Corporate Compliance Code of Conduct

The Code of Conduct (Code) is designed to assist you in making the right decision when you encounter situations involving legal or ethical issues in your daily activities. Obviously the Code cannot cover every aspect of your job. When you are confronted with an unusual situation or you have any doubts about the right course to follow, always use your practical judgment. Other resources are available to answer your questions and concerns, such as your supervisor or your supervisor’s manager, Human Resources, the Corporate Compliance Officer and the Compliance Hotline. Our managers maintain an open door policy.

Over the years, Virtua Health has established numerous policies and procedures to promote compliance with sound legal and ethical principles, which are not described in the Code. Nothing contained in this Code is intended to lessen the importance of adhering to these established policies and procedures.

The Code is for all Virtua Health colleagues and entities under Virtua Health Inc. to ensure compliance  with federal and state laws and outlines the organizational commitment to compliance.

Message from Virtua President and CEO

Dear Virtua Health Colleagues:


Virtua Health’s mission is to help people Be Well, Get Well and Stay Well. Part of our commitment to the communities we serve is to provide services of the highest quality, to conduct our business according to the highest ethical standards, and to comply with all regulations. Virtua Health’s Code of Conduct (Code) outlines the expectations for meeting our rigorous standards. We must conduct our business activities in full compliance with all federal, state and local laws and regulations. The Code and Corporate Compliance Program are intended to guide and direct all Virtua Health colleagues, officers, board members and others who work at or are associated with our organization. Compliance is everyone’s responsibility.  

The Code helps us make the right choices when confronted with difficult decisions. Each of us has an obligation to know and to abide by the laws, rules, regulations, policies and practices that have specific application to our job. Our commitment to compliance remains the same, regardless of position within Virtua Health.  

Please read the Code carefully and completely, and promptly approach your leader with any questions.

If you have questions or concerns about a particular situation you are facing, there are a number of ways to seek assistance. First, we hope you will feel comfortable discussing your question or concern with your leader. If for any reason you do not wish to do so, or if your leader is not able to address your questions or concerns, you may contact your Human Resources Representative, the Corporate Compliance Officer, or call the confidential Compliance Hotline at 1-800-268-0502.

On behalf of the entire management team, I pledge my commitment that no retaliatory action will be taken against you for reporting a problem or concern in good faith to the Compliance Hotline or through any other appropriate channel. We all have a personal obligation to identify issues and uphold the standards described in the Code.  

Managers have a special responsibility as part of the Corporate Compliance Program.  Our management team maintains an open door policy and is ready and willing to listen to any and all concerns, questions, or suggestions that you many have regarding this Code, the Corporate Compliance Program or any other issue.

Thank you for your continued hard work and dedication.  

Dennis W. Pullin, FACHE
President and Chief Executive Officer

Corporate Compliance Program

Virtua Health implemented the Corporate Compliance Program in February 1999. Virtua Health has a Corporate Compliance Officer to oversee the day-to-day operations of our Corporate Compliance Program. The Program elements, as required by the Office of Inspector General (OIG), are as follows:


  • We establish and maintain standards of conduct through the Code. 
  • We report to the Audit and Compliance Committee of the Virtua Health Board of Trustees on all compliance related issues.  
  • We develop and conduct trainings that instruct colleagues in compliance-related decision making. 
  • We oversee the operation of the Compliance Hotline as a mechanism to receive concerns. 
  • We review problem areas identified by callers to the Corporate Compliance Officer and the Compliance Hotline, and consistently enforce standards through appropriate interventions and/or disciplinary mechanisms.
  • We establish auditing and monitoring mechanisms in accordance with the Office of Inspector General’s Workplan to ensure compliance. 
  • We respond to detected violations of standards, laws, and regulations and work to prevent future similar occurrences.
  • We will verify that all  colleagues, medical staff and vendors are permitted to participate in the Medicare/Medicaid programs.

Compliance Hotline and Web Intake

Virtua Health strongly encourages all colleagues to discuss their question or concern using the chain of command, beginning with your supervisor, and prior to calling the Compliance Hotline or Web Intake.  A toll-free Compliance Hotline is available to you when you have a question or concern and do not feel comfortable discussing the matter with your supervisor, manager, Human Resources representative or the Corporate Compliance Office.

Information from your call will be communicated to the Corporate Compliance Officer for review, follow-up and response. Your request for information or action will be handled promptly and professionally. All reports of improper conduct will be investigated. No disciplinary action will be taken solely on the basis of a hotline report (e.g., innocence is presumed). Please also refer to the Non-Retaliation section below.

All calls are confidential to the extent permitted by law. Although you are encouraged to identify yourself, you may make an anonymous report. However, if you tell others (i.e., co-workers, friends, etc.) about your call, your anonymity and confidentiality cannot be guaranteed.

You also may make a follow-up call to learn what action was taken on your report. If you make an anonymous report, you will be given a “pin” number, which will permit you to make a follow-up call and learn about the action taken.

To reach the confidential Compliance Hotline, call 
1-800-268-0502 or complete the online web intake form ( Both platforms are available 24 hours a day, 7 days a week. 

Or  contact the Corporate Compliance Officer:

Susan Hatch, Corporate Compliance Officer
Virtua Health


We encourage open and candid communication, and we respond to issues and concerns in a timely manner. Any actual or perceived communication problem should be reported through the Management chain of command, Human Resources, the Corporate Compliance Officer or the Compliance Hotline.


  • We inform colleagues of their duties and responsibilities, and provide timely feedback about their performance. Performance reviews are conducted after 90 days of employment and annually. Feedback concerning performance is provided on an on-going basis.
  • We are committed to transparency, accuracy and honesty in our communications.
  • We share ideas and treat all opinions with respect and consideration.
  • We practice an “open-door policy” that encourages colleagues to raise legitimate questions or concerns to their immediate supervisor or another member of their facility’s management. 
  • We respond to questions and concerns in a timely manner.  If we are unable to address a question or concern in a reasonable time, we refer the individual to the proper source for response. 
  • We respect every patient’s right to voice his or her opinion about the care and services he or she receives.
  • We solicit colleagues’ feedback to implement changes to maintain high colleague engagement and customer loyalty. This includes, among other opportunities, participation in the Colleague Culture Survey, Town Hall Meetings, RISE committees and Employee Advisory Group Shared Governance Teams as well as campus and departmental staff meetings.

Colleague Responsibility

You are expected to become familiar with and adhere to Virtua Health’s Code, and all relevant laws and regulations and Virtua Health’s policies and procedures that affect the performance of your job. Compliance is everyone’s responsibility. Your knowledge, or reasonable suspicion, of a violation of the Code, law or regulation, or any other Virtua Health policy and practice should be reported immediately. Failure to report your knowledge of a violation may subject you to legal liability.

You should never hesitate to ask a question or raise a legitimate concern. Correspondingly, you should also be open and responsive to questions, complaints and concerns expressed by patients and the people you supervise or with whom you work.

If you have any questions about the Code, a law or regulation, or any other Virtua Health policy or practice, you are encouraged to:

  • Talk to your supervisor.
  • Talk to another member of management.
  • Talk to your Human Resources representative.  

Most situations can be resolved at this level. If, however, your question or concern cannot be resolved at this level, you should report the matter to the Corporate Compliance Officer.

Susan Hatch, Corporate Compliance Officer
Virtua Health

Call the confidential Compliance Hotline at 1-800-268-0502 (anonymous reporting is an option) or web intake form (

Non-Retaliation Policy

Virtua Health will not take any disciplinary action or treat an colleague negatively for reporting in “good faith,” a concern, issue, problem, violation of law/regulation of the Code to Management, Human Resources, the Corporate Compliance Officer or the Compliance Hotline. “Good faith” means that you are telling the truth as you know it.  

Any colleague who believes that he or she has been retaliated against for making a report should contact the Corporate Compliance Officer or call the Compliance Hotline. Any manager or colleague who retaliates will be subject to disciplinary action up to termination.

Virtua Health will not protect colleagues from the intentional misuse of the Compliance Hotline. Deliberately making a false accusation is a serious violation of Virtua Health’s policy and may lead to disciplinary action, up to and including, termination of employment.

Virtua Health complies with the Deficit Reduction Act of 2005 – Section 6032, which details certain federal and state anti-fraud statutes and qui tam or whistleblower provisions. The policy is also located on Virtua Health's intranet under “Compliance Corner."

Patient Care

We are dedicated to providing high-quality healthcare services that meet the needs and respect the rights of those we serve. Any actual or perceived quality of care or patient rights issues should be reported to through the Management chain of command, Human Resources, the Corporate Compliance Officer or the Compliance Hotline.

  • We treat all patients with dignity and respect their right to privacy (refer to the  Privacy and Security on this webpage). We provide each patient with care that is both appropriate and necessary for the patient’s medical condition.
  • We render services to patients without regard to their sex, gender identity, age, disability, race, color, creed, religion, national origin, veteran status, sexual orientation or ability to pay.
  • We provide patients seeking emergency medical treatment a medical screening, and manage such patients in accordance with Emergency Treatment and Active Labor Act (EMTALA) regulations.
  • We utilize personnel with proper credentials and experience in meeting the needs of our patients. We inform patients or their authorized representative of the identity of all personnel who participate in their care.
  • We maintain complete, accurate and legible accounts of all care and treatment provided to patients.
  • We maintain strict confidentiality regarding individually identifiable health information and prevent the unauthorized release of such information. Unless otherwise permitted by law, information contained in a medical record will not be released to anyone outside the organization without the individual’s consent or authorization.
  • We respect every patient’s (or healthcare proxy) right to make his or her own healthcare decisions, including the refusal of medication or treatment after possible consequences have been clearly explained.
  • We support informed consent and communicate the benefits, risks and alternatives of diagnostic and therapeutic procedures, and the use of advance directives and POLST (Practitioner Orders for Life Sustaining Treatment).
  • When needed, we address ethical issues, including end of life care, by accessing our ethics committee.
  • We treat patients in a safe environment appropriate to meet their individual needs. 
  • We follow all IRB (Institutional Review Board) and the Clinical Trials Office (CTO) policies and procedures as well as all ethical, legal and contractual agreements when conducting research Clinical Trials.
Note: Virtua Our Lady of Lourdes Hospital (Lourdes) is a Catholic Hospital sponsored by the Diocese of Camden, which follows the Ethical and Religious Directives (ERD) for Catholic Healthcare Services. These directives provide official church guidance and teachings on issues that are central to a Catholic health care ministry. Colleagues consult the Vice President of Mission & Ministry with questions regarding how the ERD may apply to their work

Privacy and Confidentiality

Virtua Health is committed to protecting the privacy and security of our patients’ information. We routinely collect and maintain confidential information about our patients, including “protected health information” (PHI) and “personally identifiable information” (PII), in order to provide care. Our patients trust that we will safeguard their information. Additionally, federal and state privacy and security laws, including the Health Insurance Portability and Accountability Act (HIPAA), and Virtua Health’s policies and procedures require that PHI and PII be handled in a confidential manner.


Every Virtua Health colleague plays an important role in maintaining our patients’ trust and protecting their information. We each have a duty to:


  • Only access, use, or disclose PHI for a valid business reason, such as for job purposes related to treatment, payment, or health care operations. Reasonable efforts must be used to limit the amount of patient information accessed, used, or disclosed to the minimum necessary to accomplish the purpose for which the access, use, or disclosure is made.”
  • Securely dispose of paper(s) that contains patient information by placing in designated shred bins.
  • Securely dispose of equipment that contains patient information that is no longer being used by contacting Virtua Health’ IT Department.
  • Lock or log off our workstation whenever we step away.
  • Not open suspicious emails or follow links in emails that appear suspect.
  • Keep our passwords to Virtua Health systems confidential.
  • Refrain from talking about patient information in public areas e.g., cafeterias, restrooms, or elevators.
  • Not share patient information on social media.
  • Only use portable devices issued or managed by Virtua Health IT to store patient information.
  • Only use Virtua Health IT supported and authorized communication methods when sharing PHI.
  • Comply with Virtua Health’s privacy and information security policies and procedures.
  • Cross-check multiple identifiers to ensure we are directing patient information to the intended individual(s).
  • Report any confirmed or suspected privacy violations. If you discover that patient or other confidential information has been improperly accessed, used, or disclosed, or if you find or receive patient or other confidential information that you are not authorized to have, you must immediately report the incident to Virtua Health’s Privacy Office or the Compliance Hotline. 

Other types of business information should also be treated confidentially, such as employment and financial information.


Inappropriate access, use, or disclosure of patient or other confidential information may result in disciplinary action, up to and including termination.

Laws and Regulations

We strive to conduct our business activities and patient care operations in compliance with all applicable federal, state, and local laws and regulations. Virtua Health has instituted many policies and procedures related to legal and regulatory compliance. A colleague should report any actual or perceived violation of a law, regulation or our professional standards to the Management chain of command, Human Resources, the Corporate Compliance Officer or the Compliance Hotline. Each Virtua Health colleague is responsible to understand the laws and regulations that apply to his or her position, Virtua Health’s policies and procedures, and to adhere to the following principles:

  • We do not pay for referrals and we do not seek or accept payment from others for our referrals.  We compensate contracted healthcare professionals and other providers at fair market value and only for legitimate, necessary and documented services.  When referring a patient to another health care provider, we consider the best interests of the patient and not the value or volume of referrals from the other health care provider.  Kickbacks, bribes, rebates or any kind of benefits intended to induce referrals or in return for referrals are strictly prohibited.
  • We do not contract with or employ anyone who is excluded or ineligible to participate in federal health care programs (such as Medicare or New Jersey Medicaid).  Before engaging any vendor, we verify that the vendor has not been excluded, debarred or otherwise ineligible from federal health care programs.
  • Virtua Health activities are subject to federal and state antitrust laws. We do not share or discuss Virtua Health proprietary or confidential information, such as pricing, market information, strategic plans or contractual arrangements, with anyone outside of Virtua Health, and especially Virtua Health competitors. We do not divide, or attempt to divide, territories or customer lists with competitors.
  • We conduct our marketing efforts with truth, accuracy, fairness and responsibility to patients, the communities we serve, and the public at large. Marketing materials reflect only those services available, the level of licensure and accreditation, and comply with applicable laws and regulations dealing with truth in advertising, non-discrimination and confidentiality.
  • We do not discriminate against any patient or potential patient on the basis of race, religion, color, national origin, age, disability, sex, or sexual orientation.
  • We record financial transactions accurately and in accordance with generally accepted accounting principles and established financial procedures and internal controls.
  • Virtua Health’s business operations are overseen by a number of federal and state governmental agencies.  We do not make false or misleading statements to a government agency, healthcare program or payer source.  We cooperate with appropriate requests for information from government auditors, investigators or other officials. Examples include: U.S. Department of Health and Human Services, Office of Inspector General, Centers for Medicare and Medicaid Services (CMS), Office for Civil Rights (OCR), and the U.S. and New Jersey Departments of Labor. If a colleague is contacted by government agency official, the colleague should contact their manager immediately. If the manager is unavailable, colleague should contact the Office of General Counsel, Privacy Officer or Corporate Compliance Officer, as applicable to the government agency request.
  • We have responsibility to report suspicion of fraud, waste and abuse to ensure compliance with all applicable laws and regulations. 
  • When performing work under a federal or state government contract or subcontract, we strive to comply with all applicable laws, regulations and operational policies and procedures. If a colleague has a question or concern about the appropriate course of action in a government contracting scenario, the colleague should contact their manager, Human Resources or the Corporate Compliance Officer.

Billing and Coding

We are committed to properly coding and billing for the services we render in accordance with all applicable regulations. Any actual or perceived billing or coding irregularity should be reported to the Management chain of command, Human Resources, the Corporate Compliance Officer or the Compliance Hotline.


  • We bill only for those services and care which are actually provided, medically necessary, appropriately authorized, and properly documented.
  • We use billing codes that most accurately describe the services and care provided. Upcoding, downcoding, or improperly bundling charges to change reimbursement is strictly prohibited.
  • We prepare and maintain all billing records accurately, reliably, honestly, and in accordance with established accounting and billing policies and practices.
  • We will not tolerate the submission of any claim for payment or reimbursement that is false, fraudulent, fictitious, or is grossly misleading or inaccurate.
  • We regularly check for credit balances and promptly refund any overpayments.
  • We make reasonable attempts to collect all deductibles and co-payments.
  • We strictly prohibit the premature destruction or the alteration of any document in response to, or in anticipation of a request for those documents by any government agency or court.
  • We require that our colleagues are made aware of the laws and regulations pertaining to billing and coding. In this respect, we take responsibility for the training and education of our colleagues so that they may properly perform their duties.
  • We conduct internal and external audits to ensure compliance with coding and billing regulations.
  • We will submit annually a Medicare and Medicaid cost report to governmental intermediaries in order to review and settle payment differences.

Conflicts of Interest

We take all reasonable precautions to avoid conflicts, or the appearance of conflicts, between our private interests and the performance of our official duties and responsibilities. Any actual or perceived conflict of interest should be reported to the Management using the chain of command, Human Resources, the Compliance Officer or the Compliance Hotline.


  • We do not tolerate any business or financial opportunity, which might conflict, or appear to conflict, with the interests of Virtua Health or those we serve. A conflict exists whenever a trustee, officer, physician or colleague (or a related party such as a business or family member) may receive a financial benefit from any decision or action that he/she takes.
  • We will report to the above mentioned, any conflicts of interests concerning ourselves, family members or business interests when known. Family members include spouse, parents, grandparents, siblings, children, grandchildren, aunts, uncles, niece, nephew and first cousin, in-law, whether by birth, marriage or residence and other persons living in the same household.
  • We do not permit family members to be in a direct reporting relationship to each other. We review other employment situations involving family members, and reserve the right to transfer colleagues if a conflict exists.
  • We do not solicit or accept gifts, payments, fees, services, valued privileges or other favors where these would, or might appear to, improperly influence the performance of our official duties. Questions regarding the acceptance of an unsolicited gift, entertainment or other favor of nominal value (greater than $75) should be discussed with your manager, Human Resources, the Compliance Officer or the Compliance Hotline.
  • We do not use our position to secure a special discount or other favorable treatment (e.g., not available to all colleagues) from a person or outside organization which does or is seeking to do business with Virtua Health.
  • We do not use our position to influence personal decisions of our staff.
  • Virtua Health’s Board Members, all colleagues Director level and higher, physicians, physician assistants, nurse practitioners, other individuals with purchasing authority and/or influence over vendor or product selection disclose annually any direct or indirect business relationship or investment in Virtua Health. Disclosure also includes compensation, remuneration, and gifts, gratuities or favors that are of a material or substantial nature received by Virtua Health.

Property, Equipment and Other Assets

We protect all assets that are entrusted in our care. Any actual or perceived loss, theft or misuse of Virtua Health’s property or the assets of others should be reported to the Management chain of command, Human Resources, the Corporate Compliance Officer or the Compliance Hotline.


  • We personally are responsible and accountable to ensure, including the access and security of our systems and our facilities, the proper business use of all Virtua Health funds, property and equipment in general and, in particular, that is entrusted to our care. All users of the computer system acknowledge the proper use each time the computer is accessed.
  • We follow established internal control procedures when handling and recording Virtua Health’s funds, property and equipment. The responsibility for physical security of laptops and portable computing devices and information contained within resides with the individual to whom the device is allocated. Prior to leaving the employment of Virtua Health, individuals must return all Virtua Health owned property.
  • We do not copy or disclose any Virtua Health information or publications which are not intended for public distribution (i.e., policies & procedures, facility listings, organizational charts, colleague, patient and provider information, etc.) to unauthorized persons either within or outside of Virtua Health.
  • We strictly prohibit making unauthorized copies of any computer software licensed to Virtua Health, including downloads or executables from the Internet. Executable software must be validated, approved and installed by Information Services. Unmanaged installations can compromise the operating environment and also constitute a security risk, including the intentional or unintentional spreading of software viruses and other malicious software.
  • We will continue to protect Virtua Health equipment and data while working remotely.
  • We will report any Virtua Health lost or stolen equipment or any personally owned devices that maintain Virtua Health data to the IT Help Desk at the time of the loss.
  • We respect and protect the intellectual property rights of individuals and companies with which we do business. We do not make copies or use this property without advance written permission.
  • We understand that any research or product developed on Virtua Health’s time or equipment, whether intellectual or physical, is the property of Virtua Health.
  • We do not permit the use of Virtua Health funds, equipment and facilities to support a political party, candidate or holder of any government position. We limit our efforts to influence legislation to those activities, which are, in the opinion of our General Counsel, appropriate and in the best interests of Virtua Health and those we serve.
  • We have established appropriate Email, Internet and Password Control policies and procedures outlining proper use.
  • We will maintain records in accordance with regulatory and accrediting agency record retention requirements regarding the appropriate time periods for maintenance and location of records. We will not prematurely destroy records.
  • We require colleagues to accurately record their time as the basis of payment for hours worked. Time is recorded either on an electronic, telephonic or written basis, depending upon the location or needs of the department or entity. We will reimburse colleagues for business expenses incurred as provided for in Virtua Health’s Colleagues Business Expense Policy. We will pursue recovery for any overpaid and/or misappropriated funds.

Health and Safety

We are committed to maintaining a safe and healthy working environment which complies with all relevant laws and regulations. Any actual or perceived health or safety issue should be reported to the Safety Officer, the Management chain of command, Human Resources, the Corporate Compliance Officer or the Compliance Hotline.

  • We will comply with state and federal laws as it pertains to maintaining a safe working and service environment. We immediately report any unsafe acts or circumstances which may create an unsafe condition.
  • We handle and dispose of hazardous materials and waste, and regulated medical waste in accordance with all applicable laws and regulations.
  • We take all reasonable precautions to ensure our safety as well as the safety of patients, visitors and co-workers. This includes employing “standard precautions” at all times.
  • We strictly prohibit unauthorized weapons of any kind on Virtua Health premises.
  • We do not tolerate the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance on any Virtua Health premises. We, moreover, will not tolerate the use of alcohol in the workplace, on Virtua Health time, and/or on Virtua Health property, except at Virtua Health sponsored events. Suspected violators will be immediately relieved of their current duties and may be requested to undergo drug and alcohol testing.
  • We have zero tolerance for bad behavior and will take all necessary actions to maintain a safe and respectful environment for our staff, patients, and visitors.
  • We immediately report to a manager all accidents involving injury to a patient, colleague or visitor. After the appropriate person(s) is notified, incident reports are completed promptly.
  • We are responsible for being knowledgeable about and strictly following emergency, safety and security plans and procedures. Emergency preparedness and safety training is provided to all colleagues on a regular basis.
  • We provide education on equipment and supplies. We proactively upgrade equipment and supplies to maintain state-of-the-art patient care.
  • We have established procedures to eliminate access to Virtua Health facilities and other proprietary information when employment at Virtua Health is ended.

Human Resources

  • We seek to treat all applicants and colleagues fairly and equitably, and in accordance with all relevant governmental rules and regulations. Any actual or perceived mistreatment, discrimination, hostile activity, or legal violation which occurs in the workplace should be reported through the Management chain of command, Human Resources, the Corporate Compliance Officer or the Compliance Hotline.
  • We comply with all employment rules and regulations set forth by federal, state and local governments.
  • We maintain a work environment that respects the rights, dignity and diversity of our colleagues. Harassment or any other form of physical, verbal or mental abuse will not be tolerated.
  • We adhere to the Code of our professions and exercise reasonable judgment and care in the performance of our duties.
  • We treat colleagues in accordance with Virtua Health policies and/or collective bargaining agreements or employment agreements, if applicable. A Dispute Resolution/Grievance Process is available to all regular staff colleagues to deal with unresolved, employment-related concerns or issues.
  • We provide everyone with equal employment and advancement opportunities regardless of race, color, creed, religion, sex, pregnancy, national origin, age, disability , marital or domestic partnership or civil union status, affectional or sexual orientation, gender identity or expression, nationality, ancestry, atypical cellular or blood trait, genetic information, and liability for military service.
  • We never discuss information contained in another colleague’s personnel file unless we are authorized or legally required to do so.
  • We strive to understand and address issues which may cause colleagues to leave the organization. We may conduct exit interviews upon or after an colleague’s termination of service.
  • We maintain staff competencies by means of credential checks, education and training, and adherence to accreditation and licensing procedures.
  • We have a No Solicitation and Distribution policy to protect the rights of every colleague and to assure no interference with patient care.
  • We conduct criminal background checks and verify applicants’ highest level of education as well as participation in the Medicare and Medicaid programs on external applicants for employment.
  • We maintain a drug-free and tobacco free work environment.
  • We provide uninterrupted patient care while recognizing, respecting and resolving any conflicts resulting from a colleague’s personal cultural values, ethics or religious beliefs.
  • We will not conduct any games of chance without the appropriate licenses.