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
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
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
• 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
• 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
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
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.
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.
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
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.
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
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.
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.
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.
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
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
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.
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.
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
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.
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.
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:
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.
Vanderbilt University is committed to the lawful referral of patients
to services outside the Medical Center for the delivery of appropriate
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.
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
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.
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.
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
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.