UPMC POLICY AND PROCEDURE MANUAL. Links to policies referenced within this policy can be found in Section V.
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1 UPMC POLICY AND PROCEDURE MANUAL POLICY: INDEX TITLE: HS-EC1800 Ethics & Compliance SUBJECT: Corporate Ethics & Compliance Program DATE: April 1, 2016 I. STATEMENT OF PURPOSE It is the policy of UPMC to establish and support a Corporate Ethics & Compliance Program (the Program ). The Program is supported by (1) an Ethics and Compliance Charter and (2) a Corporate Ethics and Compliance Plan. The Charter is attached and made a part of this policy. The Compliance Plan is a stand alone document created to assist in establishing and maintaining an effective compliance program and can be found on the Infonet. A Compliance plan details the essential elements a program must contain in order to be considered effective. This Program shall promote a high level of ethical and lawful conduct throughout UPMC, including all subsidiary entities. Links to policies referenced within this policy can be found in Section V. II. SCOPE This policy applies to all UPMC entities and locations. III. RESPONSIBILITY Designated Compliance Officers at each UPMC subsidiary are responsible for implementing Ethics & Compliance programs and assuring their effectiveness throughout their facility by administering their programs consistent with the Ethics & Compliance Charter and Plan. The Program is intended to examine, evaluate, and coordinate the adequacy and effectiveness of systems designed to promote ethical behavior and compliance with applicable rules and regulations. IV. ACCOUNTABILITY All UPMC employees, physicians, and agents of UPMC are required to comply with this policy and the Program. Any violations can result in disciplinary action up to and including termination. Certain matters prohibited by UPMC may also violate applicable laws and could lead to individual criminal prosecution.
2 PAGE 2 V. POLICIES REFERENCED WITHIN THIS POLICY: HS-EC1900 Code of Conduct SIGNED: Linn Swanson Chief Audit and Compliance Officer ORIGINAL: July 18, 2002 APPROVALS: Policy Review Subcommittee: March 10, 2016 Executive Staff: April 1, 2016 PRECEDE: July 9, 2015 SPONSOR: Chief Compliance Officer Attachments
3 STATEMENT OF PURPOSE ETHICS & COMPLIANCE DEPARTMENT CHARTER It is the policy of UPMC to establish and support a Corporate Ethics & Compliance Program. This Program shall promote the highest level of ethical and lawful conduct throughout UPMC including all of its subsidiary entities. The Chief Compliance Officer reports to the Chairman of the UPMC Ethics & Compliance Committee and administratively to the Chief Legal Counsel and reports all allegations of wrongdoing, including results of any investigations, subsequent punishment and remedial action taken, to the various Ethics & Compliance, Audit and Finance Committees throughout UPMC. The Program shall examine, evaluate, and coordinate the adequacy and effectiveness of systems designed to promote ethical behavior and accomplish compliance with applicable rules and regulations. INTERNATIONAL UPMC operates in different countries. These countries encompass a variety of cultures, laws, regulations and political systems. UPMC respects the laws of the countries in which it operates and is committed to complying with all such applicable laws and regulations. AUTHORITY To facilitate the Program s effectiveness, the Chief Compliance Officer is authorized to have unrestricted access to all relevant company records, documents, facilities and personnel. ADMINISTRATION OF THE CORPORATE ETHICS & COMPLIANCE PROGRAM The UPMC Ethics & Compliance Program is administered by the UPMC Chief Compliance Officer who reports to the Chairman of the UPMC Ethics and Compliance Committee and administratively to the Chief Legal Counsel. The UPMC Chief Legal Counsel and the Senior Associate Counsel & Vice President, Litigation provide strategic direction, oversight and advice to the Ethics & Compliance Department through regular meetings with the Chief Compliance Officer. UPMC subsidiary entities are covered under the Program and may have entity specific programs as well which support the Program. These entity specific programs are administered by a Compliance Officer of the respective entity under the direction of the UPMC Chief Compliance Officer. Programs focused on specific operations or legal/regulatory requirements within a Division, Corporate Services or a subsidiary may also be established. These programs are administered by high level personnel within the program(s) that have knowledge about the specific legal/regulatory requirements.
4 PAGE 4 The UPMC Chief Compliance Officer assists in the development, implementation and maintenance of all compliance programs, both corporate and subsidiary. The UPMC Chief Compliance Officer utilizes corporate resources such as Legal Services, Human Resources, Internal Audit, and if necessary, outside parties such as consultants, in order to effect compliance through policies, training, investigations and corrective actions. RESPONSIBILITY UPMC Chief Legal Counsel and Senior Associate Counsel & Vice President, Litigation are responsible to:. Assist in the establishment of policies and procedures with regard to the ethics & compliance functions.. Review status reports of ethics & compliance activities.. Provide advice and guidance to the Chief Compliance Officer on issues brought to its attention.. Approve policy development/changes and strategic initiatives as they relate to the Program. The UPMC Chief Compliance Officer is responsible for establishing, maintaining and overseeing a program that includes, at a minimum, all of the necessary elements of an effective compliance program as identified in the US Sentencing Guidelines. This includes the following: Established Standards and Procedures to Prevent and Detect Criminal Conduct Oversight of the Program by the Board of Directors Exclusion of Certain Individuals from Management Training Programs with regard to particular ethics and compliance functions Auditing and Monitoring to Assure Compliance with the Program Incentives for Compliance with the Program; Discipline Promoting an Organizational Culture that Encourages Ethical Conduct and a Commitment to Compliance with the Law Responding to Criminal Conduct by taking reasonable steps to respond appropriately to the criminal conduct and to prevent further similar criminal conduct including modifications to the compliance and ethics program. Activities shall be conducted in a lawful and ethical manner. CODE OF ETHICS The UPMC Code of Ethics consists of the Code of Conduct (HS-EC1900 Code of Conduct) and the values and principles contained within the Workplace Ethics Guide located at http//infonet2.upmc.com/ourorganization/enterprise/compliance/documents/ethicsguide.pdf. The Code of Conduct and the Workplace Ethics Guide are intended to assist and guide employees and agents as they carry out their job responsibilities.
5 PAGE 5 ADHERENCE TO PROGRAM REQUIREMENTS Ethics & Compliance programs are adapted in response to legal, regulatory and organizational changes. UPMC encourages employees to direct comments, questions, and suggestions to correct or improve a program to a Compliance Officer. No employee or agent shall act in disregard of any requirements of a compliance program without the express permission of a Compliance Officer. REPORTING OF PROGRAMS The activities of all individuals responsible for compliance programs (Officers and high-level personnel) are reported to the UPMC Ethics and Compliance Office on a semi-annual basis and more frequently if requested by the Ethics and Compliance Office. The UPMC Chief Compliance Officer is authorized to access any and all documentation of compliance activities and to require changes to any and all programs or plan documents in order to effect corporate-wide compliance. The UPMC Chief Compliance Officer shall report compliance activities to the Ethics and Compliance Committee of the Board of Directors at least quarterly. SAFEGUARDING PROGRAM INFORMATION Ethics and Compliance programs are the property of UPMC or its subsidiaries. Disclosure of confidential program information in whole or in part to anyone outside of UPMC or its subsidiaries is prohibited. Reviewed by the Ethics & Compliance Committee of the Board: February 4, 2016
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