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Health System: Compliance Code of Conduct

©April 2002; Revised March 2009

Mission Statement

To provide excellence, innovation, and superlative quality in the care of patients, the training of health professionals, and the creation and sharing of health knowledge within a culture that promotes equity, diversity, and inclusiveness.

Our Values

This institution exists to serve others, and does so through the expression of our core values:

  • Respect: To recognize the dignity of every person.
  • Integrity: To be honest, fair, and trustworthy.
  • Stewardship: To manage resources responsibly.
  • Excellence: To work at the highest level of performance, with a commitment to continuous improvement.

Our Commitments

Obey the law

We are committed to full compliance with the laws and regulations that apply to our business, including all Federal Health Care Program (including Medicare and Medicaid) requirements, and are committed to prepare and submit accurate claims consistent with such requirements. All of our officers, managers, administrators and employees are expected to comply with our policies and procedures and with all Federal Health Care program requirements. We co-operate with and support our Code of Conduct by committing the

  • We educate ourselves so we know the laws and policies that apply to our performance.
  • We report suspected wrongdoing and cooperate with investigations.
  • We know internal corrective action will be taken if we do not follow laws and that unlawful activities must be reported.
  • We know everyone is responsible for making sure we observe high standards of ethical behavior.

Observe antitrust laws

As employees or agents of UVAHS, we do not share price or wage information with competitors.

Obey laws relating to government and donor contacts

We conduct all political activities and contacts with government officials according to law and requirements of a non-profit, tax exempt entity. This means we do not permit political fund-raising or lobbying activities by individuals acting in their official roles representing the Hospital or the Health

Avoid conflicts of interest

As employees we understand we must avoid even the appearance of a conflict of interest by disclosing pertinent facts and exercising the best care and judgment for UVA, not for personal benefit or for the benefit of others at UVA's expense.

Carefully negotiate and bid contracts

We fairly and accurately bid and negotiate outside contracts at an arm's length and at fair market value.

Do not solicit or accept gifts, favors, or kickbacks

We follow UVAHS policies that prohibit receiving gifts, favors, promotional materials or kickbacks from vendors

Work safely

Everyone is responsible for following standard precautions in caring for patients and for helping others to do so. We will maintain a drug-free workplace and understand this means we may be subject to drug testing for cause. We report any environmental or safety hazards or concerns

Promote a positive work environment

We are courteous and respectful to all. Harassment or discrimination of any kind is totally unacceptable and we will report it. This includes discrimination based on race, color, religion, gender, age, national origin, disability,

Maintain confidentiality of sensitive patient information and

Our professions require that we gather a great deal of personal information about patients. Therefore, carefully avoid unwarranted invasion of patient privacy. The inappropriate release of sensitive patient information may be harmful to the patient and the University. The inappropriate release of confidential patient or employee personnel information may be subject to civil and criminal prosecution as well as disciplinary action. You are expected to limit access to patient information and obtain appropriate release of information forms to the extent required by

Use assets wisely

We understand the community has entrusted us with assets to be used and protected for our patients' health. We safeguard, invest and use these assets to achieve our mission. Proper use of UVAHS property and equipment is everyone's responsibility and we will not misappropriate UVAHS property or proprietary information. In addition, we avoid waste and try to find ways to cut costs without cutting quality. We are committed to obeying

Report Suspected Wrongful Conduct as Soon as Possible

We report suspected wrongful conduct, including suspected violations of any Federal Health Care Program requirements or of our own policies and procedures, either by directly reporting such violations to the Corporate Compliance Officer (CCO) or his/her designee or by calling the Compliance Help Line. The Compliance Help Line can be used anonymously to disclose to our CCO or some other person who is not in the disclosing individual's chain of command, any identified issues or questions associated with our policies, practices or procedures, including but not limited to those with respect to a Federal Health Care Program believed to be a potential violation of criminal, civil or administrative law. We will not tolerate any threat of or actual retribution or retaliation for making a good faith report of

All reports will be kept confidential, investigated if necessary, and all relevant information will be obtained from the disclosing individual and proper follow-up conducted. The CCO, or his or her designee, shall maintain a confidential disclosure log, which shall include a record and summary of each disclosure received, the state of the respective internal reviews, a summary of findings and any corrective action taken in

Your reporting of suspected wrongful conduct in good faith as soon as you become aware is important. Employees who in good faith report suspected wrongful conduct will be protected from retaliation. Employees also may be protected under the "whistleblower" protections of both the Federal False Claims Act and the Virginia Fraud Against Taxpayers Act (see "Appendix - Facts About False Claims"). Individuals engaging in wrongful conduct, including the failure to comply with our policies and procedures and all Federal Health Care Program requirements or of failure to report such non-compliance will be subject to sanctions which may lead to suspension, termination or

UVAHS and individual employees of UVAHS who engage in improper conduct also are subject to various significant criminal and civil sanctions for non-compliance, including imprisonment, large money penalties, and exclusion from Federal Health Care Programs and all other Federal procurement and non-procurement programs. For example, under both the Federal False Claims Act and the Virginia Fraud Against Taxpayers Act, a person who makes, or causes to be made, false claims or false statements to a governmental program such as Medicare or Medicaid can be liable for significant penalties (see "Appendix - Facts ").

Staff Responsibilities


"Do the right thing, the right way, at the right time, every time!"

UVAHS expects all staff to:

  • Live the UVAHS values.
  • Read and understand the Code of Conduct. (Login Required)
  • Think compliance.
  • Act responsibly.
  • Obey all applicable legal and regulatory requirements as well as UVAHS policies and procedures.
  • Participate in training.
  • Respect the rights of UVAHS patients, families, and staff.
  • Maintain confidentiality.
  • Report suspected violations of the law and the UVAHS Compliance Code of Conduct.

Continue reading the entire Health System Code of Conduct here. (Login Required)