OHSU's Commitment to Integrity
We ask you to take a few moments to review and complete the newly updated Booster in March, and each year.
New version of the required Integrity Booster launched in March, 2014, incorporating new information as well as a Code of Conduct attestation.
Who needs to take the booster?
The booster is required of all OHSU workforce members (employees, faculty, staff, students, and volunteers) annually.
A completed Integrity Booster certificate is required, in addition to the HIPAA and Respect at the University course certificates, in order to receive an OHSU badge.
Why are we making these changes?
The Integrity Office, with approval of executive leadership, will now require all employees to complete the new version of the booster annually.
Recent data breaches have highlighted the need for more frequent education and training not only around data protection, but also on fraud, conflict of interest and safety based on the nature of your work. Additionally, the booster meets Centers for Medicare and Medicaid Services "meaningful use" incentives.
I just took the booster recently, why do I need to retake it?
Even though you may have completed the previous version of the booster recently, you'll be asked to complete the new version now and annually. The Integrity Office would like to apologize for any inconvenience this may cause you and appreciates your continued efforts to ensure education compliance.
Whom Can I Contact if I have Questions?
Please direct any questions to the OHSU Integrity Office at 503.494.8849 option 2 or firstname.lastname@example.org
Conflict of Interest
For more information: E-mail Mark Peters, Export Compliance Officer
Environmental Health And Radiation Safety (EHRS)Hazard Labeling Elements
For more information: Contact EHRS
Fraud, Waste and Abuse
Information Privacy & Security (IPS)
Safety and Physical Security
503-494-4444 (or Ext 4-4444)
Conflict of Interest
Approving Authority: For each of the employee types listed below, the corresponding authority to receive the disclosure is listed:
- Faculty - Department Chair and, as required by the Dean/Director, to the Dean/Director.
- Faculty Member without a Dept. Chair - Dean or Director
- Department Chair - Dean
- Executive Committee Member - Officer to whom he or she is accountable.
- President - Chair of the Board of Directors.
- Any employee not mentioned above - The Director (or middle management equivalent) unless the Executive Committee member to which the employee's unit is accountable designates someone else.
Clinician: OHSU employee who provides clinical care to patients and can prescribe medication or therapy, such as Licensed Independent Practitioner.
Conduct of Research: In the Report on Individual Financial Interest in Human Subjects Research, the Association of American Medical Colleges (AAMC) defines the conduct of research as: "conducting research means, with respect to a research protocol, designing research, directing research or serving as the principal investigator, enrolling research subjects (including obtaining subjects' informed consent) or making decisions related to eligibility to participate in research, analyzing or reporting research data, or submitting manuscripts concerning the research for publication.
Conflict of Interest: A conflict of interest exists when an employee's financial interests or other obligations interfere, or appear to interfere, with the employee's obligations to act in the best interest of the University and without improper bias. The mere appearance of a conflict may be as serious and potentially damaging to the public trust as an actual conflict. Therefore, potential conflicts must be disclosed, evaluated, and managed with the same thoroughness as actual conflicts.
Conflict of Interest in Research (CoIR): A determination by the designated official that a significant financial interest (SFI) might affect, or reasonably appear to affect, the design, conduct, or reporting of research. Such situations may require management, but may not be found to constitute a FCOI as defined below.
Executive Position: Any position which includes responsibilities for a material segment of the operation or management of a business. This would include a position on a Board of Directors.
Financial Conflict of Interest (FCoI): A determination by the designated official that a significant financial interest (SFI) could directly and significantly affect the design, conduct or reporting of the PHS funded research.
Financial Interest: Any equity interest (e.g. stocks, stock options, warrants, contractual rights to acquire or receive ownership interests other than interests in a diversified mutual fund); compensation (anything of monetary value); or intellectual property rights.
Gift: A gift is defined as something with financial value including items of token value such as notepads, pens, coffee mugs, clocks, or similar items; food; beverages; travel; entertainment such as (but not limited to) attendance at or tickets to theater or sporting events, movies, concerts, or similar events; but excluding informational material, publications, or subscriptions related to the OHSU Member's official duties.
Investigator: The principal investigator, co-investigator and other OHSU employees or volunteers, or any OHSU research collaborator, including visiting scientists, responsible for the design, conduct or reporting of research or educational activities or responsible for preparting a proposal for research funding.
Outside Activity: Any activity engaged in by an OHSU employee but not in the employee's job description and not reimbursed by OHSU.
Position of Authority: is a position in which one does or may influence the selection, retention, evaluation, direction, or supervision of a vendor, including influencing the decision to place business, increase or decrease business, or continue, modify, or terminate a relationship with a vendor. this includes but is not limited to:
- Prescribing OHSU health care providers relative to Pharmaceutical Vendors;
- OHSU Members with grants relative to vendor suppliers;
- OHSU Members with fiscal authority relative to a specific business decision with a vendor; and
- Each OHSU employee as to all Vendor relationships:
- Within the employee's oversight authority;
- Where the vendor relationship is a part of a Vendor selection process in which the employee participates such as an RFP; and/or
- Where the employee exerts or attempts to exert influence over the awarding of business to the vendor.
Related Outside Activity: Any Outside Activity (OA) that requires the employee to use the academic, professional, or institutional expertise for which he/she is employed by OHSU; an OA conducted at OHSU owned or controlled premises or that uses OHSU facilities or support; or an activity that interferes with the employee's duties to OHSU, including but not limited to his/her time commitments.
Research: A systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge. As used in OHSU policies, the term "research" encompasses basic and applied research and product development.
Researchers: The Principal Investigator, co-investigator and other OHSU employees or volunteers, or any OHSU research collaborator, including visiting scientists, those responsible for the design, conduct or reporting of research or educational activities or responsible for preparing a proposal for research funding.
Significant Financial Interest (SFI): Includes the following interests of the discloser (and those of the discloser's spouse or registered domestic partner and dependent children)
- Compensation: I.e., anything of monetary value including, but not limited to, salary, gifts, consulting fees, honoraria or other payments for services that is more than five thousand US dollars ($5,000) in the aggregate over the last twelve (12) months;
- Equity interests: e.g. stocks, stock options, warrants, contractual rights to acquire or receive ownership interests, or other ownership interests in a publicly-traded company that is more than five thousand US dollars ($5,000) in the aggregate over the last twelve (12) months or any amount in a non-publicly-traded company;
- The aggregated value of equity interest and compensation, as defined above, that exceed $5000 over the last twelve (12) months in a publicly-traded company;
- Intellectual property rights: e.g. patents, copyrights and royalty income or the right to receive future royalties under a patent licenses or copyright;
- Non-royalty payments or entitlements to payments in connection with the research that are not directly related to the reasonable costs of the research (e.g. bonus or milestone payments to the investigators in excess of reasonable costs incurred);
- Service as an officer, director, or in any other executive position in an outside business, whether or not remuneration is received for such service; and
- Reimbursed or sponsored travel (applies to investigators involved in Public Health Service funded research only and not their spouse, registered domestic partner or dependent children). Disclosures shall include the purpose of the travel, the identity of the sponsor/organizer, the destination and the duration of the travel, and any other information as requested by the disclosure form or designated official. See exemptions in (6) below.
Exceptions: Significant financial interests do not include the following:
- Interests of any amount in publicly traded, diversified mutual funds or retirement accounts so long as the investigator does not directly control the investment decision made in these vehicles.
- Payments to the institution, or via the institution to the individual, that are directly related to reasonable costs incurred in the conduct of research as specified in the research agreement(s) between the sponsor and the institution.
- Salary and other remuneration from OHSU, including approved faculty practice plan earnings and the distribution of those earnings that may be established by departmental or other similar agreements provided that those agreements and departmental/divisional group plans are approved by the President.
- Income form seminars, lectures, or teaching engagements sponsored by a federal, state, or local government agency, an Institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute that is affiliated with an Institution of higher education; or
- income from service on advisory committees or review panels for a federal, state, or local government agency, an Institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute that is affiliated with an Institute of higher education.
- Reimbursed or sponsored travel that is reimbursed or sponsored by a federal, state or local government agency, and Institute of higher education, an academic teaching hospital, or a research institute that is affiliated with an Institute of higher education.
Fraud, Waste and Abuse
Abuse: Practices that are inconsistent with sound fiscal, business, or medical practices and result in unnecessary costs. This includes the intentional destruction, diversion, manipulation, misapplication, maltreatment, or misuse of resources.
Fraud: The intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person.
Waste: The overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs.
Unbundling: The practice of submitting bills piecemeal or in a fragmented fashion to maximize the reimbursement for various tests or procedures that are required, pursuant to Medicare and Medicade guidelines, to be billed together and therefore at the reduced cost. Frequently seen in laboratory billing, also known as "fragmentation".
Upcoding: Occurs when a provider intentionally uses a higher-paying code on the claim form for a patient to fraudulently reflect the use of a more expensive procedure or device than was actually used or was necessary.
Information Privacy & Security
Classified: information that is not for public review or access and would carry risk to the organization if used or disclosed inappropriately.
Confidential: information by which use by or disclosure to unauthorized individuals would violate OHSU Policy or applicable regulations.
Duty to Preserve: OHSU has a duty to preserve a record when someone knows or should have known that the record is:
Reasonably likely to lead to the discovery of admissible evidence;
Relevant to anticipated or pending legal action;
Reasonably likely to be requested in discovery or the subject of a pending discovery.
Intellectual Property: Intellectual property includes any invention or improvement in technology, whether patentable or not, conceived or developed using the expertise for which an employee is employed by OHSU; OHSU facilities, personnel, information or other resources, educational professional or tangible materials, whether or not registered for copyright or trademark, that result from the instructional, research, or public service activities of OHSU; and data developed using OHSU facilities, personnel, or other resources or resulting from the instructional, research, or public service activities of OHSU.
Minimum Necessary: When using, disclosing or requesting PHI from another health system or provider, only use or disclose the minimum necessary PHI to do your job.
Proprietary: information that is not for public review or access and would carry risk to the organization if used or disclosed inappropriately.
Records Custodians: all OHSU members are the custodian of their records. They must be familiar with the records that are their responsibility, what records exist, where these records are stored, and how the records can be retrieved or preserved.
Restricted Information: Information or data - any confidential or personal information that is protected by law or policy and that requires the highest level of access control and security protection whether in storage or in transit.