Trinity Health Organizational Integrity Program

Trinity Health was established on a foundation of faith-based principles: Respect, Social Justice, Compassion, Care of the Poor and Underserved, and Excellence. These principles and the Mission serve as a compass to guide our ongoing health care ministry.

Trinity Health is committed to acting with integrity and making decisions based on the highest standards of ethical behavior, including complying with all applicable laws and regulations. Under the direction of the Board of Directors, Trinity Health established the Organizational Integrity Program in 1997 in support of this commitment.

Why is it called an Organizational Integrity Program? Trinity Health is not only concerned with compliance with laws and regulations, but also with behaviors and actions consistent with our Mission and Values. Compliance asks the question, “Can we do this?” Integrity asks the question, “Should we do this?”

The Organizational Integrity Program provides our associates, medical staff, vendors and other business partners with resources to assist them in meeting applicable legal, ethical and professional responsibilities in Trinity Health. One key resource is Trinity Health’s Standards of Conduct (Also see addendum), which describes expected behaviors and conduct of all who work in Trinity Health and provides appropriate responses to common issues that are often encountered in the workplace. Other key components of program include education and training for associates, auditing and monitoring of Trinity Health business activities, and mechanisms that allow associates, medical staff, vendors and other business partners to raise issues and concerns so they may be dealt with timely and appropriately.

Education and Training

All newly hired Trinity Health associates are required to attend an orientation session on the Organizational Integrity Program and sign an agreement to abide by the Standards of Conduct. The information is reinforced through ongoing education and training, particularly for associates whose positions require additional knowledge and understanding of the laws and regulations that apply to their work responsibilities.

Reporting Issues and Concerns

Delivering health care services is an increasingly challenging task with complex and ever-changing rules and regulations that apply to our operations. As a result, there are times when the answer to a particular issue or situation may not be clear. Associates in Trinity Health are encouraged to seek answers to their questions or concerns through various resources and options made available to assist them. The Trinity Health Integrity Line is one of these resources. The Integrity Line is staffed 24 hours a day, 7 days a week by an outside company on behalf of Trinity Health. An online system is also available through the Integrity Line for those who prefer to submit their concerns in writing.

Corporate Responsibility and Governance

Trinity Health is committed to corporate responsibility and strong corporate governance practices. Trinity Health’s audited financial statements are posted on our Internet site to promote transparency and timely financial reporting to external parties. Even though non-profit organizations are not required to comply with corporate governance requirements in the Sarbanes-Oxley Act, Trinity Health has voluntarily adopted many provisions of Sarbanes-Oxley, including standards for independent audit committees and standards to maintain the independence of Trinity Health’s external audit firm.