For Employees

You have an important role in Healthcare Integrity

When acting in any capacity for OHSU, all employees must:

  • Act in accordance with the OHSU Code of Conduct and all applicable OHSU policies.
  • Carry out their responsibilities in an ethical, effective and professional manner.
  • Follow all federal, state, and local laws, regulations and standards that apply to their responsibilities.
  • Report potential integrity or compliance concerns through the reporting mechanisms described in the OHSU Code of Conduct.
  • Read OHSU Integrity Program Roles & Responsibilities and Program Elements and ask your supervisor about your specific responsibilities. Note that managers have additional responsibilities that are discussed below.

Complete Compliance education:

Complete Hospital Compliance or Fraud Awareness along with the other required  training programs for your position.  Go to Integrity Training to learn more.

If you have questions about any of this or about any concern at OHSU,
the first person to ask is your supervisor.

Management Has Additional Compliance Responsibilities


Compliance roles and responsibilities

As a director, manager or administrator you are responsible for integrity and compliance in your area. It is important for you to know what is expected of you and your staff. Be certain to read in detail about your specific responsibilities in OHSU Integrity Program Roles & Responsibilities and Program Elements.  Some of your additional compliance responsibilities are summarized below:


Compliance language in position descriptions and performance appraisals

Compliance language must be included in the position descriptions for all the employees in your department/org. Compliance language must also be included in your position description or notice of appointment. Please refer to Options for Including Compliance Expectations in Position Descriptions in OHSU Healthcare for detailed suggestions in this area. 

Compliance is a core competency on which employees and managers are evaluated. Please read Performance Management Review for more information on this topic.


Compliance education

  • Consult ADM 3.30 for training requirements for your department.
  • Assist your employees in completing their compliance education requirements.
  • Monitor the status of their completion of education and training
  • Reporting on educuation completion in Big Brain is availalbe to all managers. Contact Integrity Education (503 494-8849) for details.
  • Develop and implement department-specific compliance training programs for your staff based on their job responsibilities.


 Establish department procedures and monitoring for departmental compliance

  • Establish departmental polices and procedures to assure compliance with laws, rules, regulations and policies.
  • Periodically check to see how well policies and procedures are being followed and how well your area of responsibility is doing in meeting its compliance obligations.
  • Develop and implement corrective action plans if you find areas of departmental non-compliance.


Respond to compliance and integrity questions and concerns that employees raise

  • Because you are often the first person with whom an employee will discuss a question or concern, you are expected to appropriately and seriously address all questions and concerns raised by your employees.
  • Listen carefully; investigate to find the facts and pertinent laws or polices; avoid making judgments; seek help from whoever can help you (OHSU Hospital Integrity, Human Resources, Environmental Safety, etc.).
  • Preserve the employee's confidentiality, if requested.
  • Provide the employee with a timely response and ask if he/she still has questions or concerns.
  • Enforce OHSU's policy that prohibits retaliation against anyone who raises a compliance or integrity concern.


Cooperate with internal and external auditors

Make sure that you and your employees provide honest, accurate and complete information so that the integrity of the audit process is assured


Compliance orientation for new department directors/managers

If you are a new department director/manager, please contact Lalita Ham, 503-494-2133, for compliance orientation.


Lead by example.