UW Medicine Compliance

Program Overview

Compliance Program Document

The Role of UW Medicine Compliance

UW Medicine Compliance develop and maintain hospital and clinic compliance programs for
Harborview Medical Center (HMC),
Valley Medical Center (VMC),
UW Medical Center – Montlake (UWMC),
UW Medical Center – Northwest (UWMC),
UW Medicine Primary Care (Formerly UW Neighborhood Clinics), and
Airlift Northwest (ALNW) for the following areas:

  • Clinical billing and documentation
  • Privacy
  • Identity theft prevention

UW Medicine’s Compliance program is based on the following 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 collaborates with other designated university offices, including Internal Audit, Risk Management, Business Affairs, and Research to prevent, detect and respond to issues involving the following regulatory areas:

  • Research compliance
  • Ethics
  • Outside work
  • Use of state resources
  • Stark and AntiKickback
  • Conflicts of interest

UW Medicine Compliance also works closely with Children’s University Medical Group (CUMG), the UW School of Medicine, UW Medicine Information Security, UW Physicians (UWP), the Seattle Cancer Care Alliance (SCCA), and central University of Washington compliance offices to:

  • Prevent, detect and respond to compliance violations
  • Assess risks
  • Share best practices
  • Enforce system-wide policies
  • Engage in system-wide initiatives, including process improvements, education, outreach

Compliance Infrastructure and Reporting Relationships

System-wide oversight and coordination occurs through the Chief Compliance Officer, UW Medicine/Associate Vice President for Medical Affairs, UW (CCO/AVPMA).  The CCO/AVPMA 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 CCO/AVPMA is also the Chief Privacy Officer for UW Medicine. Beth DeLair is the current CCO/AVPMA.

Please see Contact Us for a list of UW Medicine Compliance contacts.

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.

Persons in Management 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.

The UW Medicine Board Compliance Committee 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.