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).
Specifically:

• 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.