Departments & Programs,UW Hospital and Clinics,Compliance,Code of Conduct/Ethics

2014 Restatement of Commitment to Compliance

2014 Restatement of Commitment to Compliance - Departments & Programs, UW Hospital and Clinics, Compliance, Code of Conduct/Ethics


Approved by the UWHCA Board of Directors on February 25, 2016

As previously resolved by the Board on November 8, 2000, May 7, 2008 and February 5, 2014, the University of Wisconsin Hospitals and Clinics Authority (UWHC) has an ongoing commitment to conducting operations in a manner that promotes quality, efficiency, honesty, integrity, respect and compliance with applicable institutional policies and procedures, laws, regulations, and ethical principles.

In furtherance of this commitment, UWHC has in place the UWHC Compliance Program. The UWHC Compliance Program applies to all activities performed by UWHC "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 elements of the UWHC Compliance Program, including the UWHC Code of Conduct and UWHC Code of Ethics on Conflicts of Interest into their daily performance.

The UWHC Compliance Program includes:


Responsibility for administering the UWHC Compliance Program shall be assigned principally to the Compliance and Privacy Officer. The Compliance and Privacy Officer shall, without limitation:

  1. Assist in the creation, review, and revision of appropriate policies, procedures and other writings to meet the objectives of the UWHC Compliance Program.
  2. Maintain mechanisms to administer those policies, procedures and other writings and to evaluate their effectiveness.
  3. Identify and remediate potential compliance vulnerability.
  4. Ensure that Staff Members are educated about compliance issues and the UWHC Compliance Program.
  5. Maintain communication channels to receive reports regarding potential compliance violations.
  6. Ensure all reports regarding potential compliance violations are investigated and resolved.
  7. Monitor activities related to the UWHC Compliance Program and report to the Compliance Executive Oversight Committee, the Audit Committee of the Board and the full Board, as appropriate.
  8. Respond, in conjunction with the General Counsel, to external agency requests regarding compliance issues.


The UW Health Compliance Executive Oversight Committee (CEOC) shall be comprised of the members of the UW Health Operations Council, the UW Health Deputy Chief Legal Officer, and the UW Health Chief Executive Officer.