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1. What are the various
areas of University activity governed by federal laws and regulations?
The activities listed below are among those governed
by federal laws and regulations. The Web site references will give
you more information about these requirements, and how Washington
University complies with them.
Managers and supervisors are responsible for
knowing the federal requirements that pertain to their areas of
responsibility. They are responsible for determining the appropriate
level of knowledge that each community member needs in order to
do his/her work correctly, and for ensuring that community members
receive appropriate information and training.
• computer
use & security policies
(http://www.wustl.edu/policies/computing.html)
Washington University
strives for balance between its desire to promote and enhance the
free exchange of ideas and its need for security of critical
information and systems. Washington University's guidelines
call for respectful and responsible use of its computer networks
to protect the rights of individuals and to warn against actions
that may violate the law, such as the use of copyrighted,
deceptive, defamatory, or obscene materials. The guidelines
also state how critical security is to the University's
physical network, computer operating systems, and application
programs. Members of the University community are required
to follow these guidelines. Additional information can be
obtained from the Associate Vice Chancellor of
Technology & Information Services at (314) 935-8604,
aortstadt@wustl.edu; the Assistant
Vice Chancellor
for Network &
Telecommunication Services
at
(314) 935-7389,
jweller@wustl.edu; the
Asstistant
Vice Chancellor for Information Services &
Technology
at (314) 935-5320, dhirschbeck@wustl.edu;
or the Assistant Dean-Chief Information Officer for Medical
Computing Services at
(314) 747-4343,
michael.caputo@wustl.edu.
• confidentiality
(hr.wustl.edu)
(Go to HR link, then
Workplace Support: Policies & Procedures, Employee Handbook,
Standards of Conduct, Confidentiality)
Washington University maintains confidential
records for a variety of business needs. Records include detailed
information about patients receiving treatment, students, job applicants,
employees, finances, and future planning. Many records such as medical
records and student records must be kept confidential as a matter
of federal law.
Members of the University community are expected
to protect this information by safeguarding it when in use, storing
it properly when not in use, and discussing it only with those who
have a legitimate business need to know. Community members who are
uncertain about the use of University records and information should
contact their supervisors.
• conflict of interest policies
-
University
Policy
(LINK)
- Medical School Policy
(LINK)
- Clinical Research
Policy (LINK)
-
Clinical Care (LINK)
-
Physician
Relationships with Drug and Medical Equipment or Device Companies
(LINK)
- Pharmaceutical and Medical
Industry - Interaction with Industry Representatives (LINK)
-
Procurement Policy
(LINK)
The University and its community members are
responsible for guarding against conflicts of interest that might
compromise the integrity and objectivity of the University community.
The University as a whole, and the School of Medicine, both have
conflict of interest policies.
Community members should familiarize themselves
with these policies and disclose conflicts of interest as required
by the policies. Additional information may be obtained from the
following:
Research - Vice Chancellor for Research at (314) 362-7010.
Clinical care and physician
relationships with drug and medical equipment or device companies
Associate Vice Chancellor for Clinical Affairs at (314)
362-6249.
Procurement -
Assistant Vice Chancellor of Resource Management at (314) 935-5727.
• environmental health and safety
(ehs.wustl.edu)
Washington University must comply with government
rules and regulations that protect the environment and promote workplace
safety. The University must operate its facilities with all of the
necessary permits, approvals, and controls, especially with respect
to handling and disposal of hazardous and regulated
materials
and waste. Anyone working with or around these materials must be
familiar with the rules, regulations, and policies that apply to
them. Additional information may be obtained by contacting the Environmental
Health and Safety Office at (314) 362-6816.
• HIPAA (Health Insurance
Portability and Accountability Act)
(hipaa.wustl.edu)
Washington University is
committed to conducting business in compliance with national
standards for privacy, security, and electronic transactions of
Protected Health Information. Members of the University community
are expected to follow the University's HIPAA policies and
procedures. Additional information can be obtained from the HIPAA Privacy Office at (314) 747-4975
or
hipaa@msnotes.wustl.edu
or from the Information Security Office at (314)
362-0735.
• human resources-related matters
including equal employment, harassment, etc.
(hr.wustl.edu)
(Go to HR link, then
Workplace Support: Policies & Procedures, Employee Handbook)
Washington University is committed to a work
environment free of harassment and disruptive behavior, and to providing
an equal opportunity work environment where every member of the
University community is treated with fairness, dignity, and respect.
No one shall discriminate against any individual on the grounds
of race, color, religion, sex, age, disability, sexual
orientation, national origin,
or any other factor prohibited by law.
All members of the University community, especially
supervisors, must be familiar with laws, regulations, and policies
related to employment matters. Some of the relevant University policies
on employment matters include (1) the policy against harassment,
including sexual harassment; (2) the Washington University School
of Medicine Policy against Abusive Conduct; (3) the Policy on
Equal Opportunity and (4) the Federal False
Claims Act. Assistance is available from the Office of Human
Resources at (314) 935-7746 or (314) 362-4900 (medical
school).
EMPLOYEE HANDBOOK - DANFORTH
EMPLOYEE HANDBOOK - MEDICAL SCHOOL
FACULTY INFORMATION BOOK
• physician and professional medical
billing and medical record documentation
(opbc.wustl.edu)
The University
has a Policy on Compliance with Physician Billing Regulations and a
Physician Billing Compliance Office. All faculty and staff who have
any involvement in the documentation, coding, and/or billing of
professional medical services must be familiar with this policy and
its related regulations (including the Federal
False Claims Act). Compliance support is available from the
Physician Billing Compliance Office at (314)
747-7661.
PHYSICIAN BILLING COMPLIANCE MANUAL
False Claims Laws for Federal and State
Health Care Programs
• research integrity
(http://www.wustl.edu/policies/research.html)
In the course of their work, community members
engaged in research may encounter situations that raise questions
about the integrity of research practices, assemblage of data, and/or
publication of such data. The Research Integrity Policy addresses
the procedures for allegations of misconduct in research, which
is defined as fabrication, falsification, or plagiarism in proposing,
conducting, or reviewing research, or in reporting results. Misconduct
in research also includes violations of federal and institutional
rules and regulations governing the conduct of research involving
human subjects. Additional information may be obtained from the
Vice Chancellor for Research at (314) 362-7010.
• sponsored research grants and contracts
(http://research.wustl.edu/)
(http://spa.wustl.edu/)
Washington University receives grants and contracts
from federal and non-federal sources. Faculty and staff who are
involved in federally sponsored research must strictly follow federal
rules and regulations related to that work. Failure to observe government
rules and regulations can result in the loss of funds from grants
and contracts, and, in some instances, civil fines and criminal
penalties. With respect to grants and contracts from non-federal
sources, the University expects compliance with their requirements.
Compliance support is available from the Associate Vice Chancellor
for Research Administration at (314) 747-6253 or the Director of
Sponsored Projects Accounting at (314) 935-7089.
• University documents and record
retention
(University
Retention Policies) (http://aishelp.wustl.edu/
)
Every member of the University community is responsible,
within the scope of his/her own work, for the integrity and accuracy
of the University's documents and records. No one may falsify or
improperly alter information on any record or document. University
documents and records are retained in accordance with the law and
the University's record retention policies.
Additional assistance
is available from the University's Accounting Department, (314)
935-4562, and the Physician Billing Compliance Office, (314)
747-7661.
• workplace health and safety (http://ehs.wustl.edu/new/workplace.htm)
Washington University seeks a healthy
and safe environment for all members of the University community and
for visitors. Every community member is obligated to perform his/her
job in a safe manner and to follow all safety rules and procedures.
Community members should immediately report any hazardous conditions
or job-related illness or injury to their supervisors. Assistance
regarding workplace safety is available from the Environmental
Health and Safety Office at (314) 362-6816.
2. Who is subject to the
Code of Conduct?
The first paragraph of the
Statement
of General Principles answers this question. As examples, faculty
and staff are included; alumni volunteers and members of the Board
of Trustees and its committees are also included.
Students are not subject to this Code of Conduct
unless they are employed by the University or represent it. Several
schools have policies that pertain to student behavior. Deans' offices
are the best source of information about these policies. Students
may be covered by other University policies depending on their circumstances.
3. The University has been
in existence for nearly 150 years. Why do we need a Code of Conduct
now?
A Code of Conduct is a restatement of guidelines
we believe members of the University community are already following.
Many activities within the University have de facto codes
of conduct, even though they might not be called by this name; the
University's policies concerning research integrity and conflict
of interest are two examples.
The University Code of Conduct complements and
reinforces these existing statements. It does not replace them.
Many other organizations and universities have codes of conduct.
Finally, the federal government expects organizations that are subject
to its laws and regulations, and that receive federal funding, to
have written codes of conduct.
4. How will my daily
work be affected by the Code of Conduct?
Your daily work should not be changed. You should
already be following the principles in the Code of Conduct.
5. How will you know
whether all members of the University community have received a
copy of the Code of Conduct?
All current members of the University community
have received or will receive a copy of the Code of Conduct. New
faculty and staff will receive the Code of Conduct during their
orientation process. A summary of the Code of Conduct will be published
annually in the Washington University Record.
6. If I am involved in
purchasing decisions, may I accept gifts or favors from vendors
even if I am confident that these gifts or favors have no influence
on my purchasing decisions or recommendations?
In general, no. Even if you are confident that
your decisions or recommendations are not influenced by gifts or
favors from vendors, the appearance of influence can be as important
as its reality. Financial gifts or favors are never permitted. Gifts
or favors in kind may be accepted if their value is incidental.
Additional information regarding procurement issues may be obtained
from the Assistant Vice Chancellor of Resource Management at (314)
935-5727.
(Procurement
Conflict of Interest Policy)
7.
Research faculty members complete conflict of
interest disclosures annually. What is the requirement for other
faculty and staff employees?
Employees
should report potential or actual conflicts of interest to their
immediate supervisors. Supervisors decide whether a conflict of
interest exists. Refer to the University’s Conflict of Interest
policy at
www.wustl.edu/policies/conflict.html,
section D.2.b.
8. Will I get into
trouble if I report what I believe is a potential violation of the
Code of Conduct and then the incident is judged not to be a violation?
No, as long as you sincerely believe a violation
may have occurred. If you aren't sure whether a violation has occurred,
you can discuss your concerns with any of the individuals listed
in the "How to Report a Violation or Discuss a Concern"
section of the
Procedures
for Reporting Violations or Concerns.
9. Will I be penalized
if I witness a violation of the Code of Conduct and I report it
even though my supervisor tells me not to report it?
No. Any such directions by a supervisor are not
authorized by the University. The University encourages you to report
any violations of which you are aware. Washington University does
not tolerate retaliation and takes disciplinary action if retaliation
occurs.
10. I do not want my supervisor
to know that I'm reporting a potential Code of Conduct violation.
Can I do so anonymously?
Yes. A telephone contact has been established
in the University Compliance Office, (314)
362-4998. All incoming
calls are anonymous, unless the caller wishes to leave identifying
information to help facilitate follow-up. This telephone line does
not have caller ID or any indication of where the call is coming
from. In addition, other existing contacts for specific activities
are listed in the Code of Conduct. You may request anonymity when
calling them.
You may also click
on the button below to access a form
(PDF format-Adobe Reader software
required) that can be used to
report violations or concerns
11. If I believe a
violation has occurred but I don't report it, what could happen
to me?
It depends on the severity of the violation,
the certainty you have about the violation, and your position of
responsibility. A final decision would be based on the individual
facts and circumstances of each case. Obviously, the University
is not well served if violations are not brought to the attention
of those in a position to address them.
12. Who will investigate
reported potential violations?
The University Compliance Office, the Office
of the Executive Vice Chancellor & General Counsel, or other offices
will investigate potential violations to the extent they have the
expertise to do so. Others with specific expertise will become involved
as appropriate and necessary.
13. Who determines
the appropriate disciplinary action for violations?
The decision will be made in consultation with
the Office of the Executive Vice Chancellor & General Counsel, the
Office of Human Resources on the appropriate campus, the University
Compliance Office, and other individuals and offices as appropriate.
14. How much will
I have to be involved in the investigations if I report a potential
violation?
Your involvement depends on the complexity of
the issue reported. The more information you are able to provide,
the easier the matter will be to investigate. Once you report a
violation, your future involvement would likely be limited to follow-up
questions from the University Compliance Office or other offices.
15. Will I be informed
of the resolution of potential violations that I report?
All violation reports and the results of the
subsequent investigations will be held in confidence and will be
disclosed only on a need-to-know basis. In some instances the reporting
party may receive feedback following the completion of the investigation.
During the investigation, the University will protect the privacy
of both the persons who report violations as well as those individuals
against whom allegations are made.
Washington University in St Louis
University Compliance Office
4480 Clayton Avenue - Campus Box 8016
St Louis, MO 63110
Office Phone: (314) 362-4909
Fax: (314) 362-4954 (private)
Email:
universitycompliance@msnotes.wustl.edu
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