Our Mission

- Compliance Plan -

Mission Statement

Fundamental to the mission of the University of Southern California (USC) is the enrichment of the human mind and spirit through teaching, research, artistic creation, professional practice and public service. The university's strategic plan includes initiatives that support this mission.

The Office of Compliance is dedicated to furthering the university's mission and strategic plan, while ensuring compliance with all applicable laws, rules, regulations and promoting adherence to the highest standards of ethical conduct. The Office of Compliance has developed a compliance program, which is intended to identify areas of risk and potential liability on a university-wide level and institute steps to minimize or eliminate those risks by:

• Emphasizing our commitment to conducting the business of the university in an ethical manner,
• Providing education, training, and guidance to administration, faculty, staff, and other employees to meet increasingly complex statutory and regulatory requirements,
• Monitoring and overseeing university compliance efforts on a proactive basis,
• Providing an avenue for reporting instances of potential non-compliance or unethical behavior;
• Investigating instances of potential non-compliance; and
• Preventing or reducing instances of accidental or intentional non-compliance, particularly in this time of increased government scrutiny in health care and higher education.

This USC Compliance Plan memorializes the university's implementation of its compliance program. The Compliance Plan is intended to provide the operational structure for how ethical conduct and integrity in our business practices will be encouraged and promoted within the university community.

Elements of an Effective Compliance Program

The following principles have been recognized as important elements for an effective compliance program:

• Appointment of a compliance officer to oversee compliance efforts;
• Development of ethics and compliance standards, policies and procedures that apply to all faculty and staff employees and others responsible for conducting business on behalf of the university;
• Communication of university standards, policies and procedures to all faculty and staff employees through dissemination of relevant information and the implementation of education and training programs;
• Publicized disclosure mechanism whereby employees can report possible compliance violations without fear of retribution;
• Consistent enforcement of compliance standards through appropriate disciplinary mechanisms and incentives to engage in compliant behavior;
• Conducting auditing and monitoring to ensure compliance;
• Performing periodic evaluations of the effectiveness of the compliance program;
• Reasonable and appropriate responses, including modification of the compliance program, as appropriate, to prevent similar offenses when detected.

USC Implementation of a Compliance Program

In order to be effective, a compliance program must be regularly monitored and modified to meet the needs of the university community. Accordingly, the university compliance program has adopted the principles stated above and has tailored them to address USC’s unique organizational structure and operational risks.

Designation of a Compliance Officer

In November 1998, the USC Board of Trustees established the Office of Compliance. The trustees charged the Associate Senior Vice President of the Office of Compliance with the responsibility for establishing a university-wide compliance program to prevent, detect and respond appropriately to violations of law and foster a corporate culture that promotes integrity and ethical behavior in all matters relating to compliance. The Associate Senior Vice President’s job responsibilities include the following:

• Identify University functions and routine business practices requiring compliance oversight;
• Coordinate and oversee existing compliance functions and build compliance infrastructure where appropriate;
• Take reasonable steps to achieve compliance with standards, procedures and codes of conduct by all employees and other agents, including oversight responsibilities, employee training, monitoring and auditing, enforcement and discipline and response and prevention that meet unique needs of the University;
• Effectively communicate such standards, procedures and codes of conduct to all senior management, faculty, staff, and other employees and agents as appropriate through education and training;
• Coordinate investigation of reports of alleged wrongdoing and respond to government inquiries in concert with the Office of the General Counsel;
• Monitor changes in laws, rules and regulations;
• Provide advice and direction to senior management, faculty, staff, other employees and agents to maximize compliance and suggest and implement improvements to administration policies where appropriate; and
• Implement and publicize effective mechanisms by which individuals may seek guidance or report alleged violations of the compliance program confidentially and without fear of retribution.

The Associate Senior Vice President, Compliance reports directly to the Senior Vice President and General Counsel and the Audit and Compliance Committee of the Board of Trustees.

Compliance Committees

The University has established ad hoc and standing committees that address various compliance issues.  The compliance committees serve as a resource to the compliance program and assist in implementing and maintaining consistent and appropriate policies and procedures and providing feedback on proposed initiatives.

The USC Healthcare Compliance Committee, which meets quarterly, was originally founded to support the Physician Billing Compliance Program.  The voting membership consists of the Compliance Liaisons from each of the faculty practice corporations. As healthcare compliance activities continue to expand beyond physician specific issues, the committee has been expanded to include representatives from Dentistry, Pharmacy, Occupational Therapy and Physical Therapy.

Through this Committee, the Office of Compliance provides updates on current/emerging risk areas, seeks guidance in the development of new policies and procedures, and discusses common problems/challenges with the implementation of required policies and procedures. 

The Information Security Liaison Committee is comprised of liaisons designated by the Deans or Vice Presidents of their respective units to serve as the liaison between that school or Unit and the Office of Information Security for all matters related to information security.  Among other things, the Committee:

• Coordinates with the Office of Information Security in conducting inventories of information covered by the USC Information Security policy;
• Assists the Office of Information Security in determining categories of individuals who have access to such information and under what circumstances;
• Disseminates educational information to faculty, staff, students, and other impacted people in the university community about information security related issues;
• Acts as the Office of Information Security’s primary contact for monitoring and auditing the implementation of USC’s information security plan; and
• Assists the Office of Information Security in implementing corrective action resulting from an investigation of incident reports as defined by the Information Security policy.

The university also creates various ad hoc committees designed to address compliance issues that arise.

Standards, Policies and Procedures

The development of appropriate policies and procedures memorializes the university's commitment to ethical conduct and adherence to relevant laws and regulations.  As set forth in the USC Code of Ethics, ethical behavior is predicated on two main pillars: a commitment to discharging our obligations to others in a fair and honest manner, and a commitment to respecting the rights and dignity of all persons. All employees must be careful to distinguish between legal behavior on the one hand and ethical behavior on the other, knowing that, while the two overlap in many areas, they are at bottom quite distinct from each other.

While the office with primary responsibility for the day to day operation of a school, unit, or department is primarily responsible for the development of policies and procedures that satisfy their ethical and legal obligations, the Office of Compliance, Office of General Counsel, Provost’s Office, and Policy Development and Communication are all resources available to the university community to assist in the identification of issues and the development of appropriate policies and procedures to address them.

A list of the University’s policies can be found at www.usc.edu/policies.

Education and Training

Communication, education and training are the hallmark of any compliance program and are necessary to ensure that the university community understands the applicable laws, regulations and university policies that apply to them. Recognizing that communication must be frequent and varied in order to be effective, the Office of Compliance and other units supporting compliance functions frequently deliver their messages in a variety of forms, including through formalized education programs that may be in-person, web-based or both; newsletters, memoranda, forums, presentations, and through committee participation and development.

Examples of education and training initiatives provided by the Office of Compliance include the Research Administrator’s Forum, the Grants Management Education program, the HIPAA Privacy Education program, Senior Business Officer Ethics programs, the Sponsored Projects Manual, Contracts and Grants training, Export Controls education and training, and the Health Sciences Compliance Newsletter.  The Office of Compliance also participates in, or acts in an advisory capacity to, a number of committees to ensure that the university community understands the laws, regulations, and university policies that apply to it, including the Financial Disclosure Review Committee, Research Misconduct Preliminary Inquiry and Investigation Committees.

Several other groups within the University also provide ongoing training and education on a variety of legal issues and USC policies.  Some of these highlights include:

• Professional Development, a division of Career and Protective Services, offers training in areas such as sexual harassment, performance improvement consulting, diversity training, executive leadership, human resource management, office administration, environmental health and safety, and ethics. 

• The Office for Protection of Human Subjects offers training in the Protection of Human Subjects in Research, and also is an educational resource for all investigators who conduct research involving human subjects.

• The Vice Provost for Research Advancement offers education and training to prepare investigators for funding strategies and proposal preparation, as well as education and training related to the identification, disclosure, and management of conflicts of interest related to sponsored research.

• The Institutional Animal Care and Use Committee (IACUC) offers education and training to all investigators and staff who conduct research involving animals.

• The Institutional Biosafety Committee offers education and training to all investigators and staff on policies and guidelines related to the use of all potentially hazardous biological agents including but not limited to infectious agents, human and non human primate materials (including established cell lines), known regulated carcinogens, select agents, recombinant DNA and studies involving human gene transfer.

• The Radiation Safety Committee offers education and training to ensure that all individuals whose duties may require them to work in the vicinity of radioactive material or radiation producing machines are properly instructed about all appropriate health and safety matters.

• The Office of Academic Records and Registrar offers education and training to all faculty and staff, as well as any other agents of the university, who request access to student academic records.  The training is intended to insure that anyone accessing student records understands the obligations under FERPA for proper use and protection of student records.

• Environmental Health and Safety offers education and training in laboratory safety and industrial hygiene, and blood borne pathogens.

•  USC’s NCAA Compliance program offers education and training to student athletes, coaches, athletic staff, and families on the rules and regulations related to participation in college athletics.

• The Office of Financial Services offers education and training with regard to general budget skills, budget development system administration and training, use of USC Procurement Cards, and use of the WEBBA system.

There are several other initiatives offered on a recurring basis throughout the university community that are designed to provide education and training to those members of the university community that may be affected by a given set of regulations or USC policies related to their work for the university.  The Office of Compliance maintains a list of these initiatives as a resource to assist all members of the university community in determining the resources available to them to assist in conducting their work in a legal and ethical manner.

Monitoring and Auditing Systems

The Office of Compliance coordinates with USC’s Office of Audit Services to develop risk mitigation strategies with the objective of improving business processes and internal controls, as well as facilitating strong stewardship and management accountability at all levels. The Office of Audit Services proactively provides guidance to improve the university’s operations by addressing risk management, control, and governance processes through evaluation of financial, operational, and information systems.
 

Reporting and Investigation of Compliance Issues

Members of the university community have various channels through which to report compliance matters or concerns. University faculty, staff and student employees are encouraged to raise such concerns directly with their supervisor, chair or Dean. In addition, several departments on campus are charged specifically with investigating compliance matters (e.g., Administrative Operations, Office of Compliance, Audit Services, Safety and Risk Management, etc.)

In addition, the Office of Compliance established the USC Help and Hotline in order to encourage faculty, staff and students to seek guidance regarding their compliance responsibilities. The Help and Hotline can be used to report good faith suspected violations of laws, regulations and university policies confidentially and without fear of retribution in the event individuals are not comfortable reporting a concern directly to their supervisors.

The Office of Compliance is also charged with investigating certain allegations of violations of laws, regulations or university policies or coordinating with departments or units that have specific oversight of the area that is the subject of the allegation.  These departments and units include Employee Relations, Equity and Diversity, Audit Services, and the Office of General Counsel, as well as individuals and groups within specific schools or units of schools charged with ensuring that staff complies with the legal rules and USC policies applicable to their work.

Enforcement

When an instance of non-compliance has been determined, the Office of Compliance will work with other relevant departments and units to develop and implement a corrective action plan to prevent similar occurrences. Corrective action could include any of the following: (1) additional training and education; (2) changes in policies and procedures; (3) further audit and monitoring; (4) disciplinary action; and (5) reporting and disclosures to the relevant government and administrative agencies, as appropriate.

Departments that conduct their own investigations into allegations of violations of applicable law or university policy may develop similar recommendations for corrective action measures to address instances of non-compliance, either on their own, or in consultation with the Office of Compliance and the Office of General Counsel.

Revisions to the Compliance Plan

This Compliance Plan is intended to be a flexible document that is adaptable to changes in regulatory requirements. The Office of Compliance will review this Compliance Plan on a regular basis to ensure that it remains current and effective.