Program Overview

Compliance Program Elements

The compliance offices at HMC and UWMC merged with a centralized UW Medicine Compliance.  UW Medicine Compliance supports compliance efforts for hospitals and clinics (including HMC, UWMC, UWPN, and ALNW) and provides centralized oversight of all UW Medicine compliance initiatives and systems.

UW Medicine Compliance, along with compliance offices at UWP, CUMG, and the School of Medicine develops and implements programs to prevent, detect and respond to noncompliance with applicable laws and regulations.

The UW Medicine Compliance program includes the following core elements:

• Commitment and support from executive leaders
• Institutional policies, standards and expectations
• Education and outreach efforts to ensure that workforce members understand their rights and responsibilities
• Monitoring and auditing activities to ensure the effectiveness of internal controls
• On-going assessment and proactive responses to emerging risks and regulatory developments
• Safe mechanisms for reporting compliance concerns, including hotlines that enable anonymous reporting
• Timely investigation of reported concerns and protection of complainant rights
• Appropriate sanctions and corrective actions to address noncompliance when it occurs
• Process improvement projects as needed to enhance compliance efforts
• On-going risk assessments, evaluations of program effectiveness, and annual reporting

UW Medicine Compliance Infrastructure and Reporting Relationships

System-wide oversight and coordination occurs through the Associate Vice President/Chief Compliance Officer (AVP-CCO) and is enhanced by activities of the UW Medicine Board Compliance Committee. The AVP-CCO reports directly to the CEO of UW Medicine, has a direct relationship with the UW Medicine Board Compliance Committee and the Office of the President of the University, and is a member of UW Medicine’s senior leadership team. The AVP/CCO is also the Chief Privacy Officer for UW Medicine.  Sue Clausen is the current AVP/CCO/CPO.

Under Sue’s leadership, compliance activity supporting HMC, UWMC, UWPN, and ALNW will be done in a centralized fashion, across the health care system.

• Lisa Westlund is the Compliance Officer for clinical care issues such as documentation, coding, billing, and audits.  She is also the contact for Stark and Anti-Kickback laws.
• Richard Meeks is the Director of Privacy, Identity Theft Prevention, and the Clinical Research Billing Audit program.
• Scott Desmond is the Director of Program Integrity, handling education and outreach as well as questions about ethics and conflicts of interest.

Senior executives, academic/clinical leaders and operational administrators at UW Medicine review compliance issues on a regular basis, identify solutions, minimize barriers, and provide personal support of compliance initiatives.

The UW Medicine Board Compliance Committee established in 2001 has a wide scope of advisory responsibilities including strategic planning, advocacy and support for compliance efforts, risk assessment and analysis of compliance issues. Additional committees within UW Medicine provide mechanisms for engaging administrative, clinical and operational leaders in compliance initiatives. Each practice plan and medical center has its own compliance committee. While the specific committee charges vary, all have some level of oversight and/or advisory responsibility.

Compliance Roles and Responsibilities

UW Medicine’s commitment to compliance is imbedded in the expectation that all members of the organization will meet the professional, ethical and regulatory standards associated with their individual roles.

• Faculty, staff, students and residents are responsible for understanding and adhering to relevant policies and procedures, participating in required training, fulfilling recordkeeping requirements, reporting compliance concerns, seeking clarification when questions arise, and responding in a timely manner to requests for information associated with internal audits or investigations.
• Persons in executive leadership positions are responsible for participating in the development and implementation of UW Medicine-wide systems.  They are entity champions supporting successful implementation and sustenance of compliance and related operational programs within their specific areas of oversight, and
• Persons in leadership or supervisory positions are expected to communicate compliance and operational expectations, ensure that appropriate training is taken, implement and enforce policies, and monitor compliance.
• Compliance professionals monitor developments in the regulatory environment, establish entity-specific policies and standards, work closely with operational departments to develop internal controls, receive and investigate allegations of noncompliance, develop and implement effective auditing programs, and provide compliance training.