STANDARD 3: Organizational Ethics

3.1 General

1. The healthcare organization shall establish a framework and procedure for documenting, monitoring, analyzing, and administering a set of ethical principles or code of conduct.

2. A Committee conducting these requirements shall be appointed by healthcare organization and possess individuals with knowledge appropriate to conducting decisions related to the issue at hand.

3. The ethical principles shall include but not limited to:

a) confidentiality of patient and personnel information;

b) avoidance of conflicts of interest;

c) complaints processes;

d) independence and objectivity;

e) encouragement of staff to raise ethical concerns;

f) accurately bill for its services;

g) provide an effective resolution within defined time bracket according to established healthcare organization policy;

h) resolve conflicts when financial incentives and payment arrangements could compromise patient care.

4. The framework shall support the healthcare organization’s professional staff and patients when confronted by ethical dilemmas in patient care, and between patients and their healthcaren practitioners. These possible dilemmas shall include those regarding care decisions, interprofessional disagreements and other potentially personal, civil, or criminal issues. This process shall define timely and immediate steps to support and to accommodate the situation as required.

NOTE 1 Examples of ethical issues described in 3.1.4. above may include but are not limited to:

a) appropriate informed consent for medical procedure;

b) awareness and adherence to conditions of an advance directive (AD);

c) conduction of procedures and processes beyond the scope and resource of the healthcare organization;

d) processes and procedures outside of current accepted WHO standard of care or other internationally recognized entities (see NOTE 3 below);

e) contemplated care in conflict with patient stated will without consulting appropriately patient or family as indicated.

NOTE 2 Ad hoc individuals may be appointed for ethics question resolution as determined by Top management and other individuals as necessary.

NOTE 3 The healthcare organization shall also respect the principles of the following international instruments:

a) Universal Declaration of Human Rights;

b) ILO Conventions 100 and 111 (Equal remuneration for male and female workers for work of equal value; Discrimination);

c) ILO Convention 155 & Recommendation 164 (Occupational Safety & Health);

d) ILO Convention 159 (Vocational Rehabilitation & Employment/Disabled Persons).

3.2 Discrimination and Work Environment

1. The healthcare organization shall not engage in or support discrimination in hiring, remuneration, access to training, promotion, termination, or retirement based on race, national origin, religion, disability, gender, sexual orientation, or age.

2. The healthcare organization shall not allow behavior including gestures, language, physical contact, or other activity that is intimidating, sexually coercive, threatening, abusive, or exploitative.

3. The healthcare organization shall have policies and procedures to resolve workplace conflicts including the management of underperformance. 

NOTE 1 The healthcare organization shall maintain an environment free of behavior or physical activity detrimental to the achievement of its intended products and services. However, the expectation of individual performance in the achievement of their assigned duties outlined in their job description shall not be unfairly diminished by the improper use of the meaning of this standard.