Dear UVA Health team members, students, and friends:
A critical part of our duty at UVA Health is to protect the health and safety of our patients, guests, team members, and community in our hospitals and clinics. That's why, to ensure we can provide the best care possible, we hold ourselves to the highest standards.
The document that follows, our Compliance Code of Conduct, outlines what we mean by that. It describes not only who we are and what we stand for but - by providing all of us with a framework of expected conduct - it also reflects our shared values. In that way, all of us need to take the time to read and understand what it says.
This code serves as a guide for our Corporate Compliance and Privacy Program, which helps us follow applicable government rules and regulations and our own policies and procedures. As you'll learn, each of us must report suspected violations of the rules that apply to our operations, either through the normal chain of command or directly to our Chief Corporate Compliance and Privacy Officer. So please get to know the laws and regulations affecting your areas of responsibility and immediately act if you think a violation has occurred.
Corporate Compliance matters at UVA Health because our integrity matters. Our patients and community already hold us to a high standard; we should hold ourselves to an even higher one.
Thank you for your time and attention to this important effort.
K. Craig Kent, MD
Chief Executive Officer, UVA Health
Executive Vice President for Health Affairs, University of Virginia
Transforming Health and Inspiring Hope For All Virginians and Beyond
To be the nation's leading public academic health system and best place to work - while transforming patient care, research, education and engagement with the diverse communities we serve.
At UVA Health, we put the patient at the center of everything we do. We ASPIRE to create a culture of excellence, engagement and trust through our values:
- Equity, Diversity & Inclusion
Our Guiding Principles
- Putting the patient-first in everything we do
- Remaining unwavering in our commitment to excellence in all missions
- Strengthening the well-being of our workforce through, collaboration, inclusiveness and teamwork
- Making decisions in a transparent, proactive, nimble and data-driven way
- Eliminating duplication and unnecessary variation
- Maintaining financial discipline, rigor and accountability
- Deepening ties to the community
Legal and Regulatory Compliance
- Fully comply with the laws and regulations that apply to our business
- Support our Compliance Code of Conduct
- Do not provide or accept any gifts, favors, or kickbacks
- Maintain the privacy of health information
- Obey antitrust laws
- Avoid conflicts of interest
- Carefully negotiate and bid contracts
Promoting a Positive Environment for our Patients and Ourselves
- Provide compassionate, safe and efficient quality patient care
- Work safely
- Do not harass or discriminate
- Use assets wisely
- Do not contract with or employ ineligible persons
- Reporting suspected wrongful conduct as soon as possible
The UVA Health Compliance Code of Conduct
UVA Health ("UVAH") is committed to providing safe, high quality care to our patients and conducting business in an ethical and honest manner and within the bounds of the law. The Code of Conduct (the "Code") applies to every UVAH employee, physician, volunteer, contractor, vendor, governing board member as well as those with whom we conduct business, such as vendors, consultants and other third-parties.
The Code provides general guidelines that are detailed in UVAH compliance policies and procedures. It is not intended to cover every situation concerning a compliance matter, but shows UVAH's desire to follow applicable rules and regulations and provide quality services to our patients.
The Code serves several purposes:
- Informs those individuals employed by, or affiliated with, UVAH about the basic policies and standards of workplace conduct.
- Emphasizes that individuals employed by, or affiliated with, UVAH must follow applicable laws and regulations.
- Stresses UVAHâ€™s commitment to follow the highest standards of ethical, honest, and fair conduct.
You should be familiar with, and follow, the Code and all compliance policies and procedures. If any part of this Code is unclear to you, please contact the UVAH Compliance Office. If you think a law or policy is not being followed, you must report it. There are several ways for you to report a compliance matter, such as:
- Contacting your direct supervisor about your concern or problem.
- If you do not feel comfortable talking to your direct supervisor, you can voice your concern to the next supervisory level, or contact the UVAH Compliance Office at 434-924-2938.
- Those not employed by UVAH should contact the UVAH Compliance Office.
- You may also call the Compliance Helpline at 1-800-235-8700. Calls to the Compliance Help Line cannot be traced and callers do not have to identify themselves; however, if they so choose, they may do so in order to be of assistance in giving further information about the situation. If a caller chooses to identify himself or herself, his or her confidentiality will be protected to the extent permitted by law.
The failure to follow the Code could subject you to disciplinary action in accordance with UVAH policies, to include, but not limited to, warnings, termination from employment or other association with UVAH.
The UVAH Compliance Program
The UVAH compliance program (the "Compliance Program") was created and exists to ensure that UVAH follows all applicable laws and regulations that relate to its operations. The Compliance Program is administered under the direction of the Chief Compliance Officer (the "CCO"), who oversees compliance throughout UVAH and its affiliates. The CCO ensures that any reported compliance problems are investigated and resolved. The CCO acts under the general direction of the Chief Executive Officer of UVA Medical Center, the EVP of UVAH, the UVAH Compliance Steering Committee, and the UVA Board of Visitors.
The Compliance Office monitors UVAH's business practices to ensure compliance with applicable laws and regulations. The Compliance Office is responsible for ensuring that reported compliance issues are promptly evaluated and resolved, and is also responsible for providing compliance education.
All of our officers, managers, administrators, and employees are expected to comply with our policies and procedures and with all Federal Health Care program requirements and other applicable laws.
We cooperate with and support our Compliance Code of Conduct by committing the necessary resources to ensure compliance.
- We educate ourselves so we know the laws and policies that apply to our performance.
- We report suspected wrongdoing and cooperate with investigations.
- We know internal corrective action will be taken if we do not follow laws and that unlawful activities must be reported.
- We know everyone is responsible for making sure we observe high standards of ethical behavior.
Maintain the privacy of health information
Our professions require that we gather a great deal of personal information about patients. Consistent with HIPAA and other applicable privacy laws, we carefully avoid unwarranted invasion of patient privacy by using or disclosing health information only as necessary to perform our respective job duties. We do not access, use, or disclose health information for any other purpose, including accessing health information out of curiosity. The inappropriate use or disclosure of patient information may be harmful to the patient and the University. The inappropriate use or disclosure of patient or employee personnel information may be subject to civil and criminal prosecution as well as disciplinary action.
We have a responsibility to use our mobile devices and applications in accordance with the UVAH social media policy. This means we do not use our personal devices to take pictures of patients or patient information. We never post patient information or photographs to a website, social media page, or public forumâ€”even if the patient is not identifiable. We also never speak on behalf of UVAH on social media unless specifically authorized.
Obey antitrust laws
As employees or agents of UVAH, we do not share price or wage information with competitors.
Do not provide or accept any gifts, favors, or kickbacks
We follow UVAH policies that prohibit providing or receiving gifts, favors, promotional materials, or kickbacks to or from physicians or other health care providers or vendors who supply us with goods and services. We do not offer, solicit, or accept any gifts or gratuities that may influence or appear to influence our objectivity in performing our duties at UVAH.
Avoid conflicts of interest
As employees we understand we must avoid even the appearance of a conflict of interest by disclosing pertinent facts and exercising the best care and judgment for UVA, not for personal benefit or for the benefit of others at UVA's expense.
We avoid any situation in which our participation is, or may appear to be, in conflict with the Mission, Vision, and Values of UVAH. We avoid any position or financial interest in any outside organization when such a relationship could improperly influence our professional objectivity or the performance of our duties on behalf of UVAH. Should a potential conflict of interest arise, we immediately disclose the situation to our immediate supervisor, UVAH leadership, and/or the UVAH Compliance Office.
In our business relationships with third-party consultants, service providers, suppliers, vendors, and other contractors, we base all decisions on quality of services and products, competitive pricing, and organizational policy - not on personal relationships or personal benefit.
Carefully negotiate and bid contracts
We fairly and accurately bid and negotiate outside contracts at an arm's length and at fair market value.
Obey laws relating to government and donor contacts
We conduct all political activities and contacts with government officials according to law and requirements of a non-profit, tax exempt entity. This means we do not permit political fund-raising or lobbying activities by individuals acting in their official roles representing UVAH.
UVAH keeps medical and billing records safely and securely for the time period required by law or policy. We are responsible for accurately documenting all clinical activity and pertinent information in the electronic legal medical record, maintaining all paper and electronic data, including medical records and financial reports, in accordance with applicable Federal and Virginia laws, regulations, and policies. We ensure that only authorized individuals have access to medical and billing records. Medical and billing records may not be removed or destroyed except under a court order, or as otherwise required by law or pursuant to UVAH's policies. We do not alter or falsify any record, contract or other document.
Coding and Billing
UVAH strives to ensure that its coding and billing practices comply with all laws governing Federal and Virginia funded healthcare programs, and the requirements of third-party payors. We bill only for services that we actually provide and that are medically necessary. Medical records must be completed according to regulatory requirements and guidelines. Billing and coding inquiries and questions will be dealt with promptly. Inaccuracies in billing and coding will be fixed in a timely manner. Refunds will be made as required by applicable laws, policies and third-party payor contracts.
We fully comply with the law and cooperate with any appropriate request by a government agency for information. Any inquiry, civil investigative demand, subpoena, or request by another agency regarding UVAH should be immediately reported to the UVAH Compliance Office or UVAH administration. Such notification will ensure that the appropriate individuals, including University General Counsel, are promptly made aware of the request and can respond, and that all patient privacy rights are maintained.
Quality of care and patient safety
We will provide our patients with high quality care, delivered in a safe, efficient, and compassionate way.
Everyone is responsible for following standard precautions in caring for patients and for helping others to do so. We will maintain a drug-free workplace and understand this means we may be subject to drug testing for cause. We report any environmental or safety hazards or concerns promptly and follow posted warnings and regulations.
Do not harass or discriminate
We are courteous and respectful to all. Harassment or discrimination of any kind is totally unacceptable and we will report it. This includes discrimination based on race, color, religion, gender identity, age, national origin, disability, sexual orientation, citizenship or veteran status.
Use assets wisely
We understand the community has entrusted us with assets to be used and protected for our patients' health. We safeguard, invest and use these assets to achieve our mission. Proper use of UVAH property and equipment is everyone's responsibility, and we will not misappropriate UVAH property or proprietary information. In addition, we avoid waste and try to find ways to cut costs without cutting quality. We are committed to obeying patent and copyright licenses and laws.
Do not contract with or employ ineligible persons
We do not contract with or employ individuals or entities who have been excluded from, or who are ineligible to participate in Federal Health Care Programs. We also do not contract with or employ individuals or entities that have been suspended or debarred from Federal government contracting.
Reporting suspected wrongful conduct as soon as possible
We report suspected wrongful conduct, including suspected violations of any Federal Health Care Program requirements or of our own policies and procedures, either by directly reporting such violations to the CCO or his/her designee or by calling the Compliance Help Line. The Compliance Help Line can be used anonymously to disclose any issues or questions associated with our policies, practices or procedures, including but not limited to those believed to be a potential violation of the Federal Health Care Program or criminal, civil or administrative law. We will not tolerate any threat of or actual retribution or retaliation for making a good faith report of suspected wrongful conduct.
All reports will be kept confidential, investigated if necessary, and all relevant information will be obtained from the disclosing individual and proper follow-up conducted. The CCO, or his or her designee, shall maintain a confidential disclosure log, which shall include a record and summary of each disclosure received, the state of the respective internal reviews, a summary of findings and any corrective action taken in response to the internal reviews.
Your reporting of suspected wrongful conduct in good faith as soon as you become aware is important. Employees who in good faith report suspected wrongful conduct will be protected from retaliation. Employees also may be protected under the "whistleblower" protections of both the Federal False Claims Act and the Virginia Fraud Against Taxpayers Act (see "Appendix - Facts About False Claims"). Individuals engaging in wrongful conduct, including the failure to comply with our policies and procedures and all Federal Health Care Program requirements or failure to report such non-compliance will be subject to sanctions which may lead to suspension, termination or other disciplinary action. UVAH and individual employees of UVAH who engage in improper conduct also are subject to various significant criminal and civil sanctions for non-compliance, including imprisonment, large monetary penalties, and exclusion from Federal Health Care Programs and all other Federal procurement and non-procurement programs. For example, under both the Federal False Claims Act and the Virginia Fraud Against Taxpayers Act, a person who makes, or causes to be made, false claims or false statements to a governmental program such as Medicare or Medicaid can be liable for significant penalties (see "Appendix - Facts About False Claims").
Do the right thing, the right way, at the right time, every time!
UVAH expects all staff to:
- Live the UVAH values.
- Read and understand the Compliance Code of Conduct.
- Think compliance.
- Act responsibly.
- Obey all applicable legal and regulatory requirements as well as UVAH policies and procedures.
- Participate in training.
- Respect the rights of UVAH patients, families, and team members.
- Maintain confidentiality.
- Report suspected violations of the law and the UVAH Compliance Code of Conduct.
If you suspect our Code is not being honored or for any compliance related inquires: