Regents' Policy Manual - Section 3.7: Health Sciences Center Institutional Compliance Program

Adopted Date: 12-14-2010
Amended: 09-12-2014
Amended: 06-17-2019

Applicability

This policy applies to the academic and clinical programs, facilities, and services operating under the University of New Mexico Health Sciences Center (HSC) and its units, clinics, centers, programs, and affiliated corporations described in RPM 3.4.

Institutional Compliance Program

The HSC attempts to ensure at all times that its business (internally and with outside contractors) is conducted in accordance with the highest ethical standards and in compliance with the various federal and state laws and regulations applicable to its activities. To fulfill these obligations, the HSC has adopted and implemented an Institutional Compliance Program, which will include all compliance functions related to its clinical, research, and educational efforts. These functions include, without limitation, clinical and clinical trials compliance, human research protection, animal research, biosafety, conflict of interest, human subjects protection, use of animals in education and research, export control compliance, research integrity, and fiscal compliance related to billing and federal grants, Family Educational Rights and Privacy Act, and other educational compliance activities.

The HSC Institutional Compliance Program is committed to building a culture that fosters integrity and ethical conduct, promoting compliance with regulatory requirements, and enhancing awareness through education, training, and guidance to faculty and staff. Employees are expected to acknowledge that they understand their responsibilities and perform their work in an ethical and legal manner as detailed in the HSC Code of Ethics. The HSC Institutional Compliance Program promotes an environment where suspected acts or events of non-compliance should be reported to their immediate supervisor, another member of management, or the HSC Compliance Officer. Reports can also be made in confidence and anonymously without fear of retaliation through the UNM Compliance Hotline at 1-888-899-6092 or online through www.unm.ethicspoint.com.

The HSC Institutional Compliance Program is based on risk-based and proactive activities in support of compliance and aligned with the compliance program guidances published by the US Department of Health and Human Services’ Office of the Inspector General for hospitals, recipients of Public Health Sservice research awards, and related health professions (including those related to physicians at teaching hospitals), and the US Federal Sentencing Guidelines. The HSC Institutional Compliance Program strives to reduce fraud, waste, and abuse while maintaining the reputation of the HSC as a reliable, honest, and trustworthy health care community partner.

References

• HSC Compliance Office
• US Federal Sentencing Guidelines: www.ussc.gov/guidelines/2015-guidelines-manual/archive/2010-8b21
• Office of the Inspector General Compliance Program Guidelines: https://oig.hhs.gov/compliance/compliance-guidance/index.asp
• Centers for Medicare and Medicaid Services Guidelines for Physicians at Teaching Hospitals: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf