Montefiore's Code of Organizational Ethics

Montefiore Medical Center strives to abide by the ethical principles embodied in this Code of Ethics in all aspects of patient care, medical education, clinical research and community service, and in all aspects of administrative functions related to those services. These ethical principles describe guidelines for honorable behavior for health care providers, managers and all other associates, and volunteers. Montefiore strives to realize these standards in all its clinical and organizational activities.

Organizational Principles
Montefiore recognizes that managers and associates have ethical obligations to patients, staff and the community. Therefore:

1. Montefiore creates an ethical organizational environment.

2. Montefiore pursues a socially responsible agenda.

3. Montefiore engages in responsible stewardship.

4. Montefiore supports fair marketing and communication practices.

Clinical Principles
Montefiore recognizes that its primary mission is to ensure the provision of high quality, ethically based patient care. Therefore:

1. Montefiore monitors quality of care.

2. Montefiore supports ethical clinical decision making.

3. Montefiore promotes multidisciplinary clinical consultation.

4. Montefiore protects patient privacy and confidentiality.

Montefiore creates an ethical organizational environment by:

• Promoting ethical decision making through mechanisms that integrate ethical analysis into clinical and administrative deliberation and policy development;

• Protecting the rights of human subjects and promoting the welfare of animals in research protocols;

• Developing mechanisms for implementing the ethical principles in the code and establishing a process for resolving ethical disputes;

• Involving staff in ethical decision making on the organizational and clinical levels by promoting discussion of ethical issues, expression of ethical concerns without fear of reprisal, and consideration of whether behavior is ethical;

• Listening and attending to the concerns of patients and families;

• Reducing institutional barriers to patients and families receiving information and guidance from providers and making informed health care decisions; and

• Creating effective, efficient and confidential dispute resolution mechanisms to address ethical conflicts and concerns on the organizational, administrative and clinical decision making levels.

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Montefiore pursues a socially responsible agenda by:

• Addressing the health of the community by working with individuals and groups to identify public health care needs, establish priorities and provide adequate notice of available services;

• Promoting accessible, affordable and convenient primary care;

• Building community alliances that work with community organizations and individuals to promote public health and safety, and coordinate health care delivery; and

• Supporting teaching and research as important parts of its responsibility to the community and the larger society.

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Montefiore engages in responsible stewardship by:

• Conserving limited health care resources by using them efficiently and responsibly, and distributing them beneficially and cost effectively;

• Promoting cost-effective care through cooperative clinical decision making that uses resources wisely, by avoiding both under- and overtreatment, and encouraging patients to assume responsibility for monitoring and improving their health;

• Maintaining continuous quality review to assess the effectiveness of resource utilization and clinical outcomes;

• Incorporating ethical principles and reasoning into resource planning and utilization review in order to promote financial accountability at all organizational levels;

• Promoting measures, including incentive plans, to increase provider productivity, motivate effective resource utilization, provide high quality patient care and enhance the work ethic;

• Providing the same standard of care, regardless of payment source, by enforcing policies that define equity and prohibit discriminatory provision of care;

• Identifying and cultivating potential sources of public and private funding for patient care, medical education and research; and

• Devoting a portion of its institutional budget to funding uncompensated care for the uninsured and underserved.

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Montefiore supports fair marketing and communication practices by:

• Promoting realistic consumer expectations by accurately reflecting the institution’s health care delivery record and capabilities, and limiting promises to what the institution can actually provide;

• Promoting informed consumer choice by providing the public with accurate and balanced information about existing and planned institutional resources, treatment capabilities and areas of specialization; and

• Disclosing information to patients about institutional relationships that create actual, potential or apparent conflicts of interest.

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Montefiore monitors quality of care by:

• Promoting best clinical practice by using measures of quality that reflect the current research on clinical outcomes and practice guidelines;

• Including all departments and disciplines in system-wide continuous quality improvement to improve the quality of care and promote clinical skills;

• Monitoring and reducing adverse clinical events by focusing on patient safety, and identifying and eliminating practice patterns and systems that deviate from accepted standards of care;

• Promoting continuity of care by sharing appropriate medical information, coordinating services among providers and developing discharge plans that monitor the transition from hospital to the community or other care facilities; and

• Abiding by the principle of truth telling and requiring appropriate personnel to disclose health-impairing mistakes to patients and, where indicated, their families, in order to respect autonomy and prevent or mitigate harm.

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Montefiore supports ethical clinical decision making by:

• Stressing the importance of ethically based and informed health care decision making by requiring that providers confirm the patient’s decisional capacity and, if the patient lacks capacity, identify the appropriate surrogate;

• Supporting informed choice by clearly informing patients, proxies or other surrogates about treatment options and their benefits, burdens and risks, with special attention to decision making for patients incapable of making health care choices;

• Respecting the rights of all concerned parties by protecting patient and family interests, providing clinical information for informed consent and refusal, enhancing patient and family voice in clinical decision making and addressing patient and family concerns and complaints;

• Supporting a principled dispute resolution system that addresses treatment and interpersonal conflicts, strives for consensus and is based on ethical, medical and legal principles; and

• Recognizing that mediator neutrality is essential in addressing and resolving clinical disputes between and among staff, patients, families and other surrogates.

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Montefiore promotes multidisciplinary clinical consultation by:

• Promoting collaborative clinical management and supporting the authority of specific multidisciplinary teams;

• Supporting attending physicians’ professional judgment and authority, while requiring institutional oversight and joint clinical management and implementing a plan of care that reflects the patient’s best interest, regardless of financial compensation; and

• Continuing its long-standing commitment to readily accessible comprehensive primary care services through its network of ambulatory care clinics, supplemented by specialty care services.

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Montefiore protects patient privacy and confidentiality by:

• Making the protection of patient information central to patient care and related services;

• Creating mechanisms that provide authorized persons easy and timely access to computerized patient information, while safeguarding patient privacy and confidentiality;

• Restricting access to medical records and other health information, including billing information, to those with a “need to know” in order to provide direct patient care,

• Review the quality of care and pursue other legitimate clinical or organizational goals;

• Educating staff about their obligations regarding access to and disclosure of patient information;

• Advising patients that medical information will not be disclosed to others, including family and friends, without patient permission, except as permitted by law; and

• Establishing policies and practices that protect against breaches of confidentiality and punish illegitimate access, use and/or disclosure of patient information.

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