SUBJECT:  UC Health Sciences Clinical Enterprise Corporate Compliance Program

This Notice is provided to invite your review and comments regarding the University of California Health Sciences Clinical Enterprise Corporate Compliance Program. In August 1999, UCSD Health Sciences and UCSD Healthcare members reviewed and provided comments on an initial draft of the proposed Compliance Program. Comments received from UCSD and other UC locations have been incorporated into the current version of the proposed Program, which is dated August 7, 2000.

Implementation of the Corporate Compliance Program will demonstrate the University's commitment to ethical and legal behavior, and clearly communicate the specific standards of conduct that address those potential areas of risk that have been identified by the Federal government. The Program will apply to management personnel, physicians, health professions faculty and students, and other health care professionals and staff involved in clinical services, including patient care and billing services at the medical schools and University-owned or leased hospital facilities. The proposed Program conforms to the Office of the Inspector General's (OIG) guidelines governing compliance programs for the health care industry.

Important elements of the Program include the following:

Code of Conduct, including standards of ethical conduct;

Educational and Training Programs;

Processes for faculty and staff to raise questions and concerns, including a toll-free Hotline telephone number to anonymously report suspected violations of compliance issues;

Emphasis on the University's existing Policy on Safeguarding Resources and Investigating Misuse of Resources, and the Policy For Reporting Improper Governmental Activities and Protection Against Retaliation, as the appropriate vehicles to report and investigate alleged improper/illegal compliance activities;

Regular self-monitoring activities to ensure compliance with the University's Program;

Emphasis on implementation of remedial actions, corrective or disciplinary actions, or both for noncompliance pursuant to the provisions of existing personnel policies and collective bargaining agreements; and

Exclusion of sanctioned individuals from Medical or Medicaid billing, reimbursements and patient care.

The UC Corporate Compliance Program is accessible for your review at http://www.ucop.edu/acadadv/acadpers/apm/corpcomp.html

A UCSD Corporate Compliance Management Manual is being developed, based on the systemwide Program document, to provide guidance to all UCSD Health Sciences and Healthcare personnel. Copies of the Manual will be made available in your departmental office and in the Compliance Office. You will soon participate in an educational session where you will be introduced to the UCSD Compliance Program. You will receive a Handbook, which includes the Code of Conduct and an overview of the Program.

Academic and staff personnel should direct their comments to Ms. Kathleen Naughton, Corporate Compliance Manager, at (619) 294-6072 or electronically at KNaughton@UCSD.EDU. by noon on Monday, September 25, 2000.

                                                Edward W. Holmes, M.D.
                                                Vice Chancellor Health Sciences &
                                                Dean, School of Medicine