MyComplianceReport is a web-based portal supported by the third-party vendor, ComplianceLine. It is a comprehensive and confidential reporting tool that enables all Ethico Personnel to address fraud, abuse, and other misconduct in our environment and to promote a healthy and safe experience for everyone.

Yes. The (ComplianceLine) Integrity Line accepts reports via telephone (866-555-5555) or the web form.

The Integrity Line is an all-inclusive term and refers to the MyComplianceReport web-based portal as well as the toll-free telephone number.

Yes. The Integrity Line does not attempt to identify reporters, whether submitting telephonically or electronically. Reporters have the option to remain anonymous or provide their name and other contact information. Reporters are provided a Report Key that allows for anonymous communication with a member of the Compliance and Ethics Department.

Any questions or concerns regarding actual or potential violations of applicable law, regulation, policy or procedure, or the Code of Conduct (Code) should be reported. Reporters are protected from retaliation for concerns raised in Good Faith (believed to be true).

Examples:

• HIPAA/privacy concerns, such as health information given to the wrong patient, wrong patient chart used, wrong armband, lost/stolen device containing hospital/patient information, accessing Epic without professional need (self, family members, co-workers, celebrities, etc.)
• Specific incidents of unacceptable or disruptive colleague behaviors (physical or verbal)
• Employee relations matters (hiring practices, retaliation, discrimination, harassment, workplace conflicts)
• Unsafe work environment (safety rules not followed, broken equipment, staff afraid to stop the line, etc.)
• Documenting or billing for services not provided
• Clinical scope of practice issues (respiratory therapist working without a valid certification, medical staff member practicing without the appropriate privileges)
• Using position or hospital resources for personal gain, non-work related reasons
• Ongoing, previously reported concerns that require an independent review
• Questions or seek guidance on matters when it is uncomfortable speaking with an Office of Talent Management (OTM) Business Partner or member of management

The Compliance and Ethics Department must receive specific details concerning the matter in order to facilitate a thorough review. Providing partial or incomplete information may result in case closure due to insufficient information. Information needed to complete a thorough review may include:

• First/last name of person(s) or organization(s) engaged in alleged wrongdoing
• Description of the event, location, and date/time of when event occurred
• Specific details or synopsis of the concern(s) being raised
• First/last names of witnesses to the event or others who may have knowledge of the concern(s) being raised
• How the event was discovered if the reporter was not a participant or directly involved
• Supporting documentation if available, including policies, memoranda, emails, text messages, etc.

The Compliance and Ethics Department must receive specific details concerning the matter in order to facilitate a thorough review. Providing partial or incomplete information may result in case closure due to insufficient information. Information needed to complete a thorough review may include:

• First/last name of person(s) or organization(s) engaged in alleged wrongdoing
• Description of the event, location, and date/time of when event occurred
• Specific details or synopsis of the concern(s) being raised
• First/last names of witnesses to the event or others who may have knowledge of the concern(s) being raised
• How the event was discovered if the reporter was not a participant or directly involved
• Supporting documentation if available, including policies, memoranda, emails, text messages, etc.

As XXXXXX continues to define the standards of excellence in public health care, we must deliver compassionate, high-quality care and act with integrity. XXXXXXX Personnel have an obligation to report unsafe practices, unethical behavior or violations pertaining to the Code, policy or procedure, or applicable law or regulation. When someone’s actions violate our Code, our policies or procedures, or applicable laws or regulations, it can harm both Ethico and our patients. If a law is violated, the result could be civil or criminal action against Ethico and the person(s) responsible.

We take any potential violation seriously. Reports of potential misconduct are reviewed carefully and steps are taken to correct the situation, including disciplinary action when appropriate.

Reports made through the Integrity Line are maintained on the Ethico secure server. A limited number of employees in the Office of Talent Management and Compliance and Ethics Departments can access these reports. These employees are specially trained to handle complex and sensitive matters in a confidential manner.

Each allegation reported through the Integrity Line is unique, so the estimated time of completion depends on many factors, such as the complexity of the issue, the number of people involved, the nature and extent of documents or other evidence involved, and the urgency of the matter. Reporters may use the Report Key to check on the status of a review or communicate with the lead investigator.

Reporters are provided a Report Key that allows for anonymous communication with the lead investigator who is a member of the Office of Talent Management or the Compliance and Ethics Department. The Report Key is a form of a report identification number that allows the reporter to check on the status of a case review or communicate with the lead investigator. On the Integrity Line homepage, click ‘Follow-up’ to ask questions, provide updates or inquire about the status of the review.

Confidentiality means that members of the Office of Talent Management and the Compliance and Ethics Departments will not disclose information to individuals outside of the reasonable “need to know” standard. This includes information received, used, maintained or accessed during the course of normal duties, such as case reviews.

Anonymity means that personnel may report any concern through the reporting channels without disclosing their identity. Reports made in good faith will be taken and reviewed without an attempt to identify the reporter.

Be advised that:

• There are circumstances in which confidentiality and anonymity may not be maintained, such as disclosures pursuant to a subpoena or court order, a lawful discovery request or a disclosure necessary to resolve a potential compliance matter.
• Anonymity applies to an individual’s identity.
• Confidentiality applies to information received, used, maintained or accessed.
• Reporters may choose to release their identity during or after a completed review.
• Information about a reporter’s identity, if provided, will be retained in the Compliance and Ethics Department’s permanent records.
• Information shared outside of the Integrity Line case review process is not protected by the Compliance and Ethics Department.
• Information shared through the reporting channels may lead to indirect identification of a reporter given the specific details provided.