(Approved by the UWHCA Board of Directors - April, 2010 and reapproved February 2014)
Application of UW Hospital and Clinic’s Compliance Program
Our Compliance Program applies to all activities performed by UW Hospital and Clinics "Staff Members" including medical staff, GME trainees, students, vendors, contractors, employees (including full time, part time, per diem and temporary employees), agency and traveler staff, volunteers and other staff of UWHC. All Staff Members are obligated to incorporate the Code of Conduct into their daily performance.
We co-operate with and support our Code of Conduct by committing the necessary resources to ensure compliance:
- We educate ourselves so we know the laws and policies that apply to our operations
- We report suspected wrongdoing and cooperate with investigations
- We know internal corrective action will be taken if we do not follow laws and that unlawful activities must be reported
We know everyone is responsible for making sure we observe high standards of ethical behavior.
- Obey the Federal Health Care Program laws: We are committed to full compliance with the laws and regulations that apply to our operations, including all Federal Health Care Program (including Medicare and Medicaid) requirements and are committed to prepare and submit accurate claims consistent with such requirements.
- Neither give nor receive any kickbacks or prohibited gifts or favors: We follow UW Hospital and Clinics’ policies regarding giving or receiving gifts or discounts from people who supply us with goods and services.
- Obey antitrust laws: We do not share price or wage information with competitors.
- Obey laws relating to government and donor contacts: We conduct all political activities and contacts with government officials according to law and requirements of a non-profit, tax exempt entity. This means we do not permit political fund-raising or lobbying activities by individuals acting in their official roles representing the UW Hospital and Clinics.
- Avoid conflicts of interest: We understand we must avoid even the appearance of a conflict of interest by disclosing pertinent facts and exercising the best care and judgment for UW Hospital and Clinics, not for personal benefit or for the benefit of others at the expense of UW Hospital and Clinics.
- Use assets wisely:We understand the community has entrusted us with assets to be used and protected for our patients' health. We safeguard, invest and use these assets to achieve our mission. Proper use of UW Hospital and Clinics property and equipment is everyone's responsibility and we will not misappropriate UW Hospital and Clinics property or proprietary information. In addition, we avoid waste and try to find ways to cut costs without cutting quality. We are committed to obeying software and copyright licenses and laws.
- Carefully negotiate and bid contracts: We fairly and accurately bid and negotiate outside contracts at an arm's length and at fair market value.
- Work safely: Everyone is responsible for following standard precautions in caring for patients and for helping others to do so. We will maintain a drug-free workplace and understand this means we may be subject to drug testing for cause. We report any environmental or safety hazards or concerns promptly and follow posted warnings and regulations.
- Promote a positive work environment and culture of safety that supports teamwork and respect for others: We are courteous and respectful to all. Harassment, discrimination, intimidation and retaliation are disruptive and inappropriate, can negatively impact patient care and staff morale, and we will report it. This includes discrimination based on race, color, religion, gender, age, national origin, disability, sexual orientation, citizenship, veteran status, marital status, or arrest/conviction record. We actively support the embodiment of our expressed values and behavioral expectations in daily interactions.
- Maintain confidentiality of sensitive patient information:Our professions require that we gather a great deal of personal information about patients. Therefore, carefully avoid unwarranted invasion of patient privacy. The inappropriate release of sensitive patient information may be harmful to the patient and UW Hospital and Clinics. The inappropriate release of confidential patient or employee personnel information may be subject to civil and criminal prosecution as well as disciplinary action. You are expected to limit access to patient information and obtain appropriate release of information forms to the extent required by applicable laws.
- Report Suspected Wrongful Conduct as Soon as Possible:We report suspected wrongful conduct, including suspected violations of any Federal Health Care Program requirements or of our own policies and procedures, either by directly reporting such violations to the Director of Compliance or his/her designee or by calling the Compliance Help Line. The Compliance Help Line can be used anonymously to disclose to our Director of Compliance or some other person who is not in the disclosing individual's chain of command, any identified issues or questions associated with our policies, practices or procedures, including but not limited to those with respect to a Federal Health Care Program believed to be a potential violation of criminal, civil or administrative law. We will not tolerate any threat of or actual retribution or retaliation for making a good faith report of suspected wrongful conduct. All reports will be kept confidential, investigated if necessary, and all relevant information will be obtained from the disclosing individual and proper follow-up conducted. The Director of Compliance, or his or her designee, shall maintain a confidential disclosure log, which shall include a record and summary of each disclosure received, the state of the respective internal reviews, a summary of findings and any corrective action taken in response to the internal reviews. Your reporting of suspected wrongful conduct in good faith as soon as you become aware of it is important.
- Understand that UW Hospital and Clinics Takes Compliance Very Seriously: Individuals engaging in wrongful conduct, including the failure to comply with our policies and procedures and all Federal Health Care Program requirements or failure to report such non-compliance, may be subject to counseling or sanctions which may lead to suspension, termination, or other disciplinary action. UW Hospital and Clinics and individual Staff Members who engage in improper conduct also are subject to various significant criminal and civil sanctions for non-compliance, including imprisonment, large money penalties, and exclusion from Federal Health Care Programs and all other Federal procurement and non-procurement programs.