Office of
Compliance
Services | UCLA
Health System

How Do I Report A Concern?
Hotline and Whistleblower
Policies
Conflict of Interest/Vendor
Relations
Current Policies and Guidance
Compliance Services
Information Security & Privacy
Policies & Procedures

Confidental Compliance
Line:  1-800-296-7188

Clinical Research, Hospital,
and Physician Billing:
310-794-6763

Privacy and Information
Security: 310-794-8638
              

Marti Arvin,
JD,
CHC-F, CCEP-F
Chief Compliance
Officer  [CCO]  
    
310-794-3274 phone
310-794-6118 fax        
marvin@mednet.ucla.edu



Paola S. Mariano
Assistant to Chief
Compliance Officer     
   
310-794-0922 phone
310-794-6118 fax        
pmariano@mednet.ucla.edu

Emma Cuenco, CHC, CPC
Physician Compliance
Manager        
310-794-8762 phone
310-794-6118 fax        
ecuenco@mednet.ucla.edu

Orni Kliebhipat, CPC
Physician Compliance
Auditor & Trainer        
310-794-8268 phone
310-794-6118 fax        
okliebphipat@mednet.ucla.edu

Yvonne Covarrubias, CPC
Physician Compliance
Auditor & Trainer        
310-794-6072 phone
310-794-6118 fax        
ycovarrubias@mednet.ucla.edu

Elise Watts, CPC, CCS-P
Physician Compliance
Auditor & Trainer        
310-794-8267 phone
310-794-6118 fax        
ewatts@mednet.ucla.edu

Isabelita Rubell, CCS, CCS-P
Hospital Compliance Auditor
& Trainer        310-794-8330
phone
310-794-6118 fax        
irubell@mednet.ucla.edu

Lynne Abe, RHIA, CCS
Hospital Compliance Auditor
& Trainer        310-794-8599
phone
310-794-6118 fax        
labe@mednet.ucla.edu
Valerie Elston
Compliance Administrative
Specialist        310-794-6763
phone
310-794-6118 fax        
velston@mednet.ucla.edu
Shanley Curran, RN, CCRP,
CHC, Esq.
Clinical Research Billing
Compliance Manager        
310-794-8269 phone
310-794-6118 fax        
scurran@mednet.ucla.edu
Polina Eshkol BA, CCRP,
CPMA
CRB Compliance Auditor &
Trainer        310-794-8266
phone
310-794-6118 fax        
peshkol@mednet.ucla.edu
Michael Brewer
Database Programmer        
310-794-8283 phone
310-794-2856 fax        
mkbrewer@mednet.ucla.edu
              
Office of
Compliance
Services -
Information
Security

Ann S. Chang, CISSP
Chief Information Security
Officer        
310-794-6761 phone
310-794-2856 fax        
achang@mednet.ucla.edu

David Bailey
Compliance - Information
Security Auditor/Analyst        
310-794-8284 phone
310-794-2856 fax        
dbailey@mednet.ucla.edu

Jamie Lam, CISA
Compliance - Information
Security Auditor/Analyst        
310-794-8761 phone
310-794-2856 fax
jlam@mednet.ucla.edu

              
Office of
Compliance
Services - Privacy

Bob Gross, CHPC
Chief Privacy Officer        
310-794-8639 phone
310-794-2856 fax        
rhgross@mednet.ucla.edu
Gagan Grewal, JD
Compliance - Privacy Auditor
& Trainer        310-794-8318
phone
310-794-2856 fax        
GGrewal@mednet.ucla.edu
Markus Avery, CHPC, CMT
(AHDI)
Compliance - Privacy Auditor
& Trainer        310-794-6746
phone
310-794-2856 fax        
mavery@mednet.ucla.edu
Arvin Tsosie
Compliance - Privacy & Info
Security Admin
Specialist        310-794-8638
Phone
310-794-2856 fax        
atsosie@mednet.ucla.edu
              

Additional Contacts

Diana L. Hedges
Director, Risk
Management     
   
310-794-3500 phone
310-794-3313 fax        
dhedges@mednet.ucla.edu

Janet Hoffberg
Director, Health
Information
Management
Services     
   310-794-5575
phone
310-206-4023 fax        
jhoffberg@mednet.ucla.edu
(replaced by
Maria Alizondo in
Sept. 2012)

Jane Boubelik, JD
Chief Counsel, Medical
Sciences
310-794-3138 phone
310-494-3313 fax        
jboubelik@mednet.ucla.edu
              
              
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UCLA Compliance
Code of Conduct and
Statement of Ethics
In June 2005, The University of
California adopted the
standards of ethical conduct
which contains 12 standards
that apply to all at the
University.  As health care has
specific rules and concerns,
the health system has a Code
of Conduct that supplements
the UC Code.

It is important to emphasize that
the foundation of the Code is
the ethical commitment of UCLA
Health System.  The David
Geffen School of Medicine at
UCLA, the UCLA hospitals,
ambulatory clinics, faculty,
students, and staff are
dedicated to building and
sustaining an ethical
environment founded on basic
values.  In carrying out the
mission of developing and
maintaining a
compliance-oriented
environment in which the
educational and scientific
programs of the Schools of the
UCLA Center for the Health
Sciences are integrated with
exemplary patient care, UCLA
Health System supports the
following values:

Respect - We treat all patients,
visitors, faculty and staff with
respect and courtesy.
Honesty - We are truthful in
how we represent our
capabilities and ourselves.
Integrity - We make decisions
and take action based only on
the best interest of the patient
and of the organization.
Compassion - We are
committed to providing
compassionate care.
Fairness - We provide a
consistent standard of care
that is coordinated across the
continuum of care.
Innovation - We support
innovation by our participation
in the advancement of medical
knowledge through research
and education to improve
patient care.
Stewardship - We seek to use
all our resources effectively
and efficiently.
The UCLA Code of Conduct
Handbook includes important
information in the following
areas:

UCLA Medical Science Integrity
and Ethics Program
Applicability of the Program
and Responsible Parties
Faculty and Staff
Responsibilities
Code of Conduct Standards
Reporting and Investigating
Violations
Corrective and Disciplinary
Actions
Federal and California State
False Claims Laws and
Whistleblower Protections
UCOP DRG
Internal Controls, Audits and
Monitoring
Conclusion
Appendix A, B, C and D
Marti Arvin seems to
have no luck at all
getting UCLA doctors to
comply with ethics rules

UCLA HEALTH SYSTEM
CODE OF CONDUCT
V.
CORRECTIVE AND
DISCIPLINARY ACTIONS

Using Existing University,
UCLA Medical Sciences,
and Medical Group Policies

In order to reduce the
likelihood of future errors,
the
CCO has been
given the authority
to implement
corrective actions.

These actions  will
follow existing
University faculty,
administrative and
medical staff policies,
or other applicable
University policies.
In the event of
intentional misconduct,
repeated violations, or
after corrective actions
have failed to address
the problem, the
University may initiate
disciplinary actions.

The University can utilize
disciplinary action in
accordance with other
existing and applicable
personnel policies,
collective bargaining
agreements, or University
policies. Employees
should review these and
other personnel policies
for a comprehensive
description of
disciplinary policies and
procedures, including their
rights under such
circumstances.
"Doing 'what is right' was replaced by doing what is
OK by the lawyers and the compliance officers:
Doing what you can get away with, you might call
it.”
--Peter Day, Global Business

Are doctors the new lawyers?  What happens when
doctors
break the rules as often as bankers?
UCLA culture: contempt and
racism?
Blog posts re UCLA

UCLA

UCLA Radiology and Medical
Records

UCLA CareConnect

UCLA Compliance

Dr. Andrew Saxon, author
of paper on harmlessness
of indoor mold

UCLA conflict of interest

UCLA Cull case

UCLA Dermatology

UCLA Patient Advocates

UCLA Patrick Harron to be
arraigned in burning death in
chemistry lab

UCSF
UC OKs paying surgeon $10 million in
whistleblower-retaliation case
The settlement ends a case brought
by the ex-head of UCLA's orthopedic
surgery department, who says the
medical school allowed doctors to
take industry payments that may
have compromised patient care.
By Chad Terhune
Los Angeles Times
April 22, 2014

University of California regents agreed to pay $10 million to the former chairman of
UCLA's orthopedic surgery department, who had alleged that the well-known medical
school allowed doctors to take industry payments that may have compromised patient
care.

The settlement reached Tuesday in Los Angeles County Superior Court came just
before closing arguments were due to begin in a whistleblower-retaliation case
brought by Dr. Robert Pedowitz, 54, a surgeon who was recruited to UCLA in 2009 to
run the orthopedic surgery department.

In 2012, the surgeon sued UCLA, the UC regents, fellow surgeons and senior
university officials, alleging they failed to act on his complaints about widespread
conflicts of interest and later retaliated against him for speaking up.

UCLA denied Pedowitz's allegations, and officials said they found no wrongdoing by
faculty and no evidence that patient care was jeopardized. But the UC system paid
him anyway, saying it wanted to avoid the "substantial expense and inconvenience" of
further litigation.

As department chairman, Pedowitz testified, he became concerned about colleagues
who had financial ties to medical-device makers or other companies that could unduly
influence their care of patients or taint important medical research.

He also alleged that UCLA looked the other way because the university stood to
benefit financially from the success of medical products or drugs developed by its
doctors.

One of the orthopedic surgeons that Pedowitz complained about testified at trial about
receiving $250,000 in consulting fees in 2008 from device maker Medtronic. In memos
to university officials, Pedowitz raised concerns about the financial dealings of other
doctors as well.

Inside the courtroom Tuesday, Pedowitz sat in the front row with his wife and daughter
as the judge told jurors that a settlement had been reached. He said he felt vindicated
by the outcome.

"These are serious issues that patients should be worried about," Pedowitz said in an
interview. "These problems exist in the broader medical system and they are not
restricted to UCLA."

The seven-week trial in downtown Los Angeles offered a rare glimpse into those
potential conflicts at a time when there is growing government scrutiny of industry
payments to doctors.

Starting this fall, the federal Physician Payments Sunshine Act, part of President
Obama's healthcare law, requires public disclosure of financial relationships between
healthcare companies and physicians.

Many doctors and universities defend long-standing industry arrangements as
essential for carrying out cutting-edge research and top-flight medical education.

In a statement Tuesday, the UC regents said they "resolved this lawsuit to end a
prolonged conflict and permit UCLA Health Sciences to refocus on its primary
missions of teaching, research, patient care and community engagement."

The statement added that "multiple investigations by university officials and
independent investigators concluded that conduct by faculty members was lawful.
Patient care was not compromised."

This latest settlement eclipses a $4.5-million payout the UC regents made last year to
resolve a racial discrimination lawsuit filed by another UCLA surgeon.

Pedowitz, as part of his settlement, left the UCLA faculty, effective Tuesday. He had
agreed to step down as department chairman in 2010 after initially voicing his
concerns to top UCLA officials. He filed a whistleblower retaliation complaint in March
2011.

Experts in medical ethics say the UCLA case shows much
more needs to be done within academia and by government
regulators to address potential conflicts of interest in
medicine.

Susan Chimonas, associate director of research at Columbia University's Center on
Medicine as a Profession, said some medical schools are still reluctant to take on
specialists who bring in considerable money from patients, medical research and
patents on breakthrough products.

"Institutions can be dependent on the money these big-earning specialties like
orthopedic surgery bring in," Chimonas said. "They are the cash cows and they can
set their terms. This is not the first time I've heard of medical schools having policies
that are not well enforced."

In an interview last week, the chief compliance officer at the
UCLA Health System flatly rejected the notion that the
university didn't enforce its policies or look fully into
Pedowitz's allegations.
She also said industry ties are unavoidable at a big
medical school and rules are in place to prevent conflicts.

"We have processes in place to identify those relationships in a transparent fashion
and ensure they don't have any inappropriate influence on the actions of the
university," said Marti Arvin, chief compliance officer. "In order to meet our mission, it
is important we have both the brilliant minds we have at UCLA and collaboration with
industry."

Arvin said the university "thoroughly and objectively investigated those allegations of
noncompliance raised by Dr. Pedowitz. We were able to determine the vast majority
were unsubstantiated."

She said two doctors fell short of university expectations in their handling of outside
income, but there was no violation of law or university policy in either instance.

Arvin cited the case of Dr. Nick Shamie, the orthopedic surgeon who testified at trial
about receiving $250,000 from Medtronic for consulting work. She said department
policy at the time didn't require Shamie to send that outside income through UCLA's
faculty compensation plan.

At trial, Pedowitz said he was deeply troubled by the large amount of money Shamie
was paid. He testified that he was particularly concerned that Shamie was trying to
enroll patients in a research study involving Medtronic at the time.

"I saw this as an obvious problem," Pedowitz testified.

In court, Shamie said he abided by university policy and didn't pursue the study
further because finding patients was too difficult. He couldn't be reached for additional
comment.

The other physician cited by Arvin for a potential shortcoming was Dr. David
McAllister, vice chairman of clinical operations for the orthopedic surgery department.

He didn't report payments from the Musculoskeletal Transplant Foundation, a
nonprofit tissue bank that does business with UCLA, because he didn't think
disclosure was required in that instance because it didn't involve a for-profit entity,
Arvin said.

McAllister also declined to comment, referring a call to UCLA.

Shortly before Pedowitz joined UCLA in 2009, the university was already facing
criticism from Congress over the failure of a top spine surgeon to report nearly
$460,000 in payments he received from Medtronic and other medical companies while
researching their products' use in patients, government records show.

Dr. Jeffrey Wang, who left for USC Spine Center last fall, stepped down as head of
UCLA's spine program in 2009 after U.S. Sen. Charles Grassley (R-Iowa) publicized
his lapse in disclosure as part of a larger investigation into medical conflicts of interest.

Several patients are now suing Wang and UCLA in state court for negligence, fraud
and malpractice in connection with surgeries involving Medtronic's controversial Infuse
bone graft. UCLA said it doesn't comment on pending litigation. Wang couldn't be
reached for comment.

Shortly after raising his concerns, Pedowitz said, he was pressured to step down as
department chairman in 2010. Pedowitz said he was further retaliated against by
being denied patient referrals and prevented from participating in grants and other
activities.

Before UCLA, Pedowitz worked at UC San Diego and as chairman of orthopedics and
sports medicine at the University of South Florida.

Mark Quigley, an attorney representing Pedowitz, said the case could have been
avoided if the UC system enforced the policies it already has in place.

"What good are all the policies if they protect the wrongdoers
and fail to protect the actual whistleblower?" Quigley said.
"The university wanted to cover it all up."
"What good are all
the policies if they
protect the
wrongdoers and fail
to protect the actual
whistleblower?"
Quigley said. "The
university wanted to
cover it all up."