University of Virginia School of Medicine

Background

The University of Virginia School of Medicine is committed to conducting its affairs in ways that support our Mission Statement and promote our Values. All members of the University of Virginia School of Medicine community are responsible for sustaining the highest ethical standards of excellence, integrity, honesty, and fairness and for integrating these values into teaching, research, patient care, business practices, and other services. Ethical conduct is a fundamental expectation for every one of us every day.

Mission Statement

To provide excellence, innovation, and superlative quality in the care of patients, the training of health professionals, and the creation and sharing of health knowledge within a culture that promotes equity, diversity, and inclusiveness.

Values

At the School of Medicine, we ASPIRE to create a culture of trust, respect and engagement through our values:

• Accountability: Acknowledging and assuming responsibility for where we have succeeded and failed in terms of our actions, decisions, policies and results.
• Stewardship: Responsibly and carefully managing our resources and commitment to continual improvement and learning while acknowledging shortcomings or problems in our quest.
• Professionalism: Approaching all that we do in a collaborative way, delivering excellent care through the lens of helpfulness, positivity, kindness and competency.
• Integrity: Being honest, open and fair through our behaviors, attitude and treatment of others.
• Respect: Being mindful of building a diverse and inclusive environment while showing compassion for everyone through our caring and intentional ways.
• Excellence: Conducting ourselves in a manner that surpasses ordinary standards through preparation, collaboration and proactivity in all that we do

Scope

The University of Virginia School of Medicine (referred to here as “UVA SOM”) engages in a variety of activities in support of its tri-part educational, research and patient care mission. This Code of Conduct applies to all members of the UVA SOM community, including our faculty, staff, volunteers, contractors, agents, affiliates, and others providing services to UVA SOM or on behalf of UVA SOM.

Students or trainees taking courses, attending classes, or enrolled in academic programs are expected to adhere to UVA SOM policies governing academic and non-academic conduct. These student-oriented policies support and reflect the standards of conduct expected of other members of the UVA SOM community described in this Code of Conduct.

Standards of Conduct

The UVA SOM Code of Conduct is a shared statement of commitment to uphold the ethical, professional, and legal standards used as the basis for daily and long-term decisions and actions. Adherence to the spirit of this Code, as well as to its specific provisions, is critical to UVA SOM’s continued success. Each member of the community is individually accountable for his or her own actions, and the UVA SOM community is collectively accountable for upholding these standards of behavior and for compliance with applicable laws and policies that guide our work.

Members of the UVA SOM community commit to the following eight standards:

1. Provide quality education, research, healthcare, business interactions, and other services

UVA SOM is committed to providing outstanding, high-quality services to our students, learners, patients, families, visitors, business partners, colleagues, affiliates, and to the community, whether those services are provided through teaching, research, patient care, or through business interactions. In performing their duties, UVA SOM community members are expected to:

• Act with high ethical and professional standards of conduct;
• Be honest in performing one’s duties, with no exceptions;
• Ask questions and request assistance when additional information is needed to properly perform one’s duties;
• Be personally accountable for one’s actions and admit mistakes when they occur;
• Be aware of UVA SOM’s obligations toward all stakeholders;
• Conscientiously fulfill those obligations toward all stakeholders; and
• Communicate to others the ethical standards of conduct and responsibilities under this Code of Conduct by instruction and example.

UVA SOM community members are not to:

• Fabricate information;
• Change or knowingly omit information to misrepresent events, circumstances, results, or outcomes in relevant records; or
• Take credit for another’s work or work product as one’s own.

With respect to teaching and research, UVA SOM community members are expected to:

• Take students seriously and treat them with respect;
• Provide an excellent and supportive environment for learners in the classroom and in the clinical setting;
• Promote academic freedom, including the freedom to discuss all relevant matters in the classroom and to explore all avenues of scholarship, research, and creative expression;
• Propose, conduct, and report research with integrity and honesty;
• Protect people and humanely treat animals involved in teaching or research;
• Undertake human subjects research only in accordance with approved protocols;
• Learn, follow, and demonstrate accountability for meeting the requirements of regulatory bodies, sponsors, and partners;
• Accurately transmit research findings;
• Protect rights to individual, UVA SOM, and third-party intellectual property;
• Ensure originality of one’s work and provide credit for the ideas of others upon which work is built;
• Be responsible for the accuracy and fairness of information reported and/or published; and
• Fairly assign authorship credit on the basis of significant contributions.

With respect to patient care, UVA SOM community members are expected to:

• Provide the highest quality of care by reaching for excellence;
• Do the right thing, at the right time, for the right person;
• Do whatever is possible to ensure the best result; and
• Partner innovative medicine and technology with compassionate care that is safe, effective, patient-centered, timely, efficient, and equitable.

2. Treat individuals with respect

UVA SOM is an institution dedicated to tolerance, diversity, and respect for differences. Central to that commitment is the principle of treating each UVA SOM community member and those we serve with respect. UVA SOM community members are expected to:

• Be respectful, fair, and civil;
• Value diversity of opinion and contributions of others;
• Avoid all forms of harassment, illegal discrimination, threats, intimidation, bullying, or violence;
• Provide equal opportunity for access to programs, facilities, and employment; and
• Promote conflict resolution.

3. Comply with applicable laws, regulations, and policies

UVA SOM is committed to sustaining a culture of trust, ethics, and compliance in which legal requirements are met. Individuals must be comfortable raising concerns to the responsible supervisors when they have a good-faith belief that actions of individuals or an entity within the UVA SOM community are not consistent with laws, regulations, policies, or standards. Additionally, UVA SOM leadership is committed to maintaining the community trust by ensuring appropriate actions are taken to resolve non-compliance. UVA SOM community members are expected to:

• Learn and follow the rules, laws, regulations, contracts, and UVA SOM policies and procedures applicable to one’s UVA SOM work or activities;
• Be proactive to prevent and detect compliance violations;
• Report suspected compliance violations through standard management channels, beginning with one’s immediate supervisor, instructor, or advisor or, if not appropriate because of that individual’s involvement, to a higher level of management within one’s unit, department, school, or entity, to Human Resources, or to a compliance officer; and
• Ensure that reports of suspected compliance violations within one’s area of responsibility are properly resolved.

4. Use confidential information responsibly

UVA SOM community members are creators and custodians of various types of  confidential, proprietary, and private information. Each UVA SOM community member is required to comply with federal and state laws and regulations, agreements with third parties, and UVA SOM and University of Virginia policies pertaining to the use, protections, and disclosure of such information. UVA SOM community members are expected to:

• Learn and follow all laws, UVA SOM and University of Virginia policies, and agreements with third parties regarding access, use, protection, disclosure, retention, and disposal of public, private, and confidential information;
• Respect the privacy of all information records, whether student, learner,  employee, or patient;
• Follow document retention and disposal policies;
• Maintain information security using appropriate electronic and physical safeguards; and
• Fulfill any applicable requirements when one’s relationship to UVA SOM is terminated.

5. Acknowledge and appropriately manage conflicts of interest

UVA SOM faculty and staff owe their professional allegiance to UVA SOM and its mission to excel in the highest levels of education, patient care, research, and scholarship. UVA SOM community members have an obligation to be objective and impartial in making decisions on behalf of UVA SOM. External professional activities, private financial interests, or the receipt of benefit from third parties can cause an actual or perceived conflict between UVA SOM’s interests and an individual’s private interests. UVA SOM community members are expected to:

• Accept benefits, awards, and prizes from external entities only in accordance with established UVA SOM and University of Virginia policies and standards;
• Disclose relationships with third parties, such as consulting, board membership, or professional services, in accordance with UVA SOM’s and the University of Virginia’s processes to ensure objective judgment in purchasing, research, and other UVA SOM business and to identify any potential or actual conflicts of interest;
• Adhere to any management plans created to manage conflicts of interest; and
• Ensure one’s personal relationships do not interfere with objective judgment in decisions affecting UVA SOM employment or academic progress of any UVA SOM community member.

6. Safeguard and accurately account for UVA SOM resources

UVA SOM is dedicated to responsible stewardship. UVA SOM resources must be used for UVA SOM business purposes and not for personal gain. All UVA SOM accounts, financial reports, tax returns, expense reimbursements, time sheets, and other documents including those submitted to government agencies must be accurate, clear, and complete. All entries in UVA SOM records must accurately reflect each transaction. UVA SOM community members are expected to:

• Use UVA SOM property, equipment, finances, materials, electronic and other systems, and other resources only for UVA SOM purposes;
• Prevent waste and abuse;
• Promote efficient operations;
• Follow appropriate protocols for obligating UVA SOM by contract/agreement;
• Follow sound financial practices, including accurate inventory accounting, financial reporting, responsible fiscal management, and internal controls; and
• Engage in appropriate accounting and monitoring.

7. Provide a safe environment

UVA SOM community members have a shared responsibility to ensure a safe, secure, and healthy environment for all UVA SOM students, patients, faculty, staff, volunteers, and visitors. UVA SOM community members are expected to:

• Promote personal safety and follow safe workplace practices, including participating in applicable education sessions, using appropriate personal safety  equipment, and reporting accidents, injuries, and unsafe situations;
• Maintain security, including securing UVA SOM assets;
• Report suspicious activities; and
• Protect the environment, including carefully handling hazardous waste and other potentially harmful agents, materials, or conditions.

8. Document, code, bill, and collect in accordance with applicable rules and regulations

As part of a comprehensive research enterprise and academic medical center, UVA SOM must coordinate its activities with the other members of the University of Virginia Health System (UVAHS) to ensure that clinical services and sponsored projects are billed appropriately and in compliance with relevant laws, regulations, and contractual obligations. UVA SOM community members are expected to:

• Provide medically appropriate goods and services to the patients UVAHS serves;
• Render services within the scope of federal, state, and professional licensure guidelines and applicable by-laws;
• Substantiate goods and services provided with complete and accurate documentation in the medical record; and
• Accurately code and bill for services based on current payer and government standards.

Violations

Adherence to this code requires UVA SOM community members to bring suspected violations of applicable laws, regulations, policies, and standards to the attention of the appropriate office. UVA SOM treats every notice of suspected compliance violation very seriously and considers reports of suspected noncompliance to be a service to UVA SOM and the UVAHS. Reporting a compliance concern in good faith will not jeopardize one’s employment. No such protection is extended to UVA SOM community members reporting in bad faith.

UVA SOM prohibits UVA SOM community members from retaliating or allowing retaliation against another community member for reporting activities suspected of violating laws, regulations, contractual obligations, or UVA SOM or UVAHS policies.

Confirmed violations of this Code of Conduct will result in appropriate consequences for the violators, up to and including termination of employment or other relationships with UVA SOM.

Code of Conduct History: Implemented October 1, 2014. Revised 6/14/19