Office of Institutional Integrity and Awareness
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Institutional Compliance Program

The Office of Institutional Integrity and Awareness (OIIA) creates an integrity-based approach program emphasizing responsibility for ethical behavior and commitments to the UNT Health Code of Culture

The U.S. Department of Justice (DOJ) provides guidelines for an effective compliance program, highlighting several key elements necessary for organizations to promote ethical behavior, ensure compliance with laws, and prevent misconduct. These elements include:

Implementing policies and procedures

OIIA connects UNT Health’s mission to the everyday work of its campus by ensuring access to institutional policies. These policies aim to create a safe, respectful, and ethical environment for both learning and working. OIIA regularly reviews policies to ensure they align with state and federal laws, UNT System Regulations, Regents Rules, and UNT Health’s mission and vision. OIIA supports policy owners in developing policies and procedures, working alongside the UNT System Office of General Counsel to ensure legal compliance.

 

Designating a Compliance Officer and Compliance Committee

Desiree Ramirez, CCEP, CHC, is the Executive Vice President, Chief Integrity and Privacy Officer for UNT Health. Ms. Ramirez is responsible for overseeing UNT Health’s compliance program. To learn more about Ms. Ramirez and the OIIA team members, please visit Meet Our Team – Office of Institutional Integrity and Awareness

The designated compliance committees include:

  • Compliance Advisory Council: Assists Ms. Ramirez in coordinating UNT Health’s compliance activities and programs, ensuring they are effectively designed, implemented, enforced, and capable of preventing and detecting non-compliance.
  • International Compliance Coordination Committee: Monitors relevant international laws and regulations to identify and mitigate regulatory risks.
  • Institutional Policy Committee: Approves all UNT Health policies before the UNT Health’s President officially adopts them. Ms. Ramirez chairs this committee and oversees the assignment of policy numbers and publications.

 

Providing training and education

To uphold UNT Health’s commitment to the highest standards of ethics and compliance, OIIA ensures that all employees and students complete mandatory compliance training annually or upon hire. LearnHSC serves as the portal for this essential training, providing education that equips individuals with the knowledge and resources to foster a safe and inclusive environment.

Additionally, OIIA encourages employees and students to stay mindful of compliance and integrity topics by organizing activities that raise awareness and spotlight key resources within the department. One such initiative is Integrity and Awareness Week, which fosters campus-wide engagement. These efforts highlight the vital role integrity and compliance play in a values-driven organization, reinforcing that everyone within the institution contributes to safeguarding its resources and reputation.

 

Program Evaluation, Assessment, and Internal Monitoring/Auditing

OIIA is responsible for continuously evaluating the effectiveness of the UNT Health compliance program, as well as assessing the community’s awareness of key resources and programs and overall attitude toward integrity, including raising concerns with our office.

OIIA also monitors and assesses clinical compliance within the program. This includes auditing medical records, identifying risks, and detecting anomalies in healthcare documentation. Our audits review coding and billing practices to ensure documentation aligns with reported information, minimizes billing compliance risks, optimizes revenue, and prevents fraud, waste, and abuse in medical claims.

Additionally, OIIA conducts routine HIPAA inspections within the UNT Health Clinical Practice Group Clinic to evaluate security and privacy risks. We also audit HIPAA shred bins across UNT Health facilities. For more details about HIPAA shred bins and off-site storage of records, please refer to the Frequently Asked Questions: Record Management at UNT Health

Other ways OIIA ensures the compliance program’s effectiveness include issuing our Annual Integrity and Awareness Survey. OIIA has also established the Risk Management Process, a step-by-step framework designed to efficiently and cohesively manage risks, allowing the institution to proactively address risks and meet its objectives. More information about the Risk Management Process can be found at Risk Management – Office of Institutional Integrity and Awareness

 

Open Lines of Communication

At UNT Health, we prioritize our students, employees, patients, and community members. By fostering open communication, we aim to create a positive environment that nurtures a culture of integrity and ethical decision-making.

The Trust Line has been established to provide impartial support for any questions or concerns you may have, ensuring that your needs come first. You will receive clear, confidential guidance on any inquiry when you reach out to this safe, risk-free reporting line. While the Trust Line offers a secure way to address concerns, it is not intended to discourage UNT Health community members from reaching out to their direct supervisor, Student Affairs, or Human Resources.

More information about the UNT Health Trustline can be found at:

 

Consistent Enforcement of Standards, Accountability, and Discipline

Consequences are applied consistently, regardless of an individual’s affiliation at UNT Health, with enforcement aligned to the appropriate disciplinary action. OIIA promotes and upholds standards and discipline uniformly across UNT Health. OIIA establishes a clear response to detected non-compliant acts, with corrective action plans implemented as needed. Standards are consistently enforced through appropriate discipline to prevent similar misconduct. UNT Health community members are encouraged to act ethically and responsibly, and fair, consistent actions are taken when wrongdoing occurs.

Responding to and Preventing Non-compliant Behavior

Incidents of misconduct and violations of laws, regulations, and policies are addressed appropriately. Systemic issues are identified, root causes analyzed, and corrective actions implemented to prevent recurrence. Non-compliant behavior is met with appropriate responses to prevent further violations, and necessary improvements are made to reduce the risk of future non-compliance while promoting a culture realignment.

Every employee is responsible for reporting known or suspected policy violations, even if personally involved. Compliance concerns and policy violations can be reported to your supervisor, the Chief Integrity and Privacy Officer, or the UNT Health Trustline. An initial inquiry will be conducted by speaking with the relevant individuals involved. The findings from this inquiry will determine if a formal investigation is necessary. Supervisors and upper management will be notified, as appropriate, if an investigation is in progress. Those who report through the UNT Health Trustline can receive updates via the Trustline.

OIIA helps guide the UNT Health community by providing structures that outline expectations for behavior. To reduce non-compliant behavior, UNT Health has implemented measures such as the UNT Health Code of Culture and UNT Health Policy 1.102 Employee Ethics and Standards of Conduct, which offer guidance on ethical conduct to deter and prevent violations.

 

For more information about the compliance investigation process and non-retaliation, please visit OIIA Investigation Process

This page was last modified on March 19, 2025