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The following resolution was adopted:

  • WHEREAS, the Board of Visitors is committed to continuing efforts to improve quality and performance;
  • RESOLVED that,
        1. The President of the University is authorized to dedicate the necessary resources toward development of an effective Corporate Compliance Program (the "Program") designed to prevent and detect potential violations of law and/or risky practices in the conduct of their business affairs by employees, physicians and agents of the Medical Center.
  • 2. The Program will:
  • a) Establish compliance standards and procedures reasonably capable of reducing the risk of wrongful conduct;
  • b) Appoint specific, high-level individual (s) (responsible to the Executive Vice President and Chief Financial Officer with responsibility to coordinate programs with the General Counsel and the Vice President and Provost for Health Sciences) with overall responsibility to oversee the administration of the program;
  • c) Take steps to communicate effectively the compliance standards and procedures to all employees and agents by, for example, mandatory training sessions or the dissemination of publications;
  • d) Take reasonable steps to achieve compliance by, for example, utilizing monitoring and auditing systems, and by publicizing a reporting system whereby employees and agents can report perceived wrongful conduct by others within the organization without fear of retribution;
  • e) Consistently enforce its standards through appropriate disciplinary mechanisms, including as appropriate, discipline of individuals for failure to detect noncompliance; and
  • f) Take reasonable steps to respond appropriately to noncompliance after detection and to prevent recurrence, which may require modifications to the compliance program.
  • 3. The development of specific recommendations, educating and training employees with respect to those specific recommendations, and reviewing and possibly enhancing internal controls and monitoring systems will be timeconsuming. Accordingly, management is directed to proceed in a responsible manner that may include several phases. Periodic progress reports shall be provided to the Board.