Note: The HIPAA Program has provided a training tool and has made compliance reports available on-line. All area Deans, Directors, Managers, and Supervisors are responsible for monitoring HIPAA training completions in their area and proactively correcting non-compliance with this federal requirement. Corrective action will proceed according to the following guidelines:

Professional Staff with Hospital privileges	Corrective action according to the current process specifically devised for medical staff. Process is driven by the Medical Executive Committee, and sanctions include suspension of privileges, withdrawl of appointment; OR Corrective action according to existing Human Resources guidelines.
Residents	Corrective action will be coordinated through GME.
Students	Corrective action will be coordinated through the appropriate school and may include suspension of clinical privileges and a record of non-compliance placed in student’s permanent file.
All other employees	Corrective action shall follow progressive steps, consistent with OHSU policy, as well as union contract provisions of ONA and AFSCME. All managers and supervisors are advised to contact the human resources office before proceeding with any corrective actions for non-compliance with HIPAA training. First step: Counseling Advise the employee of the need to complete HIPAA training, and afford a defined time period, i.e. 48 hours, to comply. Second step: Formal verbal warning – call human resources first (union employees, call labor relations, other employees call HR director) Advise the employee of the earlier instruction to comply with required training, provide a new instruction with a time limited compliance period (i.e. 24 hours) and then document in writing both of these actions (forward a copy to human resources). Third step: Formal Written Warning – call human resources first Advise the employee of the two (2) earlier steps and instruct employee to comply with required training. Document such earlier warnings and formal written warning to immediately comply – with the notation that additional serious corrective action will result in the event of non-compliance. Additional action: CONTACT HUMAN RESOURCES DEPARTMENT
Volunteers	Corrective action will be coordinated through the appropriate volunteer services coordinator.