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Vanderbilt University Compliance Program and Standards of Conduct

A Message from the Chancellor

Dear Faculty and Staff:

At Vanderbilt University, patients, students, parents, and society at large have
placed their faith and trust in the faculty and staff who compose this great
institution. In carrying forward our noble mission of educating, healing, and
advancing scientific research, it is vital that we hold a deep commitment to the
highest levels of ethical standards and lawful conduct.

The Vanderbilt University Compliance Program articulates specifically what
is expected of us, and reviewing the Standards of Conduct will ensure that you
have a thorough understanding of institutional standards of integrity and honesty,
as well as the laws, rules, and regulations specific to your profession. I
urge you to read the information in the Faculty Manual carefully and to
ingrain these important principles into your daily work. Through our individual
efforts to uphold these practices and obey the laws, we collectively help
Vanderbilt achieve its promise as an academic and health care leader.

Sincerely,
Nicholas S. Zeppos
Chancellor

Introduction

Vanderbilt University is committed to the highest standards of ethics, honesty, and integrity in pursuit of its mission of education, research, patient care, and public service. All members of the Board of Trust, the chancellor, general officers, members of the executive administration, administrative officers, members of the faculty and staff, and others representing Vanderbilt University are expected to adhere to these standards of conduct in the discharge of their duties. The Vanderbilt University Compliance Program demonstrates the university’s commitment to ethical conduct and compliance by setting forth guidelines for conduct designed to prevent and detect violations of law, uphold accreditation standards, comply with university policies, and encourage compliance by providing support, training, and educational resources. The Compliance Program is designed to assist the university in fulfilling its compliance responsibilities by creating an operational structure and process to monitor the university’s compliance efforts and is designed to work in conjunction with other university offices and compliance programs. For more details, the Vanderbilt Compliance Program Plan is available here.

Compliance Program

Vanderbilt University has two compliance committees which have direct oversight responsibility for the compliance activities of Vanderbilt and which assist the Vanderbilt community in fulfilling its legal compliance obligations. The Compliance and Corporate Integrity Committee (the “VUMC Compliance Committee”) provides oversight and support for Vanderbilt University Medical Center (“VUMC”) functions and all institution-wide research activities. The Administrative Compliance Committee (the “ACC”) provides oversight and support for University Central operations and institution-wide administrative activities. The committees oversee the following areas of compliance activity:

  1. Informing, training, and educating the Vanderbilt community about the Standards of Conduct and ethical obligations under those Standards;
  2. Monitoring compliance activities, including policies and procedures and training and education programs;
  3. Serving as a resource to Vanderbilt on matters of compliance and legal and regulatory changes, and assessing and identifying areas of risk;
  4. Maintaining a reporting helpline for compliance matters;
  5. Assisting operational units in developing corrective action plans;
  6. Reporting on compliance activities to the Audit Committee of the Board of Trust through the Compliance Officers.

Each compliance committee is supported and assisted in its oversight responsibilities by a compliance officer. Each compliance officer is responsible for the day-to-day operations of the compliance program as it relates to each compliance officer’s areas of responsibility. Their responsibilities include employee training on the Standards of Conduct, routine monitoring of compliance activities, assisting with corrective action plans, monitoring emerging issues in the field of compliance, maintaining and responding to calls made to their respective reporting helplines, coordinating interdepartmental compliance efforts, providing staff support for the committees’ operational activities, and submitting biannual reports to the Audit Committee on the activities of the Compliance Program.

Compliance and Corporate Integrity Committee
Vice Chancellor for Health Affairs

Associate Vice Chancellor for Health Affairs and VUMC Chief Compliance Officer

VUMC Assistant Vice Chancellor for Compliance and Corporate Integrity

Confidential Compliance Hotline
1-866-783-2287

Administrative Compliance Committee
Vice-Chancellor for Administration

Vice Chancellor for University Affairs and Athletics, General Counsel, and Secretary of the University

Manager of Compliance, University Compliance Office

Confidential Compliance Hotline
1-866-783-2287

Standards of Conduct

Consistent with the Faculty Manual and Human Resources policies, the Vanderbilt University Standards of Conduct provide the guiding standards of conduct for the university’s faculty, staff, and others representing the university and set forth the university’s commitment to good practices and following the law. The deans of the schools are responsible for assuring that the Standards of Conduct are observed by faculty. Staff and other university representatives are responsible for those employees under their supervision. All members of the university community are responsible for reading and understanding the Standards of Conduct. See http://www.vanderbilt.edu/compliance/html/standards.pdf.

Compliance with the Law

Vanderbilt University is committed to compliance with all applicable laws, rules, and regulations. It is the responsibility of each member of the university community, including staff, faculty, health care professionals with hospital privileges, agents, representatives, contractors, and vendors, to follow, in the course and scope of their work at Vanderbilt, all applicable laws, rules, regulations, and university policies, and to maintain an educational, health care, and business environment that is committed to integrity and ethical conduct.

Research and Health Care Services

Vanderbilt University is committed to compliance with applicable law in the conduct of research and health care services. In particular, Vanderbilt is committed to the protection of the health, safety, and welfare of human and animal research subjects and the conduct of research with scientific integrity. Vanderbilt has adopted policies and procedures designed to foster the responsible conduct of research, and it is essential that the conduct of research activities and the delivery of health care services be accurately documented as required by applicable laws, rules, and regulations. Federal regulations relating to effort reporting and appropriate expenditure of grant funds must also be followed. Additionally, members of the medical center community, including physicians, billing representatives, and independent contractors, must follow laws and regulations governing financial and billing transactions, and all medical center clinicians must follow the Medicare and Medicaid documentation requirements. Questions concerning Medicare and Medicaid billing rules should be directed to the VUMC Compliance Office at 343-2777. For assistance with budget development, research contract negotiation, and grant applications, contact the Office of Grants and Contracts Management at 322-2631.

False Claims Act and Whistleblower Protection

Vanderbilt University requires all faculty and staff to report all known or suspected violations of the Federal False Claims Act (“FFCA”) or the Tennessee False Claims Act (“TFCA”) (collectively referred to as “FCA”). A person violates the FCA by knowingly submitting, or causing another to submit, false claims for payment of government funds. Examples of violations of a FCA are (i) submission of a claim to Medicare for payment for services not rendered, or (ii) falsification of a time and effort report in connection with a claim for reimbursement from government grant. Vanderbilt University does not allow retaliation against persons reporting such suspected violations (sometimes referred to as “whistleblowers”) for making such reports in good faith.

Report any known or suspected violation of either the FFCA or the TFCA to the appropriate supervisor, department head or chair, the University Compliance Officer, the Medical Center Compliance Officer, or the 24-hour Confidential Help Line for the university at (615) 322-0133, or the Medical Center Confidential Help Line at (615) 343-0135. In making reports to either confidential help line, the caller may make a report anonymously. The compliance helplines have no call identification or number recognition capability.

Faculty and staff may also report known or suspected violations of the FFCA to the following Federal hotline, (800) 447-8477, or by email at HHSTips@oig.hhs.gov.

All persons making reports of compliance concerns are assured that such reports will be treated as confidential to the extent permitted by law. Such reports will be shared with others only on a bona fide need-to-know basis. Vanderbilt prohibits retaliation and will take no adverse action against persons who make such reports in good faith (“whistleblowers), even if the report turns out not to be correct. Any faculty or staff member who believes that he or she has been subjected to or affected by retaliatory conduct for reporting a suspected violation of an FCA or for refusing to engage in activity that would be a violation of an FCA should report such retaliation to the university compliance officer or medical center compliance officer.

Kickbacks

It is against university policy for any person acting on behalf of the university to accept or pay a kickback. When someone who can influence purchasing decisions made at the university takes money or anything of value from a vendor, it can be considered a kickback, which is illegal. No gifts or accommodations of any nature, including unrestricted grants, may be accepted by the university or individual members of the university community when to do so would place them in a prejudicial or compromising position, interfere in any way with the impartial discharge of their duties to the university, or reflect adversely on their integrity or that of the university.

Additionally, it is illegal for the medical center or anyone acting on behalf of the medical center to provide gifts or other remuneration in exchange for referrals of patients covered by Medicare, TennCare, Medicaid or other federal health care programs, such as CHAMPUS and the Railroad Retirement Board. It is also illegal to accept a kickback in return for purchasing, leasing, ordering, or recommending the purchase, lease, or ordering of any goods, facilities, services, or items reimbursable under the Medicare, TennCare, or Medicaid programs.

Antitrust Laws and Regulations

Vanderbilt University is committed to complying with state and federal antitrust (monopolies) laws and regulations. University policy and business practices prohibit setting charges in collusion with competitors, certain exclusive arrangements with vendors, and joint ventures that are in restraint of trade or which attempt to monopolize any part of interstate trade or commerce. The sharing of confidential information such as salaries or charges for services with competitors is also prohibited.

Conflicts of Interest and Commitment

Vanderbilt University is committed to following and enforcing its conflict of interest and commitment policies. All university faculty, staff, and representatives should avoid potential or perceived conflicts of interest and/or commitment. Any concerns about a proposed transaction that may involve inducements offered by a vendor or supplier or a business relationship with a company that is connected with you or a family member, should be discussed with the appropriate dean, supervisor, or compliance officer. Vanderbilt conflict of interest policies and commitment policies are found on the Vanderbilt Compliance Web site at www.vanderbilt.edu/compliance/, the Vanderbilt University Medical Center Compliance Web site at www.mc.vanderbilt.edu/compliance/, the Human Resource Services Web site at www.vanderbilt.edu/HRS, and in the hospital policy manual.

Environment

Vanderbilt University is committed to complying with all applicable environmental laws and to maintaining all necessary environmental permits and approvals. Environmental compliance includes the proper handling, storage, use, shipment, and disposal of all materials that are regulated under any applicable environmental law. If any employee has actual knowledge that a spill, release, or discharge of any material regulated pursuant to an applicable environmental law has occurred, such employee must immediately report such event to his or her immediate supervisor so that necessary action may be taken. Necessary action may include evacuating employees, reporting such event to a governmental authority if required pursuant to any environmental law, and containing and cleaning up any such spill, release, or discharge. Employees should also report any other violations of applicable environmental law of which they have actual knowledge that could endanger the health and safety of other individuals. Questions concerning environmental regulations should be directed to Vanderbilt Environmental Health and Safety at 322-2057.

Confidentiality

Vanderbilt University is committed to the appropriate protection of confidential information. Many faculty and staff have access to various types of sensitive, confidential, and proprietary information. Vanderbilt prohibits the unauthorized seeking, disclosing, or selling of such information, including confidential information contained in patient medical records, student educational records, and employment records. See VUMC Addendum below for more information about the confidentiality of patient information.

Controlled Substances

In accordance with the university’s Drug-Free Workplace policy, Vanderbilt and its medical center prohibit the unlawful manufacture, distribution, possession, or use of a controlled substance by any member of the university community in the workplace or while conducting university business off the university’s premises. Federal law may impose sentences of up to twenty years in prison and fines of up to $1,000,000 for violation of criminal drug laws. Additionally, if the medical center or any of its employees are convicted under federal or state law of unlawfully manufacturing, distributing, prescribing, or dispensing a controlled substance, the medical center can be excluded from participation in the Medicare, TennCare, and Medicaid programs. For more information, see the Vanderbilt Compliance Program Plan at http://www.vanderbilt.edu/compliance/plan.php.

Non-Discrimination

Vanderbilt University is committed to the principles of equal opportunity and affirmative action. Vanderbilt does not discriminate on the basis of race, color, religion, sex, national or ethnic origin, age, disability, sexual orientation, or military service in administration of its educational policies, programs or activities; its admission policies; scholarship and loan programs; athletic or other institution-administered programs; or employment. The Equal Opportunity, Affirmative Action, and Disability Services Department (EAD) has responsibility for monitoring Vanderbilt’s Affirmative Action Plan and assisting with the application and interpretation of laws that impose special obligations on Vanderbilt. The EAD also assists with compliance with the Americans with Disabilities Act and with providing accommodation to students, faculty, and staff.

The EAD receives complaints regarding unlawful discrimination within the university community and, where possible, assists in the resolution of those complaints. Any faculty or staff member who experiences harassment or inappropriate discrimination should immediately seek assistance through the EAD by calling 322-4705. Vanderbilt prohibits retaliation against persons who utilize the EAD in good faith to voice complaints of harassing or discriminatory conduct. Other employment concerns related to personnel issues or human resources, such as salary, promotion, or hiring, should initially be directed to Human Resource Services at 322-8330.

Response to Investigation

Vanderbilt University is committed to cooperating with government investigators as required by law. If an employee receives a subpoena, search warrant, or other similar document, before taking any action, the employee must immediately contact the Office of the General Counsel. The Office of the General Counsel is responsible for authorizing the release or copying of documents. If a government investigator, agent, or auditor comes to University Central or the Vanderbilt University Medical Center, a supervisor, the Office of the General Counsel, or the hospital administrator on-call should be contacted before an employee discusses any matters with such investigator, agent, or auditor.

Compliance Training

Vanderbilt University is committed to providing training and education to the university community about compliance with applicable laws, rules, and regulations. In addition to employee orientation, the VUMC Safety Fair, and the Hearts and Minds Medical Center Orientation, ongoing training and education is available on the university Web site with the Institutional Review Board, Office of Grants and Contracts Management, Research Support Services, and other relevant departments. Also, the compliance officers are always available to assist and coordinate specific education and training efforts.

Conclusion

Vanderbilt University is committed to following local, state, and federal laws, rules, and regulations. The compliance officers maintain help and reporting phone lines to enable faculty, staff, and other university representatives to report violations and to discuss any questions. To assist the university with its commitment to appropriate conduct, all faculty, staff, and representatives are encouraged to report violations of any law or policy to a supervisor, a department head or chair, or a compliance officer. It is the duty of all faculty, staff, and university representatives to report Vanderbilt job-related criminal conduct of which they have actual knowledge or Vanderbilt-job-related situations that endanger the health and safety of any individual. All persons making such reports are assured that such reports will be treated as confidential to the extent permitted by law. Such reports will be shared with others only on a bona fide need-to-know basis. Vanderbilt will take no adverse action against persons making such reports in good faith. Vanderbilt prohibits retaliation against persons who make such reports in good faith.

University Central faculty and staff wanting to make a report of a violation or a potential problem may contact the University Central Compliance Officer at 322-5162, or call the anonymous, confidential helpline at 322-1033. Members of the medical center community may contact the VUMC Compliance Office at 343-7266. Concerns can also be reported confidentially and anonymously on VUMC’s confidential helpline at 343-0135. For more information, see the Vanderbilt Compliance Program Plan at http://www.vanderbilt.edu/compliance/html/ComplianceProgramPlan.doc. In addition, relevant Human Resource Policies are available at http://hr.vanderbilt.edu/
policies/index.htm
.

Standards of Conduct Addendum: Medical Center Only

These additional Standards of Conduct apply exclusively to members of the Vanderbilt University Medical Center community, which includes medical center staff or faculty, and any person who provides services at the medical center, including health care professionals with hospital privileges.

Billing and Claims

Vanderbilt University is committed to charging, billing, documenting, and submitting claims for reimbursement for hospital and professional services in the manner required by applicable laws, rules, and regulations. All of our faculty/staff should know and carefully follow the applicable rules for submission of bills and claims for reimbursement on behalf of the medical center. If you know or suspect that a bill or claim for reimbursement is incorrect, you are required to report it immediately to your supervisor or to the medical center compliance officer.

Patient Referrals

Vanderbilt University is committed to the lawful referral of patients to services outside the medical center for the delivery of appropriate patient care. If a referring physician, or his or her immediate family member, has an ownership or investment interest in or a compensation arrangement with the entity to which a patient is referred, and payment for the referred services will be made from a federal or state health care program, such as Medicare, Medicaid, or TennCare, a federal law, commonly referred to as the “Stark Law,” may prohibit the referral. No medical center physician shall refer a patient for services in violation of the law. If a physician has questions about referrals, he/she should consult with the medical center compliance officer or the Office of the General Counsel.

Emergency Treatment for Patients and Women in Labor and Patient Transfers

Vanderbilt University is committed to following state and federal laws and regulations with respect to the evaluation, admission, and treatment of patients with emergency medical conditions and pregnant women who are in labor, regardless of a patient’s financial or insurance status. As the health care arm of the university, the medical center conducts its activities in furtherance of the university’s charitable mission in the areas of education, research, and patient care. Emergency services are available to all persons in need of those services without regard to their financial or insurance status. If any individual comes to the Emergency Department of the hospital for examination or treatment of a medical condition, then the medical center must provide the individual with an appropriate medical screening examination to determine if an emergency medical condition exists, and, if one does, it must stabilize the emergency medical condition within its capabilities. A woman in active labor is deemed to have an emergency medical condition. Additionally, the medical center must accept for transfer from another hospital an individual requiring specialized capabilities of the medical center if the medical center has the capacity and capability to treat the individual. The medical center’s commitment to patients is reflected in our willingness to help anyone in need and not be influenced by race, creed, ethnicity, or sex. To ensure that these factors do not affect staff and faculty decisions, all people will be given emergency treatment and be discharged and referred without discrimination. It is also important for medical center staff and faculty to keep all patients’ medical information confidential.

Discharge Planning and Ancillary Service Referrals

Vanderbilt University is committed to appropriate discharge planning and the lawful referral of patients for ancillary health care services. The medical center recognizes that the discharge of a patient to a residence or post-hospitalization provider is an important decision. In developing and implementing discharge plans, medical center faculty and staff shall act in the best interest of the patient, in the judgment of the health care provider. This includes the involvement and consent of the patient or patient’s legal representative.

Disciplinary Action

All medical center faculty, staff, and representatives, as well as those who hold professional staff privileges, must carry out their duties for the medical center as stated in these policies, and, as required by law, report violations of local, state, or federal laws, rules, or regulations to a supervisor or the Medical Center Compliance Officer. If any faculty, staff, or representative does not report violations, knowing that such a failure violates a clear legal obligation, the individual may be subject to disciplinary action and may be terminated from employment. Such disciplinary conduct must abide by all substantive and procedural protections applicable to discipline in the Faculty Manual or, for staff, in the Human Resource Services Staff Guidelines. Disciplinary action may apply to a supervisor who knowingly directs or approves a person’s improper actions, or is aware of those improper actions but does not act appropriately and within the supervisor’s scope of authority to correct them, or who, by knowingly violating a clear legal or professional duty, otherwise fails to exercise appropriate supervision.