UW Medicine Compliance
Compliance Policy Development – COMP.001
Compliance policies may be enterprise-wide, entity-specific, or have otherwise limited scope. This policy articulates the purpose of compliance policies and establishes the minimum requirements for their development, approval and maintenance throughout the enterprise.
This policy applies to the UW Medicine compliance department.
Applicability: UW Medicine and UW Medicine Affiliated Covered Entity
Policy Title: Compliance Policy Development
Policy Number: COMP.001
Superseded Policies: N/A
Date Established: October 11, 2017
Date Effective: November 4, 2019
Next Review Date: November 4, 2021
Compliance policies are designed by subject matter experts to reflect the legal, regulatory and organizational requirements that must be followed by workforce members.
- Policies that apply to all members and entities of UW Medicine enterprise, including the UW Medicine ACE for purposes of HIPAA compliance, are developed and managed through the office of the Chief Compliance Officer/Associate Vice President for Medical Affairs (CCO/AVPMA).
- Policies with less than enterprise-wide application are developed and managed by the compliance official with related scope and jurisdiction, and undergo separate approval and implementation processes.
- All compliance policy planning is coordinated through the UW Medicine senior leadership team to avoid duplication and/or conflicts.
All compliance policies:
- Are in writing, maintained in an easily accessible central location and include the following minimum information:
o Relevant regulation(s);
o Policy owner;
o Key dates (effective date, next date of review, etc.);
o Links to companion policies, guidance documents, related standards and implementation procedures; and
o Roles and responsibilities associated with the policy when appropriate.
- Have an official owner who has specific scope and jurisdiction authority for the subject matter.
- Are authored by appropriate subject matter experts in consultation with legal counsel.
- Undergo a comprehensive and documented review process that provides stakeholders and leaders with a rationale for the policy, the plan for its dissemination and required education and/or outreach.
- Are approved by an appropriate governance body, signed and dated by the UW Medicine Chief Executive Officer or official designee, and undergo a full review at least every three years (and additionally as needed to reflect regulatory changes or new risks).
All new policies and material changes to existing policies are disseminated in a timely manner to affected UW Medicine and UW Medicine ACE workforce members, posted on the UW Medicine Compliance website, and when necessary, reflected in the Notice of Privacy Practices.
Changes that do not impact the policy requirements or scope in any way (e.g. grammar/spelling corrections, form or department name updates) require only review and approval by the Chief Compliance Officer/Associate Vice President for Medical Affairs (CCO/AVPMA).
All official records, including superseded policies, are retained in accordance with applicable records retention policies.
- UW Medicine Compliance Glossary
- UWP, C-005 Compliance Policy Development and Implementation
- United States Sentencing Commission, Guidelines Manual, §8B2.1 (Nov. 2018).
- Compliance Program Guidance for Hospitals, 63 Fed. Reg. 8987 (February 23, 1998).
- Supplemental Compliance Program Guidance for Hospitals, 70 Fed. Reg. 4858
(January 31, 2005).
- Employee Education About False Claims Recovery, Deficit Reduction Act of 2005 § 6032 (codified at 42 U.S.C. § 1396a(a)(68)).
- Administrative Requirements, 45 C.F.R. §164.530.