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

Yes. ComplianceLine accepts reports for our organization via telephone (800-859-8905) or the web form, 24 hours a day, seven days a week.

Yes!  As a reporter, you are NOT required to identify yourself, whether submitting your report by webform or by telephone. Providing your name contact information is entirely optional.  At the completion of the reporting process, you will be provided a case number that will allow you to follow-up on your case at a later time.  

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.

Yes. When reporting online, you can upload documents, related evidence, photos, etc., as attachments.  If you report by telephone, ComplianceLine’s agents may be able to provide you with an email address so you can forward supporting documentation. 

As our organization continues to achieve standards of excellence, we must be diligent and maintain high standards of integrity.  In the best interest of our organization, you 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 not only the involved parties, but our whole organization.  If a law is violated, the result could be civil or criminal action against our organization and/or 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 ComplianceLine are maintained on Ethico’s secure server. A limited number of designated employees at our organization have access to view and investigation these reports.  Ethico’s employee’s and our organization’s personnel are specially trained to handle complex and sensitive matters in a confidential manner.

Each allegation reported 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.

As a reporter, you may check on the status of your case at any time, either by telephone or online. 

Reporters following up on a case will be required to provide the original case number and a passcode if following up online.  For verification purposes, reporters following up by telephone will be required to verify key report content along with providing their original report number. 

Confidentiality means that members of our organization’s 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.