Office of Healthcare Compliance

Medical Center Compliance
University Compliance
Confidential Hotline






Compliance means adhering to the laws, rules, regulations, policies and procedures governing the operations of the organization as well as the jobs performed by our employees.  Examples of agencies that enforce the laws, rules and regulations that govern our organization include but are not limited to:

These are only a few examples of the multitude of local, state and federal agencies that Vanderbilt must comply with in order to operate successfully.  Due to the multitude of agencies we must work with on a daily basis, there are various areas within Vanderbilt that are charged with implementing compliance requirements to educate and provide our employees with the most current information related to their jobs.  Every employee is a member of the Compliance Team and charged with understanding the compliance risks associated with the job they perform.
How do we begin to comply with the thousands of laws that govern the organization?
The first step for you as an employee is to understand the Standard of Conduct at Vanderbilt.  These standards are a critical portion of the Vanderbilt University’s Compliance Program Plan.  Developing an effective Compliance Program Plan is essential to the success of any compliant organization.  With any successful program there must be a solid foundation.
Reporting a Compliance Violation
What exactly is a “compliance violation” and do you have to report it?
Compliance violations can occur anywhere at anytime.  A violation can be intentional or unintentional.  The environment that we work in is very complex and so are the laws that govern our industry.  A simple explanation of a compliance violation is any action that has caused Vanderbilt to non-comply with a law, rule, regulation, policy or procedure.
Reporting a violation is the responsibility of every employee.  The reporting of a compliance violation is your responsibility because without reporting a violation, resolution of the issue may not occur.  The goal of any Compliance Professional when a violation is reported is to immediately stop the violation from continuing until it can be reviewed in more detail to determine if a violation has occurred.  In the event that a violation has occurred, our job is to educate those involved with the violation to prevent future violations and monitor periodically to detect any future violations.
You are also encouraged to report suspected violations, as the perception of a violation should be addressed with everyone involved, as well.  In many cases, the activity may not be not an actual violation.
You are also protected from retaliation when reporting a compliance violation.  Vanderbilt has a non-retaliation policy that protects anyone that comes forward to report a violation from retaliation.
How to report a compliance violation
Once you have detected, or suspect that you have detected, a compliance violation you should report it.  How do you begin to report the violation?
  1. Contact your immediate supervisor and explain that you think you have identified a potential compliance violation.  Your immediate supervisor is the initial line of defense when reporting potential violations.
  2. If you do not feel comfortable contacting your immediate supervisor, you always have the right to report a potential violation directly to the Compliance Office at 343-7266 or compliance.office@vanderbilt.edu.
  3. The helpline is another option.  When using the Confidential Helpline you may remain anonymous.  This option is available 24 hours a day, 7 days a week, by calling toll-free 1-866-783-2287 or online at  www.vanderbilt.edu/integrityline.

This page was last updated July 22, 2014 and is maintained by