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The Joint Commission
Code of Conduct

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TABLE OF CONTENTS

Letter from the President ………………………………………………………………………………….. 3

Purpose, Vision and Mission Statements ……………………………………………………………. 5

Enterprise Corporate Values ……………………………………………………………………………… 6

Introduction and Definitions …………………………………………………………………………….. 7

Principle 1: Legal Compliance ……………………………………………………………………………. 8

Principle 2: Business Ethics ………………………………………………………………………………. 10

Principle 3: Confidentiality ……………………………………………………………………………….. 12

Principle 4: Conflicts and Dualities of Interest …………………………………………………….. 16

Principle 5: Core Activity and Relationships ……………………………………………………….. 18

Principle 6: Protection of Assets ………………………………………………………………………… 20

Principle 7: Workplace Conduct and Employment Practices …………………………………. 22

Administration and Application ………………………………………………………………………… 25

Getting Help and Reporting ………………………………………………………………………………. 26

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A message from the President…

To Joint Commission Enterprise Personnel:

Life can be challenging, and it can test one’s character. Recently, the pandemic and resulting economic
disruption showcased companies and individuals failing the test and displaying bad behavior, taking
advantage of the situation to further scams, offering fraudulent treatments, and engaging in greedy behavior
by hoarding personal protective equipment (PPE) or accepting exceedingly large loans from the Small
Business Administration. On the other hand, there were prominent examples of stellar behavior which
are the ones we will remember and talk about. The individual heroes who fought daily battles on the front
lines and the leaders who took accountability, working hard to get the job done in a safe manner so the
organization could retain a reputation of integrity and resiliency. I am proud to say The Joint Commission is
one such organization, one that cares, and one that maintains a reputation of integrity and continually leads
by example for the future.

There are many reasons why we maintain our remarkable reputation. These include remaining true to
our mission, practicing our values and the ethical responsibilities outlined in our Code of Conduct. We are
releasing a refreshed Code of Conduct this year to make sure it is up to date, provides clarity, and is written in
a user-friendly language.

This means that each of us is called upon to:
• Conduct all our activities in a way that is truly compliant with our professional, legal, and ethical

responsibilities.
• Observe the principles and adopt the behaviors of a Safety Culture.

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“ The Code of Conduct sets forth the basic principles we hold dear
in conducting our business, and it
recognizes our responsibilities to
our peers, partners and the health
care community that we serve.
– Dr. Chassin ”

The Code of Conduct is sent to each employee annually to renew the commitment to the mission, values and
ethical principles and to practice it within The Joint Commission, and with our peers, partners and the health
care community that we serve. I think you will agree that one of our most valuable assets is our reputation,
and I thank you for doing your part.

The new Code of Conduct is better able to guide responsible decision-making with tools to promote
organization-wide integrity and to demonstrate that complying with our legal and ethical obligations is a
natural extension of what we do every day. The Code of Conduct is our map toward these goals; it orients and
directs us in our day-to-day work and in our dealings with others. Our work is not easy, but it is also both
professionally and personally rewarding. I thank you for the pride you take in your work and I encourage you
to be mindful of the Code of Conduct and of your role in keeping the Joint Commission’s reputation one that
others strive to emulate.

Sincerely,

Mark R. Chassin, MD, FACP, MPP, MPH
President and Chief Executive Officer
The Joint Commission

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Always strive to do the right thing. If you’re unsure what
the right thing is, use this Code of Conduct as

your guide to responsible decision making.

PURPOSE
This Code of Conduct has been adopted by the Board of Commissioners of The Joint Commission,

the Board of the Joint Commission Center for Transforming Healthcare and the Board of Directors of
Joint Commission Resources to provide standards to guide Joint Commission Personnel (as defined

on page 7) in conducting themselves in a manner which protects and promotes organization-wide
integrity and enhances The Joint Commission’s ability to achieve its declared mission.

VISION STATEMENT
All people always experience the safest, highest quality, best-value health care across all settings.

MISSION STATEMENTS
The Joint Commission

To continuously improve health care for the public, in collaboration with other stakeholders,
by eval uating health care organizations and inspiring them to excel in providing safe

and effective care of the highest quality and value.

Joint Commission Center for Transforming Healthcare
To transform health care into a high-reliability industry by developing highly effective,

durable solutions to health care’s most critical safety and quality problems
in collaboration with health care organizations, by disseminating the

solutions widely, and by facilitating their adoption.

Joint Commission Resources
To continuously improve the safety and quality of health care in the United States and in the

international community through the provision of education, publications,
consultation, and evaluation services.

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Enterprise Corporate Values

QUALITY
We believe that our customers are entitled to quality services and products provided in the most cost-effective manner

TEAMWORK
We believe that a productive work environment requires teamwork, active collaboration,

and clear and open communication within and across organizational units

RESPECT
We value the contributions of each individual, encourage development of individual capabilities,

emphasize the importance of individual well-being, and gain strength from the diversity of our staff

COURTESY
We affirm that courtesy is essential in all relationships

INTEGRITY
We pledge that honesty and ethical behavior will characterize

all of our transactions

EMPOWERMENT
We believe that each employee should have the authority and support necessary to contribute effectively

to continuous improvement in organization performance

RESPONSIVENESS
We seek to understand and be responsive to the needs of one another and the needs of those who use

our products and services

RECOGNITION
We believe that effective performance should be recognized

IMPROVEMENT
We seek to continually improve our performance

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GETTING STARTED

INTRODUCTION

Ethical situations vary across the organization and it might not always be
clear which path to take. This Code of Conduct contains principles which
articulate The Joint Commission’s broad policy goals and standards, to help
Joint Commission Personnel make good choices to enhance our integrity. This
Code of Conduct guides our commitment to a Safety Culture that promotes
openness, trust and respect to support the organization’s visions, mission, and
value statements. The Code of Conduct is distributed periodically to all Joint
Commission Personnel, and their behaviors and activities must be consistent with
this Code of Conduct, and as applicable, with the Joint Commission’s policies and
procedures, and the Joint Commission Employee Handbook.

As part of our performance management system, we set expectations in two areas: business objectives and
behavioral expectations. The behavioral expectations are aligned with our corporate values, RPI, and Safety
Culture. They are designed to drive outstanding performance. Both the Code and Enterprise Behaviors are
aligned through our Enterprise Corporate Values.

DEFINITIONS

THE JOINT COMMISSION
Refers to the corporate enterprise and each of its divisions and operating units including, but not limited to,
The Joint Commission’s wholly controlled not-for-profit affiliates, Joint Commission Resources, Inc. (JCR),
JCR’s international division, Joint Commission International (JCI), and the Joint Commission Center for
Transforming Healthcare (the Center) and any wholly owned foreign subsidiaries and affiliates as they may be
formed.

JOINT COMMISSION PERSONNEL
Includes the terms “officer,” “commissioner or director,” “employee,” designated “contractors, “ student
“interns”, “fellows” and “agents” and certain collaborators, alliances, or strategic partners

JOINT COMMISSION EMPLOYEE
Refers to officers and employees but not “commissioner or director, independent contractors or agents”

BUSINESS
Includes all operations of The Joint Commission

ACCREDITATION
When the term Accreditation is used, the term incorporates accreditation, certification, designation and any
other evaluation-type activities of The Joint Commission

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PRINCIPLES AND STANDARDS

PRINCIPLE 1. LEGAL COMPLIANCE
The Joint Commission shall strive to ensure that all activities by or on behalf
of the organization are in compliance with applicable laws and regulations.

Joint Commission Personnel are required to comply with all applicable laws and
regulations, regardless of whether specifically addressed in this Code of Conduct. The
following standards, although not exclusive or complete, provides guidance to all Joint
Commission Personnel to support their compliance with applicable laws and regulations.

STANDARD 1.1. ANTITRUST

Joint Commission Personnel must comply with all applicable
antitrust and similar laws that promote competition.
Examples of conduct prohibited by the antitrust laws include:

STANDARD 1.2. TAX EXEMPTION

As a tax-exempt, not-for-profit entity, The Joint Commission is obligated to act in
compliance with applicable tax laws, to engage in activities that further its charitable
purpose, and to ensure that its resources are used in a manner to further the public good
rather than the private or personal interests of any individual or groups of individuals.
Accordingly, The Joint Commission and all Joint Commission Personnel must: (1) avoid
compensation arrangements in excess of fair market value, (2) provide accurate reports
to appropriate taxing authorities, (3) file all tax and information returns in a manner
consistent with applicable laws and (4) avoid any impropriety including any appearance of
impropriety. (See Principle 4: Conflicts and Dualities of Interest.)

• Agreements to fix prices, rig bids, or other collusion
with competitors intended to reduce competition for
purchases of goods or services;

• Boycotts;
• Certain kinds of exclusive dealing;
• In certain circumstances, the tying of the sale of one

product or service to a requirement to purchase another
product or service; and

• Unfair trade practices that may include bribery,
misappropriation of trade secrets, deception,
intimidation, or similar unfair business activity.

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POLITICAL ACTIVIT Y/ LOBBYING

Unless authorized, Joint Commission Personnel must not engage in lobbying on behalf of
The Joint Commission. All political campaign activity on behalf of The Joint Commission is
prohibited because it jeopardizes the tax-exempt status of our organization.
Political Activity – Joint Commission Personnel must not contribute or agree to
contribute any money, property, or services to any political candidate, party, organization,
or committee as a representative of The Joint Commission. Any contribution of money,
time, or service to political organizations or campaigns must be done as an individual and
not as a representative of The Joint Commission.
Lobbying – The Joint Commission may participate in designated lobbying activities
including:
• Advocacy when consistent with our mission, and to analyze and take positions on issues

that impact The Joint Commission’s operations, its interests and/or the quality and
safety of care;

• Providing recommendations through written or oral testimony and statements
concerning legislation, regulations, or policy decisions being considered by
governmental agencies; and

• Commenting on existing federal or state law and administrative procedures.

The Joint Commission lobbying activities are coordinated through the Department of State
& External Relations or The Joint Commission’s Washington, D.C., office.

STANDARD 1.3 INTERNATIONAL BUSINESS PRACTICES

The Joint Commission’s policy is to comply with all laws applicable to the jurisdictions
in which it operates. Accordingly, The Joint Commission expects all Joint Commission
Personnel and its contracted third parties, including all agents and subcontractors, to
comply with those laws. Further, all Joint Commission Personnel, joint-venture partners, or
anyone else doing business with The Joint Commission is required to comply with The Joint
Commission’s International Ethical Business Practices Policy and all applicable laws.

I. Legal Compliance – Use of another’s copyrighted work normally
requires permissions. Contact Legal to discuss.

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STANDARD 1.4. PROTECTING THE ENVIRONMENT

The Joint Commission manages and operates its businesses in a manner that
respects its environment and conserves natural resources. All Joint Commission
Personnel should utilize resources appropriately and efficiently, recycle where
possible, dispose of waste in accordance with applicable laws and regulations,
and work collaboratively with the appropriate authorities to remedy any
environmental contamination for which The Joint Commission may be
responsible.

STANDARD 1.5 INTELLECTUAL PROPERT Y

The Joint Commission is committed to comply with the laws and regulations
that govern the rights to and protection of our own and other’s copyrights,
trademarks, patents, trade secrets, and other forms of intellectual property.
Joint Commission Personnel must not use other organization’s logos or
trademarks without appropriate authorizations.

PRINCIPLE 2. BUSINESS
ETHICS

In furtherance of The Joint Commission’s commitment to the highest
standards of business ethics and integrity, all Joint Commission Personnel
shall accurately and honestly represent The Joint Commission and shall
not engage in any activity or scheme intended to defraud anyone of money,
property or honest services.

The standards below provide guidance so that The Joint Commission’s business activities
reflect the high standards of business ethics and remain consistent with the corporate value
of integrity. Leadership will inspire others to be accountable to deliver results with integrity,
and Joint Commission Employees will foster ethical decision-making through teamwork
and by sharing information. Joint Commission Personnel’s conduct must be consistent with
Principle 2, whether or not specifically addressed by these standards.

II. Business Ethics
• You must treat all customers, fellow employees and contracted

third parties with respect, honesty, fairness and integrity.
• Never compromise integrity for a quick solution.

Q&A
Jennifer is campaigning
for a local candidate and
would like to bring in a
support statement for her
colleagues to sign.
Is this okay?

As a tax-exempt
organization, The Joint
Commission cannot
support political
candidates. Your activity
in this area must be
separate from The Joint
Commission and only be
done on personal time.

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STANDARD 2.1. ETHICS OF INFORMATION

(a) Honest Communication
The Joint Commission requires candor and honesty from

all Joint Commission Personnel while performing their
responsibilities and when communicating with each other,
the government, customers, and The Joint Commission
attorneys and auditors. Joint Commission Personnel must
not knowingly make false or misleading statements of any
kind, including through email or social media, about The
Joint Commission, its products and services, or competing
accreditation entities and their products and services. All
Joint Commission Employees applying for research grants
or performing research are responsible for maintaining high
ethical standards in any written or oral communications
regarding their research projects, as well as for following
appropriate research guidelines and Joint Commission policies.

(b) Use of Other’s Proprietary Information
Joint Commission Personnel must obtain appropriate authorizations prior to use of any

confidential or proprietary information, publication, computer program or software,
or product belonging to any other person or entity. All Joint Commission Personnel
must not improperly copy for their own use or for The Joint Commission’s use any
documents, presentations, or software in violation of applicable copyright, trademark
laws, or licensing agreements.

STANDARD 2.2. ETHICS OF ACCOUNTING INFORMATION

The principle of business ethics incorporates The Joint Commission values of integrity and
respect as a core elements of our corporate culture. This often involves doing what’s right
for the business, without regard to personal outcomes or ulterior motives.
(a) Internal Control
The Joint Commission has established control standards and procedures so that assets

are protected and used responsibly, and that financial records and reports are accurate
and reliable. All Joint Commission Personnel are responsible for maintaining and
complying with required internal controls.

(b) Financial Reporting
All financial reports, accounting records, research reports, expense accounts, time

sheets, and other documents must accurately and clearly represent the relevant facts
of the transaction’s true nature. Improper or fraudulent accounting, documentation,
or financial reporting is against Joint Commission policy and may be in violation of
applicable laws.

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STANDARD 2.3. FRAUD

PRINCIPLE 3. CONFIDENTIALITY
In accordance with applicable legal and ethical standards, Joint Commission
Personnel shall maintain the confidentiality of The Joint Commission’s
intellectual property, employee and financial information, and any confidential
proprietary or otherwise sensitive information received from or about health
care organizations, including protected health information.

The Joint Commission and Joint Commission Personnel may have access to a wide variety of
confidential, sensitive, and proprietary information, the inappropriate release of which may
be unlawful or could be harmful to staff or health care organization customers and clients. All
Joint Commission Personnel must actively protect and safeguard confidential, sensitive, and
proprietary information, as defined below and in Joint Commission policies, to prevent the
unauthorized disclosure of such information. Unless authorized, Joint Commission Personnel
are prohibited from releasing confidential, sensitive, or proprietary information even after their
relationships with The Joint Commission terminates.

STANDARD 3.1.

Organization-Specific Information
The Joint Commission commits to health care organizations that certain documents received
through the Accreditation processes will be kept confidential. Likewise, JCR and the Center
commit to their clients and participating organizations that confidential organizational
information obtained in connection with the performance of services will be treated as
confidential and will not be disclosed without the organization’s written authorization unless
covered under existing agreements or as required by legal process.

Q&A
Sue heard Joe say he’s
going to pad his expense
report to make it more
worth his while. What
should Sue do?

Call the Compliance
Officer at 630-792-5627 or
the Compliance Hotline at
1-800-750-4972.

Honest behavior is expected from all Joint Commission Personnel. Fraud is
prohibited, and includes, but is not limited to:
• A dishonest or fraudulent act;
• Embezzlement;
• Forgery or alteration of checks;
• Misappropriation of Joint Commission assets;
• Unauthorized handling or reporting of Joint Commission transactions;
• Falsification of records or financial statements for personal or other reasons;

and
• Unauthorized use of corporate card for personal purchases.

Any Joint Commission Personnel who suspect that fraudulent activity may
have occurred or are aware of any Code of Conduct violation must report their
concerns to an Officer, the General Counsel, or the Corporate Compliance
Officer.

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All Joint Commission Personnel are responsible for maintaining the confidentiality of
any organization-specific information in accordance with applicable laws, contractual
obligations, and Joint Commission policies. Joint Commission Personnel also have
an obligation to maintain the confidentiality of any outside organization’s proprietary
information acquired while providing services to that organization. When Joint
Commission Personnel obtain knowledge of a health care organization’s intellectual
property or confidential proprietary information, it must be treated with the
same degree of confidentiality that is given to Joint Commission’s confidential information.

III. Confidentiality – You must comply with all company
policies relating to the use of encryption. For example, to protect
confidential information all company laptops are encrypted,
and when transmitting files containing personally identifiable
information via email, the file should be encrypted.

STANDARD 3.2. PROTECTED HEALTH INFORMATION

All Joint Commission Personnel must maintain the confidentiality of protected health
information. This includes any access to patient data given to The Joint Commission
as an employer or in the course of providing business associate services to health care
organizations. Joint Commission Personnel must comply with applicable HIPAA laws and
regulations regarding the confidentiality of protected health information and complete any
required HIPAA privacy and security training.

STANDARD 3.3. PERSONNEL ACTIONS/DECISIONS

Salary, benefit, and other personnel information relating to Joint Commission Employees
must be treated as confidential. Personnel files, payroll information, disciplinary matters,
and similar information must be securely maintained to ensure confidentiality in accordance
with applicable laws. Joint Commission Personnel must exercise a high degree of care to
prevent the release or sharing of personnel information. In addition, personnel information
must only be released or shared with those who may need such information to fulfill their
job functions.

STANDARD 3.4. CERTAIN FINANCIAL INFORMATION

The Joint Commission believes in transparency of certain financial information.
Therefore, IRS Form 990 is posted on The Joint Commission’s website. Additionally, the
Accreditation fee schedule is posted on the accredited organization’s extranet site and is
available to potential customers. However, the following financial information must be
treated as confidential and limited to those persons with a business need-to-know:

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• Insurance claim information;
• Business rules;
• Internal audit reports;
• Survey contract information;
• Customer financial information;
• Vendor bids;
• Certain business contract information such as negotiated discounts;
• Tax analyses and assessments;
• Government approved contract rates, including calculations and methodology;
• Corporate credit card information;
• Credit card information submitted with expense reports for employees or guest travelers;

and
• JCR consulting and JCI Accreditation pricing information.

Q&A
Julie prefers to work from
her personal laptop and
sends her work materials
to her personal email so
she can access them from
her personal laptop. If she
deletes the emails right
away is this ok?

It is never permissible to
forward confidential work
information to a personal
email address. Julie
should use the Office365
web portal to access her
files and work on them
securely in the cloud.
Julie should contact the IT
Service Desk for assistance
if she does not know how
to access the web portal.

STANDARD 3.5. INFORMATION SECURIT Y

The Joint Commission is committed to providing appropriate information
security safeguards. Joint Commission Personnel are provided access to The
Joint Commission’s IT network when authorized for business purposes. Joint
Commission Personnel are responsible for ensuring that they adhere to all
administrative, physical, and technical safeguards, including but not
limited to:

(1) protecting their passwords;
(2) protecting their computing and storage devices (laptops, tablets, USB

devices, cloud storage, etc.);
(3) maintaining the security of sensitive data;
(4) only accessing information to which they are authorized;
(5) only installing authorized material on their PCs;
(6) reporting any security vulnerabilities or breaches immediately to the IT

Service Desk; and
(7) following IT Service Desk instructions when remediating a security risk.

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STANDARD 3.6. FIREWALL POLICIES

The Joint Commission is committed to maintaining the integrity and independence
of its accreditation process and the integrity of JCR consultative activities. To prevent
improper sharing of information, The Joint Commission’s Firewall Policy is designed to
ensure that no confidential organization-specific information is shared between The Joint
Commission’s Accreditation activities and JCR’s consultative activities. Joint Commission
Personnel are responsible for complying with the established Firewall Policy, procedures,
protocols, and guidelines. All violations of the policy must be reported to the Compliance
Department. Personnel are encouraged to raise concerns or to ask questions to clarify their
understanding of the Firewall Policy.

STANDARD 3.7 DATA PRIVACY

International, federal and state laws regulate the access, use, maintenance, transfer, and
destruction of personally identifiable information maintained by The Joint Commission.
Examples of personally identifiable information includes, but is not limited to: social
security numbers, names with demographic information, credit card information, account
numbers, dates of birth, or driver’s license numbers. To protect personally identifiable
information, all Joint Commission Personnel must:
• Be aware of any personal information to which they have access;
• Understand the legal and contractual limitations on the use of personal information;
• Collect, use, maintain, share, and disclose personnel information consistent with

applicable laws and Joint Commission policies;
• Respond appropriately to data subject requests and concerns;
• Securely store or transport personal information; and
• Report any unauthorized access, use, or disclosure.

STANDARD 3.8 TELEWORKER SECURIT Y

While teleworking or working remotely, individuals must
ensure the physical and technical security of their electronic
information. Employees should:
• Lock their screen when away from their device;
• Physically lock or secure their device when it is not in

their immediate possession;
• Power down their device when it is not in use; and
• Keep confidential data in encrypted space.

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Avoid:
• Leaving their device or materials unattended in an unsecured location;
• Allowing non-Joint Commission Personnel to use their device; and
• Using a public or unsecured internet connection, but if necessary, only access

Joint Commission systems through the Joint Commission VPN.

PRINCIPLE 4. CONFLICTS AND
DUALITIES OF INTEREST
Joint Commission Employees and Board members owe a duty of
undivided and unqualified loyalty to the organization. Persons
holding such positions may not use their positions to profit
personally or to assist others in profiting in any way at the expense
of the organization. Additional provisions regarding conflicts that
apply to Joint Commission Employees and Personnel are set forth in
the applicable conflicts policies.

Joint Commission Personnel must avoid actual impropriety and/or the
appearance of impropriety (improper, inappropriate, or unethical behavior)
that might arise from their activities or involvement with other persons or
entities that, if not disclosed, have the potential to adversely impact The Joint
Commission. Joint Commission Personnel must not make public statements with
regard to Joint Commission matters unless authorized. All potential or actual
conflicts or duality of interest must be disclosed. All Personnel are encouraged to
refer to the relevant Conflict of Interest Policy for more detail.

Definition:
Conflict of Interest – A conflict of interest or potential conflict of interest
occurs when a Joint Commission Employee, contractor or Board Member have
a financial interest individually or as it relates to a family member, which is or
may (a) impair the individual’s objectivity or (b) create an unfair competitive
advantage for any person or organization other than The Joint Commission.
Conflict of interest means more than individual bias. There must be a financial
interest that could directly affect the work or services of Joint Commission
Personnel to be considered a conflict.

Duality of Interest – A duality of interest occurs when a Joint Commission
Employee, contractor or Board member has a significant personal interest or a
competing fiduciary obligation which could affect the professional objectivity
or commitment to service, or compete with that individual’s duty to The Joint
Commission.

Q&A
Mike is traveling to Dubai
for Joint Commission
International and he
would like to work on his
budget on his laptop and
possibly make a work-
related phone call while
on the plane. Is this a
problem?

You must be careful not
to discuss or display Joint
Commission confidential
information in public
places, such as in planes,
taxis, trains, elevators
or at conferences and
trade shows. When it is
necessary to conduct a
telephone call in a public
place, be mindful of your
surroundings. Privacy
screens should be used
on computers to prevent
others from seeing your
work. Reconsider any use
of free public Wi-Fi in
airports as it is at high risk
of hacking.

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STANDARD 4.1. OUTSIDE FINANCIAL INTERESTS

While not all-inclusive, the following are types of activities by Joint Commission
Personnel, or a family member, which would create a conflict or duality of
interest:

• Accreditation-Related Consulting. Providing accreditation-related
consulting services outside the work performed for The Joint Commission.

• Ownership or Employment Interests. Ownership in, employment by, or
engagement in another business relationship with any outside concern which
does business with The Joint Commission. This does not apply to stock or
other investments held in a publicly held corporation, provided that the value
of the stock or other investments does not exceed 5% of the corporation’s
stock.

• Conduct of Outside Business.
• Using the Joint Commission name or information to achieve a personal

advantage when conducting any personal business with any Joint
Commission vendor, supplier, contractor, or agency, or any of their
officers or employees.

• Any Joint Commission Personnel, or a family member, representing
The Joint Commission in a transaction in which they have a substantial
financial interest.

• Involvement in the management or oversight of a business or charity,
whether or not competitive to The Joint Commission, which may divide
the loyalty of Joint Commission Personnel to The Joint Commission.

STANDARD 4.2. SERVICES FOR COMPETITORS/VENDORS

Unless approved by Senior Leadership, Joint Commission Employees must
not perform work or provide services outside of the normal course of their
employment with the Joint Commission for:
• any competitor of The Joint Commission; or
• any organization with which The Joint Commission does business; or
• any organization which seeks to do business with The Joint Commission.

Q&A

Q&A

Joan has been asked to
review the medication
reconciliation process of a
former employer. Can she
do that?

Since this is an area
covered by Joint
Commission standards
and national patient
safety goals, helping an
organization in any non-
employed capacity with
medication reconciliation
would be considered
“accreditation-related”
consulting and therefore
prohibited activity under
the conflict of interest
policy.

John needs to make some
extra money and wants
to get a part-time job as
an Uber driver. Is this a
problem?

As long as the extra job
does not create a conflict
under the Conflict of
Interest Policy, and the
organization with which he
works is disclosed on his
Conflict of Interest annual
statement, this would be
acceptable.

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STANDARD 4.3. PARTICIPATION ON BOARDS OF DIRECTORS/TRUSTEES

STANDARD 4.4. HONORARIA

Any honoraria provided to a Joint Commission Employee for a speaking
engagement or educational program that relates to the activities of The Joint
Commission and/or the individual’s position with The Joint Commission must be
turned over to The Joint Commission.

PRINCIPLE 5. CORE ACTIVITY
AND RELATIONSHIPS

Joint Commission transactions with
organizations seeking to obtain or retain Joint
Commission business vendors, contractors, and
other third parties shall be conducted free from
offers or solicitation of gifts and favors or other
improper inducements in exchange for influence
or assistance in a transaction.

The following standards are intended to guide Joint
Commission Personnel in determining the appropriate
actions or behaviors in the context of The Joint
Commission’s core activities and relationships. This policy
should be interpreted broadly to avoid even the appearance
of improper activity.

• Each Joint Commission Employee must obtain approval from
the responsible supervising officer prior to agreeing to serve as
a member of the Board of Directors/Trustees of any accredited
organization or an organization whose interests may conflict with
those of The Joint Commission. Thus, supervisory approval is
not necessary for organizations whose interest do not impact The
Joint Commission (e.g., civic, charitable, fraternal organizations).

• All fees and/or compensation (other than reimbursement for
expenses arising from Board participation) that are received for
Board services provided during work time shall be paid directly
to The Joint Commission.

• The Joint Commission retains the right to prohibit membership
on any Board of Directors/Trustees where such membership
might conflict with the best interests of The Joint Commission.

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V. Core Activity and Relationships – Gifts given internationally
must be given consistent with Joint Commission policies and
authorized by the JCR Office of the CEO.

STANDARD 5.1. GIFTS AND GRATUITIES

The Joint Commission needs to preserve and protect its reputation at all times
and avoid even the appearance of impropriety. Unless otherwise authorized,
Joint Commission Personnel should not accept gifts, favors, services, or other
things of value when making purchases or decisions, or acting on behalf of The
Joint Commission. Similarly, Joint Commission Personnel are prohibited from
offering or giving money, services, or other things of value with the expectation of
influencing the judgment or decision-making process of any purchaser, supplier,
customer, government official, or other person. Please refer to the Gift, Meals,
and Entertainment Standards Policy for more information.

STANDARD 5.2. CONTRACTING

Joint Commission Personnel may not utilize “insider’’ information from any
business activity conducted by or on behalf of The Joint Commission for their
own benefit. All business relations with contractors must be conducted at arm’s
length both in fact and in appearance and in compliance with Joint Commission
policies and procedures. Joint Commission Personnel must disclose personal
relationships and business activities with contractors that could be construed by
an impartial observer as improper.

Joint Commission Personnel have a responsibility to obtain clarification from management on
questionable practices that may arise. Non-governmental grant support or sponsorship must be
approved by the Corporate Sponsorship Committee and formalized in an approved written agreement.

STANDARD 5.3. BUSINESS INDUCEMENTS

Joint Commission Personnel must not seek to gain any advantage through improper payments, business
courtesies, or other inducements. Offering, giving, soliciting, or receiving any form of bribe or other
improper payment is prohibited. Customary commissions, rebates, discounts, and allowances are
acceptable business inducements provided that they are approved by Joint Commission management, or
the CFO or their designee, and that they do not constitute illegal or unethical payments.

Q&A
During the holidays,
Microsoft offered me
Chicago Cubs tickets
and gift card to a local
restaurant. Can I accept
them?

Unfortunately, the Gift,
Meals, and Entertainment
Standards Policy prohibits
accepting cash or cash
equivalents, such as a
gift card, or any kind of
entertainment from a
Joint Commission vendor.
You should politely thank
the vendor and let them
know about our gift policy.

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Any such payments must be reasonable in value, competitively justified,
properly documented, and made to the business entity to whom the original
agreement or invoice was made or issued. Such payments are not to be made
to individual employees or agents of business entities. In addition, Joint
Commission Personnel may provide gifts, entertainment, and meals of nominal
value to Joint Commission customers, current and prospective business
partners, and other persons when such activities have a legitimate business
purpose, are reasonable, comply with Joint Commission reimbursement
guidelines, and are consistent with all applicable laws.

STANDARD 5.4. RELATIONSHIPS WITH GOVERNMENT AGENCIES

Relationships with government agencies, officials, and employees must be
conducted with honesty and integrity and in compliance with all applicable
laws and regulations. Accordingly, Joint Commission Personnel are prohibited
from offering or giving gifts when procuring goods or services on The Joint
Commission’s behalf. It is Joint Commission policy to cooperate with all
reasonable requests concerning company operations from federal, state,
municipal, and foreign governmental agencies, such as the Government
Accountability Office, the Department of Health and Human Services, the
Office of Inspector General, various state agencies, and/or Ministries of
Health. However, prior to responding to nonroutine requests from government
agencies, Joint Commission Personnel should consult with senior management,
the Department of State & External Relations (for state agency requests), The
Joint Commission’s Washington, D.C., office (for federal agency requests), or
the Legal Department.

PRINCIPLE 6. PROTECTION OF
ASSETS
All Joint Commission Personnel shall strive to preserve and protect
The Joint Commission’s assets by making prudent and effective
use of Joint Commission resources and properly and accurately
reporting its financial condition.

The following standards are intended to guide Joint Commission Personnel
by providing The Joint Commission’s expectations with respect to activities or
behaviors which may impact The Joint Commission’s financial health, or which
reflect reasonable and appropriate use of the assets of a not-for-profit entity.

Q&A
Olivia gets asked to dinner
by a vendor who has
submitted a proposal in
response to a Request
for Proposal (RFP). She
wants to know if she can
go.

If Olivia is part of the
decision process to select
the vendor, then no gift
or acceptance of dinner is
appropriate. However, if
she is not part of a decision
process, she can accept a
meal from a vendor that is
business-related and falls
within Joint Commission
reimbursement guidelines.

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VI. Protection of Assets
• Corporate credit cards are to be used for approved

business purposes.
• Always protect Joint Commission property.
• Intellectual property can be many things such as

marketing strategies, business plans and other items.
If you are not certain, contact the Legal Department.

STANDARD 6.1. INTERNAL CONTROL

The Joint Commission has established control standards and procedures to
ensure that its assets are protected and properly used, and that financial records
and reports are accurate and reliable. All Joint Commission Personnel share
responsibility for maintaining and complying with required internal controls.

STANDARD 6.2. TRAVEL AND ENTERTAINMENT

Travel and entertainment expenses must be consistent with each Joint
Commission Personnel’s role and responsibility and the organization’s needs
and resources. Joint Commission Employees should not suffer financial loss or
experience financial gain as a result of business travel and entertainment. Joint
Commission Employees must exercise reasonable judgment in the use of Joint
Commission assets and spend the organization’s assets as carefully as they would
spend their own money. Joint Commission Personnel must also comply with
Joint Commission policies relating to travel and entertainment expenses.

STANDARD 6.3. USE OF CORPORATE ASSETS

All Joint Commission Personnel are expected to refrain from converting assets
of The Joint Commission to personal use. All property and business of The Joint
Commission must be conducted in a manner to further The Joint Commission’s
interests rather than the personal interest of any individual.

a. Joint Commission Equipment
Joint Commission portable devices, including tablets, smartphones, and laptops
must be safeguarded, from loss, theft or unauthorized use. Joint Commission
Personnel using these devices must comply with all Joint Commission policies.
Permission must be obtained before installing any software on Joint Commission
owned devices. Prior to engaging in any non-work activity on company
time or the use of The Joint Commission’s assets for personal or non-work
related purposes, Joint Commission Personnel must obtain approval from an
appropriate manager.

Q&A
I am bored sitting at the
airport. Can I load a game
onto my company laptop?

Games are not approved
to be loaded on company
laptops.

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b. Joint Commission Data
Data gathered for or provided to The Joint Commission may be confidential
and is considered a Joint Commission asset. Accordingly, Joint Commission
Personnel are prohibited from using or manipulating such data in a manner
which is inconsistent with Joint Commission policies or for non-Joint
Commission purposes.

STANDARD 6.4 PROPRIETARY INFORMATION

Ideas and intellectual property assets of The Joint Commission are important
to organizational success. Confidential information pertaining to The Joint
Commission’s competitive position, strategies to accomplish its mission, or
information relating to negotiations between The Joint Commission and
third parties must be protected and shared only with Joint Commission
Personnel having a need to know such information in order to perform their
job responsibilities. Joint Commission Personnel must exercise care to ensure
that The Joint Commission’s intellectual property rights, including patents,
trademarks, copyrights, and software are carefully maintained and managed to
preserve and protect their value.

PRINCIPLE 7. WORKPLACE
CONDUCT AND EMPLOYMENT
PRACTICES
The Joint Commission is committed to providing a work
environment that values diversity among its employees. All Human
Resources policies and activities are intended to create a respectful
workplace consistent with Joint Commission Safety Culture and
where every individual has the opportunity to reach their highest
potential. The Joint Commission gains strength from the diversity
of our staff, values the contributions of each employee, encourages
the development of individual capabilities, and emphasizes the
importance of individual well-being. The Joint Commission has a
strong commitment to cultural diversity.

The following standards provide guidance to ensure that The Joint Commission’s
Human Resources activities reflect high standards and remain consistent with the
corporate value of teamwork, courtesy, integrity and empowerment. Leadership
will inspire others to be open, fair and honest, and all staff will use teamwork and
deal with others in a respectful manner. Joint Commission Personnel’s conduct
not specifically addressed by these standards should be consistent with
Principle 7.

Q&A

Q&A

My spouse needs to use
my company laptop to
complete work he did not
get done in the office this
week. Is that ok?

Access to Joint
Commission equipment is
for authorized personnel.
Consider that by providing
access, you either have to
share your encryption key
(not allowed) or sign him
in, which gains him access
to anything on your laptop.
If confidential information
is contained on your
laptop, then that would be
considered a breach of
confidentiality.

Can I give information
regarding a Joint
Commission or JCR
customer to my uncle
who does health care
consulting?

Joint Commission and JCR
data can only be used for
Joint Commission
business unless specifically
authorized.

23

STANDARD 7.1. EQUAL EMPLOYMENT OPPORTUNIT Y

The Joint Commission believes that fair and equitable treatment of Joint Commission
Employees and all who deal with The Joint Commission is critical to fulfilling its mission,
vision, and values. To further this policy, Joint Commission employees will be recruited,
hired, trained, promoted, assigned, transferred, laid-off, recalled, and terminated based on
their own abilities in balance with corporate needs, achievements, experience, and conduct
without regard to race, color, religion, sex (including gender identity, sexual orientation,
and pregnancy), national origin, age, disability, genetic information, retaliation or any other
classification prohibited by applicable law.

VII. Workplace Conduct and Employment Practices
• Harassment or discrimination of any kind is prohibited.
• Our diverse and open inclusive work environment helps us better

serve our customers.

STANDARD 7.2. ETHICS OF THE WORKPLACE

a. Safety Culture
The Joint Commission supports and functions within a Safety Culture – that is, a work
environment that fosters mutual trust and individual accountability by embracing a
respectful exchange of ideas and other behaviors that lead to organizational learning;
continuous improvement; and processes, services, and products that are consistently
excellent. Enterprise behaviors reflect the three imperatives of trust, report, and improve.

b. Professional Conduct
Joint Commission Personnel are expected to use common
sense and good judgment, and demonstrate professionalism
in all of their employment-related dealings with customers,
vendors, and co-workers, in support of the organization’s
mission and vision. The Joint Commission reserves the right to
take disciplinary action with employees whose behaviors and
actions are unlawful, violate others’ rights, threaten the well-
being of others, or are serious violations of company policies
and work rules. It is against Joint Commission Safety Culture
for employees to exhibit unprofessional conduct of any kind,
including but not limited to disruptive, discourteous, intimidating, disrespectful or abusive
behavior, threats or physical assaults, to other Joint Commission Personnel or the personnel
of any entity having a relationship with The Joint Commission. The Joint Commission
reserves the right to impose appropriate disciplinary or contractual action for any behavior
it considers to be disruptive and/or inappropriate.

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c. Harassment
The Joint Commission is committed to a work environment in which all
individuals are treated with respect and dignity. Each Joint Commission
Employee has the right to work in a professional atmosphere that promotes equal
employment opportunities and prohibits discriminatory practices, including
harassment. Therefore, The Joint Commission expects that all interaction among
persons who work for or on behalf of The Joint Commission will be business-like
and free of bias, prejudice and harassment. No Joint Commission Personnel is
exempt from this policy.

Harassment is a form of unlawful discrimination that includes all types of
physical or verbal conduct which shows offensive behavior toward a person
because of that person’s race, color, religion, gender, national origin, age,
disability, sex (including gender identity, sexual orientation, and pregnancy), or
other legally protected characteristic. This physical or verbal conduct constitutes
harassment/discrimination if it is intended to or creates a hostile, intimidating,
or offensive working environment, unreasonably interferes with a person’s
work performance, or otherwise adversely impacts the terms, conditions, or
opportunities of a person’s employment.

All concerns regarding harassment of any kind are encouraged to be addressed
at the time of occurrence and shared with the Joint Commission Employee’s
manager or Human Resources. Staff are encouraged to speak up in the moment
and to make sure these incidents are raised so they can be addressed. The
procedure to report and address harassment is stated in the Harassment Policy.

STANDARD 7.3. SAFET Y

The Joint Commission is committed to providing a safe work environment for
all Joint Commission Personnel. As an employer, The Joint Commission adheres
to applicable laws, regulations, rules, and guidelines to ensure an environment
free from recognized hazards that might cause harm to Joint Commission
Personnel. Joint Commission Personnel are responsible for carrying out their
duties in a safe and efficient manner when working at or on behalf of The Joint
Commission. All Personnel must report any unsafe conditions immediately to
their manager, including any suspicious, or unauthorized person found on The
Joint Commission’s premises. Threats or acts of violence, abuse, or intimidation
are not tolerated. The possession of firearms or any weapons is prohibited on
company property. The Joint Commission is committed to a drug free workplace
and prohibits Joint Commission Employees from engaging in the unlawful
manufacture, distribution, dispensation, possession, sale, or use of controlled
substances at the workplace, or while conducting Joint Commission business off
the company’s premises.

Q&A
Sammie was in a team
meeting and she heard a
comment which sounded
offensive and harassing in
nature. Because it wasn’t
directed at her she didn’t
say anything. Was that
the right thing for her
to do?

It’s uncomfortable to hear
these comments and not be
sure what to do. It’s okay
to tell the co-worker in the
moment at the meeting
that the statement wasn’t
appropriate, if the team
member is comfortable
doing that. Alternatively,
Sammie should report it
to her manager or the HR
department so it can be
confidentially looked into
and resolved.

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ADMINISTRATION AND APPLICATION
The Joint Commission expects each person to whom this Code of Conduct applies to abide
by the principles and standards set forth herein and to conduct all Joint Commission
Accreditation activities, business, and affairs in a manner consistent with the general
statement of principles set forth in this Code of Conduct, in all Joint Commission Policies
and Procedures, and in The Joint Commission Employee Handbook.

Responsibilities:

Failure to comply with this Code of Conduct and its guidelines for behavior, or the other
policies and procedures referenced herein, may lead to disciplinary action. For alleged
violations, The Joint Commission will evaluate relevant facts and circumstances, including,
but not limited to, the extent of the violation of the Code of Conduct or other relevant
policies, the egregiousness of the behavior, the Joint Commission Personnel’s history with
the organization, and other factors which The Joint Commission deems relevant. Discipline
may, at The Joint Commission’s discretion, range from verbal counseling to termination of
employment or relationship. In the event that any Joint Commission Personnel are covered
by the terms of a collective bargaining agreement, discipline shall be in accordance with the
provisions of that agreement.

Note: This Code of Conduct or other policies referred herein should not be interpreted as
to provide any additional employment or contract rights to Joint Commission Personnel
or other persons. While The Joint Commission generally attempts to communicate policy
changes concurrent with or prior to the implementation of such changes, The Joint
Commission reserves the right to modify, amend or alter this Code of Conduct and its
related policies at any time.

Read, understand and comply with the Code of Conduct

Prevent compliance violations and protect the reputation
of the company

Report concern about potential violations of any laws,
regulations, the Code of Conduct or policies

Ensure personnel providing services or interacting with
The Joint Commission read, understand, and comply with
this code

Promote ethical conduct and ensure all employees are
familiar with the Code of Conduct

Create an open environment to support employees in
asking questions and making ethical decisions

X X X

X X X

X X X

X X

X

X

Responsibility
Contractor/
Partner

Employee Leadership

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GETTING HELP
When an ethical question arises, all Joint Commission Personnel are encouraged to make
decisions consistent with this Code of Conduct and applicable policies and to maintain the
integrity of The Joint Commission. The Joint Commission’s reputation rests on the strength
of each individual’s business conduct, so if the answer is still not clear, Joint Commission
Personnel should contact their supervisor, an Officer, the General Counsel, or the Corporate
Compliance Officer.

The Joint Commission will not tolerate any retaliation against
employees from good faith reporting of a compliance concern. This
includes, but is not limited to, protection from retaliation in the form
of an adverse employment action such as termination, compensation
actions, poor work assignments, or threats of physical harm.

If any requirements in this Code of Conduct directly conflicts with applicable law, the
applicable law shall govern.

REPORTING OF POTENTIAL VIOLATIONS
All Joint Commission Personnel are expected to report
potential Code of Conduct violations as follows:
• To their supervisor, who will report up as necessary;
• To HR at x5621, if it is an HR related issue;
• To the Security Officer through the IT Help Desk, if it

is a security breach matter;
• To the Corporate Compliance and Privacy Officer

at x5627 or through the “Report a Compliance
Concern” online form on jNet, for all other
compliance related matters;

• Call the HOTLINE at 1-800-750-4972 if anonymity
is desired.

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HIERARCHY OF JOINT COMMISSION
ETHICAL PRINCIPLES

The Joint Commission Mission, Vision and Values, Code of Conduct, Employee Manual and Policies and Procedures
Definitions and Relationships with each other.

MISSION/VISION/VALUES

High level statements of purpose of the organization, a definition of the way we look to the future
and the shared beliefs which define our culture.

THE JOINT COMMISSION CODE OF CONDUCT
A set of principles and standards to guide individual Joint Commission Personnel behavior to achieve our mission.

The values are incorporated into the Code of Conduct.

POLICIES AND PROCEDURES
Administrative and more detailed statements related to specific corporate or department operations

which require day to day operational guidance and controls.

EMPLOYEE HANDBOOK
Summarizes key HR policies with pertain to employees.

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Thank you for your commitment to operate ethically,
lead with honesty and integrity

and for your continued dedication to uphold
the standards and principles set forth

in our Code of Conduct.

12/20

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