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Institutional Compliance Committee

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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Institutional Compliance Committee

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  1. Institutional Compliance Committee Structure and Function

  2. 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

  3. 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)

  4. 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.

  5. 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.

  6. 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.

  7. 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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