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Institutional Compliance

Institutional Compliance Committee Charge

Committee Makeup

Cross-functional managers who have high-risk compliance issues within their area of control.

Committee Charge

The committee is to develop a compliance plan. The committee will also be responsible for organizing, directing and controlling compliance activities. This will be an ongoing working committee that meets at least quarterly (more frequently initially).


  • Each committee member will conduct a comprehensive risk assessment of compliance issues within the area represented. This risk assessment will be accomplished through a smaller working team within the department. Those team members will be identified on the Risk Assessment for each department.
  • Each identified compliance issue will be evaluated and assigned a level of risk.
  • Each committee member will then assess the current monitoring mechanisms for the high risk areas that were identified within the department;
  • Each committee member will then identify and implement additional monitoring, training or other efforts that need to be initiated to mitigate the higher risks identified.
  • Mitigation efforts include:

    1. Operating Controls: Those procedures that are applied to every event/transaction in a process to ensure compliance with the policies and procedures governing the process. This includes policies and procedures, segregation of duties and reconciliations, etc.
    2. Supervisory Controls: Those procedures performed immediately thereafter by first line management, usually on a sample of all events/transactions to determine if the operating controls have been applied as designed.
    3. Oversight Controls:  Those procedures applied periodically by senior management to ensure that supervisory and/or operating controls have been applied as designed. Examples include: status reports, exception reports, budgeted versus actual comparisons, etc.
    4. Internal Auditor Controls: Those procedures applied periodically by auditors outside the department to test and evaluate sample populations of events or transactions for compliance with policies and procedures.
  • The committee as a group will prepare a report of its findings according to the UHS Action Plan and timeline. Administration will then have an opportunity to review and take corrective action where appropriate.
  • Each committee member will prepare a periodical report (minimally semi-annually) reporting on the status of Institutional Compliance efforts within the department.