Franciscan Children’s is a critical provider of complex care for children with medical, behavioral health, and special education needs. Our mission to provide world-class, accessible, compassionate care to help children and families realize their full potential, so every kid can.
Our mission spans four key service areas:
Our expectation is that all employees adhere to a leadership development model.
Regardless of role in the organization, all colleagues should meet standards against 5 dimensions:
Franciscan Children’s has a long history of service for children without regard to race, religion, or ability to pay. Consistent with the values of Franciscan Children’s, and with the Ethical and Religious Directives for Catholic Health Care Services, all employees are responsible for maintaining a high standard of ethical conduct. You are responsible for acting ethically in your own conduct, and you are also responsible for reporting any conduct that you believe to be illegal or unethical to the proper persons within Franciscan Children’s.
Many of the standards of conduct stated below are also applicable to persons or companies who Franciscan Children’s has contracted with for various services.
Any person or company contracting with Franciscan Children’s is responsible for adhering to the standards of conduct set forth below to the same extent as Franciscan Children's employees.
This Code was developed to provide general guidance on key laws, standards, and policies which each staff member is required to follow. Any employee who has a question regarding a specific standard or policy should discuss the matter with their supervisor, Human Resources or with the Compliance Department.
Franciscan’s mission is to provide high quality, accessible, compassionate and appropriate care to every child, regardless of ability to pay. Our work is guided by always doing what is best for the child and their family. We ensure quality through our many Franciscan programs that monitor all aspects of the care we provide and work to continuously improve it. Our commitment to quality of care is the responsibility of every Franciscan colleague. In any circumstance where you question whether we are providing the highest quality care possible, you have the right and responsibility to raise your concern through appropriate channels to help keep out commitment to quality.
Safety is a top priority for Franciscan Children’s, which has been affirmed by our Board of Directors, CEO, and management team. In that spirit we work to always keep our children safe. We work to create an effective Safety Culture and keep our children safe from preventable harm. A “culture of safety” is one where all workforce members are constantly mindful of the risks inherent in our work and continuously strive to eliminate them.
We do this by:
We report any incident or unsafe situation we see that causes harm or could cause harm to patients, visitors, staff, or Franciscan Children’s. When mistakes or adverse events are reported, we promptly and fairly review what happened and make appropriate corrections.
For more information, please consult Franciscan Children’s policies ADM023 “Quality Assurance and Performance Improvement (QAPI) Plan,” ADM024 “Culture of Safety Plan,” and SAF003, “Safety Event Reporting.”
Q: I almost gave a patient a wrong dose of medication. Do I need to report this “near miss?”
A: Yes. Reporting this incident allows Franciscan to investigate and make any changes in process needed to prevent this from happening again.
We respect the rights of the children and families we serve. The rights of our patients and students are guaranteed by federal and Massachusetts laws. These include the right to review and receive copies of records (for a fee in some cases), the right to privacy during medical treatment or care and the right to informed consent. We ensure that these rights are respected at all times. Franciscan provides a copy of the Patients’ Bills of Rights to every patient we serve and information on education rights to every KDS family. We serve all children and their families with dignity and respect. We are culturally competent and sensitive to the ethnic, religious, language and cultural differences of the children and families we serve. We do not discriminate against any person in the provision of services based of race, ethnicity, religion, family status, national origin, sexual orientation, gender identity and expression. To assure our patients that we provide the best and most appropriate care for everyone, we do not accept personal gifts from the children and families we serve or otherwise allow personal bias or self-interest to affect the services we provide.
To protect rights of the children we serve, we:
For more information, please consult Franciscan policies PC025 “Patient Rights and Responsibilities,” PSY019 “Human Right Officer,” and PC023B “Informed Consent.”
Franciscan’s goal is to create a care environment in which every patient and every family receives exceptional care. One way we do this is by advocating for our children at the bedside, at school and in the community. Despite our best efforts, we may not always meet our children’s expectations. When this happens, we want to learn from our children so that we can remedy their concerns. Our Patient Advocacy Program serves as the liaison between children, families, and the Franciscan community.
The Patient Advocate works collaboratively with staff to address and resolve children’s expressions of commendation and concern. She assists patients and their families in the following areas: patients’ rights and responsibilities; patients’ rights to make a complaint; overall issues related to patient and family experience, and addressing problems, concerns or unmet needs of patients and their families.
We advocate for patients and their families by:
Q: I need to obtain a copy of the Patients’ Bill of Rights. Where can I find it?
A: The Patients’ Bill of Rights can be found on FRANCISCAN’s external website, www.franciscanchildrens.org
For more information, please contact the Patient Advocate at 617-779-7723.
We maintain the privacy and security of our children’s protected health information, education records, and other personal and financial information at all times. The Privacy Regulations enacted as part of the Health Insurance Portability and Accountability Act of 1996, known as HIPAA, and other federal and state laws, prohibit the use or disclosure of patient information unless it is for treatment, payment or health care operations or is otherwise allowed by law.
These rules also apply to all patients, including Franciscan colleagues, family members and acquaintances who are receiving treatment or care at Franciscan Children’s.
In addition to the HIPAA Privacy Regulations, Franciscan Children’s is also subject to the Family Educational Rights and Privacy Act (FERPA), a federal law, which protects the privacy of every student’s educational record such as those created and held by Franciscan Children’s Kennedy Day School. Like HIPAA, FERPA places affirmative obligations on schools and school staff to protect confidential education records and to comply with restrictions on how the education records may be used.
The increased use of technology to provide virtual medical and educational services via Zoom or other virtual meeting systems, and the increased use of social media by patients, families, and staff, create new privacy and security risks that Franciscan Children’s and its workforce must remain vigilant to address.
You must ensure that you comply with all applicable guidance and policies when using technology for any matters related to work, including any personal social media activities which may implicate your professional responsibilities. You should never post pictures of, or information about, a patient or student, except when such photo or disclosure has been authorized by Franciscan Children’s Marketing Department (you can, of course, like information posted by the Franciscan Children’s Marketing Department). If you have a question or concern, please contact our Privacy Officer at Privacy@franciscanchildrens.org.
Gaining access to or sharing a child’s personal information in violation of law or Franciscan policy or without proper consent is a serious matter that may result in disciplinary action up to and including immediate termination of their employment or Franciscan affiliation, and may also result in significant individual criminal and civil liability.
To protect the confidentiality and security of patient information, we:
Q: How can I protect patient privacy when I am caring for patients in shared rooms?
A: You can close the curtains around the patient’s bed, speak as quietly as possible to the patient and make sure the patient is willing to discuss treatment and care if visitors are present.
HIPAA also provides patients with certain rights regarding their protected health information. Patients can request an amendment or correction to the information contained in their medical records and an accounting of all disclosures of their protected health information. Patients also can choose to opt out of the hospital directory to maintain their privacy. All Franciscan patients are provided with a copy of our Notice of Privacy Practices which informs them of these and other rights.
FERPA gives similar rights with respect to the student's education records, including the right to inspect and review the student's education records and the right to request an amendment of the student’s education records in some situations.
If you have any questions about the release of patient, student, or other personal information, you should contact the Franciscan Privacy Officer at 617-779-1111 or at Privacy@franciscanchildrens.org. For more information, please consult the
Franciscan Children’s Notice of Privacy Practices, and the following policies: ADM049 “HIPAA Minimum Necessary,” IS023 “Enterprise Cybersecurity Program,” “Mobile Device Management and Encryption,” IS008 “Access Control to Network Systems,” and ADM044 “Written Information Security Plan.”
Q: A colleague’s son has been admitted to Franciscan and our department is worried about him. Can I look at his medical record to see how he is doing?
A: No. HIPAA protections apply to Franciscan employees and children who also are patients. You can only look at a medical record if your job responsibilities require you to do so.
Franciscan colleagues follow the RESPECT behavioral attributes in all their workplace interactions. These attributes are:
Franciscan Children's is proud to be an integral part of the diverse community of Boston. It is this community, comprised of people from a wide variety of cultures and backgrounds, that Franciscan draws upon as a resource for its employees and patients. Franciscan is committed to creating and sustaining a workplace where we respect and value our employees, not despite, but because of the differences in their backgrounds and cultures.
We believe there is strength in diversity, not only of race, gender, age, religion, and disability, but also of education, family status, national origin, sexual orientation, gender identity and expression and all the other factors that make people individuals. Honoring the diversity of our community will promote and ensure the mutual respect, collaboration and productivity that is necessary to provide the highest quality health care.
For more information, please consult Franciscan policy HR001 “Equal Employment Opportunity.”
Franciscan Children’s is committed to recognizing and honoring the diversity in our organization and community, and dedicated to keeping diversity, equity, and inclusion at the forefront of everything we do. Franciscan Children’s has a cross departmental Diversity, Equity and Belonging (DEB) team to promote and celebrate the diversity of our staff, the individuals we serve and our community at Franciscan Children’s. Franciscan Children’s does not exclude people or treat them differently because of their race, color, national origin, age, disability, religion, sex, pregnancy, sexual orientation, or gender identity. Franciscan complies with all laws and regulations governing all aspects of employment, including hiring, promotion, and termination. We do not tolerate discriminatory or harassing conduct and we do not permit retaliation against or intimidation of anyone who makes a good-faith complaint of discrimination or harassment.
Franciscan investigates and takes appropriate action on all complaints of harassment and discrimination that are made to employees’ supervisors, Human Resources 617-779-4900, or the Compliance Hotline 617-779-1111.
For more information, please consult Franciscan policy HR035 “Anti-Harassment.”
To provide high quality patient care, we must be able to collaborate, communicate and cooperate at all times. We can achieve this only if we treat each other with respect, courtesy, dignity and understanding. Appropriate professional behavior is any reasonable conduct intended to advocate for patients, to recommend improvements in patient care and to participate in the operations, leadership or activities of the staff.
Behaviors that undermine the culture of safety include, but are not limited to:
If you are subjected to unprofessional behavior, you should report it to your supervisor or manager, Human Resources 617-779-4900, or the Compliance Hotline 617-779-1111.
For more information, please consult Franciscan policies HR032 “Rules of Conduct / Disciplinary Action,” and HR047 “Impaired Health Care Providers.”
Franciscan is concerned about the well-being and personal safety of its employees and anyone doing business with Franciscan. Acts of violence and threats of violence in the workplace are prohibited. Violent acts include physical violence, stalking, threats, or similar acts. Workplace violence is any conduct that is offensive or intimidating enough to make an individual reasonably fear for his/her personal safety or the safety of family, friends, or property. No firearms, weapons, explosive devices, or other dangerous materials are permitted in Franciscan facilities.
Any Franciscan colleague, regardless of position, who commits or threatens to commit an act of workplace violence will be subject to disciplinary action up to and including termination of employment. Any threat or actual violence should be reported as soon as possible to your immediate supervisor or Franciscan Children’s Security Manager at 617-779-1402. Franciscan will promptly and thoroughly investigate all reports and will not tolerate retaliation against anyone who makes a good faith report.
For more information, please consult Franciscan policy HR050 “Workplace Violence Prevention.”
Franciscan Children's makes clinical and business decisions based solely on the best interests of our patients and best business practices. Your outside financial or other personal interests must not influence – or appear to influence – your professional decision-making on behalf of Franciscan. You also may not personally benefit from any actions that you take on behalf of Franciscan. You must always put Franciscan interests ahead of your own.
To identify and manage potential conflicts of interest, you are required to disclose any potential or actual conflict of interest to the Franciscan Compliance Officer.
Certain Franciscan colleagues are required to file annual disclosure forms that describe any potential or actual conflicts of interest the individual may have. The Compliance Officer reviews the disclosures and determines how to resolve any conflicts of interest. Most conflicts can be resolved easily; however, in some instances, you may be required to refrain from participating in certain decision-making activities.
Q: My husband just took a job with a vendor who sells medical supplies to Franciscan Children’s. What should I do?
A: Contact the Compliance Officer at 617-779-1111 to disclose this potential conflict. The Compliance Officer will determine any actions that should be taken to manage the potential conflict.
We prohibit the unsafe use of alcohol, drugs, or medications in the workplace. Abusing substances or working while impaired can lessen your ability to perform your responsibilities and compromise the safety of colleagues, patients, and the public. On-the-job use, possession, theft or sale of drugs and alcohol is strictly prohibited. Franciscan reserves the right to test employees for drugs or alcohol when there is a reasonable suspicion that an employee is under their influence in the workplace.
For more information, please consult Franciscan policy HR037 “Drug Free Workplace.”
Franciscan Children's may not employ, credential, or contract with any “ineligible person.” An “ineligible person” is any individual or entity that is currently excluded from participation in state and federally funded health care programs such as Medicare or Medicaid or that has been convicted of a criminal offense related to the provision of health care items or services and has not yet been reinstated after a period of exclusion or ineligibility.
Franciscan routinely screens all colleagues against the Excluded Provider lists published by the federal government and the Commonwealth of Massachusetts as well a licensing board. If you have exclusion or licensing questions regarding your participation in the federal or state health care programs, you must notify Human Resources immediately at 617-779-4900. You should also contact the Compliance Department if you become aware any exclusion or licensing issue that may affect care delivery at Franciscan Children’s.
We do not use any Franciscan Children's resources, including email, to engage in political activity either personally or on behalf of Franciscan. Franciscan is a 501(c)(3) tax-exempt, not-for-profit corporation, so Franciscan cannot take positions on political elections, campaigns, or candidates. Franciscan also does not make contributions or expenditures, directly or indirectly (or using intermediaries, consultants or otherwise), on behalf of any candidate for political office, political party, or political committee. This prohibition includes monetary contributions and non-monetary contributions, such as colleagues’ work time or Franciscan’s telephones, vehicles, or premises.
Franciscan may, however, engage in public policy debates by making independent expenditures related to political speech. For example, Franciscan may provide relevant, information about the impact of public policy decisions on health care operations.
We can participate as individuals in political activities during our non-working time. However, we must be sure that we keep our personal political activities separate from our job duties and responsibilities and we can never suggest or imply that we are representing Franciscan when we participate in these activities.
For more information, please consult Franciscan policies COR003 “Charitable Nature,” and HR045 “Political Activity.”
We do not use Franciscan resources, such as materials, supplies and equipment, for personal use. Generally, you should not conduct personal business during working time, and you should not use Franciscan’s assets for personal financial gain. Occasional use of certain assets is permissible if the cost to Franciscan is negligible, such as making a personal telephone call. However, you should not expect that any such activities are private, as Franciscan reserves the right to monitor and obtain your communication usage and content and to impose discipline when your usage violates Franciscan’s policies.
For more information, please consult Franciscan policies ADM 028 “Use of Hospital Property, IS008 “Access Control to Network Systems.”
We expect colleagues to protect Franciscan’s confidential business information, such as pricing, our services in the market, key costs, employee compensation and marketing plans. We exercise caution when we share the information with competitors and at trade association meetings. Our competitors include other health systems and facilities in markets where we operate. We also respect our competitors’ confidential information. We gather information about competitors ethically and do not accept information if we suspect it was obtained inappropriately. We must take care to protect Franciscan’s confidential business information.
The following examples of information are considered confidential:
Confidential business information cannot be shared. Many members of the Franciscan workforce have access to confidential Franciscan information. We must exercise care and diligence to maintain the confidentiality of the information and use that information only as needed to perform our jobs. We must also protect the confidential information that our business partners share with us.
We comply with all applicable intellectual property laws. We respect these laws as they apply to publications, media and other forms of expression and communication. We only use software that has been properly licensed, and we use it in conformity with the terms of the license.
Franciscan’s intellectual property rights are valuable business assets. Any work of authorship, invention, or creation by a Franciscan colleague during the scope of his or her employment is Franciscan property. This includes, for example, patents, trademarks, and trade secrets. We have a shared responsibility to protect Franciscan’s property rights while we are employed at Franciscan and after the termination of our employment. We should notify Franciscan Children’s Legal Counsel. if we become aware of any new work that could benefit from intellectual property protection. We also respect the intellectual property rights of others and do not knowingly infringe on any valid third-party rights.
Advertising and marketing are useful ways to inform the community, educate patients and their families, and attract clients, business partners and employees.
We engage in truthful, informative, and non-deceptive marketing and advertising.
If you have questions about Franciscan’s advertising and marketing initiatives, please contact the Marketing Office at 617-779-1157.
We allow Franciscan’s Marketing Office to handle all media relations and external communications on behalf of Franciscan. The Franciscan Marketing Office is responsible for our media and public relations and between Franciscan and the public. All news and other information that is released to the media by Franciscan must be approved by and coordinated through the Marketing Office. If you believe that non-public information from or about Franciscan has been or is about to be released inappropriately without the consent of the Marketing Office, please notify your supervisor immediately. If you have any questions about the posting of sensitive or confidential information, you should contact the Privacy Officer at 617-779-1111 or at Privacy@franciscanchildrens.org.
For more information, please consult Franciscan policies SAF051 “Handling of Situations involving Media,” and ADM035 “Photo and Media Consent.”
At Franciscan Children’s, we comply with all applicable federal and state laws and regulations and professional standards governing our operations and the delivery of health care and educational services and products. These laws, regulations and standards are numerous, complex, and technical in nature. Those laws have been modified over the past few years, including new rules regarding the use of telehealth in response to the COVID 19 pandemic. It is the responsibility of all workforce members to comply with all applicable federal and state laws, including compliance with the Federal and State False Claims Acts and professional obligations under Medicare and Medicaid (MassHealth) programs.
Franciscan colleagues whose positions may affect Franciscan’s compliance with those laws, regulations and standards are expected to attend educational or training programs offered by Franciscan for the purpose of knowing and understanding those laws, regulations, and standards and to certify their intent to comply with them.
It is important to remember that violation of any of these laws may result in personal criminal and civil sanctions and penalties. For example, some of the laws, such as fraud and abuse and licensure laws, subject violators to imprisonment. Other laws subject violators to fines of up to $100,000 per occurrence, loss of licensure or exclusion from participation in the Medicare and Medicaid programs for a specified number of years or permanently.
Because the sanctions and penalties can be so severe, Franciscan cautions and advises all colleagues to always act professionally and in strict accordance with all applicable laws, regulations, and professional standards. We document, code and bill appropriately for all treatments and services rendered. Franciscan is committed to complying with all federal and state regulations governing health care documentation and the coding and billing of claims submitted for payment.
Complete, factual, and legible documentation in medical records is essential for accurate coding and billing. Accurate records also demonstrate our credibility as a health care provider and allow us to make the best decisions possible for our patients.
Colleagues who make good-faith reports regarding actual or potential violations of the legal requirements for billing and coding may not be subjected to retaliation or intimidation. All contractors or agents of Franciscan retained to perform billing or coding services must comply with this Code and Franciscan’s billing, coding and documentation policies.
In order to avoid liability for false claims, you should:
Under federal law, all identified overpayments must be refunded to the government payer within 60 days of identification. Failure to do so can result in fines and other penalties.
For more information, please consult Franciscan policies CIS011 “Completion of Medical Records,” and FIS002 “Credit and Collections.”
Q: What are some examples of false claims?
A: Examples include billing for services not provided; billing for a higher level of service than was provided; billing under one provider’s name/NPI for a service provided by another provider; and billing for services not documented in the medical record.
We retain records as required by law. Federal and state laws require that we retain medical and other records for specified periods of time. We carefully follow the rules for each type of record. All Franciscan colleagues are responsible for ensuring that our records are accurate, up-to-date and maintained in compliance with the law and Franciscan policies. Franciscan may suffer serious consequences up to and including sanctions, fines, and loss of accreditation if we fail to comply with the legal requirements.
We fully cooperate with all appropriate government requests for information, site visits, audits, and investigations. These interactions with government authorities may have significant legal and financial impacts on Franciscan and you.
It is vitally important that you notify your supervisor and the Franciscan Compliance Department immediately if you are contacted by a government agent for information or if any government agency initiates a non-routine site visit. In this situation, you should ask for the government representative’s official identification, the reason for the visit and whether he/she has a subpoena or warrant. You should then notify your supervisor and the Compliance Department and ask the government agent to wait while you do so.
If you are approached by a government agent regarding your relationship with Franciscan, you have the right to:
For more information, please contact the Franciscan Children’s Legal Counsel.
Franciscan Children's holds several accreditations and certifications which are vitally important to our continued successful operation. We maintain these accreditations and certifications by participating in surveys and audits. We must always be direct, open, and honest when we interact with accrediting bodies and surveyors. We can never mislead these agency representatives or conceal or alter any documents in preparation for or during a survey or urge our colleagues to do so.
Franciscan conducts research that will lead to improvements in health care and health status for all people, and to further scientific advances in medicine. All research must be conducted according to the highest ethical standards and in compliance with all applicable policies, federal and state laws, and regulations.
We protect the rights and well-being of our patients who choose to participate in research studies. Refusal of a patient to participate in research will not compromise their access to our services or the care that they receive at Franciscan.
We require our Institutional Review Board (IRB) to review and approve all research that involves human subjects. We engage human research participants in a meaningful, informed consent process. We also maintain an environment that fosters privacy and security.
Franciscan will not tolerate acts of plagiarism, falsification or fabrication of data, or other research misconduct. We are committed to full compliance with our policy for responding to allegations of research misconduct. Our investigators are expected to be accountable for the funds received from sponsors of research and to comply with the terms and conditions of research grants and contracts.
Franciscan Children’s recognizes that relationships between providers and vendors can further a mutually beneficial exchange of information about products or services relevant to patient care, but also recognizes that those same relationships may create potential for conflicts of interest or abuse. For this reason, we have adopted a policy that prohibits Franciscan colleagues from accepting any form of personal gift, regardless of value, from health care vendors or their representatives.
The policy also sets forth the basic requirements for consulting arrangements between providers and vendors, attendance by providers at educational conferences and other activities sponsored by vendors, vendor access to Franciscan facilities, educational grants and scholarships funded by vendors and the disclosure of provider/vendor financial relationships.
We also require vendor representatives to adhere to the requirements of this policy.
All the policy requirements must be followed by Franciscan colleagues in order to ensure the integrity and transparency of our industry relationships and to assure our patients that we provide the best and most appropriate care for each individual, free from the influence of industry or personal self- interest.
For more information, please consult Franciscan policies: ADM008 “Conflict of Interest Policy,” and HR044 “Employee Gifts.”
The federal Anti-Kickback Statute and other laws prohibit the receipt of anything of value in return for making referrals of patients who are beneficiaries of federal or state health care programs. These laws also bar the payment or receipt of anything of value in return for directly purchasing, leasing, or ordering (or for recommendations to purchase, lease or order) any goods, facilities, services or items covered under the benefits of the Medicare or Medicaid programs. In Massachusetts, state law applies these prohibitions to all patients, regardless of payer source.
Q: What actions might influence referrals and violate the Anti-Kickback Statute?
A: Three examples are: a hospital providing discounted office space to a physician to induce the physician to make referrals; a pharmacy routinely waiving co-payments to encourage patients to get their prescriptions filled there; and a gift from a health care vendor to thank hospital staff for their orders.
Franciscan is committed to complying with these federal and state laws. All Franciscan colleagues are expected to be vigilant in identifying potential anti-kickback violations and reporting them to the Compliance Officer or to the Compliance Hotline as soon as they are discovered.
Franciscan Children’s is committed to compliance with the Stark Law. This law generally prohibits a physician from referring a patient for designated health services to an entity in which the physician (or his/her immediate family) has a financial interest. The choice of hospital, diagnostic facility or supplier should be made by the patient with guidance from his/her physician as to which providers are qualified and medically appropriate.
Franciscan employs only those individuals who are properly licensed and credentialed for the position for which they are hired. Proper credentialing and licensing are important ingredients of high-quality patient care and are required by federal and state laws. We conduct credentialing reviews before providers commence their work with Franciscan and we re-credential them at regular intervals in accordance with regulatory requirements. We also conduct criminal background checks on all colleagues before they are employed or affiliated with Franciscan.
For more information, please consult Franciscan policies HR 057 “Background Checking Policy” and MSO003 “Medical Staff Credentialing Procedures.”
The mission of the Franciscan Children's Compliance Program is to protect public confidence in Franciscan’s Children's clinical and business practices through:
The Program partners with Franciscan’s leadership and operational departments to promote an ethical workplace through adherence to this Code of Conduct and Franciscan’s policies and procedures. The Compliance Program is designed to detect and prevent fraud, waste, and abuse and to ensure our adherence to the many laws and regulations that govern the provision of health care and education services. The Program is a vehicle for preventing violations of the law and enabling Franciscan to rectify any situation before it becomes a problem or legal violation. Since the Program benefits both Franciscan and its colleagues, Franciscan expects good-faith cooperation from all colleagues in making the Program effective.
The Franciscan Compliance Program also promotes ethical decision making.
When you are confronted with a difficult decision, ask yourself these questions:
If your answer to all of the above questions is “yes,” you are making the right decision.
Privacy and Security Programs are designed to implement the requirements of HIPAA, FERPA, the HITECH Act, Massachusetts data privacy regulations, and other federal and state laws that govern the use and disclosure of patient, student, employee, donor, financial proprietary, and other confidential information.
Franciscan Children’s will not tolerate intentional or reckless behaviors that pose a threat to the privacy or security of our confidential information. Franciscan Children’s Privacy Officer | HIPAA Privacy Officer can be reached at 617-254-3800, extension 1158, or at Privacy@franciscanchildrens.org.
The Franciscan Children’s Security Program, which is led by our IT Department, ensures the security of our electronic systems, communications, and technical safeguards to confidential information. The IT Security Officer | HIPAA Security Officer can be reached at 617-254-3800, extension 1206, or at Privacy@franciscanchildrens.org.
The Franciscan Children’s Privacy Program provides education and training on federal and state privacy issues. The Privacy Program also receives reports of potential and actual privacy violations and investigates and resolves them appropriately. Franciscan Children’s colleagues always respect patient privacy. If you do not know whether patient information should be released, or if you have questions about HIPAA, please consult the Franciscan Children’s Privacy Officer at 617-779-1158, or at Privacy@franciscanchildrens.org.
Franciscan Children’s is committed to safeguarding the personal and sensitive information that is under our control as a hospital and educational facility. We take the security of personal information and protected health information very seriously. We actively protect against external threats though cybersecurity systems and educational programs for workforce to raise awareness of cybersecurity vulnerabilities and to reduce risk and potential cyberattacks.
All Franciscan Children’s colleagues have a duty to comply with this Code of Conduct, Franciscan Children’s policies and procedures and all applicable state and federal laws. If you become aware of any actual or threatened violation of these requirements, you must report the situation to the Compliance Officer immediately by calling 617-779-1111, or at Compliance@franciscanchildrens.org.
Franciscan Children’s will not take any adverse action against any staff member who reports, in good faith, any violation, actual or threatened, regardless of whether the situation giving rise to the report is ultimately determined not to have any factual basis. If you know of any actual or threatened violation of any applicable law, regulation or standard and fail to report the situation, you may be subject to disciplinary action.
Q: How do I report a Data Security, Data Privacy, or Compliance incident?
A: For IS Department and Data Security incidents, submit an IS Ticket. For Data Privacy, email Privacy@franciscanchildrens.org or call extension 1158.
Franciscan Children’s also has a Compliance and Privacy Hotline at 617-779-1111 and encourages all staff members to report questions and concerns about compliance with the Code of Conduct, Franciscan Children’s policies and procedures and applicable laws and regulations governing health care, educational, behavioral health, or data privacy. The Hotline is available 24 hours a day, seven days a week.
Franciscan Children’s has established a Compliance and Privacy Hotline 617-779-1111 to encourage all staff members to report questions and concerns about compliance with the Code of Conduct, Franciscan Children’s policies and procedures and applicable laws and regulations governing health care. The Hotline is available 24 hours a day, seven days a week. You can make a complaint anonymously if it is more comfortable for you from a Franciscan Children’s phone by dial 9-1-617-779-1111.
Franciscan Children’s compliance program is well designed, applied earnestly and in good faith, and empowered to function effectively. It is approved by our Board of Directors. All workforce members have a responsibility to promote and maintain Franciscan Children’s reputation through compliant, safe, and ethical behavior and to cooperate with and support our compliance program. You are encouraged to report any concerns or ask questions of your supervisor or the Compliance Department directly. However, the Compliance Hotline is available for reporting concerns, and you do not need to raise an issue with your supervisor first before calling the Compliance Hotline. You also can contact the Compliance Department by sending an email to Compliance@franciscanchildrens.org.
Franciscan Children’s will not retaliate against anyone who brings a compliance matter to the attention of our organization. All reports will be investigated and appropriately resolved under the direction of the Compliance Officer.
For more information, please consult Franciscan policy ADM029 “Compliance Policy Against Retaliation.”
Franciscan does not permit retaliation against, or intimidation of, any Franciscan colleague who makes a good faith report of a compliance-related concern internally or to an outside government entity. Retaliation is prohibited by both state and federal laws and will not be tolerated at Franciscan.
We seek to have an open and supportive environment where colleagues feel comfortable raising issues, and everyone works to resolve them as quickly as possible. Franciscan colleagues are protected against retaliation and intimidation whether the situation giving rise to the report is ultimately determined not to have any factual basis. However, false reports made for malicious reasons may subject the reporter to discipline. If you believe you are being retaliated against for making a report of a Compliance-related issue or for participating in a Compliance or Security/Privacy investigation, please contact the Compliance Officer at 617-779-1111, or at Compliance@franciscanchildrens.org.
Q: I want to make a report of a problem but I’m afraid my supervisor will find out I made the report. What can I do?
A: You can call the Compliance Hotline anytime and make an anonymous report.
Q: I was told by my supervisor that I am going to be interviewed by Compliance about a report made by one of my co-workers. I am worried that I will be retaliated against if I tell the truth. What can I do?
A: You are required to participate in Compliance investigations, but you cannot be retaliated against for doing so. If you believe you have been subject to retaliation, please contact the HR Department, Compliance, or Franciscan’s Legal Counsel
Within their work units, Franciscan supervisors and managers have special responsibilities to educate others about the Franciscan Compliance, Privacy and Security programs and to implement each program’s policies on an ongoing basis.
Managers also serve as role models for our colleagues, so we expect them to treat everyone affiliated with Franciscan with respect and to act with compassion, honesty, and integrity at all times.
It is the obligation of every Franciscan supervisor and manager to create an environment where Franciscan colleagues feel comfortable expressing concerns or raising issues without fear of reprisal. For this reason, managers and supervisors are required to have a thorough knowledge of the Franciscan Compliance, Privacy and Security programs and must act to support program policies at every opportunity.
Franciscan Children's enforces its standards of conduct through appropriate disciplinary action taken on a fair, equitable and consistent basis for every employee, regardless of position. Any Franciscan colleague who violates the provisions of this Code of Conduct or Franciscan policies and procedures will be subject to disciplinary action. The appropriate disciplinary action will be determined on a case-by-case basis. Franciscan policy provides for a range of possible disciplinary actions, from a verbal warning to discharge from Franciscan employment.
For more information, please consult Franciscan policy HR 032 “Rules of Conduct/Disciplinary Action.”
All reports of Compliance or Privacy violations will normally be investigated within 10 days of receipt. Investigations of reports will be conducted by, or at the direction of, the Compliance Officer or the Privacy Officer. The Compliance Department may enlist the assistance of persons with relevant expertise or experience while conducting the investigation.
Once an investigation is complete, the Compliance Officer or Privacy Officer will inform the individual who made the report as to whether the report was substantiated and, to the extent appropriate, the corrective actions being taken to remedy the problem. All Franciscan colleagues have a duty to cooperate with investigations conducted by the Compliance Officer or Privacy Officer and with the implementation of any corrective action plans.
Franciscan Children’s Compliance Officer
30 Warren Street
Brighton, MA 02135
Phone: 617-779-1111
Email: Compliance@franciscanchildrens.org
Compliance Hotline: 617-779-1111
(For anonymous messages from a Franciscan Children’s phone dial 9-1-617-779-1111)
Franciscan Children’s Privacy Officer
Phone: 617-779-1158
Email: Privacy@franciscanchildrens.org
Franciscan Children’s Human Resources Division
Phone: 617-254-3800, extension 4900
Franciscan Children’s Interpreter Services Department
Phone: 617-254-3800, extension 4701
Beeper number: 6042
Franciscan Children’s General Counsel
Phone: 617-779-1155
Franciscan Children’s Patient Advocate/ Human Rights Officer
Phone: 617-254-3800, extension 7723
Franciscan Children’s Security Manager
Phone: 617-779-1402
Centers for Medicare and Medicaid Services
www.cms.hhs.gov
Mental health | Centers for Disease Control and Prevention
https://www.cdc.gov/mentalhealth/learn/
U.S. Department of Education
https://www.ed.gov/
Phone: 1-800-872-5327
US Department of Health and Human Services, Office of Inspector General (OIG)
www.oig.hhs.gov
Phone: 1-800-447-8477
US Department of Health and Human Services, Office of Civil Rights (HIPAA)
www.hhs.gov/ocr/privacy
Massachusetts Department of Elementary and Secondary Education
https://www.doe.mass.edu/
Phone: 781-338-3000
Massachusetts Department of Public Health
www.mass.gov/eohhs/gov/departments/dph
Board of Registration in Medicine (BORIM)
www.mass.gov/eohhs/gov/departments/borim