December 15, 2006

Compliance program gets revised to ease adherence

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James Snell Jr., M.D.

Compliance program gets revised to ease adherence

Ruth Nagareda, J.D.

Ruth Nagareda, J.D.

It's difficult for employees to stay current with all of the rules and regulations governing health care, research and education.

To make the task easier, the Vanderbilt University compliance program plan has been revised. The University's two compliance offices pared it down to a third of its former length, put it in layman's terms and posted it on their Web sites for easy reference.

“Compliance is part of every employee's daily operation,” said James Snell Jr., M.D., professor of Medicine and VUMC's corporate compliance officer. “Everybody needs to do their part.”

Compliance breaks down into several categories, including patient confidentiality, the disposal of hazardous materials, conflicts of interest, discrimination in hiring, kickbacks, scientific integrity and the management of federally funded grants.

Each category involves a number of possible infractions, from benign to serious, explained Ruth Nagareda, J.D., the University's compliance officer and former director of the Office of Student Conduct and Academic Integrity.

“If somebody is having an employee work extra hours off the clock and not keeping track of their overtime, that is a violation of wages and hours,” Nagareda said.

“Maybe you see someone who's painting your building pour paint thinner down the drain. Maybe somebody's locked a fire door, or you think a piece of equipment is dangerous,” she said. “Those are all things that should be reported.”

Confidentiality regulations don't only apply to patients, Snell added.

“Just because you happen to know something about a colleague doesn't mean you should tell everybody,” he said. “That's a common mistake, where people e-mail the whole office when someone's having surgery or is pregnant. They think they're doing a good thing, but what they're really doing is violating the person's privacy.”

Another compliance infraction is giving out one's Vanderbilt-issued password.

“Many times we find that people's intuition is telling them they should raise a question, and this (plan) gives them the confirmation that they should ask that question,” Snell said. “Our job is to address those concerns, to investigate the worry and help solve the problem if one exists.”

To confidentially report a possible violation, call the compliance hotlines at 343-0135 for the Medical Center or 322-1033 for University central.

Compliance-related questions also can be directed to Snell at 343-7266 or Nagareda at 322-5162. Phone calls will be kept in the strictest confidence.

In addition, concerns may be reported directly to a supervisor or to the appropriate departments, such as Environmental Health and Safety, the Opportunity Development Center, Human Resources or the Office of Contract and Grant Accounting.

To read the revised compliance program policy, visit or