The mission of the Institutional Compliance Program is to form an accountable, integrated compliance organization which shall ensure that the health science center maintains compliance with all relevant federal and state regulations, including those governing clinical practice, professional fee reimbursement, responsible conduct of research, safety, labor, finance and education.
The purpose of the Institutional Compliance Program is to form a framework that will establish policies, implement procedures, and foster a work environment that imbues the workplace and all of its employees with the characteristics of a highly ethical institution that recognizes appropriate behavior and standards of conduct in all of its business activities.
The mission of the Institutional Compliance Program is managed by the Compliance Office, Staff, and Council members, individually and collectively, and is accomplished through adherence to the following seven elements of a successful compliance program, as articulated by the Office of the Inspector General of the US Department of Health and Human Services. The components of the mission are managed by:
- Publication of written standards, policies and procedures:
The Compliance Program is responsible for the development of compliance plans for the institution and for each of the eleven compliance divisions. The Compliance Program is also responsible for ensuring that written policies are in place for reporting and responding to compliance violations. The Compliance Office is responsible for ensuring that a Code of Ethics/Standards of Conduct brochure has been published, and that each employee reads and
acknowledges the Code each year.
- Appointment of appropriate oversight:
The Compliance Program has the responsibility of assuring that the Chancellor, on behalf of the Board of Regents, and working through the President of the Health Science Center, has appointed a senior Health Science Center administrator to function as the center’s Chief Compliance and Enterprise Risk Management Officer. The Chief Compliance and Enterprise Risk Management Officer reports directly, through the President, to the Board of Regents at each quarterly meeting. The Compliance Office will be staffed by individuals with appropriate training and competency in the field. The Compliance Program will be divided into divisions that appropriately reflect the
make-up of the institution, and are under the direction of the appropriate vice president or director.
- Effective Education and Training:
The Compliance Program mission is to facilitate each division’s responsibility for providing recurring compliance education and training. The Compliance Office will work with the Division of Human Resources to assure high quality Compliance Training for each new-hire during new employee orientation, and recurrent training for all institutional employees.
- Process to receive complaints/concerns:
The Compliance Program is responsible for establishing an anonymous telephone “hotline” called the Ethics Hotline, which offers employees an opportunity to report alleged compliance violations in a confidential manner. Additionally, the Compliance Program is responsible for receiving compliance complaints directly, through Division Directors, or through supervisors’ communications.
- Response and Disciplinary Mechanism:
The Compliance Council assures that there is a Report and Response Protocol in place which details the step-by-step process for conducting compliance violation report investigations, and subsequent sanctions or other actions as necessary. The essence of this process is designed to place the initial response in the appropriate compliance division, with the Compliance Office providing oversight and review, and participation in the process when appropriate. The Report and Response Protocol has been developed as an on-line process accessible to each Compliance Division office.
- Auditing and Monitoring Plan:
The Compliance Office assures that each division conducts timely audits of its compliance activities. To facilitate this process, each division conducts an annual risk assessment and risk reduction plan. The Compliance Office is responsible for monitoring all investigations and internal audits and records each external audit as they occur. The Compliance Office is responsible for monitoring the effectiveness of all policies and programs developed under the
Compliance Initiative. (Ethics Hotline, Enterprise Risk Management Process, Report and Response Protocol, etc.)
- Investigation/remediation of systemic problems:
It is the Compliance Program’s responsibility, through its Report and Response Protocol and its mandatory reporting system, to conduct incident and system investigations. The Compliance Council is responsible for conducting an annual review of its activities, and creates a Work Plan for action during the following year.