Effective Date: 4/1/01
Original Date: 4/1/01
Next Review Date: 4/12
This policy/procedure supersedes: POLICY #002
It is the policy of The New York Hospital Medical Center of Queens (NYHQ) to provide an effective process for employees to express problems, concerns or opinions without fear of retaliation or reprisal through the Corporate Compliance Program.
Employees include all regular, temporary, per diem, on-call and Graduate Medical Staff.
To provide managers with appropriate guidelines for addressing problems or concerns
identified by employees.
Managers are expected to assure staff that NYHQ encourages the reporting of problems
or concerns. In addition, employees must be assured that they will not be retaliated
against for making such reports.
Concerns regarding any issue should be addressed to NYHQ in the following order: immediate manager, department head and then the senior administrator / vice president within the division.
Graduate Medical Staff should report issues to their appropriate Program Director for resolution and have recourse to the GME Graduate Staff Evaluation, Disciplinary Procedures & Appeals Policy (Due Process).
If, for any reason, an employee feels constrained or uncomfortable following the order established above, the employee is encouraged to address concerns to the Human Resources Department.
If an employee’s concern or problem cannot be satisfactorily resolved through the methods described above, the employee should address the concern to the Corporate Compliance Officer, either directly or through the Helpline by calling 670-2492.
Promote an open door attitude to address employee problems or concerns.
Be receptive to employee concerns, problems or opinions and explore with the employee suggestions for resolving the issue.
Inform Human Resources if a concern or problem is raised by an employee indicating potential systematic or pattern problem.
Advise the Compliance Officer if a concern or problem is raised by an employee which may involve legal, fraud or abuse issues.
Maintain the confidentiality of employee concerns or problems at all times, informing only those that have a need to know.
Provide guidance to managers receiving and addressing employee concerns or problems.
Advise administration of concerns or problems raised by employees.
Investigate issues and, if a resolution can be reached, inform the employee of the results of an investigation as soon as possible. Depending on the nature of the report, the Compliance Officer may need to be notified prior to the beginning of an investigation.
If a resolution cannot be reached, refer the matter to the Compliance Officer for assistance and resolution.
Ensure the confidentiality of the employee raising the concern or problem at all times to the extent legal and practical, informing only those personnel who need to know about the issue.
Every employee must understand that retaliation in response to an issue or concern will not be tolerated. Reports of retaliation will be investigated thoroughly and expeditiously with appropriate disciplinary action, up to and including termination of employment.
Employees will be advised of NYHQ’s Non-Retaliation Policy at the time of employment, during Corporate Compliance training and at annual employee training.
George F. Heinrich, M.D., Chairman of the Board of Trustees
Stephen S. Mills, President and CEO
William P. Wissemann, Esq., Senior Vice President and General Counsel
Lorraine Orlando, Vice President for Human Resources
Adam K. Weinstein, Vice President, Regulatory Affairs and Corporate Compliance Officer