Ethics & Governance Policies

Ethics & Governance Policy

Sri Lakshmi Multi Speciality Hospital is committed to maintaining the highest standards of ethics, integrity, transparency and professional conduct in every aspect of healthcare delivery. Ethical governance is fundamental to building patient trust, ensuring accountability and delivering safe, compassionate and high-quality healthcare services.

This Policy has been developed with reference to the National Medical Commission (Registered Medical Practitioner – Professional Conduct) Regulations, 2023, the Prevention of Corruption Act, 1988 (as amended by the Prevention of Corruption (Amendment) Act, 2018), the Consumer Protection Act, 2019, the Companies Act, 2013 (where applicable), the Digital Personal Data Protection Act, 2023, the Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable), the Tamil Nadu Clinical Establishments (Regulation) Act, 1997 (where applicable), applicable Central and State Government healthcare regulations and the governance principles promoted by the National Accreditation Board for Hospitals & Healthcare Providers (NABH).

The Hospital is committed to conducting all clinical, administrative and business activities honestly, responsibly and ethically while maintaining compliance with applicable laws, professional standards and accepted principles of good governance.

Purpose of this Policy

The purpose of this Policy is to establish a comprehensive framework for ethical behaviour, responsible governance, professional accountability and organisational integrity across Sri Lakshmi Multi Speciality Hospital.

This Policy promotes patient-centred healthcare, fair treatment, transparency, ethical decision-making, prevention of corruption, responsible reporting of concerns and continuous improvement of governance practices.

Scope of this Policy

This Policy applies to all directors, doctors, consultants, nurses, allied healthcare professionals, administrative personnel, contractual staff, trainees, interns, volunteers, vendors and any individual acting on behalf of Sri Lakshmi Multi Speciality Hospital.

It governs all clinical, administrative, financial, procurement, operational and organisational activities, including patient care, business relationships, vendor interactions, procurement processes, financial transactions, information management and regulatory compliance.

"Ethical behaviour is everyone's responsibility and is fundamental to maintaining public trust in healthcare."

Our Commitment to Ethical Governance

Sri Lakshmi Multi Speciality Hospital is committed to fostering an organisational culture founded on honesty, fairness, respect, compassion, professionalism and accountability. We believe that ethical governance is essential for protecting patient interests, maintaining public confidence and delivering high-quality healthcare.

Code of Ethics

Sri Lakshmi Multi Speciality Hospital is committed to maintaining the highest standards of ethical conduct in patient care, professional practice and organisational governance. Every employee, healthcare professional and representative of the Hospital shall perform their duties with honesty, integrity, compassion and accountability.

All decisions shall be guided by the best interests of the patient while respecting applicable laws, professional ethics and recognised standards of healthcare practice.

Ethical Conduct & Professional Behaviour

All Hospital personnel shall conduct themselves with professionalism, courtesy and fairness while interacting with patients, colleagues, visitors, regulatory authorities, suppliers and the public. Decisions shall be based upon clinical evidence, professional judgement and patient welfare rather than personal, financial or other improper interests.

The Hospital maintains a zero-tolerance approach towards harassment, discrimination, intimidation, abuse or any conduct that undermines patient rights, employee dignity or the reputation of the Hospital.

"Professional integrity requires honesty, respect, accountability and fairness in every interaction."

Anti-Bribery & Anti-Corruption Policy

Sri Lakshmi Multi Speciality Hospital strictly prohibits bribery, corruption, kickbacks, illegal commissions, facilitation payments and any improper financial or personal advantage in connection with Hospital operations. All clinical, administrative and business decisions shall be made honestly, transparently and in the best interests of patients and the Hospital.

Employees, consultants, contractors and business partners shall neither offer nor accept any unlawful payment, commission, gift or benefit intended to improperly influence professional judgement, procurement decisions, referrals or healthcare services.

Conflict of Interest

All Hospital personnel are expected to avoid situations in which personal, financial or external interests could improperly influence, or reasonably appear to influence, their professional responsibilities or decision-making. Actual, potential or perceived conflicts of interest shall be disclosed promptly through appropriate Hospital channels.

Hospital Management shall review disclosed conflicts and, where appropriate, implement suitable measures to manage, reduce or eliminate the conflict while protecting patient interests and organisational integrity.

Whistle-blower Protection Policy

Sri Lakshmi Multi Speciality Hospital encourages all employees, consultants, contractors and authorised personnel to report genuine concerns regarding unethical conduct, fraud, corruption, patient safety issues, regulatory non-compliance or other misconduct that may adversely affect patients, employees or the Hospital.

Reports made in good faith shall be treated with confidentiality to the extent reasonably practicable. Individuals who report concerns honestly and without malicious intent shall not be subjected to retaliation, discrimination, harassment or other adverse treatment for making such reports.

Reporting Ethical Concerns

Ethical concerns should be reported promptly through the Hospital's designated reporting channels, including supervisors, department heads, Hospital Administration, Human Resources or any authorised ethics or compliance representative, as applicable.

Reports should include sufficient factual information to enable an appropriate review. Individuals are encouraged to act honestly and responsibly when raising concerns. Knowingly false or malicious reports may themselves be subject to review under applicable Hospital policies.

"Early reporting of concerns supports patient safety, organisational integrity and continuous improvement."

Investigation of Reported Concerns

All reported concerns shall be reviewed in a fair, objective and confidential manner by the appropriate Hospital authority. Where necessary, a formal investigation may be conducted to determine the facts, evaluate supporting evidence and identify any breaches of applicable laws, Hospital policies or professional standards.

Investigations shall be conducted with due regard for confidentiality, procedural fairness and the rights of all individuals involved. Appropriate records of the review and findings shall be maintained in accordance with Hospital policies and applicable legal requirements.

Corrective & Disciplinary Actions

Where an investigation identifies non-compliance, unethical conduct or policy violations, the Hospital may implement appropriate corrective and preventive actions (CAPA). Measures shall be proportionate to the nature and seriousness of the findings and consistent with applicable laws, employment obligations and Hospital policies.

Corrective actions may include process improvements, additional training, enhanced supervision, policy revisions, counselling or disciplinary measures, where appropriate. The objective is to strengthen ethical governance, prevent recurrence and promote continuous organisational improvement.

Roles & Responsibilities of Hospital Staff

Every employee, consultant, healthcare professional, trainee, volunteer, contractual staff member and other authorised representative of Sri Lakshmi Multi Speciality Hospital shares responsibility for maintaining the highest standards of ethical conduct, professionalism and organisational integrity. Compliance with this Policy is mandatory for all personnel.

Hospital Responsibilities

Sri Lakshmi Multi Speciality Hospital is committed to establishing and maintaining an ethical, transparent and accountable governance framework that promotes integrity, regulatory compliance and patient-centred healthcare. The Hospital shall provide appropriate leadership, oversight, policies and resources to support ethical decision-making throughout the organisation.

Continuous Improvement & Ethical Culture

Sri Lakshmi Multi Speciality Hospital shall periodically review its governance practices, ethical standards, compliance programmes and organisational culture through internal reviews, staff feedback, audits, incident trends and quality improvement initiatives.

Lessons learned from investigations, compliance reviews and governance assessments shall be incorporated into policies, procedures, staff education and organisational practices to strengthen ethical leadership and reduce the likelihood of future misconduct.

Policy Review

This Ethics & Governance Policy shall be reviewed periodically by Hospital Management to ensure continued alignment with applicable Indian laws, recognised professional ethics, healthcare governance principles and evolving regulatory requirements.

"Ethical governance strengthens patient trust, protects organisational integrity and promotes excellence in healthcare."

Contact Information

Questions regarding this Ethics & Governance Policy, ethical concerns, whistle-blower reports or compliance matters may be directed to the Hospital Administration, Human Resources Department or the designated Compliance Officer, where appointed.

Regulatory & Standards Reference

This Ethics & Governance Policy has been developed with reference to applicable Indian laws, recognised professional regulations and healthcare governance standards that promote ethical conduct, accountability, transparency, anti-corruption measures and responsible organisational leadership.

"Sri Lakshmi Multi Speciality Hospital is committed to conducting all clinical, administrative and business activities with honesty, integrity, transparency and accountability, while protecting patient interests, complying with applicable Indian laws and fostering an ethical organisational culture in support of our ongoing journey towards future NABH accreditation."