General
Each director or manager of an affected department is responsible for: Implementing and maintaining compliance standards and policies and procedures and manuals specific to their departments providing training to all his or her employees in compliance standards, policies, procedures, laws and regulations applicable to employees of the department; 3) enforcing this Program, the Code of Ethical Conduct, medical Center policies and procedures, and applicable laws and regulations; 4) investigating reports or reasonable indications of violations of this Program, the Code of Ethical Conduct, Medical Center policies or procedures; 5) reporting to the Compliance Officer any reports or reasonable indication of violations of applicable law or regulation by any member of the department; 6) initiating and/or implementing corrective or disciplinary action in the event of violation of the Compliance Program, the Code of Ethical Conduct, Medical Center policies, procedures and applicable laws and regulations; and 7) taking all measures reasonably necessary to ensure compliance with this Program and applicable laws and regulations.

Department Compliance Manuals

Contents
The compliance standards for each affected department shall contain a statement of compliance policy for that department and shall define and assign responsibility for updating the compliance standards, the department compliance manual, training and education, record keeping and the completion of audit work plans requested by the Compliance Officer. The department compliance manuals may contain such other matters as the director or manager deems necessary or appropriate so long as it does not conflict with this Program.

Resource.
The department compliance manuals shall be a resource for the employees of each affected department to enhance the ability of employees to perform their jobs in compliance with this Program and applicable laws and regulations. Employees should be encouraged to periodically review their departmental compliance manuals and to discuss any compliance issue with their supervisor or director or manager. Directors and managers are encouraged to involve their employees in the preparation of such department manuals.

Approval
Department compliance manuals must be approved by the Compliance Officer. The Compliance Officer may assist in the preparation and maintenance of any such manual upon request.