Compliance and Ethics Program Charter
The purpose of the University of Texas at Austin (“University”) Compliance and Ethics Program (“CEP”) is to promote and support a working environment which reflects the University’s commitment to maintaining the highest level of integrity and ethical standards in the conduct of its operations. Towards this end, the CEP will include programs and practices designed to nurture and preserve the University’s culture of respect and honesty while building compliance and ethics consciousness into the daily activities of its faculty and staff.
Goal and Objectives
The CEP shall be designed and administered to help the University’s employees perform their duties as efficiently as possible while affirming the University’s commitment to the highest standards of ethics and integrity. The CEP shall be implemented as a risk based process that reasonably satisfies the requirements of the U.S. Sentencing Commission’s Guidelines for Organizations for an effective compliance and ethics program, and complies with all applicable laws, regulations and policies of The University of Texas System (“UT System”). In particular, the CEP shall include elements intended to achieve the following objectives:
a. promotion of an organizational culture that encourages all employees to conduct University business ethically and with a commitment to compliance with the law;
b. assurance that executive level personnel of the University are knowledgeable about the content and operation of the CEP and exercise reasonable oversight with respect to its implementation and effectiveness;
c. effective communication regarding the CEP to all levels of employees and to relevant vendors and other third parties;
d. establishment of clear compliance standards for all employees and consistent enforcement of these standards;
e. maintenance of training programs appropriate for the proper education of employees with respect to compliance issues related to their job functions;
f. development and maintenance of a compliance and ethics risk assessment and management process that provides for
i. designation of the compliance and ethics risk areas of the University;
ii. completion of a risk assessment (to inventory compliance and ethics risks and to evaluate each inventoried risk for potential impact on the organization and probability of occurrence) in each risk area;
iii. based on these risk assessments, identification of the critical institutional compliance and ethics risks (“A Risks”);
iv. establishment of a “risk management process” that is fully responsive to the identified objectives for each A Risk (a risk management process evaluates current activities and identifies changes, if necessary, that will improve assurance of compliance, follows up to ensure that agreed upon changes are implemented, and then evaluates the results after implementation); and
v. designation of an individual to be held accountable for the implementation of an appropriate action plan to achieve compliance and ethics risk management improvement in the respective risk area;
g. maintenance of a process for continuously monitoring the compliance and ethics environment of the institution to identify new or changing compliance and ethics risks;
h. establishment of a mechanism for reporting suspected compliance and ethics violations that provides for anonymity and confidentiality to the extent allowed by applicable law;
i. maintenance of a process for investigating reports of suspected non-compliance, and effecting appropriate corrective, restorative and/or disciplinary actions;
j. maintenance of a process for the continued enhancement and improvement of the CEP and
k. prevention and detection of criminal activity and other misconduct and the recurrence thereof.
The structural components of the CEP include the Executive Compliance Committee (“ECC”), University Compliance Services (“UCS”) (under the guidance of its Director ([“Director”]), the Compliance Officers Group (“COG”), the Triage Group (TG) and the risk area Designated Responsible Party (“DRP”). The major documentary components of the CEP include this CEP Charter, the ECC Charter and the formally adopted policies and practices of the University set out in the Handbook of Operating Procedures, including those set out in Part 4 of the Handbook of Operating Procedures entitled “Standards of Conduct”, and UT System policy (the “UT Policies”) and generally described in the Employee Compliance Guide (“Guide”). To the extent there is a conflict in the provisions of these documentary components, the provisions of the Policies shall prevail.
The ECC is composed of the President of the University, as chair, and those members of the University’s faculty and staff serving as provided for in the ECC Charter. The ECC shall be responsible for the oversight of the CEP and shall have the duties and responsibilities set out in the ECC Charter.
UCS shall be responsible for the strategic design and implementation of the CEP as authorized and provided for by the ECC. In fulfilling this obligation, UCS will provide advice and services in four primary areas: (1) training and general education – help faculty and staff identify and understand relevant legal, regulatory and policy constraints, emphasizing the personal responsibility of all employees to eliminate misconduct and other wrongdoing and to conduct University business in an ethical and legal manner, (2) operational support – help faculty and staff having management responsibilities develop and implement practical strategies to avoid compliance and ethics failures using risk-based and other appropriate methodologies, (3) effort coordination – serve as a liaison between and among employees of the various University divisions having compliance responsibilities and executive management to better associate their CEP related activities, and (4) assurance – undertake those processes and actions well suited for verification and validation of the CEP’s effectiveness and otherwise provide assurance to the ECC that compliance and ethics risks are being managed and mitigated to acceptable levels. UCS will conduct such other activity as reasonably calculated to achieve the goals and objectives of the CEP.
The Director shall be responsible for the daily administration of UCS and shall serve as the University’s designated Institutional Compliance Officer for purposes of UT System policy UTS 119. The Director shall also serve as an ex-officio member of the ECC and as chair of the COG.
The COG shall be composed of (1) the Director, as chair, (2) a representative from the Office of Internal Audits, (3) a representative from the Office of the Controller, (3) a representative from the Office of the Vice President for Research, (4) a representative from the Office of Environmental Health and Safety, (5) a representative from the Office of the Chief Information Officer, (6) a representative from the department of Intercollegiate Athletics, and those faculty and staff having compliance related job responsibilities and duties who have been invited to join the COG by the Director. The COG will meet at least semi-annually, and at other times as necessary, to discuss and advise the Director on non-fiscal policy and operational issues related to: CEP design, risk assessments, assurance and training activities, professional development and other issues pertinent to the compliance risk areas of the University.
The TG shall be primarily responsible for evaluating the merits and significance of compliance reports made through the Hotline and other designated reporting processes that are brought to its attention. The TG will initiate compliance investigations, monitor the progress of those investigations, and confirm that appropriate corrective actions are taken when warranted. The TG shall be composed of the Associate Vice President for Human Resources Services, the Director of Internal Audits, the Vice President for Legal Affairs, and the Director. Other persons may be added on an ad hoc basis to investigate areas where special knowledge is required. Any such other persons included will be added at the sole discretion of the Director.
For purposes of the CEP and this CEP Charter, the term “compliance report” shall mean any complaint or report made to any supervisor or office within the University that makes allegations concerning compliance by the officers and employees of the University with applicable laws, rules, regulations and policies, including, but not limited to, matters of ethics and standards of conduct, financial reporting, internal accounting controls or auditing whether or not actually communicated to UCS or the TG, and all such complaints or reports shall be deemed to have been made under the CEP. Additionally, the term “compliance investigation” shall mean the investigation by University personnel of any allegations made in or associated with a compliance report, as well as any investigation by University personnel, or external parties designated by or associated with the University, regarding allegations of or self-reported violations of NCAA or Big 12 Bylaws or Rules.
The DRP is that individual designated by the ECC as being responsible for management of each A Risk specified in risk assessments of the University. Each DRP shall have the knowledge and authority necessary to manage that risk and shall cooperate with the UCS to develop a risk management process which includes training, monitoring and reporting plans for each A Risk. Even though the DRP may have delegated the actual management duties to a subordinate, the DRP shall continue to be responsible to the ECC for the performance of these obligations.
The CEP shall be designed recognizing that building and maintaining a culture of compliance, ethics and integrity are shared responsibilities and require individual commitments from all University faculty and staff. The standards by which University employees are expected to conduct their activities are set out in the Policies and generally described in the Guide. The Policies provide the framework within which all employees are expected to operate and apply to all University employees, including administration, faculty, fellows, residents, and students. Moreover, many of the Policies are applicable to University subcontractors, independent contractors, consultants and vendors. The Guide summarizes and makes citation to the Policies, applicable law and regulations, and the Rules and Regulations of the Board of Regents of the University of Texas System, known as Regents’ Rules and Regulations. The Guide is designed to (1) communicate to all University employees an expectation and requirement of ethical conduct and compliance with all applicable laws, policies, rules, and regulations, (2) provide specific examples of conduct and behavior that are consistent with these expectations and (3) along with the Policies, serve as a reference for measurement of the CEP’s effectiveness. The Guide does not address all general compliance issues, nor does it deal with the many special compliance issues that are job specific. Instead, the Guide should be regarded as a set of guiding principles that apply to every University employee.