Conducting Ethics and Compliance Investigations Guidebook

Roles and Definitions

Complaint Committee – Upon receipt of Hotline complaints, or concerns reported through other avenues that constitute a violation of law, regulation, University policy, or ethical standards, the Complaint Committee will convene (either via email, over the phone, or in person) to discuss the case.  A recommended best course of action will be determined, to include who should conduct the investigation, and any specific protocols that should be followed. The Complaint Committee may also review conclusions by investigators prior to posting in the EthicsPoint Case Management System, and track progress of investigations to assure they are closed-out within reasonable time frames.

Committee members are as follows:

  • Kristin Dukes, General Counsel
  • John Elliott, Assoc VP, Finance & Admin/Human Resources
  • Chris Hansen, Compliance Specialist

USA Health representatives, as follows (cases originating from USA Health):

  • Andrea Rosler, Chief Human Resources Officer (CHRO)
  • Shannon Scaturro, University Hospital Administrator
  • Deborah Browning, Children’s and Women’s Hospital Administrator
  • Michelle Dudley, Physicians Group Administrator

Primary Investigator (“Primary Case Assignee”) – assigned by the Complaint Committee to oversee a compliance investigation in response to a Hotline complaint (or allegation of wrongdoing reported via other channels). The Primary Investigator may be the only person assigned to investigate a matter, or may be the lead investigator if there are co-investigators involved. A Primary Investigator will typically be either:

  1. a recognized Subject Matter Expert in an applicable regulatory topic,
  2. a Human Resources Department, Office of Compliance, or Internal Audit Department employee
  3. an Administrator or Supervisor responsible for the department of an alleged subject.

The Primary Investigator may at their discretion recruit an additional investigator, consult with a Subject Matter Expert, or recruit someone to serve as an interviewer. For instance, if a Human Resources Dept employee is assigned as the lead investigator into a matter, they might ask an alleged subject’s supervisor to assist with the investigation.

Co-Investigator – an employee recruited either by the Primary Investigator or by the Complaint Committee to assist with an investigation.

Subject Matter Expert – an employee who is recognized by management and peers as sufficiently knowledgeable in a particular topic who can assess whether or not a regulatory or policy violation has occurred based on investigative findings. There may be more than one Subject Matter Expert assigned to a given investigation, depending on the complexity of the case.

Interviewer – an employee assigned by the Primary Investigator (or the Primary Investigator him/herself) to interview specific individuals, and document the conversation in a written summary to be provided to the Primary Investigator.

Compliance Violation – may represent a violation of the Staff Employee Handbook, Faculty Handbook, Code of Conduct, USA policies and procedures, or federal or state laws and regulations. An alleged Compliance Violation may represent a financial or reputational risk to the University, and should therefore require a compliance investigation.


▼   Receipt of Complaint or Alleged Violation
  1. Via the Ethics and Compliance Hotline – the Chief Compliance Officer will notify the Complaint Committee and prompt a discussion on how the investigation should proceed, including who should be assigned as Primary Investigator. Upon a decision, the case will be assigned to the chosen investigator in the EthicsPoint, and the Chief Compliance Officer will alert the Primary Investigator via phone or email.
  2. Via Other Avenues (i.e., complaint made directly to a supervisor, to Human Resources, to the Title IX Office, etc.) – the recipient of a complaint or allegation should report it to an appropriate authority (i.e., the Chief Compliance Officer, H.R. Dept, Internal Audit, Title IX, etc.). The Complaint Committee should also be notified, to assure approaches to investigations remain uniform.
▼   Key Objectives of the Investigator
  1. Begin and end any discussion with those you involve in the investigation (co-investigators, interviewers, interviewees, witnesses, subject matter experts, alleged subjects, supervisors, etc.) by asking them to be mindful of:
    1. Protecting the anonymity of the complainant, in order to uphold the integrity of our Hotline
    2. The importance of the University’s Non Retaliation Policy
    3. Not repeating anything discussed during the course of interviews or the investigation
    4. Protecting the integrity of the Hotline by following the aforementioned principles. USA employees need to know the Hotline is a safe way to report misconduct, free from any perception of retaliation.
  2. Consider the need for recruiting others to assist with the investigation, as Co-Investigator, Subject Matter Expert, Interviewer, or possibly someone with necessary skills such as an IS application system administrator or Internal Audit staff member.
  3. Determine whether a subject’s supervisor should be notified. You may or may not need the assistance of the supervisor in the course of the investigation, yet may need to notify them in the event there are reasonable steps the supervisor should take to keep their staff and others safe, safeguard data and material, and maintain department operations. Any action taken by a supervisor should be in coordination with the investigator.
  4. Consider all aspects of the allegation(s), and formulate a plan for how to proceed with the investigation. Consider any potential conflicts, and how to avoid them.
  5. Proceed with the investigation with an unbiased, objective, and open-minded perspective; be sure to record your findings based on facts rather than opinions, and derive your conclusions in the same manner.
  6. Document all steps taken, to include summaries of interviews and conversations.
  7. Consideration of potential disciplinary steps should be left to the discretion of H.R. Dept and the alleged subject’s supervisor, upon their review of the investigative findings.
▼   Commence the Investigation
  1. If electronic record systems can be used to assist in determining if there is merit to an allegation, consider system and/or database audits. Based on what you know about the allegation, determine reasonable parameters for a data query, then reach out to the system administrator. If a system administrator objects to providing the requested support after you have explained the purpose, contact the Chief Compliance Officer or Assoc. VP, Finance & Administration / Human Resources. 
  2. Employ any other necessary, independent research prior to setting up interviews, such as familiarizing yourself with state or federal laws and regulations, or University policies, procedures, etc., to determine if the alleged act is in violation of such.
  3. Select interview candidates (if necessary), typically those named as witnesses. In some cases a random selection of employees, students, etc., located in the same department as the alleged subject, may be necessary.
  4. Interview questions: Without divulging details of the complaint or who the subject of the allegation is, begin with a series of open-ended questions such as, “have you ever witnessed inappropriate, disruptive or offensive conduct by employees in this department, or heard others talking about it?”, and document their responses. Try to avoid "leading" interviewees; let them do most of the talking. From there, continue with more specific, clarifying questions, as necessary. This technique may assist you in identifying important aspects of a situation unknown up to that point, or beyond what the complainant is aware of.
  5. Upon analysis of preliminary findings from the aforementioned investigative processes, develop a list of questions and then meet with the alleged subject for a formal interview. You may wish to include the subject’s supervisor or other witness in the interview.
  6. Be sure you are documenting your findings. It is important to document interview summaries as soon after the interview as possible so that key details aren’t forgotten. Prepare a summary of all findings and a conclusion, and enter into EthicsPoint either as a WORD Attachment or a Note.
  7. Investigative findings should be referred to the supervisor of the alleged subject (and possibly someone higher up the chain of command depending on severity of the potential financial or reputational risk to the University), and an H.R. Dept representative, for determination of disciplinary steps (if necessary), and/or a corrective action plan. While Primary Investigators may not necessarily be involved in determining disciplinary steps, they will need to document them in EthicsPoint. A brief summary of corrective actions, including disciplinary action, assigned training, monitoring, etc., should also be logged in the EthicsPoint Synopsis (see step e in the next section)
▼   Documenting Investigative Findings in EthicsPoint
  1.  Follow-Ups:  Start off an investigation by reaching out to the complainant, including those who have reported anonymously, using EthicsPoint's "Follow-Up" feature. Choose the option as follows,
    1. “Thank you for your report. We will review it to determine if an investigation is necessary. Please follow up on a regular basis, in case we have additional questions as we review this matter.”
    2.  There are other Follow-Up options, including a way to ask specific, clarifying questions to the complainant. Anonymous complainants won’t be notified that you have posted a Follow-Up note to them; they must independently log-in to their complaint periodically (as they are encouraged to do upon submission of their complaint). This feature allows the investigator and complainant to communicate, without compromising the identify of an anonymous complainant. If the complainant did not file the complaint anonymously, you may choose to contact them via phone or email, but please document any such follow-up communication, either as an Attachment or a Note.
  2. Assignments and Access:  If a Primary Investigator assigns a Co-Investigator and needs them to have access to the assigned case in EthicsPoint, their name should be selected from the list provided in EthicsPoint. If their name is not listed, contact the Chief Compliance Officer (251-460-7115, or, who can add them. You can then place a check in the box to the far-right of your screen for “send email,” which will alert them of the new assignment. New users will first be prompted in an introductory email (initiated by an EthicsPoint system administrator) to login for the first time using their email prefix (usually the first letter of first name, and full last name), then prompted to establish a password.      
  3. Participants:  This field is auto-filled with names provided by the complainant. Although not required, the Primary Investigator may also wish to include others involved in the investigation (subject, witness, victim, interviewee, etc.) by entering their names in this section.
  4. Attachments: you may attach various types of files, including WORD docs, spreadsheets, photos, sound or video files. Ideally, provide a description of the file you are attaching in the available text box. It would also be helpful to name files in a way that will be meaningful to other potential reviewers of the case (such as the Chief Compliance Officer, Executive Director, Internal Audit, or General Counsel), such as,
    1. Investigative Findings (a WORD doc with your investigative findings, entered chronologically)
    2. Interview with John Doe
    3. Interview with Jane Doe
    4. Summary of findings, determination, and conclusion/resolution.
    5. Data Query from Banner
  5. Synopsis:  Completion of this section is important because the data appears on an annual report to USA's external auditor (KPMG) for their annual review. This section includes the following required fields:
    1. Primary Outcome: One of the following outcomes should be selected:
      1. Substantiated
      2. Unsubstantiated
      3. Partially Substantiated
      4. Frivolous
      5. Insufficient Information
      6. Other
        (Repeat above step for Secondary Outcome if necessary)
    2. Action Taken: One of the following actions should be selected:
      1. No action necessary,
      2. Policy/process review,
      3. Training,
      4. Discipline, or
      5. Termination
    3. Potential Next Steps: Provide corrective action steps (if applicable)
    4. Synopsis Notes: Provide a summary and conclusion of investigative findings.
  6. Case Notes:  This should include each of your investigative findings, either entered sequentially over time, or altogether. Enter into the text box by either typing or copy-pasting from a source document. The note will be date/time stamped. This is an ideal method for noting progress in the investigation, or alerting a reviewer to attachments you have posted (i.e., “I interviewed John Doe today; please see interview summary in attached document, ‘Interview with John Doe’”).
▼   Best Practices
  1. Summary of Conclusions:  Ideally, this report will involve the following components (at a minimum): 
    1. Summary of allegation(s)
    2. Summary of findings which directly correlate to the allegation(s)
    3. Summary of any noteworthy incidental findings 
    4. Determination of whether there was merit to the allegation(s)
    5. If allegations are substantiated, cite the specific law, regulation, policy or procedure that was violated.
    6. Corrective action plan, to include disciplinary action, assigned training/education, follow-up monitoring, etc., as necessary
    7. Proposed Follow-Up comment to the complainant (examples):
      • The issue you reported was investigated and not substantiated. No further action was necessary. Thank you for filing your report.
      • The issue you reported was investigated and substantiated, however, was not a violation of policy and procedure, nor determined to negatively affect the workplace. No further action was necessary. Thank you for filing your report.
      • The issue you reported was investigated and substantiated, however, was not a violation of policy and procedure. Action as necessary was taken. Thank you for filing your report.
      • The issue you reported was investigated and substantiated. Appropriate follow-up action has been taken. Thank you for filing your report.
  2. EthicsPoint Documentation:  
    1. Utilize a WORD document, titled “Case _ (#) Investigative Findings” maintained in your computer, to progressively document all your findings per the aforementioned guidance. You may post this document as an "attachment" to the case in EthicsPoint. Or if you prefer, copy-paste your findings into your EthicsPoint case as "Notes." If choosing this latter option, it works best if you are entering your notes contemporaneously - to show an accurate timeline of your progress.
    2. Upon attaching all findings, determinations, conclusion/resolution, complete the aforementioned Synopsis components and close the case.
    3. If you are not using the "Notes" feature to post findings, you are encouraged to use it if only to direct a reviewer’s attention to a document you have attached.
    4. Ideally, use a separate WORD document to summarize each of your interviews, titled, "Case _ (#) Interview with John Doe," which should be attached to the case in EthicsPoint contemporaneously.
▼   Access to Cases in EthicsPoint 

The only employees who will be given access to any given case will be as follows:

  1. The Primary Case Assignee will be determined by the Complaint Committee, then given access by the System Administrator (Chief Compliance Officer),
  2. The Primary Case Assignee may, at his/her discretion, or if indicated by the Complaint Committee, also provide case access to an additional Case Assignee,
  3. For “Primary Case Assignees” who are frequently assigned investigations, they may arrange with a System Administrator for permission for a secretary or administrative assistant to post Documents, Notes, etc. in EthicsPoint on their behalf.