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Institutional Compliance Committee. Structure and Function. President Executive Vice President (Chairman) Vice President for Business and Admin Vice President for Research Chief Financial Officer. Dean, School of Medicine Director, Health and Safety Services Director, Legal Affairs

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Presentation Transcript
committee members
President

Executive Vice President (Chairman)

Vice President for Business and Admin

Vice President for Research

Chief Financial Officer

Dean, School of Medicine

Director, Health and Safety Services

Director, Legal Affairs

Director, Audit Services

Hospital Administrator

Committee Members
committee members cont
Physician-in-Chief

Medical Director of the Practice Plan

One MD faculty member

One Basic Science faculty member

Ex Officio

Executive Directors of Institutional Compliance

Director of Monitoring and Investigations

Committee Members (cont)
committee function
Committee Function
  • Executive Vice President is the Institutional Compliance Officer and Chair of the Institutional Compliance Committee
  • Committee meets monthly for one hour
  • Meetings are scheduled at least six months in advance.
committee function5
Committee Function
  • Most responsible persons are on the Institutional Compliance Committee
  • Committee ensures an annual compliance risk assessment is conducted, ranks the items, and assigns responsible persons for each risk
  • Each high-risk Item on our Risk Assessment has an Action Plan or Established Process for ensuring compliance.
committee function cont
Committee Function (cont)
  • Status and/or monitoring of each high-risk area is reported to the committee at least quarterly.
  • Committee discusses reports of non-compliance.
committee function cont7
Committee Function (cont)
  • Compliance investigations are discussed in the committee and necessary actions determined.
  • Committee votes on official actions taken related to specific faculty or department.
  • Votes are recorded in minutes to protect the compliance officer and indicate the determination and intent of the committee.
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