UW Medicine Compliance
Reporting and Non-Retaliation – COMP.004
The purpose of this policy is to help prevent, detect and deter noncompliance by requiring all workforce members to report conduct, incidents or practices that may violate UW Medicine compliance policies or related state and federal laws and regulations, and prohibiting retaliation against individuals who make good faith reports.
Applicability: UW Medicine and UW Medicine Affiliated Covered Entity
Policy Title: Reporting and Non-Retaliation
Policy Number: COMP.004
Superseded Policies: PP-05 Complaints and Incidents Related to Privacy and Information Security
ALNW, 1102 Complaint and Concern Reporting
HMC, 135.14 Compliance Reporting and Hotline
NWH, Compliance Issue Reporting
NWH, Compliance Issue Resolution
UWMC, 15-4 Employee Participation and Reporting
UWNC, Compl008 Employee Participation and Reporting
UWNC, Compl005 Non-Retaliation
UWP, C-007 Reporting and Non-Retaliation
Date Established: October 11, 2017
Date Effective: November 4, 2019
Next Review Date: November 4, 2021
A. Duty to Report
All workforce members shall promptly report potential or suspected violations of UW Medicine compliance policies or other compliance concerns through the appropriate reporting channels.
B. Reporting Channels
Suspected noncompliance may be reported through a workforce member’s chain of command, to a designated entity representative, to the appropriate compliance department(s), or to the UW Medicine Compliance Hotline.
All levels of management encourage and welcome reporting through any of the channels outlined in the preceding paragraph.
UW Medicine Compliance
Compliance Anonymous Hotline: 206.616.5248 (local) or 866.964.7744 (toll free)
Main telephone line: 206.543.3098 (local) or 855.211.6193 (toll free)
Address: 850 Republican Street, Building C, Box 358049, Seattle, WA 98195-8049
Compliance concerns may also be reported to external agencies (see external resource links below).
C. Institutional Response to Reported Concerns
UW Medicine responds to compliance concerns in a timely manner, takes reasonable precautions to maintain the confidentiality and anonymity of the reporter upon request and follows established policies and procedures for compliance investigations (see COMP.005 Compliance Investigations).
Workforce members may self-report their own conduct when they suspect it violates compliance policies. Self-reporting does not exempt an individual from corrective actions but will be taken into consideration when corrective actions are required (see COMP.006 Corrective Actions).
UW Medicine prohibits retaliation against workforce members or other individuals for good faith reporting of compliance concerns. Individuals suspected to have engaged in or condoned retaliatory conduct, harassment or retribution are subject to timely investigation and, if substantiated, appropriate corrective action, up to and including, termination. Workforce members who witness or experience retaliatory conduct should report it to
UW Medicine Compliance.
- Washington State Auditor’s Office or other designated public official listed in UW Administrative Policy 47.1: http://www.washington.edu/admin/rules/policies/APS/47.01.html. Available only to Washington state employees for reporting suspected improper governmental actions.
- Office for Civil Rights (OCR): http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. Available to anyone for reporting suspected violations of the Privacy, Security or Breach Notification Rules by a covered entity or business associate.
- Office of the Inspector General (OIG):https://forms.oig.hhs.gov/hotlineoperations/nothhsemployeeen.aspx. Available to anyone for reporting certain healthcare-related complaints involving suspected fraud, waste or abuse.
- UW Medicine Compliance Glossary.
- NWH, Security Incident Reporting and Response.
- 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)).
- Relief from Retaliatory Actions, Federal False Claims Act, 31 U.S.C. §3730(h).
- Refraining from Intimidating or Retaliatory Acts, 45 C.F.R. § 164.530(g).