Presentation - Society of Corporate Compliance and Ethics
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SCCE Higher Education Compliance Conference SCCE HIGHER EDUCATION COMPLIANCE CONFERENCE Austin, TX Sunday May 31, 2015 – Session P2 CHALLENGING! EXCITING? REESTABLISHING THE COMPLIANCE AND ETHICS PROGRAM Sonal Shah, CPA, MSPA, CHC Senior Director, Compliance and Ethics Stanford Office of Audit, Compliance and Privacy Stanford Office of Audit, Compliance and Privacy COMPLIANCE… 2 1 SCCE Higher Education Compliance Conference YESTERDAY… 3 Stanford Office of Audit, Compliance and Privacy Stanford Office of Audit, Compliance and Privacy TOMORROW… 4 2 SCCE Higher Education Compliance Conference YESTERDAY… 5 Stanford Office of Audit, Compliance and Privacy Stanford Office of Audit, Compliance and Privacy TOMORROW… 6 3 SCCE Higher Education Compliance Conference Stanford 7 Office of Audit, Compliance and Privacy SONAL SHAH - BIOGRAPHY Responsible for: Accounting, Internal Audit, Compliance, Ethics, Privacy, Risk, Conflict of Interest, Enterprise Risk Management, Investigations… Organizations: Aetna, Yale New Haven Health Services, Landmark Medical Center, Tufts Medical Center, Hartford HealthCare, Harvard School of Dental Medicine… Currently at Stanford University Senior Director, Compliance and Ethics 8 Stanford Office of Audit, Compliance and Privacy 4 SCCE Higher Education Compliance Conference Stanford 9 Office of Audit, Compliance and Privacy REESTABLISHING THE COMPLIANCE AND ETHICS PROGRAM Strengthening the Foundation – The Seven Elements Reinforcing The Pillars – The 4 Committees Reconditioning The Roof – Tone at the Top, and – 5 Values 10 Stanford Office of Audit, Compliance and Privacy 5 SCCE Higher Education Compliance Conference MISSION TO PROVIDE INDEPENDENT, OBJECTIVE ASSURANCE, CONSULTING AND INVESTIGATIVE SERVICES DESIGNED TO ADD VALUE AND IMPROVE OPERATIONS. ______________________________________ Assurance Services Consulting Services Investigative Services A C P Stanford 11 Office of Audit, Compliance and Privacy VISION TO BE A VALUED PARTNER AND ADVISOR TO MANAGEMENT, FACULTY AND THE AUDIT AND COMPLIANCE COMMITTEE _______________________________________________________________________________________________ CHARTER – THE AUDIT AND COMPLIANCE COMMITTEE CHARTER – COMPLIANCE AND ETHICS PROGRAM 12 Stanford Office of Audit, Compliance and Privacy 6 SCCE Higher Education Compliance Conference SENIOR MANAGEMENT’S PRIORITIES _______________________________________________________________________________________________ BALANCED SCORE CARD OBJECTIVES GOALS DIRECTIVES BIG 5 TOP 10 Stanford 13 Office of Audit, Compliance and Privacy LISTING OF RISKS _______________________________________________________________________________________________ ENTERPRISE RISKS • RISK MATRIX, RISK PROFILES COMPLIANCE RISKS • RISK LIST, DATA COLLECTION FORMS 14 Stanford Office of Audit, Compliance and Privacy 7 SCCE Higher Education Compliance Conference ORGANIZATION CHART Pictorial Representation Reporting Structure Functionally, Administratively Stanford 15 Office of Audit, Compliance and Privacy ASSESSING STAFFING REQUIREMENTS 1. Qualifications/Skill Sets 2. Number of Staff 3. Attitude/Mindset 16 Stanford Office of Audit, Compliance and Privacy 8 SCCE Higher Education Compliance Conference THE FY 20__ COMPLIANCE WORK PLAN 17 Stanford Office of Audit, Compliance and Privacy STRENGTHENING THE FOUNDATION THE SEVEN (7) ELEMENTS 18 Stanford Office of Audit, Compliance and Privacy 9 SCCE Higher Education Compliance Conference MISSION – TO ENHANCE COMPLIANCE ACROSS THE UNIVERSITY FOLLOW “ BEST BUSINESS PRACTICES” AND THE FEDERAL SENTENCING GUIDELINES 19 Stanford Office of Audit, Compliance and Privacy Stanford Office of Audit, Compliance and Privacy THE FIRST ELEMENT STANDARDS 20 AND PROCEDURES 10 SCCE Higher Education Compliance Conference THE SECOND ELEMENT GOVERNANCE, ORGANIZATION AND REPORTING COMPLIANCE OFFICER, COMPLIANCE COMMITTEE Stanford 21 Office of Audit, Compliance and Privacy THE SECOND ELEMENT, CONTD… ONLY ENGAGE PERSONNEL IN APPROPRIATE CONDUCT 22 WHO HAVE ENGAGED Stanford Office of Audit, Compliance and Privacy 11 SCCE Higher Education Compliance Conference THE THIRD ELEMENT TRAINING AND EDUCATION 23 Stanford Office of Audit, Compliance and Privacy Stanford Office of Audit, Compliance and Privacy THE FOURTH ELEMENT MONITORING 24 AND AUDITING 12 SCCE Higher Education Compliance Conference THE FOURTH ELEMENT, CONTD… ASSESSING RISK Stanford 25 Office of Audit, Compliance and Privacy THE FIFTH ELEMENT REPORTING AND INVESTIGATING IF YOU HAVE A CONCERN… _______________________________________________ A C P 26 Stanford Office of Audit, Compliance and Privacy 13 SCCE Higher Education Compliance Conference COMPLIANCE AND ETHICS HELPLINE MEMBERS OF THE STANFORD COMMUNITY FACULTY, STAFF, STUDENTS, CONSULTANTS, VENDORS, CONTRACTORS AND VOLUNTEERS A LL RESPONSIBLE AND ACCOUNTABLE - TO SUPPORT STANFORD’S MISSION __________________________________________________________ ______ REPORTING AVENUES: IF YOU SEE SOMETHING, SAY SOMETHING • • • • SUPERVISOR OR OTHER MANAGEMENT PERSONNEL HUMAN RESOURCES OFFICE OF THE GENERAL COUNSEL OFFICE OF THE OMBUDSMAN • COMPLIANCE AND ETHICS HELPLINE ACP o o CONFIDENTIAL OR ANONYMOUS NON-RETALIATION POLICY 650-721-2667 COMPLIANCE@STANFORD.EDU HELPLINE.STANFORD.EDU (WEB FORM) Stanford 27 Office of Audit, Compliance and Privacy THE SIXTH ELEMENT CONSISTENT ENFORCEMENT DISCIPLINE 28 AND APPROPRIATE Stanford Office of Audit, Compliance and Privacy 14 SCCE Higher Education Compliance Conference THE SEVENTH ELEMENT RESPONDING TO NON-COMPLIANCE AND MODIFYING THE PROGRAM AS NECESSARY 29 Stanford Office of Audit, Compliance and Privacy REINFORCING THE PILLARS THE FOUR (4) COMMITTEES 30 Stanford Office of Audit, Compliance and Privacy 15 SCCE Higher Education Compliance Conference REINFORCING THE PILLARS THE 4 COMMITTEES T HE A UDIT AND C OMPLIANCE C OMMITTEE OF THE B OARD OF T RUSTEES 31 Stanford Office of Audit, Compliance and Privacy REINFORCING THE PILLARS THE 4 COMMITTEES T HE C ABINET (S ENIOR M ANAGEMENT G ROUP ) 32 Stanford Office of Audit, Compliance and Privacy 16 SCCE Higher Education Compliance Conference REINFORCING THE PILLARS THE 4 COMMITTEES T HE C OMPLIANCE AND E THICS S TEERING C OMMITTEE 33 Stanford Office of Audit, Compliance and Privacy REINFORCING THE PILLARS THE 4 COMMITTEES T HE C OMPLIANCE AND E THICS O FFICERS N ETWORK 34 Stanford Office of Audit, Compliance and Privacy 17 SCCE Higher Education Compliance Conference REINFORCING THE PILLARS… MORE THAN JUST COMMITTEES STAFF MEETINGS T HE S ENIOR S TAFF M EETING T HE M ONTHLY S TAFF M EETING __________________________________ S TA F F M E E T I N G APRIL 21, 2015 9 : 3 0 AM – 11 : 3 0 AM AGENDA Stanford 35 Office of Audit, Compliance and Privacy REINFORCING THE PILLARS… MORE THAN JUST COMMITTEES COLLABORATION, REACHING OUT 1. 2. 3. 4. 5. THE OFFICE OF THE GENERAL COUNSEL HUMAN RESOURCES RESEARCH COMPLIANCE PRIVACY INFORMATION SERVICES/INFORMATION SECURITY 6. FINANCIAL MANAGEMENT SERVICES 7. UNIVERSITY COMMUNICATIONS 36 Stanford Office of Audit, Compliance and Privacy 18 SCCE Higher Education Compliance Conference REINFORCING THE PILLARS… MORE THAN JUST COMMITTEES COLLABORATION, REACHING OUT 1. 2. 3. 4. 5. 37 THE DEAN OF THE SCHOOL OF MEDICINE THE PROVOST’S OFFICE THE REGISTRAR’S OFFICE THE TITLE IX OFFICE ENVIRONMENTAL AND HEALTH SERVICES Stanford Office of Audit, Compliance and Privacy RECONDITIONING THE ROOF THE TONE AT THE TOP, and FIVE (5) VALUES 38 Stanford Office of Audit, Compliance and Privacy 19 SCCE Higher Education Compliance Conference RECONDITIONING THE ROOF TONE AT THE TOP As a member of the Stanford University c o m m u n i t y, e a c h o f u s i s responsible for maintaining the highest ethical standards and performing activities with the utmost integrity and fairness.” – J o h n H e n n e s s y, P r e s i d e n t Stanford 39 Office of Audit, Compliance and Privacy RECONDITIONING THE ROOF TONE AT THE TOP AND 5 VALUES T RUST 40 Stanford Office of Audit, Compliance and Privacy 20 SCCE Higher Education Compliance Conference RECONDITIONING THE ROOF TONE AT THE TOP AND 5 VALUES H ONESTY Stanford 41 Office of Audit, Compliance and Privacy RECONDITIONING THE ROOF TONE AT THE TOP AND 5 VALUES R ESPECT 42 Stanford Office of Audit, Compliance and Privacy 21 SCCE Higher Education Compliance Conference RECONDITIONING THE ROOF TONE AT THE TOP AND 5 VALUES F AIRNESS Stanford 43 Office of Audit, Compliance and Privacy RECONDITIONING THE ROOF TONE AT THE TOP AND 5 VALUES I NTEGRITY 44 Stanford Office of Audit, Compliance and Privacy 22 SCCE Higher Education Compliance Conference LIVING 3 ADDITIONAL VALUES O BJECTIVITY I NDEPENDENCE T RANSPARENCY “A L ACK OF TRANSPARENCY RESULTS IN DISTRUST…” DALAI LAMA 45 Stanford Office of Audit, Compliance and Privacy PREVENTING FRAUD, WASTE AND ABUSE (FWA) _____________________________________________________ A C P 46 Stanford Office of Audit, Compliance and Privacy 23 SCCE Higher Education Compliance Conference FRAUD, WASTE AND ABUSE (FWA) FRAUD INTENTIONALLY, KNOWINGLY AND WILLFULLY ATTEMPTING TO EXECUTE A SCHEME TO FALSELY OBTAIN PAYMENT FROM A FEDERAL, STATE OR OTHER GOVERNMENTAL ORGANIZATION. ____________________________________________________ HOW DOES IT APPLY TO MEMBERS OF THE UNIVERSITY COMMUNITY? KNOWINGLY PERPETRATING A SCHEME TO DEFRAUD A GOVERNMENTAL AGENCY OR THE UNIVERSITY OR ANY OF ITS AFFILIATES. MERRIAM-WEBSTER’S DICTIONARY: A “TO DEPRIVE OF SOMETHING BY DECEPTION OR FRAUD”. “CHEAT, SHORT-CHANGE, SWINDLE, FLEECE, SKIN, C BLEED, HUSTLE, VICTIMIZE, ETC.” P Stanford 47 Office of Audit, Compliance and Privacy FRAUD, WASTE AND ABUSE (FWA), CONTD.… WASTE SPENDING THAT CAN BE ELIMINATED WITHOUT REDUCING QUALITY OF THE SERVICE OR PRODUCT. __________________________________________________ HOW DOES IT APPLY TO MEMBERS OF THE UNIVERSITY COMMUNITY? CARELESSLY USING GOVERNMENTAL RESOURCES OR THE OF THE UNIVERSITY OR ANY OF ITS AFFILIATES. RESOURCES MERRIAM-WEBSTER’S DICTIONARY: “TO DAMAGE OR DESTROY GRADUALLY AND PROGRESSIVELY” “TO SPEND OR USE CARELESSLY OR USELESSLY: SQUANDER” 48 ACP Stanford Office of Audit, Compliance and Privacy 24 SCCE Higher Education Compliance Conference FRAUD, WASTE AND ABUSE (FWA), CONTD.… ABUSE IMPROPER BEHAVIOR OR BILLING PRACTICES THAT CREATE UNNECESSARY COSTS. _____________________________________________________ HOW DOES IT APPLY TO MEMBERS OF THE UNIVERSITY COMMUNITY? IMPROPERLY USING GOVERNMENTAL RESOURCES OR THE RESOURCES OF THE UNIVERSITY OR ANY OF ITS AFFILIATES SO AS TO RAISE THE COSTS OF SERVICE OR PRODUCT . MERRIAM-WEBSTER’S DICTIONARY: “CORRUPT PRACTICE” “INCORRECT OR IMPROPER USE: MISUSE” “TO USE SO AS TO DAMAGE: MISTREAT” “TO USE TO EXCESS” 49 Stanford Office of Audit, Compliance and Privacy Stanford Office of Audit, Compliance and Privacy FRAUD TRIANGLE ACP 50 25 SCCE Higher Education Compliance Conference THE FRAUD EXPOSURE RECTANGLE Fraud Exposure Rectangle Management & Directors Company’s Relationship w Other Entities 1 2 The Organization & Its Industry Financial Results & Operating Characteristics ACP 3 4 51 Stanford Office of Audit, Compliance and Privacy 52 Stanford Office of Audit, Compliance and Privacy 26 SCCE Higher Education Compliance Conference 53 Stanford Office of Audit, Compliance and Privacy 54 Stanford Office of Audit, Compliance and Privacy 27 SCCE Higher Education Compliance Conference 55 Stanford Office of Audit, Compliance and Privacy QUESTIONS AND COMMENTS 56 Stanford Office of Audit, Compliance and Privacy 28
