Standards of Conduct
The University of Oklahoma
The University is committed to the highest standards of ethics and to compliance with all applicable laws and regulations. To promote legal and ethical behavior and to prevent and detect violations of law, the Board of Regents approved the adoption of the Compliance and Quality Improvement Program. The goals of the Program are to: (1) protect research subjects, patients and employees; and (2) assist faculty and staff with the myriad of complicated laws and regulations to which they are subject in a way that facilitates the University’s missions. Training and education are the key mechanisms for achieving these goals.
The Program includes Standards of Conduct, set forth below, which are a non-exclusive compilation of guidelines regarding ethical and legal standards that all University employees are expected to follow when performing services for or on behalf of the University and that are related to the areas covered by the Program. A complete copy of the Program is posted on the University’s Office of Compliance website at: www.ouhsc.edu/compliance.
In addition to the Standards, this booklet includes general information about the program in order to educate employees about their responsibilities.
Statement of General Principles
The Standards of Conduct are applicable to all members of the University community, including: (1) officers, faculty, and staff; (2) consultants, vendors, and contractors when they are doing business with the University; (3) trustees; and (4) individuals who perform services for the University as volunteers or are otherwise paid by the University. The Standards of Conduct may refer to these persons as “investigators,” “professionals,” and/or “University employees.”
2. Compliance with Laws and Policy
University members must educate themselves regarding the applicable laws and policies concerning their area of performance. University policies may be found online at www.ou.edu and/or www.ouhsc.edu under appropriate subject matter and departmental tabs. Hard copies may be found in the Office of Human Resources and the Office of the Senior Vice President and Provost. In general, the University members are expected to:
· Comply with contract and grant obligations (including reporting criminal or unethical conduct, including, but not limited to, bribery, fraud, and gratuity violations to the Office of Inspector General through the appropriate Sponsored Programs Office or the Office of Research Administration;
· Comply with Federal procurement guidelines where applicable;
· Comply with internal financial protocols, ensuring accurate recording and reporting of costs and charging the appropriate accounts (appropriateness of charges on a grant should be directed to the appropriate Sponsored Programs Office or Office of Research Administration);
· Compliance with University policies on conflicts of interest and applicable State and Federal laws; e.g.:
o Not using your University position to obtain a personal gain for yourself or any person or entity with whom you have a personal, business or financial affiliation;
o Avoiding any relationship, influence, or activity that may adversely affect or give the appearance of adversely affecting independence of judgment in making professional decisions;
o Ensuring your professional allegiance is with the University and that your outside business activities do not create an actual or potential conflict of interest (consult your departmental supervisor or the Office of the Senior Vice President and Provost);
o Advising appropriate parties of potential conflicts of interest
o Complying with certain federal ethical requirements for principal investigators on certain federal grants (disclosure of significant financial interests);
o Complying with procurement policies and prohibitions on:
§ Soliciting, accepting, or discussing future employment with a contractor;
§ Disclosing proprietary information or source selection information to a competing contractor;
§ Seeking or accepting any money, gratuity or other thing of value from a potential, current, or competing contractor.
· Use electronic communications and systems in a responsible manner and in compliance with University policy, state law and policy, and federal requirements.
· Use confidential information acquired in the course of University affiliation only for official or legal purposes, not for personal or illegal advantage, during or after such affiliation;
· Disclose confidential information acquired in the course of employment or University affiliation on a need-to-know basis and only when authorized to do so;
· Refrain from engaging in a romantic or sexual relationship with a student or employee whom you teach, coach, advise, or supervise in any way, or have a management control plan in place;
· Abide by all rules and laws governing the use of copyrighted materials, patented ideas, licenses, and proprietary information;
· Use University resources legally and properly;
· Refrain from engaging in personal use of University facilities, equipment, time, employees, students, or voluntary help unless prior written permission is obtained from appropriate University officials;
Additional Federal Considerations
To ensure the highest standards of ethical conduct and to ensure the University is in compliance with federal regulations, there are several significant federal laws with which the University community must be aware:
· Federal rules prohibit the use of federal funds to influence officials of Congress and Executive Branch agencies (there are similar state law prohibitions as well) in connection with a specific award. Further, any lobbying utilizing University funds must be approved and coordinated through the University’s Vice President of Governmental Relations.
· The Foreign Corrupt Practices Act prohibits offering or providing a federal official (or anyone affiliated with a federal official) with things of value in exchange for the act or omission of that federal official in the performance of his/her duties. Books, records, and accounts must be accurately maintained to reflect the transactions and dispositions of assets. A system of internal accounting control must be maintained.
3. Standards Relating to Research
The University is committed to dealing ethically with the human and animal subjects participating in research projects conducted by faculty, staff, and students and research involving University property. Employees involved in human subject or animal research must comply with all federal and state statutes and regulations for research and must adhere to all University policies and procedures regarding research.
Protection of Human Subjects In order to protect human subjects, each investigator must:
a) Design and implement ethical research consistent with the three ethical principles delineated in The Belmont Report. The three principles are: justice, beneficence, and respect for persons.
b) Comply with all applicable Federal regulations impacting the protection of human subjects (e.g., 45 C.F.R. § 46 and 21 C.F.R. § 50 and 56).
c) Ensure that all research involving human subjects is submitted to and approved by one of the University’s institutional review boards (“IRB”) prior to subject recruitment and data collection, as required by the policies and procedures of the IRB of the respective campus.
d) Comply with all applicable IRB policies, procedures, decisions, conditions, and requirements.
e) Implement research as approved by the IRB and obtain prior IRB approval for any changes to the research protocol prior to implementation.
f) Obtain informed consent and assent in accord with Federal regulations and as approved by the IRB.
g) Document informed consent and assent in accord with Federal regulations and as approved by the IRB.
h) Report progress of approved research to the IRB, as often and in the manner prescribed by the IRB.
i) Report to the IRB any injuries, adverse events/effects, or other unanticipated problems involving risks to subjects or others.
j) Retain signed consent documents and IRB research records for at least three years past completion of the research activity.
Protection of Animal Subjects In order to protect animal subjects, each investigator must:
a) Comply with all applicable Federal laws and regulations impacting the protection of animal subjects (e.g., the Animal Welfare Act and the Public Health Service Policy on Humane Care and Use of Laboratory Animals).
b) Ensure that all research involving animal subjects is submitted to and approved by one of the University’s institutional animal care and use committees (“IACUC”).
c) Comply with all applicable IACUC policies, procedures, decisions, conditions, and requirements.
d) Implement research as approved by the IACUC and obtain prior IACUC approval for any changes to the research protocol.
e) Choose a species for study that is well suited for investigation of the issues posed.
f) Use the smallest number of animals necessary and sufficient to accomplish the research goals.
g) If procedures used in research or teaching involve exposure to painful, stressful or noxious stimuli, consider whether the knowledge that may be gained is justified.
h) Use only reputable suppliers for the procurement of animals.
i) Ensure that caging conditions and husbandry practices meet applicable standards.
j) Dispose of animals in accordance with applicable laws and standards.
Scientific Misconduct The University will not tolerate scientific misconduct, which includes, but is not limited to: (i) plagiarism; (ii) falsification; (iii) fabrication; and (iv) other unethical scientific practices. Scientific misconduct is further defined in and governed by University policy.
Research Financial Issues Research costs and budgets must be prepared and submitted accurately and in accordance with (i) generally accepted accounting principles, (ii) OMB Circular A-21 and/or (iii) the terms set forth in an industry-sponsored or government grant or contract, whichever is applicable, in addition to applicable statutes and regulations. Financial conflicts of interest must be reported in accordance with University policy.
4. Standards Relating to Health Care Activities
Hiring and Retention All health care professionals seeking employment and/or credentials must provide information concerning: (a) criminal convictions; (b) exclusions from any Federal Health Care Program; and (c) sanctions by any Federal Health Care Program. Health care professionals must notify the University of any changes in this information.
Billing in General Honesty and accuracy are vital in billing and in the submission of claims. No University employee shall submit, authorize, or sign a false claim for reimbursement in violation of applicable laws and regulations. Claims for the provision of services and/or supplies should be submitted only by the University department or college that generated the charges unless an alternative billing arrangement has been approved.
Billing and Coding - Specifics University-employed health care professionals will refrain from any of the following practices and will work to identify and correct instances in which mistakes have occurred in the following areas:
a) Billing for items or services not rendered or not provided as claimed;
b) Submitting claims for equipment, medical supplies, and services that are not reasonable and necessary;
c) Double billing resulting in duplicate payment;
d) Billing for non-covered services as if covered;
e) Knowingly misusing provider identification numbers, resulting in improper billing;
f) Unbundling (billing for each component of the service instead of billing or using an all-inclusive code);
g) Failure to properly use coding modifiers;
h) Falsely indicating that a particular health care professional attended a procedure or that services were otherwise rendered in a manner they were not;
i) Clustering (billing all patients using a few middle levels of service codes, under the assumption that it will average out to the appropriate level of reimbursement;
j) Failing to refund credit balances as required by University Policy; and
k) Upcoding the level of service provided.
Write-Offs. University-employed health care professionals are not permitted to write-off charges for their services, unless the write-off is consistent with applicable State and Federal laws and regulations, University Policy or contract, and guidance issued by the DHHS Office of Inspector General. Examples of impermissible write-offs include, but are not limited to: (1) the routine waiver of co-payments and deductibles (or “insurance only” arrangements) and (2) the provision of professional courtesies to referral sources. Permissible waivers include, but are not necessarily limited to, waiver based on indigency and contractual write-offs and discounts. Waivers of payment are permitted in order to preserve State and/or University assets.
Documentation Claims for payment must be coded and billed based on the documentation contained in the patient’s medical record. University-employed health care professionals will appropriately document the services and supplies provided to, or the diagnosis and treatment of, each patient and will complete medical records in a timely manner. Medical record documentation must be complete and legible.
Anti-Kickback Statute No University employee may pay, or accept a payment, to induce the referral of a patient in violation of the federal or state anti-kickback statutes.
Self-Referral Proscription No University employee may have an ownership or compensation relationship that violates the Physician Self-Referral Statute, more commonly known as Stark II. Compensation and ownership relationships with physicians, including physician employment and independent contractor arrangements, must satisfy an exception to Stark II.
Gifts from Patients Employees are prohibited from soliciting tips, personal gratuities, or gifts from patients and from accepting monetary tips or gratuities. Employees may accept non-monetary gratuities and gifts of nominal value from patients, subject to the State Ethics Rules, Conflict of Interest policy, and departmental policy.
Gifts Influencing Decision-Making Employees shall not accept gifts, favors, services, entertainment, or other things of value to the extent that decision-making or actions affecting such employee may be influenced. Employees may accept gifts when they are of such limited value that they could not reasonably be perceived as an attempt to affect the judgment of the recipient, and subject to the State Ethics Rules, Conflict of Interest policy, and departmental policy
Confidentiality of Patient Information All employees have an obligation to protect the confidentiality of individually identifiable health information in accordance with the HIPAA Privacy and Security Regulations and all other applicable laws and regulations and to adhere to the University’s policies and procedures implementing such laws and regulations.
5. Standards Relating to Environmental Health and Radiation Safety
Workplace Health and Safety The University is committed to providing a safe and healthy environment for the entire University community and to complying with all applicable Federal and State laws and regulations pertaining to occupational, environmental, and radiation health and safety. All employees must perform their jobs in compliance with all applicable laws and University policies. In addition, all employees must ensure that they have completed all required safety training and have been authorized to perform a job before undertaking it. Employees should seek advice regarding workplace safety and compliance issues from their supervisors or the Environmental Health and Safety Office or the Radiation Safety Office. Each employee is responsible for advising his or her supervisor, the Environmental Health and Safety Office, or the Radiation Safety Office of any situation that presents a danger of exposure or injury so that timely corrective action may be taken.
Use of Radioactive and Biological Materials. No use of radioactive materials or radiation producing devices is permitted without the written permission of one of the University’s Radiation Safety Committees (“RSC”). No use of microorganisms, recombinant DNA, or biological toxins is permitted without first obtaining the written approval of one of the University’s Institutional Biosafety Committees (“IBC”), if such approval is required by University policies. Employees must comply with all applicable RSC and IBC policies, procedures, decisions, conditions, and requirements.
Protection of the Work Environment All University employees must manage and dispose of hazardous chemical, radioactive, and other wastes in a way that maximizes protection of human health and the work environment and is in accordance with all applicable laws and institutional policies. All employees must be trained to perform their duties and conduct their activities in an environmentally responsible manner in accordance with applicable University policies.
6. Reports of Wrongdoing
All University employees have a duty to report possible wrongdoing or suspected violations of applicable Federal and State laws and regulations. The University will not retaliate or discriminate against any employee who makes a good faith report of a suspected violation regarding the observed conduct or actions by another person. It is a violation of this Program to make a report of a suspected violation that is known to be false.
Reports of suspected violations can be made to an employee’s immediate supervisor, to the University’s Director of Compliance, or to the University’s Hotline, which is available 24 hours a day. The Hotline number is (405) 271-2223 or toll free 1-866-836-3150. The call will not be traced, and the person need not give his or her name. The Hotline should be used only for raising issues regarding one of the areas covered by the Program.
7. Where to Go for Help
Ethical issues are often not black and white. Should employees need assistance in resolving an ethical dilemma, there are several sources available:
· Consult the Faculty or Staff Handbooks, Student Code, or other policies applicable to your situation.
· Consult with your immediate supervisor, or if this is not practical, with Human Resources, the Compliance Officer, the Senior Vice President and Provost, or the appropriate Sponsored Programs Office or Office of Research Administration (for faculty or grant questions), or the University Ombuds Office. Students should contact their supervisor, faculty adviser, the Vice President for Student Affairs, or the Graduate Office, as appropriate.
8. Training and Education
Education and training are critical parts of the Program and are the primary mechanisms for preventing and correcting compliance issues. Employees will participate in any applicable training programs mandated by law or the University.
9. Audits and Investigations
In today’s legal and regulatory environment, it is reasonable to anticipate that various government agencies will audit and investigate from time to time. If a University employee is contacted by a government investigator or auditor, the employee should fully and appropriately cooperate and should refer to the Employee University and Audit Response Guidelines for guidance regarding the appropriate response. These Guidelines are attached to the Program and available on the Office of Compliance website at www.ouhsc.edu/compliance.
If you have any questions about the Standards or the Program, please contact the Director of Compliance at (405) 271-2511 or ou firstname.lastname@example.org.
The University of Oklahoma Office of Compliance |
755 Research Parkway, Building 4, Suite 429
Oklahoma City, OK 73104
Hot Line: (405) 271-2223 or (866) 836-3150
The University of Oklahoma Office of Compliance
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