Ethical Standards and the Code of Conduct

UC Davis medical students at the capitol in Sacramento. © UC Regents

The University of California (UC) has adopted the Statement of Ethical Values (PDF), which contains 12 standards that apply to all members of the UC community. We recognize that we hold the University in trust for the people of the State of California and are committed to Integrity, Excellence, Accountability and Respect as outlined in the statement. UC Davis Health observes the same standards and commitments.

The UC Davis Health Code of Conduct (PDF) is made up of 14 standards, each of which addresses an area that is known to be at risk for compliance violations. Each standard gives you information on appropriate conduct to follow and suggestions for handling problems that could arise. Some standards will fully cover a topic while others are too complex to be fully covered by the standard, in which case you should obtain further information as needed.

The following principles are the foundation for the Code:

  • University personnel shall treat patients without discrimination and with respect, dignity and professionalism without regard to race, age, gender, religion, national origin, medical condition, physical or mental disability, ancestry, marital status, sexual orientation, citizenship, ability to speak English or status as a covered veteran.
  • University personnel shall adhere to all applicable standards of professional practice and ethical behavior in carrying out the business of the clinical enterprise and should not feel forced or compelled to take part in unethical, improper or illegal conduct.
  • University personnel are strongly encouraged to report all known or suspected improper governmental activities (IGAs) under the provisions of the Policy on Reporting and Investigating Allegations of Suspected Improper Governmental Activities (Whistleblower Policy).  Managers and persons in supervisory roles are required to report allegations presented to them and to report suspected IGAs that come to their attention in the ordinary course of performing their supervisory duties.  Reporting parties, including managers and supervisors, will be protected from retaliation for making such a report under the Policy for Protection of Whistleblowers from Retaliation and Guidelines for Reviewing Retaliation Complaints (Whistleblowers Retaliation Policy).
  • University personnel shall immediately communicate questions and concerns regarding any of the Code standards, the federal regulations, or if a federal or state healthcare insurance carrier's instructions are not clear to a supervisor.  The University, federal and/or state government carriers, and other payers should, when necessary, work collaboratively to clarify and revise policies, procedures, and instructions in order to prevent errors or mistakes.
  • Since unintentional errors can occur in the normal course of doing business, it is the responsibility of both the University, as a health care provider, and the federal government's contracted carrier, to report in a timely manner any errors and to adjust reimbursements accordingly for those errors.

The UC Davis Health Code of Conduct applies to all employees and students. For purposes of the UC Davis Health Code of Conduct, the term "employees and students" refers to all responsible parties who are involved in either the direct provision of patient clinical care services, or with providing staff, business, administrative, or patient care support services on campus, the medical center and clinics, and the School of Medicine. If you are an employee or student of UC Davis Health (this includes the UC Davis Medical Center, the UC Davis School of Medicine, and the Betty Irene Moore School of Nursing), you are responsible for knowing the Code of Conduct and following it. UC Davis Health recognizes and endorses the University of California Statement of Ethical Values and University of California Standards of Ethical Conduct.

On February 8, 2006, President Bush signed the Deficit Reduction Act of 2005 (DRA) into law.  The DRA is legislation addressing deficit reductions ranging from education to housing and Medicare to Medicaid.  The University of California's policies include specific details regarding procedures for detecting and preventing fraud, waste, and abuse.  The policies incorporate requirements under State of California laws.  The UC Health Sciences Clinical Enterprise Compliance Code of Conduct (the Code) has been updated with DRA information and includes a section covering the laws described above, the rights of employees to be protected as whistleblowers, and UC's policies and procedures for detecting fraud, waste, and abuse.  For more information on the UC Whistleblower policies visit: http://www.ucop.edu/uc-whistleblower/.

You are also responsible for following all federal and state laws, regulations, policies and procedures that apply to your area of work. Failure to do so could result in you being subject to corrective action and/or disciplinary measures.

Fulfillment of the UC Davis Health commitment to certain standards in the conduct of our business is dependent upon the same commitment by all employees. It is the responsibility, therefore, of everyone to:

  • Know and comply with the Code and the Compliance Program as they apply to your job;
  • Avoid involvement in illegal, unethical, or otherwise improper acts;
  • Seek guidance as provided by the Compliance Program when in doubt about your responsibilities;
  • Report any violation of the Program;
  • Assist authorized personnel in investigating all allegations of violations;
  • Take responsibility for your actions; and
  • Immediately notify the Compliance Department or the university's Office of the General Counsel if the government excludes you from participation in any federally-funded programs

In addition, you should be aware that existing university Business and Finance Bulletin G-29 "prescribes responsibilities and procedures for investigating known or suspected misuses of resources by university employees..." Employees should refer to this policy for information on these investigations.

The opportunity for you to ask questions and raise concerns is a cornerstone of a successful corporate compliance program. We support open discussion of ethical and legal questions and concerns regarding compliance issues and will not tolerate retaliation against any individual who, in good faith, raises questions or reports suspected violations.

The rules governing the health-care industry can be complicated. For this reason, it is not always easy to make the right choices when it comes to compliance. If you have questions or concerns with any area of compliance, please ask for help (see below for the suggested approach). It is always better to ask before taking an action that might be improper.

As a university employee or student, you have a personal responsibility to report any activity that appears to violate the Code of Conduct or any applicable laws or regulations. In general, if you are aware of a compliance violation and fail to report it, you may be subject to corrective or disciplinary action.

If you have a question or concern regarding the appropriateness of a decision or action, you should take the following steps:

  1. Communicate with an immediate supervisor or manager
    You should immediately discuss the issue with your supervisor, manager, or team leader because these individuals should be the most familiar with the particular job requirements and business practices. The supervisor should provide a timely response or work to seek alternative solutions.

  2. Talk with higher level management
    If you are not comfortable speaking with a direct supervisor or manager, you should contact a higher level manager in the department or within UC Davis Health.

  3. Contact the chief compliance officer
    The chief compliance officer (CCO) has been designated as the individual with lead responsibility for compliance issues. The CCO reports directly to executive leadership within UC Davis Health. At any point in the process, you can bring a question or concern to the chief compliance officer or staff within the Compliance Department. This would include situations where you believe that you have not received an appropriate, timely or ethical response from a supervisor.

  4. Obtain help from other university resources
    You can contact university management within other departments or the Office of the President. There are a number of resources within the university that are available to help, including the corporate compliance office, human resources, internal audit, and campus counsel.

  5. Call the Compliance Hotline
    At any point, you can contact the Compliance Hotline to raise questions and clarify issues or to report suspected violations. Reports will be investigated or referred to appropriate personnel for resolution. If you contact the Compliance Hotline, you may choose to remain anonymous. The Compliance Hotline can be reached at the following telephone number:

    (877) Ethics-2
    or
    (877) 384-4272

If you are not comfortable taking any of the above steps, contact the UC Davis Health Compliance Department at (916) 734-8808, e-mail us at smreed@ucdavis.edu.

The people working in these areas are available to respond to any kind of question you might have. If they don't know the answer, they will try to find someone who does. Don't be shy about asking — we are all here to help each other.

At any time, you can contact the UC Davis Health Compliance Hotline to report a concern. The University of California has selected EthicsPoint to provide a confidential means for reporting suspected misconduct. You may report your concerns or ask a question by calling the hotline or simply click on the link below to submit your concern via the internet.

When submitting your concern by telephone here is what to expect:

  • The person answering the telephone will ask you if you want to remain anonymous. If you do, your call will be assigned a number. You can use this number to call back and obtain information on the status of your question or concern
  • Calls are not traced or recorded
  • The person taking the call will document the call and forward it to the UC Davis Health Compliance Department. For anonymous calls, no UC Davis Health employee will be given the name of the caller. Call (800) 403-4744 to reach the hotline

When submitting your concern via the internet you can expect the following:

  • You will need to provide the location where the incident took place
  • You will receive a report key and password that will allow you to check on the status of your report
  • To check the status of a report you previously made, please click on the location
  • To report a concern via the internet click here.