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Consistent
with the Faculty Manual and the Human Resource Services'
Staff Guidelines, the Vanderbilt University Standards of
Conduct provide the guiding standards of conduct for the
University's faculty, staff and others representing the
University and set forth the University's commitment to
good practices and following the law. The Deans of the
schools are responsible for assuring that the University's
Standards of Conduct are observed by faculty. Staff and
other University representatives are responsible for those
employees under their supervision.
COMPLIANCE
WITH THE LAW
Vanderbilt University is committed
to compliance with all applicable laws, rules,
and regulations.
It
is the responsibility of each member of the University, including
staff, faculty, health care professionals with hospital privileges,
agents, representatives, contractors and vendors, to follow,
in the course and scope of their employment at Vanderbilt,
all applicable laws, rules, regulations and University policies,
and to maintain an educational, health care and business
environment that is committed to integrity and ethical conduct.
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RESEARCH
AND HEALTHCARE SERVICES
Vanderbilt University is committed
to the accurate and complete documentation
of research and health care services and the
conduct of research with scientific integrity.
Vanderbilt
has adopted, and published in the Faculty Manual, policies
and procedures designed to deal with misconduct in research,
and it is essential that the conduct of research activities
and the delivery of health care services be documented as
required by applicable laws, rules and regulations. Federal
regulations relating to accurate reporting and appropriate
expenditure of grant funds must be followed. Additionally,
members of the Medical Center community, including physicians,
billing representatives, and independent contractors must
follow laws and regulations governing financial and billing
transactions, and all Medical Center physicians must follow
the documentation rules in the Medicare Teaching Physician
guidelines.
Questions
concerning grants should be directed to the Medical Center
Office of Research at 322-2281, the Office of Sponsored Research
for University Central at 322-2631, or the appropriate Compliance
Officer to ensure that all regulations are observed. Regulations
relating to documentation of all medical services and research,
federally funded grants, and scientific integrity can be
obtained by contacting the Medical Center Compliance Office
at 343-2777.
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KICKBACKS
Vanderbilt University is committed to following
federal and state anti-kickback laws and regulations.
When
someone who can influence purchasing decisions made at the
University takes money or anything of value from a vendor,
it can be considered a kickback which is illegal. Additionally,
members of the Medical Center community should be aware that
if someone refers a patient to another provider and receives
something of value in exchange, it can be considered a kickback.
Anti-kickback rules also apply to the recruitment of physicians,
recruitment of research subjects, and the acquisition of
physicians' practices.
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MARKET
COMPETITION
Vanderbilt University is committed
to complying with state and federal antitrust
(monopolies) laws and regulations.
University
policy and business practices prohibit setting charges in
collusion with competitors, certain exclusive arrangements
with vendors, and the sharing of confidential information
with competitors. Additionally, members of the Medical Center
community are prohibited from sharing confidential information
with competing providers, such as salaries or charges for
services rendered.
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PURCHASING
All purchasing decisions must be made without any conflicts of
interest that could affect the outcome. Any concerns about
the legality of a proprosed transaction such as inducements
offered by a vendor or supplier should be discussed with
the supervisor or the appropriate Compliance Officer.
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CONFLICTS
OF INTEREST
Vanderbilt University is committed to following
and enforcing its conflict of interest policies.
All
University faculty, staff, and representatives should avoid
potential or perceived conflicts of interest. Any concerns
about a proposed transaction that may involve inducements
offered by a vendor or supplier or a business relationship
with a company that is connected with you or a family member,
should be discussed with the appropriate Dean, supervisor
or Compliance Officer. Vanderbilt conflict of interest policies
are found in the Faculty Manual, and on the University website
at www.vanderbilt.edu/compliance
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INDEPENDENT
CONTRACTORS AND VENDORS
All contractors and vendors who provide services to Vanderbilt
University and Medical Center must comply with all applicable
laws and Vanderbilt University and Medical Center policies.
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FEDERALLY
FUNDED GRANTS
All Vanderbilt University and Medical Center faculty, staff and
representatives will follow all applicable federal regulations
relating to accurate reporting and appropriate expenditure of
grant funds. Questions concernign grants should be directed to
the Medical Center Office of Reserch at 322-2281, the Office
of Sponsored Research for University Central at 322-2631, or
the appropriate Complicance Officer to ensure that all regulations
are observed.
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SCIENTIFIC
INTEGRITY
Vanderbilt University is a premier research institution and is
committed to follow all laws and regulations related to scientific
research. Vanderbilt has adopted, and published in the Faculty
Manual, policies and procedures designed to deal with misconduct
in research. All Vanderbilt University and Medical Center faculty/staff
who have information about inappropriate activities connected
with research conducted at Vanderbilt should follow the procedures
set forth in the Faculty Manual or contact the appropriate Compliance
Officer.
In
the interest of maintaining the highest standards of patient
care and scientific integrity, researchers and physicians
must familiarize themselves with all federal and state laws
governing their activities. Regulations relating to documentation
of all medical services and research, federally funded grants,
and scientific integrity can be obtained by contacting the
Medical Center Compliance Office at 343-2777.
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ENVIRONMENT
Vanderbilt University is committed to complying
with all applicable environmental laws and to maintaining
all necessary environmental permits and approvals.
Environmental
compliance includes the proper handling, storage, use, shipment
and disposal of all materials that are regulated under any
applicable environmental law. If any employee has actual
knowledge that a spill, release, or discharge of any material
regulated pursuant to an applicable environmental law has
occurred, such employee must immediately report such event
to his or her immediate supervisor so that necessary action
may be taken. Necessary action may include evacuating employees,
reporting such event to a governmental authority if required
pursuant to any environmental law, and containing and cleaning
up any such spill, release, or discharge. Employees should
also report any other violations of applicable environmental
law of which they have actual knowledge that could endanger
the health and safety of other individuals.
Questions
concerning environmental regulations should be directed to
Vanderbilt Environmental Health and Safety at 322-2057.
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CONFIDENTIALITY
Vanderbilt University is committed to the appropriate
protection of confidential information.
Many
faculty and staff have access to various forms of sensitive,
confidential, and proprietary information. University policy
prohibits the unauthorized seeking, disclosing or giving
of such information, including confidential information contained
in a patient medical record.
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CONTROLLED
SUBSTANCES
Vanderbilt University prohibits the unlawful
possession, use, manufacture or distribution
of illicit drugs and alcohol.
Vanderbilt
prohibits the unlawful possession, use, manufacture or distribution
of illicit drugs and alcohol on its property or as part of
any University sponsored activity. Additionally, members
of the Medical Center community and health care professionals,
including those who maintain Drug Enforcement Agency (DEA)
registration must comply with all federal and state laws
regulating controlled substances.
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DISCRIMINATION
Vanderbilt University is committed to the principles
of equal employment and affirmative action.
Vanderbilt
does not discriminate on the basis of race, color, religion,
sex, national or ethnic origin, age, disability, sexual orientation,
or military service in administration of educational policies,
programs or activities; its admission policies; scholarship
and loan programs; athletic or other institution-administered
programs; or employment. The Opportunity Development Center
has responsibility for monitoring Vanderbilt's Affirmative
Action Plan and assisting with application and interpretation
of laws that impose special obligations on Vanderbilt.
Any
faculty or staff member who experiences harassment or discrimination
on the basis of sex, race, color, religion, national origin,
age, disability, or sexual orientation should immediately
seek assistance through the Opportunity Development Center
at 322-4705. The Opportunity Development Center receives
all complaints of unlawful discrimination raised within the
Vanderbilt community and, where possible, assists in the
resolution of those complaints. Vanderbilt prohibits retaliation
against faculty or staff members who utilize the Opportunity
Development Center in good faith to make complaints of harassing
or discriminatory conduct. Other employment concerns related
to personnel issues or human resources, such as salary, promotion,
or hiring, should initially be directed to Human Resources
Services at 322-8330.
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RESPONSE
TO INVESTIGATION
Vanderbilt University is committed to cooperating
with government investigators as required by
law.
If
an employee receives a subpoena, search warrant or other
similar document, before taking any action, the employee
must immediately contact the Compliance Officers or the Office
of General Counsel. The Compliance Officers and the Office
of General Counsel are responsible for authorizing the release
or copying of documents. If a government investigator, agent,
or auditor comes to University Central or the Medical Center,
a supervisor, the Compliance Officers, the Office of General
Counsel, or the Hospital Administrator-on-Call should be
contacted before an employee discusses any matters with such
investigator, agent, or auditor.
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COMPLIANCE
TRAINING
Vanderbilt University is committed to providing
training and education to the University community
about compliance with applicable laws, rules
and regulations.
In
addition to employee orientation, the VUMC Safety Fair, the
Hearts and Minds Medical Center Orientation and the ODC Alphabet
Soup Training Program, ongoing training and education is
available on the University Website. Also, the Compliance
Officers are always available to assist and coordinate specific
education and training efforts.
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CONCLUSION
Vanderbilt University is committed to following local,
state and federal laws, rules and regulations.
The
Compliance Officers shall maintain a help and reporting phone
line to enable faculty, staff and representatives to report
violations and to discuss any questions. To assist the University
with its commitment to appropriate conduct, all faculty,
staff and representatives are encouraged to report violations
of any law or policy to a supervisor or a Compliance Officer.
It is the duty of all faculty, staff and University representatives
to report Vanderbilt-job-related criminal conduct of which
they have actual knowledge or Vanderbilt-job-related situations
that endanger the health and safety of any individual to
the appropriate supervisor or the Compliance Officers. All
persons making such reports are assured that such reports
will be treated as confidential; such reports will be shared
with others only on a bona fide need-to-know basis. Vanderbilt
will take no adverse action against persons making such reports
in good faith. Vanderbilt prohibits retaliation against persons
who make such reports in good faith. False accusations made
with the intent of harming or retaliating against another
person can subject the accuser to disciplinary action.
University
Central faculty and staff wanting to make a report of a violation
or a potential problem may contact the University Central
Compliance Officer at 322-8363, or call the anonymous, confidential
helpline at 322-1033. Members of the Medical Center community
may contact the Medical Center Compliance Office at 343-2777
or may contact the Medical Center Compliance Officer at 343-7266.
Concerns can also be reported confidentially and anonymously
on the Medical Center's 24-hour Confidential Helpline at
343-0135.
The
Compliance Officers have no disciplinary enforcement authority;
the Compliance Officers will investigate, evaluate, and make
recommendations consistent with University policies and procedures
to the appropriate Dean or supervisor regarding matters of
non-compliance by faculty and staff, respectively. Any disciplinary
action shall be determined and enforced by the appropriate
Dean or supervisor pursuant to existing disciplinary standards,
policies and procedures set forth in the Faculty Manual and
the Human Resource Services' Staff Guidelines.
Following
these Standards of Conduct will help you do the right thing.
It will also protect you and the Vanderbilt community. You
are encouraged to talk with your supervisor/manager and colleagues
if something is not clear and of course, the Compliance Officers
are always available to assist you.
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RELEVANT
UNIVERSITY POLICIES
HR Policy #2: Anti Harassment
HR Policy #14: Performance Improvement Counseling
HR Policy #15: Discharge
HR Policy #22: Dispute Resolution
HR Policy #27: Work Place Violence
HR Policy #33: Relationships in the Workplace
HR Policy #35: Substance Abuse
Drug and Alcohol Policy
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