General Compliance

No single department, clinic, or individual is solely responsible for building and maintaining a culture of compliance; rather, it is the responsibility of every member of the organization. The general compliance program exists to provide support and guidance to the Cheyenne Regional community and to meet the evolving compliance needs of the organization. This program has been developed in alignment with our core mission, vision, and values.

An effective compliance program is a critical step in preventing non-compliance and increasing the likelihood of identifying and correcting non-compliant activities. The Compliance Department promotes the program’s effectiveness by offering compliance education and training to workforce members, providing timely responses to compliance issues, and maintaining effective communication channels for the good-faith reporting of concerns.

The general compliance program not only assists Cheyenne Regional in fulfilling its institutional mission but also serves to:

Maintain and enhance the quality of care
Demonstrate sincere, ongoing efforts to comply with all applicable laws
Revise and clarify current policies and procedures to improve compliance
Strengthen communication with governmental entities regarding compliance activities
Empower all responsible parties to prevent, detect, and resolve conduct that does not conform to applicable laws, regulations, and the compliance program
Establish mechanisms for employees to raise concerns about compliance issues and ensure those concerns are addressed promptly and appropriately

The Code of Conduct and True Care Ethical Standards

Cheyenne Regional Medical Center and Cheyenne Regional Medical Group (Cheyenne Regional) are committed to providing quality health care that is medically necessary and efficient while adhering to applicable laws, rules, and regulations, as well as the ethical standards outlined in this Code of Conduct and our True Care Standards of Behavior.

The Code of Conduct comprises our True Care Standards, each addressing an area at risk for compliance violations. Each standard provides information on appropriate conduct and suggestions for handling potential problems. While some standards fully cover their topics, others may be more complex, requiring further information beyond what is outlined in the standard.

The Code of Conduct is intended to serve as a guide to ensure that our work and decisions are honest, ethical and legal. It also helps Cheyenne Regional personnel understand where to seek answers or report issues internally when they arise. This Code establishes a roadmap and defines Cheyenne Regional’s compliance and ethics standards.

Does the Code of Conduct apply to me?

Yes, the Cheyenne Regional Code of Conduct applies to all employees. For purposes of the Code of Conduct, the term “employees” refers to all responsible parties involved in either the direct or indirect provision of patient clinical care services, as well as those providing staff, business, administrative, or patient care support services at all Cheyenne Regional facilities.

What are my responsibilities?

Cheyenne Regional’s commitment to certain standards in business conduct depends on the same commitment from all employees. Therefore, it is the responsibility of everyone to:

Know and comply with the Code of Conduct and the Compliance Program as they apply to your role
Avoid involvement in illegal, unethical, or otherwise improper activities
Seek guidance from the Compliance Program when in doubt about your responsibilities
Report any violations of the Program
Assist authorized personnel in investigating all allegations of violations
Take responsibility for your actions
Immediately notify the Compliance or Legal Department if you are excluded from participating in any federally funded programs.

What if I have questions or concerns?

The opportunity to ask questions and raise concerns is a cornerstone of a successful compliance program. Cheyenne Regional supports open discussions of ethical and legal questions and concerns regarding compliance issues and does not tolerate retaliation against any individual who, in good faith, raises questions or reports suspected violations.

As a Cheyenne Regional employee or volunteer, you have a personal responsibility to report any activity that appears to violate the Code of Conduct, policies, or applicable laws or regulations. If you have a question or concern about the appropriateness of a decision or action, follow these steps:

Communicate with an immediate supervisor or manager. Raise the issue with your supervisor, manager, or team leader, as they are most familiar with job requirements and business practices. The supervisor should provide a timely response or seek alternative solutions.
Contact the Compliance Department/Officer. The Chief Compliance Officer (CCO) has lead responsibility for compliance issues and reports directly to executive leadership. You can bring any questions or concerns to the CCO or Compliance Department staff if you feel you did not receive a timely or ethical response from your supervisor.
Call the Compliance Hotline. You can contact the Compliance Hotline at any point to raise questions, clarify issues, or report suspected violations. Reports will be investigated or referred to appropriate personnel for resolution. You may choose to remain anonymous. The Compliance Hotline can be reached at 1-877-778-5463 (toll-free).

If you’re uncomfortable with the above steps, contact the Compliance Department at (307) 432-6625 or email at [email protected].

Conflict of Interest

Cheyenne Regional is bound by federal regulations relating to healthcare Conflicts of Interest (COI) and, as a matter of policy, prohibits employees from engaging in any activity that places them in a COI with their official duties. Such conflicts may make it difficult for employees to discharge their responsibilities. More information can be found in Cheyenne Regional Policies and Procedures (#07.01.020, Conflict of Interest).

What is a Conflict of Interest?

A conflict of interest (COI) occurs when an employee is in a position to influence a decision that may have a financial effect on the employee, a relative, or a person/entity with which the employee has a personal financial connection. COIs can be “actual” or “perceived.” While actual COIs involve specific circumstances, perceived COIs create an appearance of wrongdoing and should also be avoided. COI questions are analyzed case-by-case, as they may involve a review of multiple rules and regulations. If you have a question about the COI policy or need help determining if you have a COI, contact the Cheyenne Regional Compliance Department. COI types may include:

Appearance of impropriety (e.g., influence on clinical decisions, drug/device prescribing, patient care/trust, and purchasing decisions)
Conflicts related to time commitment and effort
Failure to recognize Cheyenne Regional’s intellectual property and interests
Improper channeling of funds
Misuse of Cheyenne Regional facilities, resources, funds and personnel.

How can I avoid a Conflict of Interest?

Disclose or recuse: Disclose or recuse yourself by abstaining from making, participating in, or influencing decisions if you have a COI.
Complete the annual Conflict of Interest Survey.
Seek guidance: Reach out to the Compliance Department for assistance.

Gifts

Cheyenne Regional is committed to promoting integrity and honesty in dealings with vendors and the community. It prohibits employees from accepting gifts from vendors. Additionally, all Cheyenne Regional employees are subject to the gift policies outlined in the Cheyenne Regional Gifts and Gratuities Policy.

What is a Gift?

A “gift” is defined as anything of more than nominal value received by an individual for which the recipient has not paid fair market value. Gifts may include rebates or discounts unless these are provided in the regular course of business to the public.

Can departments/clinics purchase items for giveaways during events?

Gift-related questions are evaluated on a case-by-case basis, as different circumstances can warrant different responses. Generally, Cheyenne Regional policy allows for the purchase of gifts for recognition purposes. Employees will be notified that appropriate taxes for the award will be calculated, withheld, and submitted to the IRS.

Cheyenne Regional employees with conflict of interest, gift, or vendor relation questions should contact the Cheyenne Regional Compliance Department at (307) 432-6625 or by using the information on the “Contact Us” webpage.