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1. Verify that effective compliance is
occurring in all activities governed by federal law and regulation,
and by University policy. Verification does not mean performing
the work of compliance. It means making sure that all relevant
activities have effective compliance organizations. It means
making sure that these compliance organizations have effective
policies and procedures, effective training programs, and
effective techniques for monitoring compliance.
2. Conduct compliance audits. Auditing
is not the same as monitoring. Auditing and monitoring are
both means of checking to see if compliance has occurred.
However, there are important differences:
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a. Monitoring is typically done
by the activity that is being monitored. Auditing is
done by an outside entity. Another way to say this is
that auditing is arm's length monitoring.
The arm's length feature is important
because, when checking is done by an office or individual
that can be perceived to have an interest in protecting
the activity, this perception can diminish the credibility
of the checking. Auditing, on the other hand, because
its connection to the activity being checked is more
distant, may have greater credibility. This is the reason
that audits are conducted by an office that does not
report to a dean or an administrator responsible for
the success of a given activity. Instead, the office
reports directly to the Chancellor, and, if necessary,
directly to the Board of Trustees.
b. Monitoring typically occurs much
more frequently than auditing. Audits are more occasional.
Audits may occur with or without advance notice.
c. Monitoring is less formal. It
checks mechanically for compliance. Audits, on the other
hand, are governed by formal protocols that involve
the checking process itself, discussions with department
heads, communications with other outside entities such
as the dean and the Office of General Counsel, and systematic
follow-up for the purpose of curing deficiencies.
d. Monitoring and auditing should
work together. Monitoring may uncover deficiencies that
suggest the need for audits. Audits may uncover deficiencies
that suggest the need for better monitoring. In other
words, monitoring and auditing should complement each
other.
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3. Develop, revise, and maintain a University
Code of Conduct.
4. Maintain a University compliance hotline
for the reporting of suspected violations or concerns.
5. Maintain effective and ongoing communication
with the University's senior management and with the Audit
Committee of the Board of Trustees concerning the state of
compliance in University activities that require compliance.
This communication should include regular reports of compliance
activity - audits, hotline activity, etc. and also of plans
for future compliance activity.
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