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Part VIII Vanderbilt University Compliance Program and Standards of Conduct

(Snapshot on 8/5/2019)

A: Introduction

Vanderbilt University is committed to the highest standards of ethics, honesty, and integrity in pursuit of its mission of education, research, public service, and in supporting health care through its affiliation with Vanderbilt University Medical Center (VUMC). All members of the Board of Trust, the Chancellor, general officers, the executive administration, administrative officers, the faculty and staff, and others representing Vanderbilt University are expected to adhere to these standards of conduct in the discharge of their duties. The Vanderbilt University Compliance Program demonstrates the University’s commitment to ethical conduct and compliance by setting forth guidelines for conduct designed to prevent and detect violations of law, uphold accreditation standards, comply with University policies, and encourage compliance by providing support, training, and educational resources. The Compliance Program is designed to assist the University in fulfilling its compliance responsibilities by creating an operational structure and process to monitor the University’s compliance efforts and is designed to work in conjunction with other University offices and compliance programs. For more details, the Vanderbilt Compliance Program Plan is available at http://www.vanderbilt.edu/compliance/.

Faculty members employed by VUMC will be responsible in the conduct of their work for complying with the standards of conduct adopted by VUMC as well as the standards of conduct adopted by the University Compliance Program.

The Administrative Compliance Committee (“ACC”) has direct oversight responsibility for the compliance activities of Vanderbilt and assists the Vanderbilt community in fulfilling its legal compliance obligations. The ACC oversees the following areas of compliance activity:

1. informing, training, and educating the Vanderbilt community about the Standards of Conduct and ethical obligations under those Standards;

2. monitoring compliance activities, including policies, procedures, training, and education programs;

3. serving as a resource to Vanderbilt on matters of compliance, legal regulatory changes, and assessing and identifying areas of risk;

4. maintaining a reporting helpline for compliance matters;

5. assisting operational units in developing corrective action plans; and

6. reporting on compliance activities to the Audit Committee of the Board of Trust.

The ACC is supported and assisted in its oversight responsibilities by a compliance officer who is responsible for the day-to-day operations of the compliance program. The compliance officers’ responsibilities include employee training on the Standards of Conduct, routine monitoring of compliance activities, assisting with corrective action plans, monitoring emerging issues in the field of compliance, maintaining and responding to calls made to their respective reporting helplines, coordinating interdepartmental compliance efforts, providing staff support for the committees’ operational activities, and submitting biannual reports to the Audit Committee on the activities of the Compliance Program.

The ACC is co-chaired by the Vice Chancellor for Administration and the Vice Chancellor, General Counsel and University Secretary.

Vanderbilt University Compliance Reporting Hotline (844) 814-5935. The web address is: www.vanderbiltcompliancehotline.ethicspoint.com.

B: Standards of Conduct

Consistent with the Faculty Manual and Human Resources policies, 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. It is of paramount importance that all University faculty in supervisory positions ensure that they themselves adhere to the Standards of Conduct. The deans of the schools are responsible for assuring that the Standards of Conduct are observed by faculty. Staff and other University representatives are responsible for those employees under their supervision. All members of the University community are responsible for reading and understanding the Standards of Conduct. They can be found here under ‘Policies and Procedures’: https://www.vanderbilt.edu/compliance/links.php.

C: 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 community, including staff, faculty, health care professionals with hospital privileges, agents, representatives, contractors, and vendors, to follow, in the course and scope of their work 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.

D: Research and Health Care Services

Vanderbilt University is committed to compliance with applicable law in the conduct of research and health care services. In particular, Vanderbilt is committed to protecting health, safety, and welfare of human and animal research subjects and to conducting research with scientific integrity. Vanderbilt has adopted policies and procedures designed to foster the responsible conduct of research, and it is essential that the conduct of research activities and the delivery of health care services be accurately documented as required by applicable laws, rules, and regulations. Federal regulations relating to effort reporting and appropriate expenditure of grant funds must also be followed. Matters involving faculty employed by VUMC will be referred to the VUMC compliance officer with the expectation that the University and VUMC will work cooperatively to handle such compliance matters.

E: False Claims Act and Whistleblower Protection

Vanderbilt University requires all faculty and staff to report all known or suspected violations of the Federal False Claims Act (“FFCA”) or the Tennessee False Claims Act (“TFCA”) (collectively referred to as “FCA”). A person violates the FCA by knowingly submitting, or causing another to submit, false claims for payment of government funds.

Examples of violations of a FCA are (i) submission of a claim to Medicare for payment for services not rendered, or (ii) falsification of a time and effort report in connection with a claim for reimbursement from government grant. Vanderbilt University does not allow retaliation against persons reporting such suspected violations (sometimes referred to as “whistleblowers”) for making such reports in good faith.

Report any known or suspected violation of either the FFCA or the TFCA to the appropriate supervisor, department head or chair, the University compliance officer, or the University’s Compliance Reporting Hotline at (844) 814-5935 (www.vanderbiltcompliancehotline.ethicspoint.com). In making reports to the confidential help line, the caller may remain anonymous. The compliance helpline has no call identification or number recognition capability.

Faculty and staff may also report known or suspected violations of the FFCA to the federal hotline, (800) 447-8477/ TTY (800) 377-4950 or by email at HHSTips@oig.hhs.gov.

All persons making reports of compliance concerns are assured that such reports will be treated as confidential to the extent permitted by law. Such reports will be shared with others only on a bona fide need-to-know basis. Vanderbilt prohibits retaliation and will take no adverse action against persons who make such reports in good faith (“whistleblowers”), even if the report turns out to be incorrect. Any faculty or staff member who believes that they/she/he has been subjected to or affected by retaliatory conduct for reporting a suspected violation of an FCA or for refusing to engage in activity that would be a violation of an FCA should report such retaliation to the University Compliance Officer.

F: Kickbacks

It is against University policy for any person acting on behalf of the University to accept or pay a kickback. 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. No gifts or accommodations of any nature, including unrestricted grants, may be accepted by the University or individual members of the University community when to do so would place them in a prejudicial or compromising position, interfere in any way with the impartial discharge of their duties to the University, or reflect adversely on their integrity or that of the University.

G: Antitrust Laws and Regulations

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 joint ventures that are in restraint of trade or which attempt to monopolize any part of interstate trade or commerce. The sharing of confidential information such as salaries or charges for services with competitors is also prohibited.

H: Conflicts of Interest and Commitment

 Vanderbilt University is committed to following and enforcing its conflict of interest and commitment policies. All University faculty, staff, and representatives should avoid potential or perceived conflicts of interest and/or commitment. 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. The Vanderbilt University Conflict of Interest and Commitment Policy can be found at http://www.vanderbilt.edu/compliance/ (and is included in Part III of the Faculty Manual) and the VUMC Conflict of Interest and Commitment Policy can be found at https://www.mc.vanderbilt.edu/root/vumc.php?site=DCCI&doc=23385 . See the Human Resource Services website at www.vanderbilt.edu/HRS.

I: 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 their/her/his 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 (615) 322-2057.

J: Confidentiality

Vanderbilt University is committed to the appropriate protection of confidential information. Many faculty and staff have access to various types of sensitive, confidential, and proprietary information. Vanderbilt prohibits the unauthorized seeking, disclosing, or selling of such information, including confidential information contained in health care records, student educational records and employment records.

K: Controlled Substances

In accordance with the University’s Drug-Free Workplace policy, Vanderbilt prohibits the unlawful manufacture, distribution, possession, or use of a controlled substance by any member of the University community in the workplace or while conducting University business off the University’s premises. Federal law may impose sentences of up to twenty years in prison and fines of up to $1,000,000 for violation of criminal drug laws. For more information, see the Vanderbilt Compliance Program Plan at http://www.vanderbilt.edu/compliance/plan.php.

L: Non-Discrimination

Vanderbilt University is committed to the principles of equal opportunity 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 its educational policies, programs or activities; its admission policies; scholarship and loan programs; athletic or other institution-administered programs; or employment. The Equal Opportunity, Affirmative Action, and Disability Services Department (EAD) has responsibility for monitoring Vanderbilt’s Affirmative Action Plan and assisting with the application and interpretation of laws that impose special obligations on Vanderbilt. The EAD also assists with compliance to the Americans with Disabilities Act and with providing accommodation to students, faculty, and staff.

The EAD receives complaints regarding unlawful discrimination within the University community and, where possible, assists in the resolution of those complaints. Any faculty or staff member who experiences harassment or inappropriate discrimination should immediately seek assistance through the EAD by calling (615) 322-4705. Vanderbilt prohibits retaliation against persons who utilize the EAD in good faith to voice complaints of harassing or discriminatory conduct. Other staff member employment concerns related to personnel issues or human resources, such as salary, promotion, or hiring, should initially be directed to Human Resource Services at (615) 322-8330.

M: 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 Office of the General Counsel. The Office of the General Counsel is responsible for authorizing the release or copying of documents. If a government investigator, agent, or auditor comes to the University, a supervisor or the Office of the General Counsel should be contacted before an employee discusses any matters with such investigator, agent, or auditor.

N: 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, ongoing training and education is available on the University Website with the Institutional Review Board, Office of Grants and Contracts Management, Research Support Services, and other relevant departments. The compliance officer is always available to assist and coordinate specific education and training efforts.

O: Conclusion

Vanderbilt University is committed to following local, state, and federal laws, rules, and regulations. The compliance officers maintain help and reporting phone lines to enable faculty, staff, and other University 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, a department head or chair, 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. All persons making such reports are assured that such reports will be treated as confidential to the extent permitted by law. 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.

Faculty and staff wanting to make a report of a violation or a potential problem may contact the University Compliance Officer at (615) 322-5162, or call the anonymous, confidential helpline at (844) 814-5935 (www.vanderbiltcompliancehotline.ethicspoint.com). For more information, see the Vanderbilt Compliance Program Plan at http://www.vanderbilt.edu/compliance/html/ComplianceProgramPlan.doc. In addition, relevant Human Resource Policies are available at http://hr.vanderbilt.edu/policies/index.htm.


Appendix A: Abbreviations

The complete term is used the first time it appears. It is noted below if the relevant term is specific to one part of the university, such as the School of Medicine.

ACC: Administrative Compliance Committee

AUP: Acceptable Use Policy

B-TRC: Tenure Review Committee (Blair)

CTTC: Center for Technology Transfer and Commercialization

CRO: Chief Research Officer (Vanderbilt University Medical Center)

ECEF: Executive Committee of the Executive Faculty (School of Medicine)

EF: Executive Faculty (School of Medicine)

FAPC: Faculty Appointments and Promotions Committee (School of Medicine)

FCA: Both the Federal False Claims Act and the Tennessee False Claims Act

FDA: Food and Drug Administration

FERPA: Family Educational Rights and Privacy Act (aka the Buckley Amendment)

FFCA: Federal False Claims Act

FSA: Flexible Spending Account

FMLA: Family and Medical Leave Act

IT: Information Technology

NSF: National Science Foundation

ORI: Office of Research Integrity

SOM: Vanderbilt University School of Medicine

PHS: Public Health Service

PRTC: Promotion and Tenure Review Committee

TFCA: Tennessee False Claims Act

TMLA: Tennessee Maternity Leave Act

TRC: Technology Review Committee

USERRA: Uniformed Services Employment and Reemployment Rights Act

VUMC: Vanderbilt University Medical Center

 

Appendix B: Gender Pronouns

Gender pronouns are a way to refer to individuals without using names. Using the correct gender pronoun is an important part of recognizing a faculty colleague. Historically, singular gender pronoun usage of she/her/hers and he/him/his conform to and reify a binary classification of man and woman. Other pronouns, however, do not fit into this binary, including, but are not limited to, they/them/theirs and ze/hir/hirs. (See https://perma.cc/9GXJ-K4FE.) So as not to misrecognize any faculty member by reifying the she-he gender binary, the faculty manual deploys they/she/he pronouns, or where readability recommends it, the universal singular “they.”