What You Need to Know and Do - U

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					UCSF Whistleblower Policy
  What you need to know and do about
        suspected wrong-doing

      www. universityof
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                                           • 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
                                           • Retaliation Protection
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                                           • 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
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                                           • 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.
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                                                         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
                                              – 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.
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                                                        Definitions (cont’d)
                                           • Whistleblower - a person or entity making a
                                             protected disclosure is commonly referred to as a
                                              – 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.
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                                             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.
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                                           Campus Roles & Responsibilities
                                           • Whistleblower Coordinator - responsible for
                                             receiving complaints and ensuring appropriate referral to
                                             the Investigations Group
                                             – Abby Zubov, Director of Audit Services, serves this role.

                                           • Investigations Group (I Group) - ensures
                                             coordination and proper reporting of investigations
                                             – Membership: Interim VC Randy Lopez (Chair), Director Abby
                                               Zubov (Whistleblower Coordinator) , Louisa Burgio (School of
                                               Medicine), Marcia Canning (Chief Campus Counsel), Susan
                                               Moore (Medical Center CFO), David Odato (Medical Center HR),
                                               Pam Roskowski (Chief of Police), and Mike Tyburski (Campus
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                                           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
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                                           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.
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                                           • 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
                                             – 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.)
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                                                       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.
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                                                      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.
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                                              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.
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                                                 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
                                           • Investigators have a duty of fairness, objectivity,
                                             thoroughness, ethical behavior, and observance of legal and
                                             professional standards.
                                           Subjects of Investigations - Rights and Responsibilities
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                                           • 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.
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                                                Investigation Participants - Rights and
                                           • 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.
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                                                         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.
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                                                             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.
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                                            Whistleblower Coordinator Role in
                                                 Retaliation Complaints
                                           • Receives retaliation complaints and administers local
                                           • 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)
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                                            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
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                                               Retaliation Complaint Officer Roles

                                           •   Cynthia Lynch - Academic employees
                                           •   Mike Tyburski - Campus staff employees
                                           •   David Odato - Hospital staff employees
                                           •   Eric Koenig - Students
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                                                        How to Report

                                           Campus Hotline: 502-2810

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                                                           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 homepage
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