31.2.02 - Integrity Hotline Policy: Reporting Improper Activity or Wrongdoing

Compliance and HIPAA: General Compliance

Last Updated: 11/16/2016

Original policy date: 05/25/2016

Applies to: Faculty, Staff, Residents & Clinical Postdoctoral Fellows, Postdoctoral Fellows, Students

I. Rationale
A confidential and anonymous reporting mechanism is required for an effective compliance program. The Baylor College of Medicine (BCM) Integrity Hotline allows confidential and anonymous reporting of known or suspected improper activity or wrongdoing, which will be investigated and appropriately addressed by BCM. As a federal contractor, BCM is required by federal law to protect persons who, in good faith, report improper activity or wrongdoing from retaliation.
II. Stakeholders Affected by this Policy
This policy applies to BCM Community Members as defined in this policy.
III. Definitions
(a)   BCM Community Members means BCM Employees, BCM Learners, patients, officers and board members, volunteers, contractors, and agents of BCM whether or not paid by BCM.
(b)   BCM Employees include faculty, postdoctoral trainees, residents, clinical fellows, and staff employed by BCM.
(c)   BCM Learners includes students enrolled in all BCM schools and degree-granting programs.
(d)   Retaliation means any action taken by BCM, BCM Employees or agents that adversely affects the employment or other institutional status of a BCM Community Member because the individual or entity has, in good faith, made an allegation concerning the violation of a law, rule, policy, procedure, inadequate institutional response to such violation, or has cooperated in good faith with an investigation of such allegation. Acts of retaliation include discharge, demotion, suspension, threats, harassment, grade manipulation, or any other punitive action that significantly impacts an individual’s employment or relationship with BCM.
(e)   Baseless Allegations means claims or assertions of improper activity or wrongdoing made without knowledge of or in reckless disregard for the truth.
(f)    Improper Activity or Wrongdoing means any activity that a BCM employee or learner reasonably believes to be a violation of any applicable law, rule, regulation, BCM policy, or policy of a BCM Affiliate, or any other activity that is likely to negatively impact the reputation of BCM or its Mission or Vision. Reporting of improper activity or wrongdoing to the College is warranted where there is evidence of:
·         mismanagement of a federal contract or grant;
·         waste of federal funds;
·         an abuse of authority relating to a federal contract or grant;
·         a substantial and specific danger to public health or safety;
·         a violation of law, rule, or regulation related to a federal contract or grant (including the competition for, or negotiation of, a contract or grant);
·         lapses in professionalism; and
·         violations of BCM policy that may not be violations of law.
(g)   Trade Secret, as defined by 18 U.S.C. § 1839, means all forms and types of financial, business, scientific, technical, economic, or engineering information, including patterns, plans, compilations, program devices, formulas, designs, prototypes, methods, techniques, processes, procedures, programs, or codes, whether tangible or intangible, and whether or how stored, compiled, or memorialized physically, electronically, graphically, photographically, or in writing if—
·         The owner thereof has taken reasonable measures to keep such information secret; and
·         The information derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable through proper means by, another person who can obtain economic value from the disclosure or use of the information.
IV. Policy
1.     Reporting Obligations. Consistent with the Code of Conduct (31.1.01) and other relevant BCM policies, BCM Employees and BCM Learners have a responsibility to promptly report improper activity or wrongdoing to their immediate supervisor or appropriate Dean. If an individual is not comfortable speaking with their supervisor or is not satisfied with the response, they may report to the following offices or resources:
a.     Office of Human Resources – 713-798-4346
b.    Office of the General Counsel – 713-798-9172
c.     Office of Risk Management – 713-798-4509
d.    Office of Compliance & Audit Services – 713-798-4366;
e.     The confidential and anonymous BCM Integrity Hotline- 855-764-7292 or electronically at www.bcm.ethicspoint.com
Anyone who knowingly, or with reckless disregard for the truth, gives false information or knowingly makes a false report will be subject to disciplinary action, up to and including termination of employment or relationship with BCM.
2.     Reporting Mechanisms. BCM shall maintain a confidential and anonymous reporting resource (BCM Integrity Hotline) that allows BCM Community Members to report improper activity or wrongdoing confidentially or anonymously, at their discretion, through a toll-free number or the BCM intranet webpage. However, anonymous reporting may significantly limit the scope of the investigation and BCM’s ability to undertake administrative action or response. For example, if the report involves an employment issue or grievance based on personal experience of the reporter, especially in the absence of witnesses, full investigation into the matter may not be possible unless additional information about the reporter (e.g. name and contact information) is provided for follow-up.
3.     Retaliation Prohibition. No retaliation shall be taken against any BCM Community Member who, in good faith, reports concerns or allegations of improper activity or wrongdoing, or who assists in an investigation of alleged improper activity or wrongdoing. 
a.     Any BCM Community Member who commits or condones any form of retaliation against a report or witness to improper activity or wrongdoing will be subject to disciplinary action up to and including termination of employment and/or termination of their relationship with BCM. 
b.    Those who self-report allegations of improper activity or wrongdoing may still be subject to disciplinary action in accordance with other relevant BCM policies.
c.     Protections afforded under this policy cannot be waived by any agreement, policy, form or condition of employment. 
4.     Confidentiality of Reports. The confidentiality of individuals who report allegations of improper activity or wrongdoing will be protected as required by applicable law and within the scope of BCM accreditation requirements.
5.     Disclosure of Trade Secrets. Any BCM Community Member who discloses a Trade Secret while making a report of improper activity or wrongdoing may be subject to criminal or civil liability under federal and state law, regardless of whether the Trade Secret is held solely by BCM or shared with a third-party.
a.     Notice of Immunity. In accordance with 18 U.S.C. §1833(b), a BCM Community Member will be eligible for immunity from criminal and civil penalties for disclosure of BCM Trade Secrets in the following limited circumstances:
1)   When the disclosure is made in confidence to a federal, state or local government official, either directly or indirectly, or to an attorney for the sole purpose of reporting or investigating a suspected violation of law;
2)   When the disclosure is made in a complaint or other document filed in a lawsuit or other proceeding, if the filing is made under seal; 
3)   When the disclosure is made to the BCM Community member’s attorney pursuant to a lawsuit against BCM for retaliation, Trade Secret information may be used in the court proceeding if:  
a)     any documents containing the Trade Secret are filed under seal, and
b)    the BCM Community Member does not disclose the Trade Secret, except as required by court order.
V. Responsibilities
·         The Chief Compliance Officer (CCO) or designee is responsible for the daily oversight of the BCM Integrity Hotline. Specific responsibilities include:
o    Timely assignment of BCM Integrity Hotline matters to the designated BCM Department/School for review and investigation;
o    Ensuring proper functioning of the Hotline;
o    Establishing reporting and records maintenance procedures;
o    Assisting departments with investigations or monitoring the status of calls referred (triaged) to the Department/School for review and investigation; and
o    Maintaining the security and confidentiality of all calls, web reports, and related documents. 
·         BCM Schools/Departments using the BCM Integrity Hotline to address improper activity or wrongdoing in their areas will designate one or more individuals (Liaisons) responsible for investigating and reporting on issues as assigned to them by the CCO or designee.  
·         Liaisons will exercise discretion and integrity during investigation and reporting, assuring reasonable and appropriate departmental response while maintaining confidentiality of the reporter’s identity in accordance with this policy.
·         College leadership must take appropriate measures to ensure proper implementation and support of this policy within each school, center, department, and functional unit, and to encourage prompt reporting of problems and concerns by BCM Community Members. To that end, the Office of Compliance will disseminate education to BCM Community Members about reporting obligations and proper use of the Integrity Hotline. The Office of Governance will ensure that this policy is published on the BCM Intranet.
·         The CCO will make routine reports about Hotline activity to the BCM Audit Committee, and to other committees as required. This report will include the total number of calls and reports received, acted upon, and the general results from the Hotline operation. In addition, the report will include any recommendations for system-wide improvements or corrective action arising from the results of the Hotline operation and related investigations.
VI. Procedures for Implementation and Review
A.    Use of BCM Integrity Hotline.
1.     Reporting by Phone.
a.     Reporting anonymously to the Hotline can be accomplished by directly calling the toll-free BCM Integrity Hotline number, 1-855-764-7292, 24 hours a day/7 days a week.
b.    All callers are given the opportunity to speak with a live operator who will document the information provided.
c.     No attempt will be made by the operator to identify a caller who requests anonymity. Whenever callers choose to disclose their identity,  their confidentiality will be protected as required by applicable law and within the scope of BCM accreditation requirements. The caller may be asked to call back in case additional information is needed by BCM. In addition, callers will be provided a key or reference number for the callback to protect their anonymity. 
2.     Reporting Online.
a.     Online reports to the BCM Integrity Hotline may also be made through the confidential website, www.bcm.ethicspoint.com.
b.    No attempt will be made to identify the reporter who requests anonymity. If the reporter chooses to identify him or herself, the identity will be held in confidence to the fullest extent practical or allowed by law. The reporter will be asked to provide a confidential password of the reporter’s own choosing and reference number will be provided by the web portal for the reporter to access the reporting website for any further communication or information. The password and reference number will protect the reporter’s identity.
3.     Documentation of Reporting.
a.     The report should describe the nature of the complaint or violation, document the date and time reported, identify the source of the information (unless reported anonymously), and the department or facility affected. If a formal report is made directly to a supervisor or BCM department Liaison (e.g., walk-ins, emails, etc.), the Supervisor (or designee) or Liaison is responsible for entering the report directly into the web portal for investigation as appropriate. Otherwise, the CCO will retrieve online and phone reports and assign responsibility for further documentation to the Liaison.
B.    Response and Investigation.
1.     The CCO or his/her designee will track all calls made to the BCM Integrity Hotline.
2.     The CCO or designee will triage the report to determine the subject matter of the investigation, what level of investigation is required regarding the reported complaint and assign the report to the appropriate BCM Department for review and investigation. BCM Employees tasked with review and investigation of the matter shall document their investigation through the BCM Integrity Hotline.
3.     In the event that the CCO is not satisfied that a matter brought through the BCM Integrity Hotline was properly addressed and resolved, the CCO will be responsible for and is authorized to take the matter to other persons in positions of authority.  
4.     Substantiated allegations of improper activity or wrongdoing will be subject to sanctions and/or corrective action. 
C.    Schedule for Review and Update. The Compliance Office will review this policy periodically and will be updated as needed to maintain compliance with applicable law.  
VII. Stakeholder Compliance
Failure to comply with this policy can result in reputational harm to BCM, monetary penalties and/or loss of federal contracts, as well as disciplinary action.
VIII. Tools
·         BCM Integrity Hotline (1-855-764-7292) and www.bcm.ethicspoint.com
·         BCM Degree Programs and Certifications – consult this resource for more detailed information on specific accreditation requirements for specific programs.
IX. Related Policies and Documents
·         23.1.01 – Code of Conduct
X. Applicable Laws, Regulations & Standards
·         41 U.S.C. § 4712;
·         18 U.S.C. §1839;