Compliance Program Policies

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Compliance Education and Outreach Policy

This policy establishes the healthcare compliance training requirements for UW Medicine workforce members and any entity that performs covered functions on behalf of UW Medicine.

For purposes of this policy, healthcare compliance includes content areas that are within the scope of the UW Medicine Compliance Program. This policy does not address other compliance training requirements outside the scope of the UW Medicine Compliance Program.

Policy Outline:

I. Healthcare Compliance Training Requirements

1. Training Type/Frequency
2. Audience
3. Content Owner
4. Content

II. Triggers for Additional Compliance Education, Training and Outreach

1. Job Changes
2. Regulatory and Policy Changes/Trends
3. Audit Results and Investigations

III. Documentation Requirements

1. Document Type
2. Responsible Party

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Compliance Auditing and Monitoring Policy

This policy establishes baseline requirements for auditing and monitoring activities conducted in support of the UW Medicine Compliance Program, and applies to all UW Medicine compliance departments.

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Reporting and Non-Retaliation Policy

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.

Policy Outline:

I. Reporting

A. Duty to Report
B. Reporting Channels
C. Institutional Response to Reported Concerns
D. Self-Reporting

II. Non-Retaliation

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Compliance Investigations Policy

This policy establishes the framework for managing and responding to alleged, suspected or potential violations of UW Medicine compliance policies or related state and federal laws and regulations. It applies to all UW Medicine compliance departments and related designated institutional officials who participate in the investigative process.

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Corrective Action Policy

This policy obligates UW Medicine to address compliance violations with appropriate and timely corrective actions. It applies to all designated institutional officials in UW Medicine who have responsibility for enforcement, discipline and corrective actions. This includes leaders, managers, chairs, supervisors, disciplinary boards and councils, and constituent-specific officials (for example, residing in human resources, academic personnel, graduate medical education, student affairs, etc.).

For specific procedures related to corrective action for violations related to billing for professional services, please see UWP Compliance Corrective Action Standard Operating Procedure.

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Exclusion Screening Policy

This policy establishes the standards by which UW Medicine screens all workforce members and vendors for restrictions on their ability to participate in federal and state healthcare programs and contracts.

This policy applies to all UW Medicine departments and operational units that perform exclusion screening.

Policy Outline:

I. Initial Hiring, Credentialing, and Contracting 

II. Ongoing Screening

III. Notification Responsibilities

IV. Exclusions

V. Document Retention

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Governmental Investigations Policy

The purpose of this policy is to ensure enterprise-wide consistency in responding to government investigations and subpoenas involving healthcare compliance matters. It applies to all UW Medicine entities, departments and individual workforce members.

Policy Outline:

I. Responsibility for Implementation

II. Prohibited Actions

III. Workforce Member Rights

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Compliance Risk Assessment Policy

This policy requires UW Medicine to engage in comprehensive and on-going formal assessments which identify and mitigate compliance risks. It applies to UW Medicine compliance departments, executive and administrative leaders and operational departments.

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Policy PDF