The HYPOTHESISDeveloping a Compliance Program
at a Small Higher Education Institution
Sheila Lockwood, CHMMChemical Hygiene and Biosafety Officer
31st CUHWC August 5, 2013
Create. Sustain. Support.
My Background
1990 Israel Research
1991-2013
1982-1990
One of 28 Jesuit Institutions
16 Colleges & Universities 34 Community & Technical Colleges
WA
Bill Ehmann PhD.Associate Provost Research and Graduate EducationExecutive Champion
Seattle University-Quick Facts
Established 189154 BuildingsMaster Plan Build UpUrban 50 Acres
EH&S Team 2 FTENo Compliance OfficeNo Risk Management OfficeLimited Internal Auditor Capabilities
Enrollment 7,755Undergraduates 4,631Graduates 3,124Academic Staff 653
Largest Independent Institution in the Northwest8 Colleges
Private Independent Jesuit Catholic
Service Learning Curriculum
Endowment $178.8 Million Environmental Sustainability Program
Research Enterprise $12 Million
Undergraduate Tuition ~$29,000/yearCollege Scorecard-High
A Journey of Discovery
1. Need to identify where we are
2. Plan where we want to be 3. Determine how we want to get there
Five is our Magic NumberProactive Universities
Build the Foundation• Executive Oversight Compliance Committee• Defining and documenting the structure• Compliance Gap Analysis• Responsible parties• Multi-year timeline
SU Compliance InventoryADA Healthcare Procurement Waste
Management
Crime Statistics Human Subjects Research Administration
Emergency Preparedness
Conflicts of Interest
Animal Subjects Securities Exchange
HazMat Transport
Donor GiftRestrictions
Human Resources
Taxes Records Privacy
EEOC/AffirmativeAction
Immigration Technology Licensing
Global Ops.
EH&S Land Use/Investment Property
Intellectual Property Sustainability
Financial Aid NCAA Workers Compensation
Export Control
Compliance Gap AnalysisCriteria
• Ask the Question• Establish the Regulatory Structure• Assign Ownership of the Issue/Topic• Corrective Actions that Fill the Gap(s)• Prioritize Actions and Define a Timeline
• Identify others with successful outcomes
Gap Analysis ModelsPerson
Interviewed Risk Owner Department Area of Concern Issues Affect On Other Departments
Probability of Occurrence H = >70%
M = 30-70% L = <30%
Impact
2. Project Update
Current Status List completed action items and project successes thus far.
Remaining Tasks List the remaining tasks/action items which are needed for the successful completion of the project.
1. General Project Information Project Title:
Project Sponsor/Department:
Project Summary:
Gap Analysis ScoringNot Known No Procedure Documented but
not implementedImplemented but not documented
Implemented and Documented
No Evidence Very little evidence
Some evidence Moderate level of evidence
A lot of evidence
Not Applicable
Nonexistent Low Medium High
Little to no evidence
Perfunctory Statement
Some discussion and some documentation
Analysis with at least one BMP
Complete Analysis and multiple BMPs
Growth Pains Subject Area Resource Gap Data Gap InformationInfrastructure Gap
Could I answer the question Y/N
Could I find an Answer Y/N
Could I define an Action Y/N
Could the Action be Achieved Y/N
Could I Prioritize the Action Y/N
SU-Two Tiered Mechanism
Priority Level Value
Level 1 = Compliance RiskGroup ASafety
Level 2 = Best PracticeGroup B
Stewardship/Sustainability
Level 3 = Future ConsiderationGroup C
Future Consideration
In Place
Developing or Requested
Needed
Multi-Year Implementation Plan
EmpathyVulnerabilityComplex UndertakingAvoiding Burnout
Resources
• NACUA http://www.nacua.org• Society for Corporate Compliance and Ethics• NACUBO http://www.nacubo.org/ • Research and Scholarly Integrity in Graduate Education 2012 third publication
(Project for Scholarly Integrity)• Higher Ed Compliance Alliance
http://www.higheredcompliance.org
• CITI Programhttps://www.citiprogram.org/
Thank You
Sheila Lockwood, CHMMChemical Hygiene and Biological Safety Officer
Seattle University 901 12th Avenue P.O. Box 222000
Seattle, WA 98122-1090
Tel: (206) [email protected]
March 18, 2013
FORUM
Questions & Answers