Standards of Conduct

A MESSAGE FROM THE CHANCELLOR

Dear Faculty and Staff:

At Vanderbilt University, patients, students, parents and society at-large have placed their faith and trust in the faculty and staff who comprise this great institution.  In carrying forward our noble mission of educating, healing, and advancing scientific research, it is vital that we hold a deep commitment to the highest levels of ethical standards and lawful conduct.

The Vanderbilt University Compliance Program articulates specifically what is expected of us, and completing the Standards of Conduct training will ensure that you have a thorough understanding of institutional standards of integrity and honesty, as well as the laws, rules and regulations specific to your profession.  I urge you to read the information on this Web site carefully and to ingrain these important principles into your daily work.   For through our individual efforts to uphold these practices and obey the laws, we collectively help Vanderbilt achieve its promise as an academic and healthcare leader.

Nicholas S. Zeppos
Chancellor

Introduction
Vanderbilt University is committed to the highest standards of ethics, honesty, and integrity in pursuit of its mission of education, research, patient care, and public service. All members of the Board of Trust, the Chancellor, General Officers, members of the Executive Administration, administrative officers, members of 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 and by encouraging compliance by providing support, training and educational resources to assist Vanderbilt in fulfilling its responsibilities through its faculty and staff. The Compliance Program is designed to assist and facilitate the University in fulfilling its compliance responsibilities by creating a process to monitor the University's compliance efforts and by documenting the University's expectations for its faculty, staff and other representatives in the performance of their responsibilities at Vanderbilt.

Compliance Program
Vanderbilt University has two compliance committees which have oversight responsibilities for the compliance activities of Vanderbilt and which assist the Vanderbilt community in fulfilling its legal compliance obligations. The Medical Center and Research Compliance Committee provides support for functions related to Medical Center operations and all institution-wide research activities. The Administrative Compliance Committee provides support for University Central operations and activities. The committees oversee the following areas of compliance activity:

• informing, training, and educating the Vanderbilt community about the Standards of Conduct and ethical obligations under those Standards
• monitoring compliance activities, including policies and procedures and training and education programs
• serving as a resource to Vanderbilt on matters of compliance and legal and regulatory changes, and assessing and
• identifying areas of risk
• maintaining a reporting helpline for compliance matters
• assisting operational units in developing corrective action plans
• recommending and reviewing disciplinary action for violations of the Standards of Conduct
• reporting on compliance activities to the Audit Committee of the Board of Trust through the Compliance Officers

Each Committee is supported and assisted in its oversight responsibilities by a Compliance Officer. Each Compliance Officer is responsible for the day-to-day operations of the Compliance Program. Their responsibilities include employee training on the Standards of Conduct, routine monitoring of compliance activities, assisting with corrective action plans, maintaining a reporting helpline, coordinating interdepartmental compliance efforts, and providing staff support for the Committees' operational activities.

Standards of Conduct
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.

Part One - 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.

Research and Health Care 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.

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.

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.

Purchasing
All purchasing decisions must be made without any conflicts of interest that could affect the outcome. Any concerns about the legality of a proposed transaction such as inducements offered by a vendor or supplier should be discussed with the supervisor or the appropriate Compliance Officer.

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, on the Human Resources Services website at www.vanderbilt.edu/HRS, and in the Hospital policy manual.

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.

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 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.

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.

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

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.

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.

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

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.

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.

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. 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.

Part Two - Medical Center Only
These additional Standards of Conduct apply exclusively to members of the Medical Center community, which includes Medical Center staff or faculty, and any person who provides services at the Medical Center, including health care professionals with hospital privileges:

Billing and Claims
Vanderbilt University is committed to charging, billing, documenting and submitting claims for reimbursement for hospital and professional services in the manner required by applicable laws, rules and regulations. All of our faculty/staff should know and carefully follow the applicable rules for submission of bills and claims for reimbursement on behalf of the Medical Center. If you know or suspect that a bill or claim for reimbursement is incorrect, you are required to report it immediately to your supervisor or to the Medical Center Compliance Officer.

Patient Referrals
Vanderbilt University is committed to the lawful referral of patients to services outside the Medical Center for the delivery of appropriate patient care. If a referring physician, or his or her immediate family member, has an ownership or investment interest in or a compensation arrangement with the entity to which a patient is referred, and payment for the referred services will be made from a federal or state health care program, such as Medicare, Medicaid and TennCare, a federal law, commonly referred to as the "Stark Law", may prohibit the referral. No Medical Center physician shall refer a patient for services in violation of the law. If a physician has questions about referrals, he/she should consult with the Medical Center Compliance Officer or the Office of General Counsel.

Emergency Treatment for Patients and Women in Labor and Patient Transfers
Vanderbilt University is committed to following state and federal laws and regulations with respect to the evaluation, admission and treatment of patients with emergency medical conditions and pregnant women who are in labor regardless of a patient's financial or insurance status. As the health care arm of the University, the Medical Center conducts its activities in furtherance of the University's charitable mission in the areas of education, research and patient care. Emergency services are available to all persons in need of those services without regard to their financial or insurance status. If any individual comes to the Emergency Department of the hospital for examination or treatment of a medical condition, then the Medical Center must provide the individual with an appropriate medical screening examination to determine if an emergency medical condition exists, and if one does, it must stabilize the emergency medical condition within its capabilities. A woman in active labor is deemed to have an emergency medical condition. Additionally, the Medical Center must accept for transfer from another hospital an individual requiring specialized capabilities of the Medical Center if the Medical Center has the capacity and capability to treat the individual. The Medical Center's commitment to patients is reflected in our willingness to help anyone in need and not be influenced by race, creed, ethnicity, or sex. To ensure that these factors do not affect staff and faculty decisions, all people will be given emergency treatment and be discharged and referred without discrimination. It is also important for Medical Center staff and faculty to keep all patients' medical information confidential.

Discharge Planning and Ancillary Service Referrals
Vanderbilt University is committed to appropriate discharge planning and the lawful referral of patients for ancillary health care services. The Medical Center recognizes that the discharge of a patient to a residence or post-hospitalization provider is an important decision. In developing and implementing discharge plans, Medical Center faculty and staff shall act in the best interest of the patient, in the judgment of the health care provider. This includes the involvement and consent of the patient or patient's legal representative.

Disciplinary Action
All Medical Center faculty, staff and representatives, as well as those who hold professional staff privileges, must carry out their duties for the Medical Center as stated in these policies, and, as required by law, report violations of local, state or federal laws, rules or regulations to a supervisor or the Medical Center Compliance Officer. If any faculty, staff or representative does not report violations, knowing that such a failure violates a clear legal obligation, the individual may be subject to disciplinary action and may be terminated from employment. Such disciplinary conduct must abide by all substantive and procedural protections applicable to discipline in the Faculty Manual or, for staff, in the Human Resource Services' Staff Guidelines. Disciplinary action may apply to a supervisor who knowingly directs or approves a person's improper actions, or is aware of those improper actions but does not act appropriately and within the supervisor's scope of authority to correct them, or who, by knowingly violating a clear legal or professional duty, otherwise fails to exercise appropriate supervision.

Statement of Receipt and Acknowledgment
Medical Center faculty, staff, and representatives must acknowledge receipt of the Standards of Conduct and acknowledge individual responsibility for knowing and adhering
to the Standards of Conduct.

A pledge card can be obtained from the Compliance office, at 343-7266 or on line at

http://www.mc.vanderbilt.edu/compliance/pledge.htm.

Signing the Pledge Card should be done on-line if at all possible. The on-line version of this is through webinservice. When you pass the "test" you are giving your receipt and acknowledgment. To do this through webinservice go to http://webinservice.com/vanderbilt webpage.