The purpose of the Institutional Compliance Program is to pro-actively promote compliance with all applicable legal and regulatory requirements. The compliance program strives to foster and help ensure ethical conduct and provide education, training, and guidance to all faculty and staff members. These goals are accomplished through regular high risk identification, training, and monitoring of the effectiveness of compliance activity.
Building Upon the Mission: Everyone has Responsibilities
Ethical conduct and following the policies, laws, and regulations which apply to the university is the responsibility of each faculty and staff member. Each of us must be aware of the legal and ethical standards which apply to our job responsibilities. We must perform our duties and responsibilities in accordance with the provisions of federal and state laws, regulations, and policies; the Rules and Regulations of the Board of Regents of the U.T. System; and the policies of The University of Texas Health Science Center at Houston. These responsibilities are outlined in the university’s General Standards of Conduct Policy.
If you have a question, concern, report or problem involving any aspect of compliance, we want to hear from you. Any member of the health science center community (faculty, staff, resident, or student) or other interested party with knowledge or suspicion of any activity that may be illegal or non-compliant is encouraged to make use of the university's Compliance Hotline, 888-472-9868, or send an email to firstname.lastname@example.org.
The Executive Compliance Committee (ECC) is responsible for providing advice and guidance to the President and the Chief Compliance Officer on the design and operation of the Institutional Compliance Program. The ECC is convened by the President and is composed of the following executive leadership positions:
- President (Chair)
- Executive Vice President for Academic and Research Affairs
- Dean, Medical School
- Executive Vice Dean for Clinical Affairs
- Sr. Executive Vice President, Chief Operating and Financial Officer
- Assistant Vice President and Chief Compliance Officer, ex officio
- Vice President and Chief Legal Officer, ex officio
- Assistant Vice President & Chief Audit Officer, Internal Audit, ex officio
The ECC is responsible for the following:
- Reviewing and approving policies and procedures that govern the Institutional Compliance Program, including plans for communicating the policies and procedures to the UTHealth community;
- Ensuring that appropriate compliance education and training (both general and specific) is provided to all members of the University community on a regular basis;
- Ensuring that the Institutional Compliance Program is designed to prevent and/or detect non-compliance with applicable laws, regulations, and policies, including regular review of the confidential reporting function;
- Ensuring that an annual compliance risk assessment is conducted, compliance risks are prioritized, and the highest risks to the University are identified and designated as Institutional High Risks;
- Ensuring that appropriate processes are in place to control or manage the Institutional High Risks;
- Reviewing and approving the UTHealth Institutional Compliance Plan and revisions to the Plan;
- Reviewing reports from the Chief Compliance Officer, regarding the investigation and resolution of confidential reports of material/significant non-compliance and providing guidance to the Chief Compliance Officer on such investigations, unless such review and guidance would compromise the investigation and/or its findings;
- Ensuring that all findings of non-compliance are appropriately resolved through corrective action and/or disciplinary action to prevent recurrence of similar non-compliance in the future;
- Ensuring the consistent enforcement of compliance standards, including the fair, equitable, and consistent disciplinary action of individuals responsible for non-compliance;
- Evaluating the Institutional Compliance Program infrastructure on a periodic basis; and,
- Support of the Institutional Compliance Program in ways the President deems appropriate.
The ECC has established an Institutional Compliance Committee (ICC) which meets quarterly in a joint meeting with the ECC. The ICC is composed of:
- Dean of the School of Dentistry
- Dean of the School of Nursing
- Dean of the School of Public Health
- Dean of the Graduate School of Biomedical Sciences
- Dean of the School of Health Information Sciences
- The University of Texas Harris County Psychiatric Center Administrator
- Any Risk Area Designated Responsible Party (DRP) not already listed
The ICC reviews quarterly summaries of all ECC activities and communicate institutional compliance information to each members respective area.
William S. LeMaistre, J.D., CHC
Assistant Vice President and Chief Compliance Officer
Loretta Davis, MPA
Manager, Compliance/Conflicts of Interest
Jacquline Stone Schnyder, CCEP
Stephen Arong, J.D.
Marsha Harris-Hall, CPC/I, CANPC, CEDC
Healthcare Billing Compliance Manager
Tricia Dean, CPC
Senior Compliance Specialist
Stuart Bernstein, CPC, COCSenior Compliance Specialist