-up as soon as possible
using a Hospital approved disinfectant. Major blood spills require
a 1:10 dilution of sodium hypochlorite solution for adequate
disinfection.
Sharps Containers
 Place all used sharps in a Sharps container. Never leave a
used needle on a table, tray, or any other surface where
you or a co-worker could be stuck.
 Always engage the safety mechanism on a sharp safety
device as soon as you use it.
 New: the BD safety butterfly device should be activated
before removing the needle from the patient’s vein/artery.
 Always use a safety device when available and use the
correct device for the correct procedure.
CHOP’s plan has been developed to meet OSHA’s bloodborne
Pathogens Standard.
Exposure Control Plan
The purpose of the Bloodborne Pathogen Exposure Control Plan
is to:
 Identify employees at risk for exposure to blood and bodily
fluids. All employees who are at risk of contacting blood
are included, even if you don’t routinely handle blood or
bloody fluids.
 Describe specific measures that employees can take to
reduce the risk while on the job. These include practices
like choosing the correct device to draw or transfer blood;
making sure you know how to use safety blood drawing
devices; using safe zones for contaminated sharps;
wearing protective equipment.
 Outline procedures for employees to follow if a blood or
bodily fluid exposure event does occur.
Scenario
Jane White, BSN, RN, had only been out of nursing school five
months when she experienced her first needle-stick injury. She
was inserting an IV line and was following guidelines to protect
her by wearing gloves. While inserting the needle, her patient
moved and Jane jammed the needle into her left palm.
Mandator y Education: Bloodborne Pathogens
Rev. 10/2010
What should you do if this happens to you?
Confidentiality of HIV-Related Information Act
Act Immediately
No matter what, act immediately upon any kind of contact with a
blood-borne pathogen.
PA Act 148 (Confidentiality of HIV-Related Information Act)
regulates the process for requesting source HIV testing.
Core Curriculum: Operation Seek
Cleanse Area
Wash the injured area immediately with soap and water. For the
eyes or the mucous membrane of the nose or mouth flush the
area immediately with water or saline.
Report the Incident
Report the incident to your supervisor/manager immediately.
Complete the Necessary Forms
Complete an Employee Occupational Accident or Illness Report
form. Be sure to describe how the exposure occurred.
Visit the Occupational Health Department
Visit the Occupational Health Department (x-41928) on the Alevel of the main hospital building, Room AW50 Monday through
Friday, 7:30 a.m. to 4:00 p.m.
After hours and on weekends and holidays, your manager should
contact the nursing supervisor at beeper 10224. If your manager
is not available, you can contact the nursing supervisor directly or
through the hospital operator.
An Occupational Health Nurse is available 24 hours a day, 7
days a week for consultation when needed. The nursing
supervisor or hospital operator can contact the nurse via pager.
When an exposure occurs after OHD business hours, always
contact the OHD on the next business day for follow-up.
Testing after a bloodborne pathogen exposure
Testing for HBV, HCV, and HIV will be offered to all employees
who have a documented exposure. If the OHD, in conjunction
with the Special Immunology Physician, determines that an
exposure poses a high risk for HBV or HIV transmission,
medication for prevention of transmission will be started
promptly.
For the injured (exposed) employee
For physicians:
 You cannot request source HIV testing until OH or the
nursing supervisor has certified the exposure, verified that
the employee has consented to baseline testing, and then
asks you to obtain consent.
 You cannot ask for source consent if you are the person
exposed. Another physician must do this
 You do need to do pre-test counseling about HIV and HIV
testing (see attachment to HIV consent form) prior to
testing
 If the source patient/family refuses HIV testing, we may be
able to run the HIV test on blood drawn prior to the
exposure. OH or the nursing supervisor will guide you in
this process.
Risk of Infection
The risk of infection after a needle stick injury with an HIVcontaminated needle is approximately 0.3%. That means that if
you have needlestick involving a patient who is HIV positive, you
have a 1 in 300 risk of becoming HIV positive yourself.
Getting treated with medication (ideally within the first two hours
after a needle-stick) may decrease your chance of becoming HIV
positive.
The risk of getting infected from a Hepatitis B contaminated
needle can vary from 1% to 31% depending on the amount of
disease in the source. If the person has active disease, the risk
is much higher. But Hepatitis B is completely preventable
through vaccination.
The risk of getting Hepatitis C from an infected patient is about
1.8%.
Note: It is very important that all exposures be evaluated
promptly.
 Your charge nurse, Occupational Health, or the nursing
supervisor will guide you through this process
Exposures at CHOP
 You should not be asked to follow up on source testing
In the year 2010, there were 95 exposures to potential
bloodborne pathogens at CHOP. Of these:
 You will receive pre-test HIV counseling
58 were needle-sticks,
 Your follow up care will be determined by the initial
evaluation and will be done per current CDC
recommendations
22 were other sharps,
 Lab results will be reported to you as soon as available.
1 was non-intact skin.
 You will receive written post-exposure notification detailing
HBV status and any follow up recommendations.
14 were mucous membrane,
Mandator y Education: Bloodborne Pathogens
Of those exposed:
27 involved physicians,
Core
Curriculum:
Operation Seek
36 were
nurses,
32 were other healthcare workers (e.g. phlebotomist,
techs, students, therapists).
Sharps Injury Prevention at CHOP
The bloodborne Pathogens Exposure Prevention Committee,
formerly called the Sharps Injury Prevention Committee, is
responsible for evaluating and implementing devices and work
practices that decrease the risk of bloodborne pathogen
exposures to employees. The committee is chaired by the
Occupational Health nurse manager, and has representatives
from many departments including direct care providers. The
Committee reports to the hospital’s Environment of Care
Committee.
If employees have any concerns related to devices or practices
that contribute to unsafe practice, or if they are interested in
being on the committee, they should contact the Occupational
Health Department (OHD) manager (x-41938) or any member of
the committee.
A complete list of committee members can be found on the OHD
website on the CHOP intranet. Employees can also report their
concerns to their immediate supervisor for follow up.
Where would you go?
If you sustain a needlestick or blood splash, where can you go to
get additional bloodborne pathogen and needlestick information?
To view bloodborne related information, click here to go to the
Occupational Health – BBP Needlestick intranet site.
Contacts
If you have any questions, you can contact:
 Mary Cooney, Occupational Health Nurse Manager
[email protected]
215-590-1938
For immediate responses you can call pager 866-8416812
 Amanda Scott, Director Environmental Health & Safety
[email protected]
215-590-3872
Rev. 10/2010
Mandator y Education: Safe Handling of Hazardous Materials
Imagine this…
Chemical Exposure
You are transporting a patient to the recovery room after a
surgery. Wheeling the patient down the hall, you notice an
unmarked container in the middle of the hall. Not knowing what
Core
Curriculum:
Seek down
is in the
container
and assuming itOperation
is secure, you continue
the hall. As you navigate past the container, the wheel chair hits
and knocks over the container. The container falls, the top
shoots off, spilling the liquid inside. Your eyes begin to tear and
you become nauseated. You immediately rush yourself and the
patient out of the area, isolate the area and inform security of the
incident. Why wasn’t the product labeled? Should you have tried
to navigate past it? Was this hazardous material properly
handled?
You can be exposed to a chemical by:
Had you reflected on the potential hazard the chemical bottle
posed you may have resolved to ensure that you or anyone else
would not have knocked it over.
Rev. 10/2010
 Breathing it (Inhalation)
 Eating it (if you don’t wash your hands after handling a
chemical)
 Having it go through your skin (Absorption).
Chemical Hazards
Physical hazards include chemicals that can cause a fire,
suddenly discharge, cause an unstable reaction or explode.
Health hazards include chemicals that are irritants (causing
coughing), corrosives (burns skin), cryogens (cause freeze
burns), reproductive hazards (cause sterility), carcinogens (cause
cancer).
Knowing the Risk
Objectives
Upon completion of the training module, our patients and
colleagues need you to be able to:
 Identify the types of hazards chemicals pose at CHOP,
Identify the level of health, fire and reactivity risks from a
hazard label,
 Demonstrate understanding of what a Material Safety
Data Sheet (MSDS) is and how to access them
 Recognize common chemical hazards, such as lack of
labeling, improper storage and leaking containers
 Indicate the steps to follow in case of an emergency spill
or exposure.
Hazardous Communication
Just because you work with a chemical, doesn’t mean you are
always being overexposed.
Factors such as how much, where and in what form you are
using it can increase or reduce your risk of exposure. It also
depends on any protective equipment you might be wearing,
such as gloves.
For example: using 3% hydrogen peroxide to clean a wound
causes no adverse health effects; whereas, using 30% hydrogen
peroxide as a disinfectant can cause a skin burn if you aren’t
wearing the proper gloves.
Reading Labels
Know what chemical hazards you’re working with by reading
labels. The Hazard Label (displayed below) on many chemical
containers can provide you with a quick snapshot of any hazards.
When it comes to chemicals, what you DON’T know can HURT
you….and FAST! That’s why the Occupational Safety and
Health Administration (OSHA) developed the Hazard
Communication Standard. The standard guarantees your RIGHT
TO KNOW about potential chemical hazards in your workplace.
Label Key: 0=no hazard to 4=extreme
hazard.
Red = Flammability, Blue = Health,
Yellow = Reactivity, White = Special
(Other hazards)
Hazardous Chemicals
You may not normally think that a hospital is a place where
hazardous chemicals are used…but think again! Cleaning
chemicals, disinfectants, anesthetic gases, laboratory reagents,
chemotherapy drugs and antiseptic wipes all contain hazardous
chemicals. It is important to understand the types of chemicals
that are present at CHOP to protect YOURSELF and our
PATIENTS!
Flammability (red quadrant):
 4 - Extremely flammable
 3 - Ignites at normal temperatures
 2 - Ignites when moderately heated
 1 - Must be preheated to burn
 0 - Will not burn
Page 1 of 2
Mandator y Education: Safe Handling of Hazardous Materials
Health hazard (blue quadrant):
Precaution Measures
 4 - Too dangerous to enter - vapor or liquid
 3 - Extremely hazardous - use full protection
Curriculum:
Operation
 Core
2 - Hazardous
- use breathing
apparatus
Rev. 10/2010
Seek
 1 - Slightly hazardous
 0 - Like ordinary material
Reactivity (yellow quadrant):
 4 - May detonate - evacuate area if materials are exposed
 3 - Strong shock or heat may detonate - use monitors
 2 - Violent chemical change is possible
 1 - Unstable if heated - use normal precautions
 0 - Normally stable
Special hazards (white quadrant):
 W or "No water“ - indicates a material that is unusually
reactive with water (e.g., sodium).
 OX or "Oxidizer“ - indicates a material that is an Oxidizer.
A material that can cause or enhance the combustion of
other materials, usually by providing oxygen.
Material Safety Data Sheet (MSDS)
Another way to know what hazards a particular chemical has is to
view the Material Safety Data Sheet (MSDS). An MSDS is a
chemical specific information sheet that provides physical and
health information to users. The Environmental Health and
Safety Department maintains a database of over 5000 chemicals
that are used at CHOP. All of CHOP’s MSDS can be accessed
through the Employee Intranet, under “Employee Resources”.
It may be necessary, depending on the type and volume of
chemical, to wear personal protective equipment. This may
include gloves, lab coats, goggles or a respirator mask. It is also
important to always wash your hands after you remove your
gloves to reduce the potential for chemical exposure by
ingestion.
Safety Departments
The Environmental Health & Safety, Office of Research Safety
and PENN’s Radiation Safety Department evaluates and reduces
your risk of exposure to hazardous materials at CHOP through
personal exposure monitoring, health hazard evaluations, risk
assessments, engineering controls and personal protective
equipment recommendations.
Responding to Chemical or Radiation Exposures
Knowing how to properly respond to an accidental exposure or
chemical spill can reduce your risk of exposure.
In the event of an exposure, rinse the affected area immediately
with water (use an eyewash, if needed) and follow-up with the
Occupational Health Department.
In the event of a chemical spill, isolate the area and contact
Security at ext. 45500.
In the event of a radioactive material spill, contact Security at
x45500 and ask for assistance in contacting PENN’s Radiation
Safety Department. Clear personnel of the area and wash any
contaminated skin gently with soap and tepid water.
Contact Information
For additional information, please contact:

The Environmental Health and Safety Department
x43872.

The Office of Research Safety x62272.

PENN Radiation Safety 215.898.7187
Radiation Safety
Ionizing radiation is a valuable aid in research laboratories and
medical practice but also poses a unique health hazard that
requires specific safety precautions. Typical occupational
exposures throughout our healthcare system are a fraction of the
allowed limits set by regulatory agencies. Safety guidelines are
established to keep radiation exposure as low as reasonably
achievable (ALARA). Employees who work with radioactive
materials or x-ray machines must receive additional training with
the Environmental Health and Radiation Safety Department from
UPENN.
Additional training specific to Clinical and Research Laboratories
and radiation workers is also offered through these departments.
Employees who are pregnant or think they may be pregnant
require additional guidance and monitoring to protect the
developing fetus. All staff should be aware of the radiation safety
symbol and never operate equipment or handle radioactive
materials with this symbol unless they’ve been specifically trained
to do so.
Page 2 of 2
ADMINISTRATIVE
POLICY MANUAL
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
No. A-1-5
Title:
Page 1 of 26
COMPLIANCE STANDARDS OF CONDUCT
Effective Date:
06/12/2008
POLICY
The Hospital and its affiliates have adopted these Compliance Standards of Conduct in recognition of
our responsibility to our patients, staff, physicians and the community. These Compliance Standards
of Conduct affirm our commitment to conduct our activities with ethics, integrity and in compliance
with applicable laws, regulations, policies and procedures.
SCOPE
This policy applies to the Trustees and Officers, employees, and Medical and Research Staffs of The
Children’s Hospital of Philadelphia and entities controlling, controlled by or under common control
with The Children’s Hospital of Philadelphia, including, without limitation: The Children’s Hospital
Foundation; The Children’s Hospital of Philadelphia Practice Association; CHOP Clinical Associates;
and the CHOPPA Practice Plans (currently Children’s Anesthesiology Associates, Children’s Health
Care Associates, Children’s Surgical Associates, and Radiology Associates of Children’s Hospital,
and their New Jersey counterparts). It also applies to any other persons or entities acting or providing
services on behalf of the Hospital.
GUIDELINES
All persons covered by this policy are responsible for following the attached Compliance Standards of
Conduct.
RESPONSIBILITY FOR MAINTENANCE OF THIS POLICY:
SENIOR VICE PRESIDENT & CHIEF COMPLIANCE OFFICER
ATTACHMENTS
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Supersedes
Approved by:
12/18/2007
Signature:
__________________________________________________________
Madeline Bell, Executive Vice President and Chief Operating Officer
This Administrative Policy is the property of The Children’s Hospital of Philadelphia and is protected by U.S.
and international copyright laws and may not be used or reproduced without the prior written consent of The
Children's Hospital of Philadelphia. This Policy is to be used solely by employees of the Hospital, the Hospital
Medical Staff and those acting on the Hospital’s behalf either on the premises of the Hospital in connection
with Hospital matters or in their Hospital duties involving the care of Hospital patients. This Policy may not be
entered into a computer database or otherwise duplicated, in whole or in part in any format. Any personal or
other use is strictly prohibited.
THE CHILDREN’S HOSPITAL OF PHILADELPHIA © 2008 All Rights Reserved
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 2 of 26
THE CHILDREN’S HOSPITAL OF
PHILADELPHIA COMPLIANCE
STANDARDS OF CONDUCT
SETTING THE STANDARD:
Your Compliance Guide
Revised June 2008
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 3 of 26
TO: Trustees, Officers, Employees, and Members of the Medical and Research
Staff of The Children’s Hospital of Philadelphia and its affiliates:
Children’s Hospital has always been a place where ethics and integrity guide our
mission of quality pediatric medical care, education, and research. Full
compliance with applicable laws and regulations is an important component of our
philosophy. In support of this effort, The Children’s Hospital of Philadelphia
publishes these Compliance Standards of Conduct, which have been approved by
the Board of Trustees.
Children’s Hospital maintains a comprehensive compliance program to help us
detect and prevent violations of law and fraud, abuse and waste, as well as to
educate everyone regarding key legal and regulatory standards.
These Standards and our commitment to compliance have been embraced by our
executive management, department chairs and Trustees. While this Guide is not
comprehensive, these Standards summarize key compliance principles. These
Standards do not replace or supercede any existing policies.
If you still have questions about particular matters after reviewing this document,
please call the Compliance Line at 866-246-7456 or contact Children’s Hospital’s
Chief Compliance Officer at 267-426-6147.
We recognize that getting the job done is not the only thing that counts. It’s also
about how we achieve our outcomes. Children’s Hospital’s reputation as an
industry leader in pediatric healthcare, education, and research requires us to do the
right things and to do them the right way. It actually goes beyond complying with
laws, regulations and policies. It means conducting ourselves with integrity in
everything we do.
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 4 of 26
Please take the time to read these Compliance Standards of Conduct, paying
particular attention to the sections that apply to your job. For detailed information,
refer to specific policies referenced in each section. These detailed policies may be
found in the Children’s Hospital’s Administrative Policy Manual, the Patient Care
Manual, the Human Resources Policy and Procedure Manual, or specific
clinical/departmental policies and procedures that apply to you (e.g., Finance
Department, Emergency Department, Operating Room, Blood Bank, Infection
Control, Environmental Safety, etc.); some of these policies may be found on
Children’s Hospital’s Intranet site.
With the personal commitment of all employees and Medical and Research Staff
members, we can maintain our excellent reputation. Please join us in dedicating
your best efforts to our compliance program.
Sincerely,
Steven M. Altschuler, M.D.
President and CEO
The Children’s Hospital of Philadelphia
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 5 of 26
TABLE OF CONTENTS
CODE OF CONDUCT STATEMENT ............................................................................6
USING THE COMPLIANCE PROGRAM ....................................................................8
Purpose of Our Compliance Standards of Conduct .........................................................8
Management’s Compliance Obligations ..........................................................................8
Disciplinary Action ..........................................................................................................9
Chief Compliance Officer ................................................................................................9
Reporting Compliance Concerns ...................................................................................10
Education and Training ..................................................................................................10
Compliance Monitoring .................................................................................................10
RELATIONSHIPS WITH PATIENTS .........................................................................11
Patient Care and Rights ..................................................................................................11
Emergency Treatment ....................................................................................................11
Charity Care and Discounts............................................................................................11
CONFIDENTIALITY OF PATIENT INFORMATION .............................................12
RELATIONSHIPS WITH PAYORS.............................................................................12
Coding and Billing for Services .....................................................................................12
Excluded Parties .............................................................................................................15
Credit Balances & Bad Debts ........................................................................................15
Cost Reports ...................................................................................................................16
RELATIONSHIPS WITH REFERRAL SOURCES ...................................................16
RELATIONSHIPS WITH COMPETITORS ...............................................................17
Antitrust..........................................................................................................................17
Marketing Our Services .................................................................................................17
RELATIONSHIPS WITH VENDORS..........................................................................17
RELATIONSHIPS WITH EMPLOYEES AND MEMBERS OF THE
MEDICAL STAFF.........................................................................................................18
Environmental Health and Safety ..................................................................................18
Background Checks and Credentialing..........................................................................18
CONFLICTS OF INTEREST ........................................................................................19
INFORMATION AND COMMUNICATION SYSTEMS ..........................................19
GOVERNMENT INQUIRIES/INVESTIGATIONS ...................................................20
POLITICAL AND LEGISLATIVE ACTIVITIES ......................................................20
APPENDIX:
Summary of Federal and State Laws..………………………………………...................21
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 6 of 26
APPLICATION OF THIS GUIDE
These Compliance Standards of Conduct apply to the trustees and officers,
employees, and medical and research staffs of The Children’s Hospital of
Philadelphia and any entity that is controlled by or under common control with The
Children’s Hospital of Philadelphia, including: The Children’s Hospital
Foundation; The Children’s Hospital of Philadelphia Practice Association; CHOP
Clinical Associates; and the CHOPPA Practice Plans, currently Children’s
Anesthesiology Associates, Children’s Health Care Associates, Children’s Surgical
Associates, and Radiology Associates of Children’s Hospital, and their New Jersey
counterparts. The term “Children’s Hospital” in this document refers to all of
those entities. These Compliance Standards of Conduct also apply to people or
entities acting or providing services on behalf of Children’s Hospital.
CODE OF CONDUCT STATEMENT
Ethics, integrity and compliance have always been valued principles at Children’s
Hospital. Our compliance program has been established to formally educate the
Medical Staff and employees about the laws, regulations, policies and procedures
governing our activities and to detect and prevent fraud, abuse and waste. By
encouraging the identification, communication and correction of compliance
issues, our compliance program helps ensure that all our activities are ethical and
legally compliant.
Please review the applicable sections of these compliance Standards of Conduct.
Children’s Hospital expects you to comply with both the letter and spirit of the
compliance program.
Our compliance program is intended to be a formal statement of Children’s
Hospital’s approach to compliance matters. However, some situations may arise in
which you are unclear whether the conduct is acceptable or not. In those
situations, raise the concern with your supervisor, or the Chief Compliance
Officer, or if it is a legal issue, contact the Legal Department.
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 7 of 26
Each employee is a valued member of the team, and each has an obligation to see
that Children’s Hospital maintains its high standards of professional, ethical
conduct.
YOUR OBLIGATION TO REPORT
If you encounter any situation that you believe may be in violation of any
applicable law or Children’s Hospital policy or procedure, you should immediately
contact your supervisor, the Compliance Officer or a member of the Legal
Department. You may also call the anonymous, toll-free Compliance Line at 866246-7456, or go to www.mycompliancereport.com. Everyone is responsible for
promoting compliance.
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 8 of 26
USING THE COMPLIANCE PROGRAM
Purpose of Our Compliance Standards of Conduct
These Compliance Standards of Conduct provide those of us who work at
Children’s Hospital with information to help carry out our job responsibilities
within appropriate ethical and legal parameters. These obligations apply to all our
relationships in connection with Children’s Hospital, including relationships with
patients, families, physicians, third-party payors, subcontractors, independent
contractors, vendors, consultants or each other.
These Standards are a critical component of our overall compliance program,
developed to help you meet ethical standards and comply with applicable laws and
regulations.
These Compliance Standards of Conduct are not intended to be a comprehensive
statement of our duties and obligations. Children’s Hospital maintains numerous
detailed policies and procedures that govern our activities. In some cases, a subject
discussed in this Guide involves such complexity that additional guidance may be
needed. In these cases, you should consult the applicable policy or procedure for
further information or contact your supervisor, the Legal Department, or the Chief
Compliance Officer for additional guidance.
Management’s Compliance Obligations
We expect leaders to set the example and be models for their staff members. As the
caretakers of our quality and reputation, you must strive to assure that everyone on
your team has sufficient information to comply with applicable laws, regulations
and policies, as well as the resources to resolve ethical and compliance dilemmas.
As leaders, you must help sustain the culture within Children’s Hospital that
promotes high standards of ethics and compliance. Managers and supervisors are
also accountable for appropriately educating their staff about our compliance
program.
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 9 of 26
Disciplinary Action
If you violate applicable laws or Children’s Hospital policies or procedures, you
may be subject to disciplinary action. The specific action will depend on the nature
and severity of the violation (and, where applicable, will be consistent with
Children’s Hospital’s Human Resources Policy and Procedure Manual or other
applicable disciplinary standards).
Discipline may include:
♦
♦
♦
♦
♦
♦
♦
General counseling
Oral warning
Written warning
Final Warning in Lieu of Suspension, or Suspension
Unpaid Suspension
Discharge
Medical Staff sanctions (set forth in the Medical Staff Bylaws)
Chief Compliance Officer
Children’s Hospital’s compliance program demonstrates the Hospital’s
commitment to high ethical standards, and compliance with applicable laws,
regulations, policies and procedures. The Chief Compliance Officer (CCO) assists
Children’s Hospital with the following activities:
♦ Assesses Children’s Hospital’s compliance activities
♦ Monitors implementation of the Hospital’s compliance program
♦ Provides/facilitates education and training regarding laws and regulations
affecting the organization
♦ Communicates to senior leaders and the Board of Trustees, including its
Audit and Compliance Committee, on the compliance program and presents
compliance policies, reports and plans for approval as appropriate
♦ Follows up on compliance findings, ensuring that appropriate corrective
action has been taken
♦ Continuously monitors the effectiveness of compliance activities, including
the effectiveness of the compliance program
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Setting the Standard: Your Compliance Guide
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Reporting Compliance Concerns
It is your duty to report any conduct that you reasonably believe violates our
policies or applicable law, to your supervisor, the Office of Compliance and
Privacy, a member of the Legal Department, or the Compliance Line. If you wish,
you may make an anonymous report to the Compliance Line (866-246-7456 or
www.mycompliancereport.com). It is the policy of Children’s Hospital not to
attempt to learn the identity of persons making anonymous reports to the
Compliance Line.
Children’s Hospital will not take any action against someone for reporting a
compliance violation in good faith. Children’s Hospital prohibits retaliation
against persons for making good faith compliance reports. If you were a party to
the non-compliant activity you reported, your good faith efforts will be considered
in assessing whether disciplinary action against you is appropriate.
We’re committed to investigating all reports promptly and protecting your
confidentiality and anonymity as much as possible. If you contact the Compliance
Line anonymously and wish to obtain an update on the status of the matter
reported, you will be given information about when and how to call back
following the initial call, and you will get a special case number given at the time
of your initial call. To the extent that is possible and appropriate, an update will be
provided to you. Once an investigation is completed, action to address the issue
will be taken as soon as practicable.
Education and Training
Children’s Hospital is committed to effectively communicating our standards and
procedures to all employees. We provide education and training to develop
compliance awareness and commitment. You must attend required compliance
training that is applicable to your job function.
We will track your participation in required compliance training and will maintain
records of participation in accordance with our compliance training procedures.
Compliance Monitoring
Children’s Hospital is committed to responsibly monitoring implementation of the
compliance program. Department managers are responsible for monitoring
compliance in their areas on an ongoing basis. In addition, the Office of
Compliance and Privacy develops annual Compliance Workplans.
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RELATIONSHIPS WITH PATIENTS
Patient Care and Rights
In our mission to provide quality healthcare, research, and education, we work hard
to treat all patients and their families with respect and dignity and to provide care
that is necessary and appropriate. We seek to make no distinctions in the
admission, transfer or discharge of patients or in the care we provide based on race,
color, national origin, ancestry, religion, sex, sexual orientation, marital status or
actual or perceived disability.
Upon admission, each patient/family is given a statement of patient rights and
responsibilities, including information about the right to make decisions regarding
medical care.
We encourage patient and family involvement in all aspects of care. Children’s
Hospital’s Patient Care Policy No. RI-2-01 provides additional guidance on Patient
Rights and Responsibilities. Please refer to this policy if you have any questions
regarding this matter.
Emergency Treatment
Children’s Hospital provides medical screening and treatment to all patients who
come to Children’s Hospital seeking treatment for an emergency medical
condition, as required by the Emergency Treatment and Active Labor Act
(“EMTALA”). We do not deny emergency treatment to any patient who comes to
Children’s Hospital based upon inability to pay or lack of insurance. EMTALA
establishes detailed requirements on when and how a patient who has an
unstabilized emergency medical condition may be transferred to another
institution. If you have any questions about EMTALA requirements, please
contact the Legal Department.
Charity Care and Discounts
Children’s Hospital provides services that are medically necessary to all pediatric
patients in our Primary Service Area, regardless of ability to pay, in accordance
with our Charity Care Policy. For more information, see Charity Care Policy No.
A-2-3 in the Administrative Policy Manual. Children’s Hospital offers prompt
payment discounts for the prompt payment of patient/family financial obligations,
in accordance with the Prompt Payment Policy No. A-2-4. Children’s Hospital
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does not grant any routine waivers or discounts in other circumstances, and does
not extend professional courtesy to patients based on their relationship with CHOP
physicians, officers or directors. For more information see Discounts and
Reductions in Patient/Family Financial Obligations Policy No. A-2.5.
CONFIDENTIALITY OF PATIENT INFORMATION
Patients and their families trust their healthcare providers with highly personal and
sometimes sensitive or embarrassing information regarding their personal and
medical history. If patients or families do not feel confident that their providers
will keep such information private, they may hesitate to discuss intensely private
issues, which could hinder their medical care. In addition, federal, state and local
laws provide protection for the confidentiality of patient medical records, and
require that only authorized personnel shall have access to that information and
that disclosures are limited.
It is critical that healthcare providers protect patient information and patient
privacy. Since this protection is one of our highest duties as a healthcare provider,
you are expected to understand when disclosures are allowable and/or required and
when they are not. These rules are outlined in detail in Children’s Hospital’s
policies related to patient health information. For more information, you can refer
to the Policy on Confidentiality of Patient and Institutional Information, No. A-3-5
and related policies.
RELATIONSHIPS WITH PAYORS
Coding and Billing for Services
Children’s Hospital takes great care to assure that there are systems in place for
submitting billings to government and private insurance payors that are truthful,
accurate and conform to the requirements of federal, state, and local laws and
regulations. These laws include the federal False Claims Act as well as laws
prohibiting schemes to defraud a healthcare benefit program.
The federal False Claims Act prohibits an individual or organization from
knowingly or recklessly submitting a false claim for payment or approval to a
federal or state health care program. It also prohibits knowingly or recklessly
making, using, or causing to be used a false record or statement to get a false or
fraudulent claim paid by the government. Violations may result in civil, criminal
and administrative actions and be punishable by substantial monetary penalties,
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fines, imprisonment and exclusion from federal and state health care programs.
We prohibit any employee or agent of Children’s Hospital from knowingly
presenting or causing claims to be presented for payment or approval that are false,
fictitious, intentionally misleading, fraudulent, or in violation of any law. For a
further description of the federal false claims laws, please refer to the attached
Appendix.
Both Pennsylvania and New Jersey have laws prohibiting persons from knowingly
or intentionally submitting false claims or statements in connection with providing
services or merchandise under medical assistance, or in connection with applying
for or continuing to receive medical assistance benefits or payments. New Jersey’s
Health Care Claims Fraud Act also prohibits health care practitioners licensed in
New Jersey and others from committing health care claims fraud in the course of
providing professional services. Violations of these laws may result in criminal
actions punishable by imprisonment, substantial monetary penalties, and fines. For
a further description of Pennsylvania’s and New Jersey’s laws, please refer to the
attached Appendix.
Children’s Hospital uses diligent efforts to maintain systems that result in fair,
reasonable and accurate claims submission, including the following specific
objectives:
(1) Billing only for items or services actually rendered
(2) Billing only for medically necessary services
(3) Preventing upcoding (the practice of using a billing code that provides a
higher payment rate than the billing code that actually reflects the service
furnished to the patient)
(4) Submitting accurate cost reports
(5) Appropriately bundling or combining services that should be billed together
(6) Billing the appropriate per-diem rate for patient transfers to another hospital
(7) Creating and maintaining supporting medical record documentation for
services billed to patients or payors
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(8) Billing for the services of teaching physicians only in accordance with
applicable laws
(9) Avoiding submission of claims arising from impermissible anti-kickback
arrangements.
We maintain oversight systems to verify that claims are submitted only for services
actually provided and that services are billed as provided. Failure to follow these
principles could result in submission of false claims.
Any subcontractors engaged to perform billing or coding services should have the
necessary skills, quality assurance processes, systems and appropriate procedures
to ensure that all billings for government and private insurance programs are
accurate and complete.
It is the obligation of all staff to bring to the attention of your supervisor or the
Chief Compliance Officer, or report to the Compliance Hotline if you prefer, any
billing practices you observe that are not truthful, accurate, or in conformity with
the requirements of federal, state and local laws and regulations.
In addition, the federal False Claims Act allows private persons to bring
“whistleblower” actions in the name of the government if they believe the False
Claims Act has been violated, and to recover substantial monetary rewards if the
action results in a settlement or judgment. The False Claims Act protects the rights
of whistleblowers; it is a violation of the Act for an employer to take any action
against someone for participating in an action under the False Claims Act,
including investigation for, initiation of, testimony for, or assistance in an action
under the False Claims Act. Other laws also provide protection of whistleblowers
in certain circumstances. We prohibit any individual or agent of Children’s
Hospital from violating the non-retaliation provisions of the False Claims Act or
any other applicable law.
Certain states also have false claims laws with private enforcement and
whistleblower protection provisions comparable to the federal False Claims Act.
Of the states in which Children’s Hospital operates or has affiliates, New Jersey
and Delaware have such a law, while Pennsylvania does not. New Jersey and
Pennsylvania have separate whistleblower protection laws that, along with New
Jersey’s and Delaware’s false claims laws, are more fully described in the attached
Appendix.
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For possible improper practices involving Pennsylvania Medicaid billing you may
also choose to contact the Pennsylvania Department of Public Welfare’s Fraud and
Abuse Hotline at 1-866-DPW-TIPS.
Excluded Parties
There are restrictions on healthcare providers and other entities employing or
entering into contracts with individuals or entities that are (at the time of
employment or contract) excluded from participation in federal or state health care
programs.
We require individuals applying for employment to disclose in their application
any felonies or other crimes or exclusion action. Screening of potential employees
and Medical Staff members includes consulting applicable government lists of
excluded persons/entities.
If an employee or member of the Medical Staff is investigated by any government
agency for violation of a licensure, certification, or health care law or regulation,
the investigation should be reported immediately to the Legal Department and/or
the Chief Compliance Officer.
If an employee or member of the Medical Staff is indicted, convicted, debarred or
excluded from participation in federal or state healthcare programs while affiliated
with Children’s Hospital, or receives notice of proposed debarment or exclusion,
this fact must be reported in accordance with applicable policies or standards of
Children’s Hospital and/or its Medical Staff, as applicable.
Credit Balances & Bad Debts
CHOP will treat credit balances and bad debt in compliance with applicable law
and regulations.
In some instances, a credit balance will exist in a patient account after payment by
both the patient and a federal or state healthcare program. We endeavor to
accurately track, report, and refund credit balances.
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Cost Reports
Our activities include reimbursement under government programs that require us
to submit certain reports of our costs of operation. Children’s Hospital will comply
with all federal, state, and local laws relating to cost reports. These laws and
regulations define what costs are allowable and outline the appropriate
methodologies to claim reimbursement for the cost of services provided to program
beneficiaries. Given the complexity of these requirements, all issues related to the
completion and settlement of cost reports must be communicated through or
coordinated with our Finance Department.
RELATIONSHIPS WITH REFERRAL SOURCES
Federal law generally prohibits payments in exchange for the referral of patients or
business to other healthcare providers or suppliers. This prohibition is very broad,
and applies both to those who offer or make such payments and to those who
receive such payments. In addition, a payment may be anything of value, not just
cash payments. There may be criminal as well as civil sanctions for violation of
this prohibition.
Children’s Hospital accepts patient referrals and admissions based on patients’
clinical needs and our ability to render the needed services. We do not pay or offer
anything of value, directly or indirectly, to anyone for referring patients or business
to us.
Similarly, Children’s Hospital makes referrals to other healthcare providers or
suppliers based on patients’ clinical needs, the ability of other providers or
suppliers to render needed services, and patient/family preferences. We do not
solicit or receive anything of value, directly or indirectly, in exchange for referring
patients to any other healthcare provider or supplier.
Federal law also generally prohibits us from giving anything of value to patients or
families that we know (or should know) would likely influence their decision to
receive services from Children’s Hospital. There are permitted exceptions to this
general prohibition when the value being offered relates to the promotion of certain
preventive care services or involves situations where the patient/family is indigent
or in financial need.
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Federal law also has prohibitions against a physician referring patients to certain
other providers (such as clinical labs) in which the referring physician (or a family
member of that physician) has a financial interest or relationship. Violations can
result in fines and exclusion from Medicare or Medicaid. The law is complex; it
applies only to certain services and has many exceptions.
Please contact the Legal Department with questions about these laws or to discuss
proposed arrangements with other providers, to be sure those arrangements comply
with applicable law.
RELATIONSHIPS WITH COMPETITORS
Antitrust
Antitrust laws are designed to create a level playing field in the marketplace and to
promote fair competition. These laws could be violated by discussing Children’s
Hospital business with a competitor (such as what our prices are or how our prices
are set), disclosing the terms of supplier relationships, allocating markets among
competitors or agreeing with a competitor to refuse to deal with a supplier.
Questions related to these matters should be directed to the Legal Department.
Marketing Our Services
We may use our marketing and advertising activities to educate the public, provide
information to the community, increase awareness of our services and recruit
employees. We will present only truthful, fully informative and non-deceptive
information in these materials and announcements.
RELATIONSHIPS WITH VENDORS
We select the vendors and contractors with which we do business on the basis of
arms-length and appropriate business criteria, and not on the basis of gifts to
persons, the existence or amount of other support a vendor or contractor provides
to Children’s Hospital (except in connection with a legally appropriate discount or
rebate), vendor or contractor support of Children’s Hospital research, or other
inappropriate factors. We endeavor to conduct business with vendors and
contractors in a way that maximizes the ability of Children’s Hospital to carry out
its patient care, research and education missions, and in accordance with legal and
ethical standards aimed at preventing conduct that may inappropriately influence
purchasing decisions.
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RELATIONSHIPS WITH EMPLOYEES
AND MEMBERS OF THE MEDICAL STAFF
We use our best efforts to comply with all state and federal laws governing
relationships with employees and independent contractors. Children’s Hospital
maintains policies that address many issues relating to employment at Children’s
Hospital. For additional guidance on any employee policy or practice, please refer
to the Administrative and Human Resources Policy and Procedure Manuals.
In particular, please refer to policies covering:
• Equal Employment Opportunities/Affirmative Action - Policy No. 2-1
• Non-Discrimination and Harassment - Policy No. 5-1
• Violence in the Workplace - Policy No. 6-4
• Drug Free Workplace - Policy No. 5-10
Environmental Health and Safety
Children’s Hospital is committed to providing a safe work place. You may work in
a variety of situations or with a variety of materials, some of which may pose a risk
of injury. You are required to comply with our policies and procedures for
workplace safety, which have been designed to comply with federal, state and local
safety laws and regulations and workplace safety directives. If you have a question
about safety, you should seek advice from the Environmental Health and Safety
Office.
It is essential that you report any work place injury or any situation presenting a
danger of injury so that timely corrective action may be taken. Please refer to
relevant Administrative policies such as Administrative Policy No. A-5-2 for more
details related to chemical hazards.
Background Checks and Credentialing
Children’s Hospital endeavors to conduct formal background and credentialing
checks on all employees, Medical Staff members, and certain vendors/contractors.
Children’s Hospital reserves the right to deny employment or continued
employment or Medical Staff membership or work/contracts for goods or services
to any individual who fails to meet our standards.
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CONFLICTS OF INTEREST
Conflicts of interest are those circumstances in which your personal interests may
actually or potentially conflict with those of Children’s Hospital or may be
perceived as actually or potentially conflicting with those of Children’s Hospital.
Children’s Hospital has adopted a Conflicts of Interest Policy (A-3-1 in the
Administrative Policy Manual). The policy outlines circumstances in which
outside interests or activities, such as accepting gifts, holding ownership interests
in companies or engaging in outside activities, may create a potential, perceived or
actual conflict of interest. The policy also contains an attachment with special
rules for conflict of interest issues in the research setting.
A potential, perceived or actual conflict of interest situation may arise at any time.
The Conflicts of Interest Policy requires that such situations be disclosed promptly,
as soon as the existence of the potential, perceived or actual conflict of interest is
or should be known, so that you can obtain guidance about the situation at the
earliest possible time. If there is any doubt about a situation, it should be fully
disclosed so that a determination can be made.
Please refer to Administrative Policy No. A-3-1 for more information regarding
Conflicts of Interest.
INFORMATION AND COMMUNICATION SYSTEMS
You may have access to Hospital technology resources such as computers,
electronic mail services, Internet access, communications devices and systems such
as telephones and faxes and portable devices such as Blackberries, PDA’s cellular
telephones and pagers. These technology resources are the property of Children’s
Hospital and are intended to be used for purposes related to Children’s Hospital’s
business and operations. You should assume that communications using Hospital
systems are not private. Children’s Hospital has the right to access, monitor, and
disclose the contents of our communications systems without notice to the users to
the extent allowable by law.
All uses of Children’s Hospital technology resources must comply with applicable
Hospital policy, including the Acceptable Use of Technology Resources Policy,
No. A-3-6. As a general rule, only minimal personal use of Children’s Hospital’s
assets is permitted. Children’s Hospital may revoke access to our technology
resources or take disciplinary action if you use them in violation of our policies or
in violation of any applicable law or regulation.
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GOVERNMENT INQUIRIES/INVESTIGATIONS
Children’s Hospital expects you to cooperate appropriately in government
investigations. However, it is essential that the legal rights of Children’s Hospital
and our employees, Medical Staff members and patients be protected.
If you receive a subpoena, inquiry, or other document from any government
agency regarding Children’s Hospital’s business or patients, whether at home or in
the workplace, notify the Legal Department (with a copy to the Office of
Compliance and Privacy) immediately. Please notify the Health Information
Management Department in the case of subpoenas for medical records.
If you are aware of an imminent or ongoing investigation, audit, or examination,
you should retain all documents (including computer records) in your custody or
control relating to the matter under review.
Any questions regarding government inquiries or investigations should be
addressed to the Legal Department.
POLITICAL AND LEGISLATIVE ACTIVITIES
The Hospital, including its affiliates, is exempt from federal income tax pursuant to
Section 501(c)(3) of the Internal Revenue Code. In order to maintain this status,
the Hospital may not participate in any political campaign on behalf of or in
opposition to any candidate for public office. This is an absolute prohibition. In
addition, the Hospital cannot engage in more than insubstantial lobbying on
legislative issues. Individuals are free to engage in political and legislative
activities in their personal capacity on their personal time. Hospital titles,
letterhead and resources may not be used for political activities; and they may be
used for legislative activities only with the permission of a member of senior
management.
###
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APPENDIX
Summary of Federal and State Laws
Federal Laws
a. The False Claims Act
The False Claims Act ("FCA") provides, in pertinent part, that:
(a) Any person who (1) knowingly presents, or causes to be presented, to an officer or
employee of the United States Government or a member of the Armed Forces of the
United States a false or fraudulent claim for payment or approval; (2) knowingly makes,
uses, or causes to be made or used, a false record or statement to get a false or
fraudulent claim paid or approved by the Government; (3) conspires to defraud the
Government by getting a false or fraudulent claim paid or approved by the Government;
. . . or (7) knowingly makes, uses, or causes to be made or used, a false record or
statement to conceal, avoid, or decrease an obligation to pay or transmit money or
property to the Government,
* * *
is liable to the United States Government for a civil penalty of not less than $5,000 and
not more than $10,000, plus 3 times the amount of damages which the Government
sustains because of the act of that person . . . .
(b) For purposes of this section, the terms "knowing" and "knowingly" mean that a
person, with respect to information (1) has actual knowledge of the information; (2) acts
in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless
disregard of the truth or falsity of the information, and no proof of specific intent to
defraud is required.
31 U.S.C. § 3729. While the False Claims Act imposes liability only when the claimant acts “knowingly,” it
does not require that the person submitting the claim have actual knowledge that the claim is false. A
person who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information,
also can be found liable under the Act. 31 U.S.C. 3729(b).
In sum, the False Claims Act imposes liability on any person who submits a claim to the federal
government that he or she knows (or should know) is false. An example may be a physician who submits
a bill to Medicare for medical services she knows she has not provided. The False Claims Act also
imposes liability on an individual who may knowingly submit a false record in order to obtain payment
from the government. An example of this may include a government contractor who submits records that
he knows (or should know) are false and that indicate compliance with certain contractual or regulatory
requirements. The third area of liability includes those instances in which someone may obtain money
from the federal government to which he may not be entitled, and then uses false statements or records
in order to retain the money. An example of this so-called “reverse false claim” may include a hospital
who obtains interim payments from Medicare throughout the year, and then knowingly files a false cost
report at the end of the year in order to avoid making a refund to the Medicare program.
In addition to its substantive provisions, the FCA provides that private parties may bring an action on
behalf of the United States. 31 U.S.C. 3730 (b). These private parties, known as “qui tam relators,” may
share in a percentage of the proceeds from an FCA action or settlement. Section 3730(d)(1) of the FCA
provides, with some exceptions, that a qui tam relator, when the Government has intervened in the
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APPENDIX, continued
lawsuit, shall receive at least 15 percent but not more than 25 percent of the proceeds of the FCA action
depending upon the extent to which the relator substantially contributed to the prosecution of the action.
When the Government does not intervene, section 3730(d)(2) provides that the relator shall receive an
amount that the court decides is reasonable and shall be not less than 25 percent and not more than 30
percent.
The FCA provides protection to qui tam relators who are discharged, demoted, suspended, threatened,
harassed, or in any other manner discriminated against in the terms and conditions of their employment
as a result of their furtherance of an action under the FCA. 31 U.S.C. 3730(h). Remedies include
reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination,
two times the amount of any back pay, interest on any back pay, and compensation for any special
damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’
fees.
b. The Federal Program Fraud Civil Remedies Act (“PFCRA”)
This federal law makes it illegal for a person or entity to make, present or submit (or cause to be made,
presented or submitted) a “claim” (i.e., a request, demand or submission) for property, services, or money
to an “authority” (i.e., an executive department of the federal government, e.g., the U.S. Department of
Health and Human Services which oversees Medicare and Medicaid programs) when the person or entity
“knows or has reason to know” that the claim: (i) is false, fictitious or fraudulent; or (ii) includes or is
supported by any written statement which asserts a material fact which is false, fictitious or fraudulent; or
(iii) includes or is supported by any written statement which omits a material fact, is false, fictitious or
fraudulent because of the omission and is a statement in which the person or entity has a duty to include
such material fact; or (iv) is for the provision of items or services which the person or entity has not
provided as claimed.
In addition, it is illegal to make, present or submit (or cause to be made, presented, or submitted) a
written “statement” (i.e., a representation, certification, affirmation, document, record, or accounting or
bookkeeping entry made with respect to a claim or to obtain the approval or payment of a claim) if the
person or entity “knows or has reason to know” such statement: (i) asserts a material fact which is false or
(ii) omits a material fact making the statement false, fictitious or fraudulent because of the omission.
Similar to the Federal False Claims Act, the PFCRA broadly defines the terms “knows or has reason to
know” as (1) having actual knowledge that the claim or statement is false, fictitious, or fraudulent; (2)
acting in deliberate ignorance of the truth or falsity of the claim or statement; or (3) acting in reckless
disregard of the truth or falsity of the claim or statement. The law specifically provides that a specific
intent to defraud is not required in order to prove that the law has been violated.
The PFCRA provides for civil penalties of up to $5,000 for each false claim paid by the government, and
in certain circumstances, an assessment of twice the amount of each claim.
In addition, if a written statement omits a material fact and is false, fictitious or fraudulent because of the
omission and is a statement in which the person or entity has a duty to include such material fact and the
statement contains or is accompanied by an express certification or affirmation of the truthfulness and
accuracy of the contents of the statement, the law provides for a penalty of up to $5,000 to be imposed
for each such statement.
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APPENDIX, continued
Pennsylvania Laws
a. Fraud and Abuse Control under the Public Welfare Code
This law contains provisions relating to acts prohibited by providers (62 P.S. §1407) and other acts
relating to applications for medical assistance or the receipt of benefits under the program (62 P.S.
§.1408).
Under Pennsylvania law, it is unlawful for providers to: knowingly or intentionally submit false information,
or false claims or costs reports for furnishing services or merchandise under the medical assistance
program, or claims or cost reports for medically unnecessary services or merchandise; solicit, receive or
offer to pay remuneration, including kickbacks, bribes or rebates in connection with furnishing services or
merchandise under the medical assistance program; submit duplicate claims for which the provider has
already received or claimed reimbursement; submit a claims for services, supplies or equipment not
rendered to a recipient; submit claims which include costs or charges not related to the services, supplies
or equipment rendered to the recipient; submit claims for or refer recipients to another provider for
unnecessary services, supplies or equipment; submit claims which misrepresent information about such
things as the services provided, the recipient, date of service, or identify of the practitioner or provider;
submit claims for reimbursement higher than the provider’s usual and customary charge for the service or
item; submit claims for a service or item not rendered; provide a service or item without a practitioner’s
written order and consent of the recipient (except in emergencies); or render a service or item without
making a reasonable effort to verify through a current medical assistance card that the patient is in fact
currently eligible (except in emergencies). Violations can result in criminal and civil penalties, including
monetary penalties and termination of participation as a provider in the medical assistance program.
Under Pennsylvania law, it is also unlawful for other persons to: knowingly or intentionally make false
statements or fail to disclose material facts regarding eligibility for themselves or another for medical
assistance benefits; fraudulently conceal knowledge of events affecting the person’s initial or continued
right to receive such benefits; convert benefits to a use other than for himself or the person for whom the
benefits were intended; visit multiple providers for the purpose of obtaining excessive services or benefits
beyond what is reasonably needed; or borrow or use a medical assistance card without entitlement to do
so. Violations can result in criminal and civil penalties, including monetary penalties and restrictions on
continued eligibility for medical assistance benefits. (62 P.S. §.1408).
b. Whistleblower Law
Pennsylvania law protects the rights of employees of public bodies, such as state or local governments,
who make good faith reports about wrongdoing or waste, or who participate in an investigation, hearing or
inquiry. (43 P.S. §§ 1422-1428).
New Jersey Law
a. New Jersey False Claims Act
The New Jersey False Claims Act (the “New Jersey FCA”, N.J. S. 2A:32C-1 to 32C-17 (2008)) is
comparable to the federal False Claims Act, making it unlawful for a person to knowingly make false or
fraudulent claims, including to: present or cause to be presented to an employee, officer or agent of the
State of New Jersey, or any contractor, grantee or other recipient of State funds, a false or fraudulent
claim for payment or approval; make, use or cause to be made or used a false record or statement to get
a false or fraudulent claim paid or approved by the State; conspire to defraud the State by getting a false
or fraudulent claim allowed or paid; or knowingly make, use, or cause to be made or used, a false record
or statement to conceal, avoid, increase or decrease an obligation to pay or transmit money or property to
the State. Liability under the New Jersey FCA results in a civil penalty equal to the civil penalty under the
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 24 of 26
APPENDIX, continued
Federal FCA (currently between $5,500 and $11,000) for each act constituting a violation, plus 3 times
the amount of the damages sustained by the State (or 2 times the amount of damages if the person
committing the violations provides full information and cooperation to the government officials
investigation the false claims violations). In addition to its substantive provisions, the New Jersey FCA
provides that private parties may bring an action in the name of the State for a violation of the FCA.
These private parties may share in a percentage of the proceeds from an action or settlement. With some
exceptions, when the government has intervened in the lawsuit, this law provides that the private party
shall receive at least 15 percent but not more than 25 percent of the proceeds depending upon the extent
to which the person substantially contributed to the prosecution of the action. When the government does
not intervene, the private party is entitled to receive an amount that the court decides is reasonable,
which shall be not less than 25 percent and not more than 30 percent.
A civil action under the New Jersey FCA may not be brought on the later of the two following dates: (1)
more than 6 years after the date on which the violation is committed; or (2) more than 3 years after the
date when facts material to the right of action are known or reasonably should have been known by the
New Jersey official charged with responsibility to act in the circumstances. However, in no event may an
action be brought under the New Jersey FCA more than 10 years after the date on which the violation is
committed. The New Jersey FCA provides protection to private parties who are discharged, demoted,
suspended, threatened, harassed, denied promotion or in any other manner discriminated against in the
terms and conditions of their employment as a result of their disclosure of information to the State or
furtherance of an action under the New Jersey FCA. Remedies include reinstatement with comparable
seniority as the party would have had but for the discrimination, two times the amount of any back pay,
interest on any back pay, and compensation for any special damages sustained as a result of the
discrimination, including litigation costs and reasonable attorneys’ fees.
b. New Jersey Medical Assistance and Health Services Act – Criminal Penalties and Civil
Remedies
The New Jersey Medical Assistance and Health Services Act contains provisions relating to acts
prohibited by persons receiving medical assistance benefits and providers receiving medical assistance
payments. The law makes it a crime for a provider to knowingly receive medical assistance payments to
which he is not entitled or in a greater amount than entitled. It is also a crime for a provider or other
person or entity to knowingly and willfully make materially false statements in applying for payments
under the medical assistance program or for use in determining rights to such payment, to conceal or fail
to disclose the occurrence of an event affecting the initial or continued right to a payment with the
fraudulent intent to secure payments not authorized or in a greater amount than authorized under the law,
or to knowingly and willfully convert payments to a use other than the use and benefit of the provider or
other person. It is also a crime for a provider or other person to solicit, offer or receive a kickback, rebate
or bribe in connection with the receipt of a payment under the Act or the furnishing of items or services for
which payment is or may be made or whose cost is or may be reported in order to obtain such payments
(except for lawful discounts or price reductions and payments to an employee under a bona fide
employment relationship). Finally, it is a crime to knowingly and willingly make or induce, or seek to do so,
the making of false statements or representations of material facts with respect to the conditions or
operations of an institution or facility in order for it to qualify for certification or recertification of a hospital
and thereby entitled to receive medical assistance payments. Violations can result in criminal penalties
including fines and imprisonment. (N.J.S. 30:4D-17 (a)-(d)).
In addition, various civil remedies are available to the government under the Medical Assistance and
Health Services Act. Persons or entities committing the crimes described in the previous paragraph are
liable for civil penalties (recoverable in an administrative proceeding) including all of the following: interest
on the excess payments, three times the amount of the payments unlawfully obtained, and $2,000 per
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 25 of 26
APPENDIX, continued
excessive claim for payments. Persons or entities who obtain medical assistance payments in amounts in
excess of that to which they are entitled, but without intent to violate the Act, may be subject to a civil
penalty in the amount of interest on the excess payments. Finally, the director of the Medical Assistance
Program has the authority to suspend, debar or disqualify for good cause any provider (or an agent,
employee or contractor of one) or other person or entity participating in the Medicaid program. (N.J.S.
30:4D-7.h; 30:4D-17 (e) – (i); 30: 4D-17.1.a).
c. Health Care Claims Fraud Act
This law makes it a crime for licensed health care practitioners and persons who are not practitioners to
knowingly or recklessly commit health care claims fraud in the course of providing professional services.
Conviction under the Health Care Claims Fraud Act subjects the person to criminal penalties as permitted
under New Jersey law, fines of up to five times the pecuniary benefit received or sought, and license or
certificate forfeiture . Health care claims fraud includes the making of false or misleading statements in, or
omission of material facts from, a record, bill, claim or other document submitted for payment or
reimbursement for health care services. (N.J.S. 2C:21-4.2 and 4.3; N.J.S. 2C:51-5).
d. Conscientious Employee Protection Act
This law prohibits retaliation against an employee who discloses to a supervisor or public body an activity,
policy or practice by an employer that the employee reasonably believes violates a law, rule or regulation,
or is fraudulent or criminal. It also prohibits retaliation against an employee who provides information or
testimony to a public body investigating a violation of law, rule or regulation by an employer, or who
objects to or refuses to participate in any activity, policy or practice that the employee reasonably believes
is in violation of a law, rule or regulation, or is fraudulent, or incompatible with a clear mandate of public
policy. The law provides a private right of action for aggrieved employees with available remedies
including injunctive relief, reinstatement, lost wages and benefits, and other compensatory damages; a
defendant may also be subject to civil fines and punitive damages. An employer may, however, recover
attorneys fees and costs if an employee is found to have brought an action without basis in law or fact.
(N.J.S. 34:19-1 to 19-14.).
Delaware Law
a. Delaware False Claims and Reporting Act
The Delaware False Claims and Reporting Act (the “Delaware FCRA”, 6 Del. C. 1201-1209) is
comparable to the federal False Claims Act, making it unlawful for a person to knowingly: present or
cause to be presented to the government of the State of Delaware (including, for example, departments,
political subdivisions, state and municipal authorities, and State-funded entities) a false or fraudulent
claim for payment or approval; make, use or cause to be made or used a false record or statement to get
a false or fraudulent claim paid or approved; conspire to defraud the government by getting a false or
fraudulent claim allowed or paid; or knowingly make, use, or cause to be made or used, a false record or
statement to conceal, avoid, increase or decrease an obligation to pay or transmit money or property to
the government. Liability under the Delaware False Claims and Reporting Act results in a civil penalty of
between $5,500 and $11,000 for each act constituting a violation, plus 3 times the amount of the
damages sustained by the government (or 2 times the amount of damages if the person committing the
violations provides full information and cooperation to the government officials investigation the false
claims violations). While the Delaware FCRA imposes liability only when the claimant acts “knowingly,” it
does not require that the person submitting the claim have actual knowledge that the claim is false. A
person who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information,
also can be found liable under the Act.
Administrative Policy A-1-5: Compliance Standards of Conduct
Attachment A: Compliance Standards of Conduct
Setting the Standard: Your Compliance Guide
Page 26 of 26
APPENDIX, continued
In addition to its substantive provisions, the Delaware FCRA provides that private parties who are
“affected” persons, entities or organizations may bring an action on behalf of the State government for a
violation of the FCRA. These private parties may share in a percentage of the proceeds from an action or
settlement. With some exceptions, when the government has intervened in the lawsuit, this law provides
that the private party shall receive at least 15 percent but not more than 25 percent of the proceeds of the
Delaware FCRA action depending upon the extent to which the person substantially contributed to the
prosecution of the action. When the government does not intervene, the private party is entitled to
receive an amount that the court decides is reasonable, which shall be not less than 25 percent and not
more than 30 percent.
A civil action under the Delaware FCRA may not be brought on the later of the two following dates: (1)
more than 6 years after the date on which the violation is committed; or (2) more than 3 years after the
date when facts material to the right of action are known or reasonably should have been known by the
Delaware official charged with responsibility to act in the circumstances. However, in no event may an
action be brought under the Delaware FCRA more than 10 years after the date on which the violation is
committed. The Delaware FCRA provides protection to private parties who are discharged, demoted,
suspended, threatened, harassed, or in any other manner discriminated against in the terms and
conditions of their employment as a result of their furtherance of an action under the Delaware FCRA.
Remedies include reinstatement with comparable seniority as the party would have had but for the
discrimination, two times the amount of any back pay, interest on any back pay, and compensation for
any special damages sustained as a result of the discrimination, including litigation costs and reasonable
attorneys’ fees.
###
Mandatory Education 2011: Data Protection Awareness
Data Protection:
It Starts With You!
Why is data
protection important?
WHAT’S NEW WITH DATA
PROTECTION AWARENESS
THIS YEAR
The Ultimate Answer: You!
There are three simple rules you can follow to keep
CHOP information private and secure.
Know It!
Do I know what confidential data is in my
possession and where all of it is located
both paper and electronic? Do I need this
information to do my job?
Purge It!
Do I need the information anymore?
Secure It!
Are the paper documents that I’m transporting properly secured to prevent loss, theft or
access by unauthorized individuals?
Everyone who touches confidential information
at CHOP has a responsibility to keep it safe.
Confidential information needs to be protected
because:
•
We have ethical, moral, and legal
obligations that require us to protect
certain kinds of information and
•
Harm can result to our patients and/or
the Hospital if the confidential information
is not properly protected.
Nothing is more important than our patients’
health and safety. Protecting their information is
an important part of keeping them safe.
Why? Because the law says so.
There are several laws governing the protection of patient and consumer information that can impose
penalties on organizations who fail to protect it.
HIPAA (The Health Insurance Portability and Accountability Act)
requires that all patient information be kept confidential and only used
or shared for certain allowable purposes without patient authorization.
It also requires that we use reasonable safeguards to protect data
from loss, theft or misuse, such as unauthorized access.
HITECH (The Health Information Technology for Economic and
Clinical Health Act)
also protects patient information. Organizations that fail to do so must
notify affected patients, the Federal government and in some cases
the media.
JOINT COMMISSION
while not really a “law”, the Joint Commission accredits all teaching
hospitals and requires them to protect patient information.
STATE DATA BREACH LAWS
Pennsylvania and New Jersey along with most states have laws that require organizations who breach the confidentiality of consumer information
to notify those individuals.
Mandatory Education 2011: Data Protection Awareness
Data Protection:
It Starts With You!
We’re in this together.
CHOP’s security and privacy efforts are supported by both the Information Security Department and the Privacy Office, with each area working together to identify, prioritize, and reduce risks to the confidentiality, integrity
and availability of CHOP data.
Although these offices help CHOP keep data safe, it is ultimately your responsibility to protect data in your
daily activities.
Keeping CHOP data confidential is important to ensure…
That information is not accessed by or disclosed to unauthorized individuals. This is an essential pillar of maintaining the privacy and security of patient information.
Maintaining the integrity of CHOP data is important to ensure…
That information has not been altered or destroyed in an inappropriate or unauthorized manner.
Protecting the availability of CHOP data is important to ensure…
That information is accessible and useable upon demand by members of CHOP’s workforce in order to perform their jobs.
What information needs to be protected?
CHOP policy governing the type of patient and institutional information that is confidential is found in the
Administrative Manual under the title “Confidentiality of Patient and Institutional Information“.
Institutional information that is confidential includes information about the Hospital,
its research activities and the Hospital
workforce.
Patient information that needs to be
protected is any information that may
identify an individual patient.
•
•
•
•
•
•
•
•
•
•
•
Demographic information - names, initials,
address, e-mail address
Dates – date of birth, admission, discharge, or
date of death
Numbers
Social security numbers
Medical record numbers
Phone or Fax numbers
Health plan beneficiary numbers
Billing account numbers
Vehicle or device numbers
Certificate and license numbers
Unique characteristics - Facial photographs,
finger / voice prints, Web URL or Internet
Protocol (IP) addresses
•
•
•
•
•
An employee’s Human Resources record
Payroll records and salary information
Non-public Hospital business information (e.g.,
long range financial plans)
Non-public research information (e.g., inventions)
Vendor trade secrets
Mandatory Education 2011: Data Protection Awareness
Data Protection:
It Starts With You!
What is a Security Incident?
A Security Incident...
Occurs whenever the confidentiality, integrity, or availability of CHOP
data or systems containing CHOP data is compromised.
Can result from a system intrusion (e.g., hacking) or can result from
less technical attacks (e.g., phishing) that exploit weaknesses in
people, processes, or systems.
Can also be the result of unintentional actions such as human error
by members or the CHOP workforce.
A security incident:
What are some common places I might
find confidential information?
Patient and institutional information
that you need to protect is likely
found in paper documents and
electronic files you access everyday.
Some examples include:
33 Patient schedules
33 Letters to patients
33 Medical charts/records
33 Reports
33 Billing records
33 Research records
33 Handwritten notes
May or may not involve a breach of confidentiality of CHOP data
33 Computer print-outs
Is always a serious matter and you should always report it here at
CHOP.
33 Emails
When such incidents compromise the confidentiality of patient
information, patient families often need to be notified so that they
can take steps to prevent possible misuse of their information.
Our policies help prevent incidents!
CHOP has policies that govern information security and they are important for you to know and understand.
The ACCESS CONTROL OF INFORMATION SYSTEMS policy is
designed to ensure members of the CHOP workforce have appropriate access to Hospital resources and CHOP information in order to
perform their job.
What this means for you is that you should have system access that
allows you to see the information you need to do your job and no
more.
IMPORTANT: Managers are responsible for ensuring that access rights for their staff are
matched correctly to their CURRENT job function and role.
You need to inform your manager if you have access to systems or
data in systems that you do not need to perform your job.
33 Faxes
33 Electronic files and databases
33 Electronic Medical Record systems
(EMR), including Epic
What are some common places I might
find confidential information?
•
Lost or stolen portable devices such
as laptops, flash drives, or other data
storage devices
•
Paper documents being lost, stolen, or
released in error
•
Electronic threats, such as phishing
(attempts to gain access by tricking a
user into providing their User IDs and
password)—currently a very frequent
threat at CHOP
•
Shared or compromised passwords
Mandatory Education 2011: Data Protection Awareness
Use your resources carefully.
ACCEPTABLE
UNACCEPTABLE
•
Using resources for Hospital activities
•
•
Accessing CHOP data only for purposes relating to your job functions
Storing, sending, or displaying fraudulent,
harassing, or profane material
•
Accessing adult websites
•
Using reasonable precautions to protect data
and devices from loss, theft, or misuse
•
Forwarding chain letters
•
Storing electronic information only on encrypted Hospital-issued portable devices (e.g.,
CHOP-issued laptops)
•
Using Hospital resources for personal activities to the extent that the use interferes with
the availability of those resources by other
members of the CHOP workforce to perform
their job functions
We have a policy for that!
The INFORMATION SECURITY INCIDENT MANAGEMENT policy describes how CHOP addresses
security incidents relating to our electronic information and systems, including:
•
Theft
•
Loss
•
Unauthorized access
•
Unsecure transmission of data
•
Modification and/or destruction of data or systems
These policies and standards were written by us
for our protection. Get to know them better and
practice them. These policies can be found on the
intranet in the Administrative Policy Manual.
Reporting:
Who Should I Call?
If it’s an incident involving electronic information or a device, call the IS Service Desk to
report it. Also notify your supervisor, manager,
or director.
Call the IS Service Desk
Use the same contact information as that
used when you have computer issues.
Call 4-HELP
All other incidents involving patient or institutional information must be reported to the
Hospital’s Privacy Office directly or anonymously through the Compliance Hotline. You
should also notify your supervisor, manager or
director so they are aware.
Contact the Privacy Office
Contact the Privacy Office at (267) 426-6036
or
[email protected]
Use the Compliance Hotline
Call the Children’s Hospital Compliance Line
at 1-866-246-7456
Log on to www.mycompliancereport.com
using CHOP as the access ID
You can always find this reporting information
by typing “hotline” in the Internet search box.
Mandatory Education 2011: Data Protection Awareness
How can I practice data protection every day?
Here are some things you can do every day to keep CHOP data safe.
Be aware of your surroundings and
keep portable devices such as a
laptop, a Blackberry, or any paper
documents containing confidential
information with you at all times or in
a secure location when traveling.
Never leave a portable device
unattended in a vehicle or public
area. Secure and lock your laptop
and other devices when not in
use.
Never provide your user ID or password
in response to any email you receive
even those that claim to be from the IS
Service Desk.
Never prop open doors, allow
someone to use your badge,
or provide physical access to a
secure area for someone who
would not otherwise have access
on their own.
Be suspicious of any e-mail
before you click on it. If you are
unsure of its authenticity, just
delete it!
Do not download or install any
programs on a Hospital resource
without first consulting the Help
Desk to ensure it is safe.
How can I choose a strong
password?
Remember:
You are responsible for all system activity performed
under your unique user ID and password for all applications, databases, servers to which you have
access.
How can I use confidential
CHOP data safely?
Move confidential CHOP data currently stored on any personally owned device (such as your home PC or laptop) or
any portable Hospital issued device that is not encrypted
(such as a flash-drive) to a secure CHOP resource.
If your job requires you to save confidential data to access
while at work, make sure to save it on either your CHOP
personal share network drive* or for research data on the
Storage Area Network (SAN)*.
A Strong Password…
•
Is something that is unique
•
Is NOT a common or easy-to-guess word
•
Is something you NEVER write down
•
Is NEVER shared with anyone
TIP: Try putting two or more words together to
form a pass phase!
TIP: Consider using a special character like a
question mark to make it harder to guess!
Meet Josiah Harmes, a member of CHOP’s Youth Advisory
Council (YAC).
Josiah, is a 14-year-old young
man who, in his
words, has been
treateda lot at CHOP for 2
years. Josiah likes Star Wars
Legos and books.
He thinks that learning isn’t
always fun, but it is useful.
Mandator y Education: Fire Safety
Introduction
Our fire safety program is designed to support the Hospital’s
mission to be the safest children’s hospital in the nation. Our
patient’s safety is our priority, whether in the clinical or
Core setting.
Curriculum: Operation Seek
environmental
This module will help you learn about:
 Fire hazards and how to prevent them
 Our fire alarm systems and Condition Red Response
Team
 Your responsibilities for fire prevention and fire response
as an employee of CHOP and
 How to use a fire extinguisher
Objectives
One of the most significant patient safety hazards we face as a
hospital is the threat of fire. The presence of oxygen, which
accelerates a fire, and the difficulty of evacuating our sickest
patients are two factors that make hospital fires particularly
dangerous.
Remember, our patient’s safety is our top priority!
To ensure their safety, you must learn to:
 Identify the hazards of fire,
 Recognize ways to prevent fires,
 Follow fire response guidelines (RACE); and,
 Properly discharge a fire extinguisher.
Fire or Fire Drill?
Is this a drill? Are they just testing the system? Did someone
burn a bag of popcorn? What should my initial response be?
Can I properly use a fire extinguisher?
On average, we experience 12 fire alarms per month.
Fortunately, the majority are false alarms caused by
testing/maintenance or fire drills. These alarms are disruptive to
patient care and to our staff and visitors; however, we should
treat each one as a potential threat and know how to properly
respond.
Rev. 10/2010
January 22, 2009 New York’s Mount Sinai Hospital
Fire originated in a mechanical area and spread quickly to
the Emergency department below - 600 patients were
evacuated horizontally to another unit
September 1, 2010 Overton Brooks VA Medical Center on
East Stoner Avenue
The electrical fire at the bottom of the elevator shaft.
Smoke filled the shaft and gotten into the hospital.
Fewer than a hundred people, mostly staffers, were briefly
evacuated.
September 2, 2010 Promise Regional Medical Center's
Heart and Vascular Center
Fire was limited to an incubator in one of the laboratories,
One automatic sprinkler came on and contained the fire
until firefighters arrived. There were no injuries and no
direct patient care areas were affected.
Fire Contributors
Fire can occur when four conditions exist:
 Ignition Source - can be an electrical spark, open flame,
smoldering cigarette, electrosurgical instrument and
lasers.
 Oxidizer - can be oxygen and other medical gases and
chemicals.
 Fuel - can include ordinary combustibles, such as paper
and linen, as well as flammable liquids, such as laboratory
solvents, alcohol hand rubs and skin antiseptics.
 Chain Reaction - provides the heat necessary to maintain
the fire.
Hazards of Fire
 Fire is fast. In as little as three minutes it can grow from a
small flame to an all-consuming fire.
 Smoke can kill. Most fire-related deaths are from smoke
inhalation, not burns.
 Toxic gases are released in a fire such as carbon
monoxide and hydrogen chloride.
Hospital Fires in the News
Cooking Devices
Over the past year, there have been several hospital fires
reported in healthcare and medical research industries…
Cooking devices cause many fire alarm activations and have the
potential to cause significant fire.
Staff must be aware of the types of cooking devices that are
prohibited (toasters, hot plates, sternos and electric grills) and to
only use approved devices responsibly.
Never walk away from a microwave while it is in operation!
Page 1 of 3
Mandator y Education: Fire Safety
Storage
An important factor in preventing fires and ensuring safety
of our patients and staff in the event of a fire is storage.
Operation
Seekto store
WhileCore
a clear Curriculum:
corridor is tempting
to use as a place
items such as carts and equipment, this presents a serious
safety hazard in the event of evacuation.
Storage of materials on shelves should not impede the
performance of sprinkler heads. Sprinklers are designed
to release water in a specific pattern to suppress a fire.
Maintain a minimum of 18 inches from storage in any area
where sprinkler heads are located.
Keeping the amount of storage we have to a minimum also
reduces the amount of potential fuel for a fire to consume.
Rev. 10/2010
 Condition Red is announced during a suspected fire or
fire drill.
 Condition White is announced during a confirmed fire or
smoke event is a specific area and evacuation of that
specific area is required.
 Condition Green is announced when the situation is
given the “All Clear” by the Incident Commander.
The Condition Red Response Team (Security, Facilities and
Environmental Health and Safety) are specially trained to
respond to fire conditions and respond to every activation in
Main, Wood and Seashore.
RACE – Wood and the Pediatric & Adolescent
Care Practices
In our outpatient facilities, many of our patients can be evacuated
safely with the parents or guardians. For those who are
undergoing treatments or procedures, we defend in place:
Closing and Propping Doors
1.
Rescue any affected patients,
Keep doors closed. Many doors serve as fire and smoke doors
and are designed to prevent the travel of fire and smoke from
one area to another.
2.
Alarm by pulling a fire alarm pull station,
3.
Contain by closing all doors: and,
4.
Prepare to Evacuate if necessary.
If your door has a closure device on it, it should not be propped
open.
Fire Response Guidelines
All staff in any facility should follow RACE in a fire emergency:
 Rescue
 Alarm
 Contain
 Evacuate/Extinguish
RACE - Business (High Rise, Research)
In our high rise occupancies, evacuation must be done in a safe
and controlled manner. High rise buildings are required to have
emergency voice communications to occupants. High rise
buildings use a staged evacuation, three floors at a time in an
effort to evacuate those in immediate danger first. Never use an
elevator during a fire alarm. Emergency stairs are safe areas of
refuge and any handicapped personnel should be assisted to the
landing within a stair tower to await Fire Department personnel.
RACE - Hospital (Main & CSH)
1.
Rescue people in immediate danger,
In our inpatient facilities, evacuating our patients is the last resort;
therefore, we defend in place. The building systems in our
inpatient facilities are highly sophisticated. We have very early
detection of fire or smoke. Our buildings are fully-equipped with
sprinklers, which aid in extinguishing a fire quickly.
2.
Alarm by pulling a fire alarm pull station,
3.
Contain by closing all the doors; and,
4.
Prepare to Evacuate if necessary.
1.
Rescue any affected patients,
2.
Alarm by pulling a fire alarm pull station (near exit stairs
and Nurses stations),
3.
Contain by closing all the doors,
4.
Extinguish and prepare to Evacuate if necessary.
Listen to the Announcements
The high rise and research buildings we occupy are
equipped with automated announcement systems to
provide directions when a fire alarm has been activated.
Immediate evacuation of the building is not always
necessary and in some situations may be more dangerous
than just staying in the nearest fire tower.
Condition Red Response
In the Main Hospital, Wood Center & Seashore House, overhead
announcements are made when the fire alarm is activated.
Page 2 of 3
Mandator y Education: Fire Safety
Rev. 10/2010
Fire Plans
Every patient care unit, satellite site and high-rise building
has a detailed written fire plan identifying evacuation
routes and location of fire safety devices. These plans are
Core
Operation
located
on theCurriculum:
Employee Intranet,
under the Seek
Environmental Health and Safety Department.
Fire Extinguishers
Fire extinguishers should only be used if the fire is small and you
have a path of escape.
There are three common types of fire extinguishers:
 Water, which can be used for paper, wood, cloth and
plastic fires.
 Dry Chemical, which can be used on all types of fires.
 Carbon Dioxide, which can be used for electrical and
flammable liquids fires.
Fire Extinguisher Use
To use a fire extinguisher, follow:
1.
Pull the pin,
2.
Aim it at the base of the fire,
3.
Squeeze the trigger; and,
4.
Sweep from side to side.
Page 3 of 3
Mandatory Education 2011: Hand Hygiene
Save Lives:
Clean your hands!
WHAT’S NEW WITH HAND
HYGIENE THIS YEAR
CHOP has adopted The
World Health Organization’s Five Moments of
Hand Hygiene for teaching
employees the most important hand hygiene moments and the key steps for
effective cleaning of hands
using hand rub or soap and
water. Find it on page 2.
You can also learn more at:
www.who.int/gpsc/5may/
Hand_Hygiene_Why_How_
and_When_Brochure.pdf
Why is hand
hygiene important?
Hands are the most common vehicle for transmitting infection causing
germs to patients and patient surroundings.
Help CHOP reduce incidents of Healthcare Acquired Infection (HAI) by
cleaning your hands at point of care: before touching patients, after
touching patients, and after touching patient surroundings. You will
learn more about these moments in this document.
How are we doing? CHOP has a goal of 90% hand hygiene compliance.
This is measured in observations of hand hygiene performed at the crucial
point-of-care moments just described. We are not there yet! Find out how
your unit is doing and learn how you can help improve your unit’s overall
hand hygiene compliance rate.
Mandatory Education 2011: Hand Hygiene
The Five Moments
When should I perform
hand hygiene?
Hand hygiene before
glove application!
An aseptic task is
a procedure that
requires clean and
sterile conditions to
prevent infection
When should I wear
Personal Protective
Equipment?
Masks, N-95
respirators
Gloves - perform
hand hygiene first
Remind your co-workers to clean
their hands if you notice hand
hygiene not being performed.
Gowns - secured
Face protection
like goggles
Source: World Health Organization
Hand hygiene must be performed at the point-of-care: anytime
when a healthcare worker, including non-clinical staff, interacts
with the patient or the patient’s surroundings.
• Moment 1 - before you touch a patient
• Moment 2 - before you apply gloves and before a
procedure that requires sterile conditions (aseptic)
• Moment 3 - after the risk of body fluid exposure - clean
with soap and water if your hands are visibly soiled
• Moment 4 - after you touch a patient
• Moment 5 - after touching patient surroundings/objects in
the patient’s environment
• Beyond the 5 Moments - clean your hands anytime you
think you might have come in contact with germs
The WHO’s Hand Hygiene: Why, How, and When Brochure
provides details on specific tasks that occur at each moment.
www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_
Brochure.pdf
You may already know that Personal
Protective Equipment should be used
with patients having a known infection
requiring expanded precautions – there
is a sign on the door.
But did you know... PPE should be
used in any situation when there is a
risk of exposure to blood, body fluids,
secretions, excretions, non-intact skin
and mucous membranes? These are
standard precautions. Evaluate your
risk prior to entering a patient room.
The following document, located on
CHOP’s intranet, explains which types
of PPE to use when performing certain
tasks:
http://intranet.chop.edu/infectioncontrol/
manual/3-03.pdf
Mandatory Education 2011: Hand Hygiene
The Steps to Clean
Hands
Using Alcohol Based Hand Rub
This is the primary method for cleaning your hands
in most scenarios. This method takes about 20-30
seconds to complete and can be done while you continue to
work - it should not slow you down! Hand rub is as effective as
soap and water if your hands are not visibly soiled. It is also
the preferred method because of easier access to hand gel
over soap and water.
Using Soap and Water
This is the preferred method of cleaning hands if your hands
are visible soiled. This method is estimated to take 30-60
seconds to complete.
The steps for cleaning your hands are the same for both
methods once you have applied the product - either gel or
soap and water. These steps ensure cleaning product is
distributed to all parts of the hands where germs can reside.
Please practice these steps now.
BARRIERS - WHY WE DON’T WASH
OUR HANDS and SOLUTIONS
33 Too busy/lack of time - correct
hand hygiene with alcohol rubs
takes only 20-30 seconds
33 Sink location/accessibility - hand
rubs are more accessible than
sinks; place at point of care.
33 Lack of soap or hand rub discuss improving the supply and
locations of soaps and rubs with
your unit leadership
33 Don’t think it is important healthcare-associated infections
are a high priority patient need
33 Patient needs come first - an
estimated 2 million patients get
infections in hospitals each year...
90,000 will die
33 Hands irritation/dryness - hand
rubs are more effective and less
damaging to skin than soap and
water
5out of19
1.
palm to palm
4.
finger grip rotate
2.
interlace tops
5.
thumb grab rotate
3.
interlace palms
6.
fingers to palm rotate
Number of units with optimal hand
hygiene observed - 1st Quarter, 2011
Meet Josh Lipovetsky, one
of CHOP’s Youth Advisory
Council members.
He is a reminder to all staff
that patients and families
rely on us to be
mindful of infection
prevention.
“Don’t forget to
clean your hands!”
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
New Product Introduction / Evaluation
Vendors who wish to present new medical products, devices or equipment to Hospital Personnel must be
aware that prior to the evaluation or purchase, the Medical Device Committee and Value Analysis Teams must
review and approve all items that introduce either new technology or significant change to existing technology
to the organization.
This policy applies to all medical devices, disposable products and clinical equipment (approved by the Food
and Drug Administration (FDA) or not) including any items that have been approved for use by the
Institutional Review Board (IRB).
Please contact the Supply Chain Department to schedule an appointment to detail your company’s products,
devices and equipment.
Phone: 267-426-2400
Email: [email protected]
Vendor Requirements
Vendor Criteria
All vendors doing business with CHOP are required to submit a completed W9 and Billing email address. Noncompliance with this request may delay the payment process. Email completed W-9 and Billing email address
to: [email protected]
If you have questions, contact Rosanna Hollingsworth at [email protected]
Supply Chain Mgmt | Vendor Guide
Page 11
The Children’s Hospital of Philadelphia
th
Vendor Credentialing
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Effective January 1, 2009, CHOP introduced a new policy for vendor access which addressed the vendor’s use
of hospital facilities and authorized/unauthorized areas. At the time, external factors were influencing the
movement among academic medical centers to develop policies to regulate the interactions between
hospitals, clinicians, researchers and vendors. These factors included increased scrutiny in the media,
heightened attention from regulators and legislators and a continued focus in scholarly literature on potential
conflicts of interest raised by these interactions and the effect of these relationships on the integrity of
research and clinical decision-making. At the time, a number of leading academic medical centers, including
University of Pennsylvania, had introduced policies addressing vendor access.
CHOP’s current vendor access policy addresses the following:
• Appointments, check-in and ID badges
o Appointments required for all CHOP visits
o Exceptions for product/device recalls, emergency deliveries, routing pre-arranged visits for
deliveries and on-site project work
o Vendors are required to check-in and obtain badges
o Annual vendor badges are given to reps who visit at least once a week
• Authorized and unauthorized areas
o Avoid meetings with vendors at locations other than private offices and conference rooms
o Avoid meetings not in patient areas except where educational and patient care benefit
requiring vendor’s presence
• Limits on vendor activity
o Restrictions on activities and use of hospital resources to solicit business or disseminate
information
At CHOP, we value strong relationships with our vendors. Compliance with these changes will provide a
streamlined payment process and better customer service.
If you have questions, contact Rosanna Hollingsworth at [email protected]
Supply Chain Mgmt | Vendor Guide
Page 12
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Vendormate© Overview
CHOP has instituted a vendor program that will provide us with greater visibility into the hospital's business
relationships for suppliers who require access to our main hospital facilities. CHOP's Vendormate© program is
designed to streamline the collection and management of key information regarding the regulatory and
compliance status, as well as business operations, of our vendors. The immense financial, legal, and
compliance risks associated with fraudulent vendors require us to put processes in place to protect hospital
assets, patients and staff.
All vendors (excluding the exception list) who visit the Main Hospital and Wood Building must complete
registration with Vendormate© in order to do [or continue to do] business with The Children’s Hospital of
Philadelphia. The registration must be initiated by the vendor.
CHOP’s vendor program is designed to streamline the collection and management of key vendor information
regarding regulatory and compliance status as well as business operations.
Through CHOP’s vendor program, you can electronically provide the information that we need to:
1. Communicate our unique and most current business policies with you
2. Ensure we have the most accurate picture of your business, capabilities and contact information
3. Screen business partners, vendors and representatives against state and federal sanctioned lists
4. Manage access to our facilities and patient care areas based on immunization, training and compliance
status
The nominal annual registration fee covers your company as well as all representatives of your company who
interact with CHOP. Based on the scope of products and services marketed to CHOP, a vendor representative
will be classified into one of the three a categories, based on the vendor’s product offerings, access to patient
areas and other qualifying criteria. There are certification requirements specific to each category; these
requirements are consistent with standards set forth by the following:
•
•
•
•
Health Insurance Portability & Accountability Act of 1996 (HIPAA)
Association of Peri-Operative Registered Nurses’ (AORN) Standards for Health Care Industry
Representatives in Operating Rooms
The Joint Commission
CHOP’s Policies and Procedures
Supply Chain Mgmt | Vendor Guide
Page 14
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Vendor Profiles and Nominal Fees
Vendor Type
High $250
Answer YES to any of these questions:
• Do you or anyone from your company
interact with procedural patient care
areas including but not limited to the
Anesthesia, Cath Lab, CTOR,
Endoscopy, ICU’s, IR, OR, PACU and
Radiology?
• Do you or anyone from your company
have direct patient contact?
• Are you a pharmaceutical vendor?
OR:
• Your company’s annual spend is
greater than $25,000.
Registration
Medium $100
Low $25
Answer NO to these questions:
Answer NO to these questions:
• Do you or anyone from your
• Do you or anyone from your
company interact with procedural
company interact with procedural
patient care areas including but not
patient care areas including but not
limited to the Anesthesia, Cath
limited to the Anesthesia, Cath Lab,
Lab, CTOR, Endoscopy, ICU’s, IR,
CTOR, Endoscopy, ICU’s, IR, OR,
OR, PACU and Radiology?
PACU and Radiology?
• Do you or anyone from your
• Do you or anyone from your
company have direct patient
company have direct patient
contact?
contact?
• Are you a pharmaceutical vendor?
• Are you a pharmaceutical vendor?
AND:
AND:
• Your company’s annual spend is
• Your company’s annual spend is
between $25,000 and $5,000
less than $5,000
All vendors who visit the Main Hospital and Wood Building must complete registration in order to continue
doing business with CHOP. Exceptions include:
• Academic institutions
• Insurance, financial and legal companies
• Construction workers with existing
• Joint Commission or other regulatory agencies
contracted access
• Non-profit groups (not including vendors)
• Catering companies
• Local “cash and carry” vendors-local grocery
• City, County, State and Federal Agencies
stores, hardware stores, gift and flower shops
• Couriers such as Fed Ex, UPS etc.
• Temporary labor employees who work full-time
at CHOP
• EMTs
• Travel industry (airline, auto rental, hotel, travel
• Gift of Life
agent)
• Healthcare facilities
You will need to register as a vendor with CHOP on https://chop.vendormate.com. A Federal Tax
Identification Number (FEIN) and a credit card are required to complete the initial registration. Additional
representatives only need the FEIN.
Vendor Recertification
All vendors doing business with CHOP are required to submit a completed W9 and Billing email address. Noncompliance with this request may delay the payment process. A copy of the W-9 form can be downloaded at
www.irs.gov/pub/irs-pdf/fw9.pdf.
Email completed W-9 and Billing email address to: [email protected]
Supply Chain Mgmt | Vendor Guide
Page 15
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
The following list depicts necessary items/requirements via Vendormate© for on-site (Main hospital or
Wood building) vendors to be eligible to do business with CHOP:
Federal Tax Identification Number (FEIN)
Credit Card
Document Compliance (See table below)
Required Documents
Certificate of Insurance w/ Workers Comp
W-9
Background
Criminal Background Check Attestation
Drug Screen Attestation
Badge Photo
Health Status or Immunizations
MMR
Varicella
Influenza (annual)
TB Test (annual)
Education/Training
Product/Service Competency
HIPAA Training
Policies
Compliance Standards of Conduct
Control of On-Site Activity by Vendors
Interactions with Vendors
Fire Safety
Safe Handling of Hazardous Materials
Operation Seek
On-site Reps
X
X
Patient Care Reps
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
W9 (all vendors doing business with CHOP)
Insurance Policy Requirements: “An Acord Certificate of Insurance in minimum amounts of One Million
Dollars ($1,000,000) per occurrence and Three Million Dollars ($3,000,000) in the annual aggregate or
otherwise CHOP contracted and approved coverage. The Children's Hospital of Philadelphia also requires
Workers' Compensation and Employers' Liability to be provided meeting Statutory Limits and One Million
Dollars ($1,000,000) in Employers' Liability Limits.”
*If you are an IS contractor and have been directed to Vendormate, please proceed with the Registration.
If you answer ‘yes’ to ‘Do you or anyone from your company interact with procedural patient care areas
including but not limited to the Anesthesia, Cath Lab, CTOR, Endoscopy, ICUs, IR, OR, PACU and Radiology?’,
you will be presented with the requirements needed to fulfill a compliant registration.
If you select ‘no’, then you will be required to submit a W-9 tax form, proof of insurance per our
requirements, as well as a place for an optional attestation to a drug screening and background check.
Supply Chain Mgmt | Vendor Guide
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The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
If you have been directed by HR, send all requested documents (listed below) to Judy Dorazio of our HR
department.
For other Vendormate questions, feel free to contact Cheri McGovern ([email protected], 267426-5784.)
Contractor Clearance Requirements (Work in/Access to Patient Care Areas*)
1. 7 year County Criminal Check
2. Health Screening & Drug Test
3. Mandatory Seasonal flu vaccinations
4. Pennsylvania Child Abuse History Clearance (PA ACT 73 Requirement)
Forms can be downloaded at:
Pennsylvania Child Abuse History Clearance Form (CY-113)
5. Pennsylvania State Police Criminal Record Check (PA ACT 73 Requirement)
(please use link below: )
Pennsylvania State Police Request for Criminal record Check Form (SP4-164)
6. FBI Clearance (PA ACT 73 Requirement)
Effective July 1, 2008, the Cogent Systems Web site www.pa.cogentid.com//index_dpw.htm, allows
individuals to apply online, as well as provide detailed information regarding the application process.
*Work in/Access to Patient Care Areas includes contractors based in a non-patient care building who attend
meetings or conduct other business in patient care buildings as part of their role.
Contractor Clearance Requirements (Non-Patient Care Areas)
1. 7 year County Criminal Background Check
2. Drug Test
Supply Chain Mgmt | Vendor Guide
Page 17
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Visits
Sign-in kiosks are located in the Main Hospital and the Wood Building for vendors to sign-in and to obtain a
badge. All vendors visiting those facilities will be required to sign-in and obtain a badge and sign-out before
they leave.
Appointment Guidelines
General guidelines
All vendors must schedule appointments prior to their visits; unscheduled appointments and drop-in visits are
not permitted.
•
•
For appointments with Supply Chain, visit the Contact Us page.
For appointments with Research Supply Chain, call the Research Contract Manager at 215-590-4661.
Exceptions to appointment scheduling requirement
Appointments are not required for visits such as routine deliveries or pick-ups, including deliveries of office
supplies or food products, pick-ups or deliveries by UPS, Federal Express, or courier services and on-site
consulting or construction work under a long-term engagement.
Emergency deliveries/services
After delivery, please take the packing slips with a valid purchase order number to the Receiving Dock and
obtain a signature of a receiver to ensure prompt payment
Check-in Procedures
Main Hospital Campus
Sign in stations have been placed in the Main Hospital and Wood Building. Registered vendors will receive an
email with information about electronic sign in when available.
Abramson Building/Colket Translational Research Building
When you schedule an appointment, you will be pre-registered, which allows the Security staff to process your
visit promptly upon arrival.
If your name is not on the Security list, a Research host will need to authorize your visit in person or by
telephone with Security. Once your visit is approved, you will receive a temporary visitor pass which is only
valid for the department where you have scheduled an appointment.
Supply Chain Mgmt | Vendor Guide
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The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
To arrange a vendor show in the Abramson Building Lobby or conference room, please contact the Research
Contract Manager in Research Supply Chain at 215-590-4661.
Wanamaker Building and 3535 Market Street
You will be asked to sign in and you will be issued a temporary visitor pass to be worn at all times while on the
premises.
Kids First, Primary & Specialty Care Centers, and Ambulatory Surgical Centers
Reception staff will verify your appointment and notify the appropriate employee of your arrival.
Hospital and Parking Maps
Please note, parking in the Wood Center garage is reserved for patients and families. Parking is available at
numerous public parking lots.
For further information, contact the Parking and Transportation department at 215-590-4375, or via email
at [email protected]
Supply Chain Mgmt | Vendor Guide
Page 19
H
Uni
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rsity
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ay en
tr ce
af s
fic D
ri
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Health Sciences Drive
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enue
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How to Get to
In this document, you will find maps and directions for getting to and from our Main Campus. Please allow extra
time to get to your next appointment with us. You may call us at 215-590-7275 or visit www.chop.edu/directions
if you need to verify your route or have other questions.
Coming to CHOP
From I-76 East South Street Exit: Take exit 346A for South Street. Stay in the right lane and turn right onto South Street. At the next
light, turn left onto Convention Avenue. At the second light, bear right and continue on Convention Avenue. At the next light, you are
directly across the street from the entrance drive to the CHOP Main Building. Make a left at the light onto Civic Center Boulevard,
and get into the right-hand lane. At the second traffic light, turn right into Osler Circle.
From I-76 West South Street Exit: Take exit 346A for South Street. Stay in the left lane and turn left onto South Street. At the next
light, turn left onto Convention Avenue. At the second light, bear right and continue on Convention Avenue. At the next light, you are
directly across the street from the entrance drive to the CHOP Main Building. Make a left at the light onto Civic Center Boulevard,
and get into the right-hand lane. At the second traffic light, turn right into Osler Circle.
LEAVING CHOP
To get To I-76 East/West When leaving the Wood Center parking garage, make a right at the top of the exit ramp and then make a
U-turn at the stop sign, proceeding around Osler Circle and exiting at the light onto Civic Center Boulevard. (Please note: Civic Center
Boulevard is a one-way street.) Turn right onto Civic Center Boulevard and get into the left lane. Turn left at West Service Drive and
left again on Health Sciences Drive. Stay in the right lane and at the second light turn right onto Convention Avenue. Proceed to the
second light and turn right onto South Street. Follow signs for I-76 East or I-76 West.
Parking AT CHOP
Children’s Hospital Main Building (open 24 hours): Garage entrance on Civic Center Boulevard. Call 215-590-2291.
Wood Center (open 24 hours): Garage entrance off Civic Center Boulevard on Osler Circle. Call 215-590-2291.
Discount parking is available ($3). Please bring your parking ticket to any patient information desk or department registration desk in the
Hospital for validation.
Public Transportation TO CHOP
Bus: SEPTA bus routes 30, 40, 42 and 90 run in front of or near Children’s Hospital.
Subway: The SEPTA Market Street-Frankford line stops at 34th and Market Streets. Follow 34th Street south toward Children’s Hospital.
Trains: The University Avenue station on Spruce Street between 33rd Street and the South Street Bridge is the closest stop. It is a direct
connection to 30th Street Station.
Taxis: Taxis are available throughout the city; refer to a telephone directory for cab company numbers. A taxi stand is located outside
the Main Building.
For more information on routes and schedules:
SEPTA (in and around Philadelphia): 215-580-7800 or www.septa.com
PATCO (to and from New Jersey): 215-922-4600 or www.ridepatco.com
Amtrak: 215-824-1600 or www.amtrak.com
Arch Str
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33
40th Stre
et
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eet
Walnut
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36th Str
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The Children’s Hospital of
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Turn into Osler Circle for parking.
See inset map.
y t ven
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N
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ONealt
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indicates traveling East/West on I-76
indicates going to CHOP from I -76
indicates leaving CHOP to I -76
Uni
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Traffic heading away from CHOP
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The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Financials
Procurement
Only authorized Hospital Personnel can commit Hospital funds for the purchase of equipment, goods and
services from a supplier. No individual may commit Hospital funds without proper internal authorizations. This
provision includes soliciting competitive bids and signing contracts.
All purchases are subject to The Children’s Hospital of Philadelphia’s purchase order terms and conditions.
• The Hospital’s payment terms are net 60 days.
• All inquiries regarding payment should be transferred to the Accounts Payable Department at 267-426-
6200.
• All invoices must reference a valid purchase order number.
• Unless otherwise specified by the Supply Chain Management Division, all deliveries are to be made to the
Hospital’s Receiving dock located at 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399.
• Over shipments will not be accepted.
All invoices should be sent to the following centralized address:
The Children’s Hospital of Philadelphia
PO Box 2015
Secaucus, NJ 07096-2015
Or invoices can be emailed to: [email protected]
Supply Chain Mgmt | Vendor Guide
Page 20
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Accounts Payable Shared Services Center
CHOP Accounts Payable changes
The Children’s Hospital of Philadelphia (CHOP) has centralized its Accounts Payable (AP) Operations, bringing
together AP functions of the Hospital, Research, Foundation, Children’s Healthcare Assoc., Children’s Surgical
Assoc., Children’s Anesthesiology Assoc., and Radiology Assoc. into a new Shared Service Center. The AP
Shared Service Center will provide our vendors a more standardized and efficient payment process, as well as
a single point of contact for Accounts Payable operations.
The transition to this new Shared Services Center has changed the way invoices are received, processed and
paid. Customer service contact information for questions about invoice processing and payment will also
change and vendors will be informed of those changes.
All summary invoices are sent to Maureen Verna for processing [email: [email protected] ].
Change to bill address
All invoices should be sent to the following centralized address:
The Children’s Hospital of Philadelphia
PO Box 2015
Secaucus, NJ 07096-2015
Or invoices can be emailed to: [email protected]
Change AP Contact Information
Contact CHOP’s APSSC Customer Service with all inquiries regarding payment:
Toll Free 1-855-247-1415 or (267) 426-2400
Or, email inquiries to: [email protected]op.edu
Use Purchase Orders
A valid CHOP Purchase Order Number must be referenced on all invoices. CHOP is standardizing use of
Purchase Orders on most supplies/services; vendors who may not have received a Purchase Order in the past
will now be receiving one. You must obtain the Purchase Order number from the requestor of the goods or
service. For additional information regarding Purchase Orders, please email [email protected]
In the few instances a valid purchase order is not required; vendors must include a Routing Code on their
invoice. The routing code must be obtained from the CHOP requestor of the goods or service. Noncompliance with this request will delay the payment process.
Supply Chain Mgmt | Vendor Guide
Page 21
IPS is pleased to announce support for receiving work items via email. You may attach documents to an email
message (addressed to a specific address) and it will be processed electronically.
Please be aware of the following limitations and helpful hints:

For faster processing, please attach documents to a blank email message, i.e. don’t include
“signatures” or any logos, graphics or links in the message body. These are Ok, but will slow down
processing a bit. PDF format is the most efficient for processing and you are assured that the
processed document will look like the original PDF.

Don’t include any instructions in the email message body as that is ignored unless your account is
specifically enabled to process instructions. By default, message body text is ignored.

In the documents to be processed, the primary page(s) should be first and any backup/supporting
pages should follow, all within the same document, e.g. PDF. The way we receive the document is the
way you will receive it back.

There is a 10MB limit for attachments, so if there are large attachments, they should be broken up and
sent over multiple email messages. Do not split work items as they will not be combined back. If you
need to send emails with large attachments, please ask your account manager about the IPS Upload
portal.

Sensitive/confidential documents (e.g. Social Security Numbers) should not be sent via email, as it is
not a secure transport. Please check with your internal information security department before
sending confidential information via email. IPS Upload supports 128-bit SSL encryption for confidential
documents.

Multiple documents may be attached to a single email message. For efficiency, each document should
be a separate invoice or work item. However, we can accept a document that contains multiple
invoices (work items) and they will be separated during the IPS Process Flow.
The following file types (formats) are supported:
File Extension
CSV
DOC
DOCX
HTM, HTML
PDF
PPT
PPTX
PRN
RTF
TIF, TIFF
TXT
XLS
XLSX
XML
ZIP
File Type
Comma-Separated Values
Microsoft Word 95-2003
Microsoft Word 2007-2010
HTML Document
Adobe Portable Document Format
Microsoft PowerPoint 95-2003
Microsoft PowerPoint 2007-2010
Printer Text File
Rich Text Format
Tagged Image File Format
Plain Text
Microsoft Excel 95-2003
Microsoft Excel 2007-2010
XML Format
Compressed Archive (no password) containing any
of the supported formats
Image Processing Systems, Inc. (IPS) ● 150 Meadowland Parkway ● Secaucus, NJ 07094 ● 201-553-0200
The Children’s Hospital of Philadelphia
th
Electronic Invoicing
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Vendors can opt to utilize electronic invoicing through EDI connection. We use Global Health Exchange [GHX]
as our third party vendor for our connection portal to our vendors.
Support Contact/Resources
External:
1.
2.
3.
CHOP Supply Chain Department: 267-426-2400, Email: CHOP Vendor Access
CHOP Vendor Relations Site
CHOP Research Institute
Internal:
1.
2.
3.
CHOP Supply Chain Research Site
Vendor Relations Site
Supply Chain Site
Supply Chain Mgmt | Vendor Guide
Page 22
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Appendix
Supply Chain Mgmt | Vendor Guide
Page 23
The Children’s Hospital of Philadelphia
th
FAQs
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Do I need an appointment?
Visits by all vendor representatives to CHOP staff are by appointment only for CHOP facilities. Exceptions are
limited to visits concerning recalls, emergent or after hour deliveries, and certain types of recurring visits such
as UPS, Federal Express, or courier services. Please visit the Appointment Guidelines section for more
information.
Where do I go on the day of my appointment?
Please visit the Check-in Procedures section for more information.
Do I need to register?
If you are visiting the Main Hospital, Wood Building, you need to register with Vendormate. Please visit the
Registration section for more information.
My district sales manager visits CHOP once or twice a year with me; is registration required?
Registration in Vendormate is required for all vendor reps who visit the Main Hospital and/or Wood Building.
Please visit the Registration section for more information.
May I bring by, or drop off, samples of medical supplies/equipment or medication samples?
Health industry representatives are not authorized to provide samples of medical products, devices or
equipment for demonstration to clinicians for use on patients without obtaining a valid purchase order or
making appropriate emergency arrangements through Supply Chain. Medication samples are not permitted at
CHOP.
Does CHOP allow a vendor representative to observe in patient care areas or shadow a member of the CHOP
workforce?
In general prior written authorization must be obtained from the patient family in order for a vendor
representative to observe or shadow at CHOP if the representative will have more than incidental contact with
patients or their information. The only exception to this requirement is when the vendor representative is:
• Providing support as part of a patient’s treatment. For example, providing information about use of a
product for a specific patient’s care (e.g. counseling a surgeon regarding the proper use or insertion of a
device; determining the appropriate size/ type of prosthesis to use during surgery; adjusting a device for a
particular patient)
• Performing a variety of services on CHOP’s behalf as outlined in a written Business Associate Agreement
with CHOP and the observation/shadowing is for the purpose of performing this work on CHOP’s behalf
(e.g., a consultant observing patient flow in the Emergency Department to assist CHOP with improving
operations).
An authorization is not required when a visitor/observer will not have contact with patients, patient
information or where any disclosure of patient information to such persons is incidental.
The law defines “incidental disclosure” as one that cannot be reasonably prevented, is limited in nature, and
occurs as a by-product of a use or disclosure of patient information that is permitted by law. Examples of
Supply Chain Mgmt | Vendor Guide
Page 24
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
incidental disclosures are when a visitor/observer on tour of the hospital walks by a patient room and sees the
patient’s name displayed by the door or walks past a nursing station and overhears health care staff
coordinating services for a patient.
Prior to any vendor observing or shadowing where there will be contact with patients or patient information,
the CHOP staff person hosting the vendor should contact the Office of Compliance and Privacy to discuss the
situation to ensure existing Hospital guidelines are followed to protect patient privacy.
Supply Chain Mgmt | Vendor Guide
Page 25
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Vendormate Approach
Below is a detailed outline of the approach and benefits of Vendormate’s presence in CHOP’s vendor
credentialing process.
Supply Chain Mgmt | Vendor Guide
Page 26
Vendormate Presentation for
The Children’s Hospital of
Philadelphia
agenda
2
»
Importance of a Vendor
Program
»
»
»
Kiosk Locations
»
»
Rep Registration
Program Scope
Document and Policy
Requirements
Vendormate Demo
why you should care
Quality & Patient Safety
» Protect our patients by safeguarding them
from disease
» Background / child abuse / drug test
attestations ensure the wrong vendors
aren’t in close contact with our patients
Physician Access
» Control vendor access to Physicians
Penalties
» Ensure we meet or exceed Joint
Commission, Health & Human Services,
OIG, AORN and other guidelines
3
what we’re asking you to do
If you see a vendor without a badge
» Accompany them to the Main Lobby so
that they can obtain a Vendormate badge
Do not escort them throughout the
hospital without a badge
» We cannot be successful without your help
If you or vendors have questions about
the program
» Direct them to Supply Chain
4
kiosks
5
vendor program scope
OFFSITE
VENDORS
CONSTRUCTION AND MAINTENANCE
ACADEMIC INSTITUTIONS
CATERING
HEALTHCARE FACILITIES
FEDERAL AGENCIES
6
LOCAL CASH AND CARRY
VENDORS
DELIVERY DRIVERS
CONTRACTED
STAFF
vendors touch everyone
COMPLIANCE
LEGAL
• CMS Clearance
• Gift/Gratuity
• Conflicts of Interest
• Insurance Liability
• Business Viability
PROCUREMENT
MEDICAL
• Contacts
• Other Policies
7
• Immunizations
• Training
Each function
requires unique,
as well as
similar, vendor
information
Vendormate VISION
TM
A Business Credentialing and Compliance Monitoring Solution
New Vendors
Existing Vendors
Captures 150+ fields of information
on the Vendor company and its
representatives
Checks 1.7 billion public and
private records for sanction lists,
financial data, and legal status
Badges are granted based on the
Vendor’s compliance status which
is continuously updated
Ethics/Compliance - Legal - Procurement
Risk Mgmt - Executive Mgmt
8
your vendor profiles
High $250
Vendor
Type
 Access to patient care areas
Medium $100
 Onsite
 Direct patient contact
Low $25
 Offsite
 Small businesses
(<50 employees)
spending less than
$5,000 with CHOP
 Pharmaceutical
 Medical Device Company
 Information Technology
Sanction
Checks
 Monthly & Historical
– Entity
– Representatives
– Principals
 Monthly
Financial
& Legal
Checks
 Annual Business Verification
 Annual Business Verification
– Entity
– Representatives
 Annual
– Entity
 Annual Financial Health
Review
 Annual Legal Review
 Weekly Financial & Legal
Monitoring
Document
Storage
9
 Verified
 Unverified
 Unverified
document and
policy requirements
CHOP requirements for Vendors
REQUIREMENTS*
VENDOR TYPE
•
•
•
•
•
•
Onsite
•
•
•
•
•
Patient Care
Areas & Direct
Patient Contact
10
W-9
Workers Compensation
Product/Service Competency
Badge Photo
Drug Attestation
Criminal Background Check
Attestation
Acknowledgment of CHOP
policies
Product/Service Competency
HIPAA Training
Influenza
Tuberculosis (TB) Test
• Hepatitis B
• MMR
• Varicella
sign in & badge process
Vendor Reps
SIGN-IN
(at facility)
BADGE
Vendormate VISION
EVALUATE
RULES
RULES
Sanction Lists Status: Representatives
identified on sanction lists are denied a badge
Registration Status: Unregistered reps
receive one temporary badge; a badge is
denied on their 2nd unregistered visit
Document Compliance: Non-compliant reps
receive three warning badges; a badge is
denied on their 4th non-compliant visit
11
PRINT OR
DENY BADGE
Vendor Reps
SIGN-OUT
badge examples
Unregistered Vendor
12
Non-Compliant Vendor
Compliant Vendor
vendor relationship management
best practices
SOURCING
 Use the UNSPSC codes
in VISION to view all
registered vendors
 Use information to send
RFI for products you are
sourcing
ON BOARDING
 Use VISION data to on
board vendors into the
Vendor Master
 Prior to executing an
agreement, require
vendors to register and
be fully compliant with
document requirements
CONTRACTING
 Include contract language
which requires registration
in vendor program in all
new agreements
 Add contract addendum
to existing agreements
with registration deadline
ACCOUNTS PAYABLE
 Implement process change for AP, to include checking
VISION for company registration and/or compliance prior
to issuing Payment
 Add a “warning” system to track compliance, using the
Score Card feature
 Include vendor company’s unique ID (from your Vendor
Master) in the company details section of vendor’s profile page
13
questions
» Supply Chain
– Email: [email protected]
– Phone Number: 267-426-2400
» Hospital Staff Tutorials: http://vendormate.com/support/clients.html
– Vendor Program Overview
– Vendor Sign In and Sign Out Process
– How to Check the Status of a Vendor
– Creating Vendor Appointments
» Vendor Support Contact Information
– Online: https://chop.vendormate.com, select the “Support
Center” link at the bottom of the page
– Phone Number: 888-476-0377
– Fax Number: 404-795-0458 (print a fax cover sheet)
» Vendor Tutorials:
http://vendormate.com/support/healthcare_vendors.html
– Vendor Registration
– How to Upload Documents
– How to Fax Documents
14
Rep
Registration
rep registration
Enter company
and rep
information
Answer vendor
company
business
relationship
questions
Complete
profile
Upload
documents
and
acknowledge
policies
Answer rep
business
relationship
questions
Answer conflict
of interest
questions
16
company and rep information
» Rep Contact Information
– Rep name, email, phone
» Company Contact Information
– Legal name of business
– Tax ID number
– Type of business
» Product/Service Offerings
» Company Business Relationship
– Credentialing risk level
» Rep Business Relationship
– Document/policy requirements
17
vendor company business
relationship questions
» What is the total amount of business your company expects to
do in the next 12 months with The Children's Hospital of
Philadelphia?
» Do you or anyone from your company visit or intend to visit a
location for The Children's Hospital of Philadelphia?
» Do you or anyone from your company interact with procedural
patient care areas including but not limited to the Operating
Room, Catherization Lab, Endoscopy, and Radiology WHEN
patients are present?
vendor company business
relationship questions
» Do you or anyone from your company access patient care
areas or have direct patient contact?
» Are you a pharmaceutical vendor or medical device
vendor?
» Are you an information technology vendor providing a
software system or IT services (if you are simply supplying
hardware, you would answer “No” to this question)?
» Is your company a small business with less than 50
employees?
rep business relationship
questions
» Do you intend to visit a The Children’s Hospital of
Philadelphia location?
» Do you interact with procedural patient care areas
including but not limited to the Operating Room,
Catherization Lab, Endoscopy, and Radiology WHEN
patients are present?
» Do you interact with patient care areas?
» Do you have direct patient contact?
20
rep business relationship
questions
» Are you a rep with a tissue vendor or tissue bank that
provides human cells, tissues, and cellular and tissuebased products (HTC/Ps) for implanting and
transplanting?
» Are you a rep with a technology vendor providing a
software system or IT services (if you are simply
supplying hardware, you would answer “No” to this
question)?
» Are you a pharmaceutical vendor?
» Are you a medical device vendor?
21
conflicts of interest
» Are you aware of any instance in which, your company's managers,
executives or board members are related to managers, executives,
medical staff, board members or employees of The Children's
Hospital of Philadelphia?
» Are you aware of any The Children's Hospital of Philadelphia
managers, executives, medical staff, board members or employee
that serve on the advisory boards or the board of directors of your
company or any of its subsidiaries?
» Are you aware of any instance in which your company or any of its
subsidiaries employ or compensate any of The Children's Hospital of
Philadelphia's managers, executives, medical staff, board members
or employees?
22
Complete registration
» Log-in at any time:
– https://chop.vendormate.com
– https://login.vendormate.com
» Upload documents and acknowledge policies
» Update information
–
–
–
–
–
Sales territory
Company diversity status
References
Supervisor information
Rep business relationship
» Extras
– Corporate plans
– Background checks/screenings (TalentWise)
– Trainings (Medcom Trainex)
23
Vendormate
Demo
Appendix
response creates
complex requirements
INDIVIDUAL
Compliance
Information
Operational
Information
26
ENTITY
•
•
•
•
•
•
•
•
Joint Commission
CDC
AORN/ACS
HIPAA
Training
Immunizations
Ethics
Federal/State Sanctions
• HIPAA
• Federal/State Sanctions
– OFAC
– HHS/OIG
– GSA
– Deficit Reduction Act/CMS
•
•
•
•
Contact Details
Access Sign In/Out
Authorized Appointments
Policies
•
•
•
•
•
Financial Health
Legal Status
Liability Insurance Status
Policies
Contract
27
The Children’s Hospital of Philadelphia
th
34 Street & Civic Center Boulevard, Philadelphia, PA 19104-4399 WWW.CHOP.EDU
Security and Badging Policy
The policy below outlines CHOP’s security policy for its Main Hospital building.
Supply Chain Mgmt | Vendor Guide
Page 27
Human Resource
Policy and
Procedure Manual
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
Policy No. 6-5
Title:
Page 1 of 5
HOSPITAL SECURITY
Effective Date: 8/1/95
Rev.: 1/01/03
PURPOSE:
The purpose of this policy is to provide an overview of the services and responsibilities of
the Security Department.
POLICY:
The purpose of the Security Department at The Children’s Hospital of Philadelphia is to
support the safe and secure operation of the campus, and to provide security services to
employees, patients and visitors through the enforcement of established and consistently
administered security policies and procedures.
Security shall plan the implementation of a comprehensive campus crime prevention
program, and assist with safety and fire prevention issues. The Security Department will be
responsible to help enforce all hospital rules and regulations when appropriate.
The Security Department is also responsible for loss prevention and detection, the
investigation of any incident of security nature, and for managing patient information and
support of inpatient visiting. The Department may supervise parking issues for employees,
visitors, patients and members of the medical staff. The Department also assists with both
internal and external disaster planning.
COVERAGE:
This policy is applicable to all employees, visitors, patients and others on the Hospital
campus in Philadelphia, Pennsylvania.
PROCEDURES:
The Security Department administrative office is located inside room 1108 on the first floor
of the main building. The department is staffed on a 24-hour basis, seven days a week. All
emergency calls and calls for security services should be directed to extension 45500 which
is answered on a 24-hour basis.
The officer answering extension 45500 is responsible for gathering necessary information,
and when necessary to dispatch a security officer or supervisor to an area where additional
security assistance is required.
Human Resource
Policy and
Procedure Manual
I.
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
Policy No. 6-5
Title:
Page 2 of 5
HOSPITAL SECURITY
Effective Date: 8/1/95
Rev.: 1/01/03
Security Incidents
To establish and maintain a permanent written record of all complaints and
incidents requiring security services, a security incident report will be prepared at
the time that each complaint or incident is received or observed. The senior
security supervisor on duty is responsible to ensure that an incident report is
prepared immediately after a complaint or incident is reported. All persons are
encouraged to report security related incidents to the department without delay,
since time is critical to the investigation process.
Examples of incidents that should be reported to security are missing property,
crimes against persons and property, trespassers, disturbances, and any incident
that may present a threat to the hospital campus.
II.
Disturbances
If an employee, patient or visitor becomes disruptive, violent, or threatens to injure
Hospital personnel, patients or visitors, or threatens to damage Hospital property, the
Security Department should be notified immediately at extension 45500. Hospital
personnel should always attempt to avoid disturbances by using tact and diplomacy
in all situations.
III.
Working Areas
Department heads, supervisors and employees are responsible to ensure that all
hospital valuables are secured when not in use, and that all unoccupied areas are
secured. Security tours will be conducted throughout the hospital campus on every
shift, seven days a week.
IV.
Key Control
It is the responsibility of the department head or designee to establish a key control
system and to collect keys from terminated employees. Requests for replacement
keys must be approved by the department head on a key issue request form. The
forms are available in the Security Department administrative office. No MASTER
KEYS will be issued. Keys are cut by the Facilities Department within one week of
request. Any special or unusual key request should be directed to the Assistant
Director of Security at extension 42372.
Human Resource
Policy and
Procedure Manual
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
Policy No. 6-5
Title:
Page 3 of 5
HOSPITAL SECURITY
Effective Date: 8/1/95
Rev.: 1/01/03
V.
Employee Id Badges
A.
The Security Department will issue permanent photo identification badges after the
employee has been cleared by Human Resources to begin work. The photo
identification badge is to be worn above the waist by all individuals and be visible to
all. ALL HOSPITAL EMPLOYEES, VOLUNTEERS, CONTRACTORS,
STUDENTS, AND OTHERS ISSUED A PHOTO ID ARE REQUIRED TO WEAR
OR CARRY THE HOSPITAL ID BADGE WHENEVER THEY ARE ON THE
HOSPITAL CAMPUS.
B.
Security staff are charged with verifying the identification of all hospital
employees, volunteers, contractors, students and business affiliates. All must
comply with security requests to verify identification.
C.
Appropriate hospital issued identification is necessary for employee admittance to
parking garages and buildings of The Children’s Hospital of Philadelphia.
Employees are PROHIBITED from loaning or otherwise giving their
identification cards to anyone for the purposes of access or entry.
Photo ID’s will be reissued to employees who change positions or have official
name changes. Employees who lose their photo ID badge must purchase a new one
from the Security Department at the current replacement cost for the department.
All payments for lost IDs must be made to the hospital cashier, and the receipt must
be presented to Security during normal photo ID hours.
VI.
Bicycles
Bicycle racks are provided for the convenience of employees, medical staff, visitors
and patients and are located on A and B levels of the Wood Center Parking Garage.
It is the responsibility of bicycle owners to properly lock and secure bicycles, and
bike parts, whenever these vehicles are parked on the Hospital campus. Other
information about bicycles can be obtained from the Security Department by calling
extension 42369 during normal business hours. All individuals wishing to use this
rack must register their bicycle with the Parking Office in Room 1108.
VII.
Control Of Contractors and Outside Service Employees:
A.
Contractor employees MUST WEAR the type of identification agreed to
between the Hospital and the contractor. For long term business
relationships, contractor employees will be issued a CHOP ID card, after
approval from the department head/administrator using the outside source
and the Security Department.
Human Resource
Policy and
Procedure Manual
B.
C.
VIII.
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
Policy No. 6-5
Title:
Page 4 of 5
HOSPITAL SECURITY
Effective Date: 8/1/95
Rev.: 1/01/03
The Hospital has designed a contractor identification sticker to be worn by
all authorized contractors while they are on hospital property. Contractors
must wear the sticker on his/her person, above the waist.
1.
It is the responsibility of the department head/administrator to ensure
that any contractor performing work under his/her direction, be
issued and wear the identification sticker.
2.
Stickers will be centrally stored and issued to departments from the
Information Desk in the Atrium of the main building. Department
heads/administrators can request the identification stickers between
the hours of 9:00 a.m. and 6:00 p.m., Monday through Friday.
3.
Issuance of stickers outside the normal business hours can be
coordinated with the Information Desk until 9:00 p.m., and then with
the Security Department Command Center between 9:00 p.m. and
9:00 a.m.
All department heads, chiefs of service, and private groups must notify
Security in advance if entry to areas is to be given after normal working
hours. If service is required on a continuing basis, written documentation,
including the names of the contractor, foreman or supervisor, and the time of
access must be submitted to the Director of Security. Upon arrival, all
outside personnel should report to the Security Department twenty-four hour
desk in the Atrium of the Hospital.
Escort Services
The Security Department provides an escort service for employees, house staff,
medical staff, visitors and patients anytime, seven days a week from the Hospital
premises to locally parked vehicles, and to remote parking lots after the shuttle
bus ends service. To arrange for an escort call the Security twenty-four (24) hour
operations base on extension 42374. The Security Department provides a
“working alone” service for all employees working alone after business hours.
Employees working alone should call the Security twenty-four (24) hour
operations base, and provide the following information to the base operator:
name, location and room number, telephone extension where they can be reached,
and approximate duration of work time. On-duty security personnel will then
make regular telephone checks and periodic personal checks during the shift
security tour.
Human Resource
Policy and
Procedure Manual
THE CHILDREN’S HOSPITAL OF PHILADELPHIA
Policy No. 6-5
Title:
Page 5 of 5
HOSPITAL SECURITY
Effective Date: 8/1/95
Rev.: 1/01/03
Approved By:
Counseling Contact:
____________________________
Jeffrey A. Rivest, Executive Vice
President & COO
Human Resources Service Team
Manager
___________________________
Margaret M. Jones,
Vice President Human Resources
This Policy is the property of The Children’s Hospital of Philadelphia and is to be used solely by
employees of the Hospital, the Hospital Medical Staff and those acting on the Hospital’s behalf either on
the premises of the Hospital in connection with Hospital matters or in their Hospital duties involving the
care of Hospital patients. This Policy may not be copied, photocopied, reproduced, entered into a
computer database or otherwise duplicated, in whole or in part in any format without prior permission
of the Hospital. Any personal or other use is strictly prohibited.
THE CHILDREN’S HOSPITAL OF PHILADELPHIA © 2002