The compliance office performs essential functions to ensure that effective compliance is occurring in all activities governed by federal law and regulation, and by university policy.
Verification does not mean performing the work of compliance. It means making sure that all relevant activities have effective compliance organizations and these compliance organizations have effective policies and procedures, effective training programs and effective techniques for monitoring compliance.
The compliance office conducts compliance audits. Auditing is not the same as monitoring. Auditing and monitoring are both means of checking to see if compliance has occurred. However, there are important differences:
- Monitoring is typically done by the activity that is being monitored. Auditing is done by an outside entity. Another way to say this is that auditing is arm’s length monitoring. The arm’s length feature is important because, when checking is done by an office or individual that can be perceived to have an interest in protecting the activity, this perception can diminish the credibility of the checking. Auditing, on the other hand, because its connection to the activity being checked is more distant, may have greater credibility. This is the reason that audits are conducted by an office that does not report to a dean or an administrator responsible for the success of a given activity. Instead, the office reports directly to the Chancellor, and, if necessary, directly to the Board of Trustees.
- Monitoring typically occurs much more frequently than auditing. Audits are more occasional. Audits may occur with or without advance notice.
- Monitoring is less formal. It checks mechanically for compliance. Audits, on the other hand, are governed by formal protocols that involve the checking process itself, discussions with department heads, communications with other outside entities such as the dean and the Office of General Counsel and systematic follow-up for the purpose of curing deficiencies.
- Monitoring and auditing should work together. Monitoring may uncover deficiencies that suggest the need for audits. Audits may uncover deficiencies that suggest the need for better monitoring. In other words, monitoring and auditing should complement each other.
University Code of Conduct
The office is responsible for developing, revising and maintaining a university code of conduct.
University Compliance Hotline
The office maintains a compliance hotline for the reporting of suspected violations or concerns at the university.
Communication with University Leadership
The office maintains effective and ongoing communication with the university’s senior management and with the audit committee of the Board of Trustees concerning the state of compliance in university activities that require compliance.
This communication should include regular reports of compliance activity—audits, hotline activity, etc. and also of plans for future compliance activity.
The most significant benefits of a university compliance program are the following:
- Furthering a university culture that does not tolerate illegal or actionable behavior and prompts faculty and staff to consider the potentially adverse legal consequences of certain conduct;
- Increasing the likelihood of early detection if potentially illegal or actionable conduct does occur, thus creating the opportunity to correct or self-report;
- Serving as a basis to persuade governmental authorities to decline prosecution or the initiation of a civil or regulatory action;
- Reducing significantly the penalties or fines assessed and avoiding the imposition of a governmentally-mandated Corporate Integrity Agreement, a set of expensive and burdensome compliance procedures, if noncompliance does occur.