Operating Policy and Procedure
HSC OP: 52.03, Fraud and Misconduct Hotline - EthicsPoint
PURPOSE: Texas Tech University Health Sciences Center (TTUHSC) is committed to compliance with all applicable laws, rules, regulations, policies and procedures. This Operating Policy/Procedure (“OP”) sets forth procedures for employees to report potential or actual violations of applicable federal or state laws, regulations, rules, policies and procedures in a manner to permit the anonymity of the person making the report, if desired.
REVIEW: This OP will be reviewed by March 1 of each odd-numbered year (ONY) by the Chief Audit Executive, the Chief Compliance Officer, and the Vice Chancellor and General Counsel, with substantive revisions forwarded to the People and Operations Council.
DEFINITIONS: For purposes of this policy, the following terms are defined as follows:
Allegation(s) of Wrongdoing means a reasonable belief that there is or has been a potential or actual violation of applicable federal or state laws, regulations, rules, Regents’ Rules and/or TTUHSC policies and procedures.
POLICY/PROCEDURE:
TTUHSC is committed to promoting ethical, honest and lawful conduct by its employees and others within the workplace. It is therefore TTUHSC policy to encourage reporting of Allegations of Wrongdoing, or other improper activities. TTUHSC employees and others are expected to cooperate in any investigation by persons authorized or responsible for the investigation of such matters.
1. Reporting and Investigating Allegations of Wrongdoing.
a. TTUHSC employees have a responsibility to promptly report Allegations of Wrongdoing. See, Regents’ Rule 07.03, Fraud Policy, and HSC OP 52.04, Report and TTUHSC Internal Investigation of Alleged Violations, Non-Retaliation.
b. TTUHSC employees are encouraged to first bring any Allegation of Wrongdoing to the attention of his/her direct supervisor or may use other available administrative processes and procedures found in TTUHSC policies.
c. The Texas Tech University System (TTUS) has contracted with an independent, private company, (the” Company”), to provide a confidential and anonymous hotline known as the Fraud and Misconduct Hotline for TTUS and its institutional components, including TTUHSC.
d. If a TTUHSC employee prefers not to report Allegations of Wrongdoing through traditional administrative channels (for example, the supervisor has not addressed the potential or actual violation of law, rule or policies/procedures; the employee fears retaliation by his/her supervisor or others; or the employee merely wishes to remain anonymous) the employee should use the Fraud and Misconduct Hotline to report Allegations of Wrongdoing.
e. Reports to the Fraud and Misconduct Hotline will be handled by a trained professional of the Company. The individual making the report (“Reporter”) will be asked to describe the issue in as much detail as possible so there is sufficient information for TTUHSC to investigate the concerns raised. If the report is made through the toll-free number, the operator will ask the Reporter various questions that will assist TTUHSC in addressing the matter. Any Reporter shall be truthful in reporting Allegations of Wrongdoing and is expected to cooperate in any investigation of an Allegation of Wrongdoing.
f. A Reporter may remain anonymous when reporting Allegations of Wrongdoing. However, certain reports may not be able to be investigated, or action by TTUHSC may be limited, unless the Reporter’s identity is disclosed. Once a Reporter provides his/her identity, confidentiality cannot be guaranteed.
g. When a phone or electronic report is received by the Fraud and Misconduct Hotline, the report will be sent from the Company within 24 hours to the TTUS Office of Audit Services and those concerning TTUHSC may be routed to one or more Department(s) within TTUHSC identified according to the type of report. The Department shall review and investigate the report unless otherwise determined by the Office of Audit Services or General Counsel.
h. The Company will assign each Reporter a unique reference code that will be used throughout the investigative process. The investigator may also utilize this mechanism to ask those Reporters who wish to remain anonymous additional questions through the Company.
i. If the Reporter chooses to identify himself/herself in the report, the investigator may speak to the Reporter directly. Although cooperation in any investigation is expected, the mere fact that a report has been made does not entitle the Reporter to be involved in an investigation, nor to be advised of the status or disposition of a matter. Confidential information obtained during the investigation shall not be disclosed to the individual submitting the report.
j. The Fraud and Misconduct Hotline provides an additional means of reporting Allegations of Wrongdoing. It is not a substitute for, nor does it supersede, any existing reporting methods or protocols already in place at TTUHSC (or established in the future) for reporting Allegations of Wrongdoing. The purpose of the Fraud and Misconduct Hotline is for reports regarding the following areas, including, but not limited to:
Financial – Accounting or internal control issues, fraud, theft, or other financial issues;
Human Resources – Employee or Supervisor misconduct, payroll or leave violations, substance abuse, threats, or similar matters (but see sub-paragraph k. below for those issues that need to be reported through established channels);
Conflict of interest – This includes nepotism, inappropriate vendor relations or undisclosed relationships with contractors, bribery and misuse of confidential information;
Regulatory Compliance – Billing and privacy compliance concerns, research misconduct, or unsafe working conditions;
Computer Security and Data Integrity – Unauthorized access or use of Texas Tech computer systems; unauthorized access to or disclosure of data or confidential information, including personally identifiable student, patient or employee information; or
Title IX/Sexual Misconduct – Sexual harassment; sexual assault; sexual misconduct; sex-based discrimination; dating violence; domestic violence; stalking or other forms of sexual misconduct that involve a University employee, student, or visitor and that occur on University property or at a University event or that affects an employee, student or visitor’s participation in any education program or activity, including work, of the University.
k. Resources are available as a primary source of guidance and reporting for Allegations of Wrongdoing in the following areas:
Faculty Grievances – This includes, but is not limited to matters relating to tenure and promotion. See HSC OP 60.03, Comprehensive Performance Evaluation of Tenured Faculty and HSC OP 60.10, Faculty Grievance Procedure;
Staff Grievances – This includes, but is not limited to complaints concerning working conditions, performance evaluations, work hours, wages or merit raises. See, HSC OP 70.10 – Non-Faculty Employee Complaint Procedures;
Discrimination or Harassment – See TTUS Regulation 07.10, Non-Discrimination and Anti-Harassment Policy and Complaint Procedure, and HSC OP 51.02 – Non-Discrimination and Anti-Harassment Policy and Complaint Procedure.
Student Concerns or Grievances – Contact the TTUHSC Student Services Director for additional information, and refer to HSC Student Handbook;
Research Misconduct – See HSC OP 73.07 – Honesty in Research and Allegations of Scientific Misconduct;
Research Participant Concerns – Contact the TTUHSC Human Research Protection Office at 1-800-396-0918.
2. Non-Retaliation Policy
No disciplinary or retaliatory action shall be taken against any TTUHSC employee who, in good faith, reports Allegations of Wrongdoing, or who assists in an authorized investigation of Allegations of Wrongdoing. See also HSC OP 52.04, Report and TTUHSC Internal Investigation of Alleged Violations, Non-Retaliation. Self-reported violations may still be subject to disciplinary action.