UCSF Whistleblower Policy

1. UCSF Whistleblower Policy What you need to know and do about suspected wrong-doing www. universityofcaliforina.edu/hotline

2. Agenda • Purpose of UCSF’s Whistleblower Policy • Important terms and their definitions • Reporting allegations at UCSF • Campus roles and responsibilities • Investigations • External reporting • Investigative rights & responsibilities of Whistleblowers, Subjects, Participants, and Investigators • Retaliation Protection

3. Purpose • UCSF, as a steward of public funds, must accept and investigate allegations of suspected “improper governmental activities” (Gov. Code Sec. 8547 - 8547.12) • These campus policies implement and support University-wide policy • Policies also promote open, honest, and accountable management of public resources

4. Definitions • University resources - cash, real, or personal property, intellectual property, effort of personnel, facilities, equipment, records, UC’s name • Improper Governmental Activities - any activity by UC or its employees that: • i) is in violation of any state or federal law or regulation, including, but not limited to, corruption, malfeasance, bribery, theft of government property, fraudulent claims, fraud, coercion, conversion, malicious prosecution, misuse of government property, or willful omission to perform duty; or • ii) is economically wasteful, or involves gross misconduct, incompetency, or inefficiency. • Note that misconduct, incompetence, or inefficiency need to be particularly extreme (“gross”) to be covered under this policy.

5. Definitions (cont’d) • Protected disclosure - any good faith communication that may evidence an improper governmental activity or a health or safety concern where the disclosure is made for the purpose of remedying that condition. • A “protected disclosure” is an official “whistleblower complaint” and provides protection from later retaliation. • Illegal Order - any directive to violate or assist in violating a law, rule, or regulation or any order to work in conditions that would unreasonably threaten the health or safety of employees or the public. • An example of an “illegal order” might be a manager directing an employee to process inappropriate and illegal payments.

6. Definitions (cont’d) • Whistleblower - a person or entity making a protected disclosure is commonly referred to as a whistleblower • Whistleblowers may be University employees, students, patients, and applicants for employment, vendors, contractors, or the general public. • The whistleblower's role is as a reporting party. They are not investigators or finders of fact, nor do they determine the appropriate corrective or remedial action that may be warranted. • Whistleblowers may file claims anonymously.

7. Reporting Allegations at UCSF • Making Reports - While “protected disclosures” can be made to ANY supervisor, manager, or other person in authority, UCSF encourages ALL such issues to be referred to the campus Whistleblower Coordinator. • Managers and other responsible authorities are expected to report any such allegations to the Whistleblower Coordinator. • Complaints can be filed with the Office of the President, particularly for allegations against the Whistleblower Coordinator, the Chancellor, or other high ranking campus officials. • Retaliation Protection - Employees and applicants who make protected disclosures shall not be retaliated against in any manner and are protected from such acts.

8. Campus Roles & Responsibilities • Whistleblower Coordinator - responsible for receiving complaints and ensuring appropriate referral to the Investigations Group • The Director of Audit Services serves this role. • Investigations Group (I Group) - ensures coordination and proper reporting of investigations • Membership: UCSF Locally Designated Official (Chair), Director of Audit Services (Whistleblower Coordinator), Chief Administrative and Human Resources Officer (Medical Center), Chief Campus Counsel, Chief Financial Officer (Medical Center), Chief of Police, Controller, Director-Office of Resource Stewardship (School of Medicine), Human Resources Director (Campus)

9. Roles & Responsibilities (cont’d) • I Group is responsible to ensure that: • Appropriate UCSF officials are informed of allegations; • Proper reporting occurs, as required by law and policy; • Proper resources are brought to bear to cause timely and thorough review of allegations; • Proper investigative channels are used; • There are no conflicts of interest in specific investigations; • Communications across investigative channels are facilitated and coordinated ; • Progress of investigations is monitored; and, • Advice on corrective or remedial actions is provided and coordinated.

10. Roles & Responsibilities (cont’d) • Managers (both academic and staff) • Managers must report allegations - whether reported as a protected disclosure by their subordinates or discovered in the course of performing their duties. • Managers should document oral reports by a written transcription and internal communications regarding allegations of improper governmental activities should normally be in writing. • If a manager is not certain that an issue is appropriate for referral or reporting, he/she should consult with the Whistleblower Coordinator to make that determination. • Managers need to ensure that subordinate supervisors are aware of and comply with this policy.

11. Investigations • I Group assigns investigations - based on individual circumstances of each complaint, the I Group assigns cases to appropriate investigative units: • Internal Audit: allegations of misuse of University resources, fraud, or other financial irregularities. • Campus Police: criminal cases and their investigations and coordination and referral to district attorney or other law enforcement agencies. • Controller for the School of Medicine: compensation plan issues. • Clinical Compliance Officer: all clinical billing issues and investigations. • Other investigations: investigations of personnel matters, scientific misconduct, student misconduct, and other matters shall be assigned by the I Group, as appropriate to issues raised (e.g. HR, Academic Affairs, etc.)

12. Off-Campus Reporting • Reporting to UCOP - University policy requires disclosure to UCOP when the matter: • represents a significant internal control or policy deficiency that is likely to exist at other units or across the University system; • is likely to receive media or other public attention; • involves the misuse of University resources or creates exposure to a liability of at least $25,000; • involves a significant threat to the health and safety of employees and/or the public; • is significant or sensitive for other reasons; or, • alleges an improper activity by the Chancellor, the Whistleblower Coordinator, or the Campus Auditor. • Based on case circumstances, reporting to other external agencies (e.g. funding agencies) may be required by law or regulation.

13. Whistleblowers - Rights • A whistleblower's right to protection from retaliation does not extend immunity for any complicity in the matters that are the subject of the allegations or an ensuing investigation. • Whistleblowers, generally, may be informed of the outcome of their complaint.

14. Whistleblowers - Responsibilities • Whistleblowers must provide complete and accurate information and have a reasonable belief that improper governmental activity occurred. • Intentional filing of a false report is, in itself, an improper governmental activity upon which the University has the right to act. • Whistleblowers shall not obtain evidence for which they do not have a right of access (may in itself be an improper activity). • Whistleblowers should be prepared to be interviewed by University investigators.

15. Investigators - Rights and Responsibilities • Whistleblower investigations should be launched only after preliminary consideration shows that the allegation, if true, constitutes an improper governmental activity, and either: • is accompanied by information specific enough to be investigated; or, • has or directly points to corroborating evidence that can be pursued. • Investigators derive their authority and access rights from University policy or Regental authority when acting within the course and scope of their responsibilities. • Investigators will have competency in the area under investigation. • Investigators have a duty of fairness, objectivity, thoroughness, ethical behavior, and observance of legal and professional standards.

16. Subjects of Investigations- Rights and Responsibilities • Identity of subjects will be confidential to the extent possible given the legitimate needs of law and the investigation. • Subjects are normally informed of a formal investigation and have opportunities for input during the investigation. • Subjects have duty to cooperate which shall not infringe upon self-incrimination protections in criminal cases. • Subjects have a right to consult with a person of their choice, including having legal representation. • During investigations an employee may be placed on an administrative leave or investigatory leave when it is determined that such a leave would serve the best interests of the employee, the University, or both. • Such a leave is not to be interpreted as an accusation or a conclusion of guilt or innocence of any individual including the person on leave.

17. Investigation Participants - Rights and Responsibilities • University employees who are interviewed, asked to provide information, or otherwise participate in an investigation have a duty to fully cooperate with UC authorized investigators. • Participants should refrain from discussing investigations or testimony with those not connected to the investigation. • Confidentiality requests by participants will be honored to extent possible within the legitimate needs of law and the investigation. • Participants are entitled to protection from retaliation for having participated in an investigation.

18. Retaliation Protection • “A University employee may not: • (1) retaliate against an employee or applicant for employment who has made a protected disclosure or who has refused to obey an illegal order; nor, • (2) directly or indirectly use or attempt to use the official authority or influence of his or her position or office for the purpose of interfering with the right of an applicant or an employee to make a protected disclosure…” • It is the intention of the University to take whatever action may be needed to prevent and correct retaliation for whistleblowing.

19. Filing a complaint • The complainant must: • have made a protected disclosure alleging improper governmental activities pursuant to current University policy; or • was threatened, coerced, commanded, or prevented by intimidation from filing a report of improper governmental activities; or • refused to obey an illegal order. • Complainant must also sufficiently detail facts to support allegation; and, • Complainant must file complaint within 12 months of alleged retaliation or intimidation.

20. Whistleblower Coordinator Role in Retaliation Complaints • Receives retaliation complaints and administers local procedures • Refers matters to existing grievance procedures, where appropriate • Refers matters to Retaliation Complaint Officers where grievance process is not appropriate • Receives and acts on fact-finding reports from retaliation complaint investigations (or reviews conclusions and applied remedies for cases heard through existing grievance procedures)

21. Retaliation Complaint Officers Role • RCO shall ensure a competent investigation is conducted on the allegation of retaliation or interference by ensuring that: • existing grievance procedures, where applicable, adequately investigate and report their findings on the allegations; • hearing officers or arbitrators, where applicable, adequately cover the allegations; and, • a competent and timely fact-finding is conducted on allegations that are not appropriately handled by existing grievance processes. • RCO shall present findings of fact to the Whistleblower Coordinator within 120 days unless an extension is granted by the Coordinator

22. Retaliation Complaint Officer Roles • Cynthia Leathers: Academic employees • Mike Tyburski: Campus staff employees • David Odato: Medical Center staff employees • Eric Koenig: Students

23. How and Where to Report • How to report: • In writing or orally. • With as much specific factual information as possible. • Anonymously, if preferred. • Where to report: • Employee’s Supervisor • Human Resources Office (Campus or Medical Center) • Academic Personnel Office • Any University Administrator • Director-Audit Services/Whistleblower Coordinator • University-wide Whistleblower Hotline: 1-800-403-4744 or • universityofcalifornia.edu/hotline • State Auditor’s Whistleblower Hotline: 1-800-952-5665 • California Attorney General’s Hotline: 1-800-952-5225

24. Other Resources • APM 350-13 Defalcations and Fraud • APM 050-11 Personal Use of University Property • APM 150-23 Reporting Improper Governmental Activities • and Protection Against Retaliation (Whistleblowing) • Whistleblower Policy web sites • OP: http://ucwhistleblower.ucop.edu/ • UCSF: http://whistleblower.ucsf.edu/ • Updated January 2011