UWM Compliance Program Plan

Table of contents

Overview

The University of Wisconsin-Milwaukee (UWM) values ethical behavior, based on integrity, accountability, and responsibility. UWM’s Compliance Program is a set of formal organizational systems intended to prevent, detect, and respond to potential problems.  The Compliance Program also provides a framework for UWM’s compliance committees and compliance staff to address priorities strategically and in a coordinated fashion, respond to identified and emerging risks, and align campus resources with these priorities.  The purpose of the UWM Compliance Plan is to detail the structure and components of UWM’s Compliance Program.

Effective compliance programs across all industries, including higher education, use a framework derived from the Federal Sentencing Guidelines, a publication of the United States Sentencing Commission, to form institutional compliance programs.  While intended to assist judges with sentencing decisions, the Guidelines related to compliance have become the blueprint for creating effective compliance programs.  The Guidelines define a compliance and ethics program as “a program designed to prevent and detect criminal conduct” and that program has seven key elements. The elements, known as “the seven elements” are considered the minimum standards to form an effective compliance and ethics program.  UWM’s Compliance Program is informed by the seven elements.  The seven elements are:

  1. High Level Oversight
  2. Standards and Procedures
  3. Communication, Education, and Training
  4. Monitoring and Auditing
  5. Culture of Accountability, Ethics, and Integrity
  6. Reporting and Investigation
  7. Risk Assessment

As the Compliance Program evolves and grows at UWM, this Compliance Plan will be updated to reflect any changes.

UWM’s Seven Elements – Compliance Program

1. High Level Oversight

UWM Compliance Framework – See Appendix A

UWM’s compliance activities occur within a decentralized structure based largely on departmental responsibility for compliance within a particular area. In order to provide increased attention, oversight, and coordination to UWM’s compliance with state and federal laws, as well as UW System Board of Regents, UW System Administration, and UWM policies, UWM created a three-tier committee structure, which connects the day-to-day compliance work, and the staff doing that work, with campus leadership so that there is ongoing information flow about compliance priorities and risks, major projects and initiatives, and emerging issues. 

Within the three-tier committee structure, the Executive Committee, comprised of the Chancellor and senior leadership, exercises overall responsibility for oversight of UWM’s compliance program and promotes a culture of compliance by providing leadership to and support for UWM’s compliance activities.  The Compliance Steering Committee, which reports to the Executive Committee, oversees seven compliance working groups, organized by related compliance topics. The Executive Committee, led by the Chancellor, has overall responsibility for oversight of UWM’s compliance activities. 

Compliance and Ethics Officer

In early 2022, UWM hired a Compliance and Ethics Officer who reports to the Chief Legal Counsel.  The Compliance and Ethics Officer coordinates UWM’s decentralized compliance network to ensure effective, collaborative, and responsive compliance activities at UWM through high-level coordination of UWM’s compliance structure.

2. Standards and Procedures

UWM is committed to compliance with all applicable federal and state laws and regulations as well as institutional and UW System policies. Every member of the UWM community is responsible for following all applicable laws, regulations, and policies within the scope and course of their work at or involvement with UWM. UWM’s Guiding Values include: “ethical behavior, based on integrity, accountability, and responsibility” and “stewardship of resources that promote sustainability, prosperity, and equity for all in the local and global communities,” and “a caring, compassionate, and collegial community characterized by mutual respect and safety.”

In addition to UWM’s Guiding Values, the UWM Code of Conduct establishes foundational guidelines for those acting on behalf of UWM. The Code of Conduct requires that those acting on behalf of UWM do so in a manner that will strengthen and maintain the public’s trust and confidence in the integrity of UWM.  Under UWM’s Code of Conduct, those acting on behalf of UWM should practice:

  • Integrity by maintaining an ongoing dedication to honesty and personal responsibility;
  • Trustworthiness by acting in a reliable and dependable manner;
  • Equity by treating others with fairness and impartiality;
  • Respect by treating others with civility and decency, not engaging in bullying, intentional physical harm or intimidation.
  • Stewardship by exercising custodial responsibility for University property and resources;
  • Compliance by following State and Federal laws and regulations, University policies and contractual obligations related to their duties and responsibilities;
  • Confidentiality by protecting the integrity and security of university information such as student records, employee files, patient records, and contract negotiation documents.
  • Personal Responsibility by complying with the UWM Behavioral Standards and Expectations

In addition to the Code of Conduct, UWM has established university policies and procedures to govern compliance obligations and reinforce existing federal, state, and UW System requirements. UWM’s Secretary of the University maintains a searchable policy library on its website. University-wide policies are reviewed on a five-year cycle and UWM provides a process for requesting new and revising existing policies. Key institutional policies and procedures are highlighted on the Secretary of the University’s website, as well as within each division and unit.

In addition to federal, state, and UW System laws and policies, UWM has specific policies and procedures in place to prevent and address misconduct. For example, UWM has policies addressing: Fiscal Misconduct, Sexual Violence and Sexual Harassment, Discriminatory Conduct and Consensual Relationships, Research Misconduct, and Conflict of Interest Policy for Individuals Engaged in Research and Other Sponsored Programs.

3. Communication, Education, and Training

UWM maintains effective, ongoing training methods and communications to further compliance initiatives across campus.

UWM has several means of communicating UWM’s compliance obligations to the campus community.  UW System maintains a Compliance Matrix to identify compliance obligations on UW campuses.  The Compliance Matrix lists over 500 obligations from federal law, state law, as well as Board of Regent and UW System policy. The matrix includes the responsible units and employees at UWM assigned to each obligation. In addition to the Compliance Matrix, the Compliance and Ethics Officer maintains a Compliance and Conduct Communication Calendar. The Calendar includes the campus-wide compliance and conduct communications required to be shared with the campus community each academic year.  The purpose of the calendar is to ensure that required communications are sent and the communications are timed to maximize the impact of the message. In addition to campus-wide messages, individual units send regular communications concerning compliance obligations managed by those units. This includes campus-wide and targeted communications to address compliance requirements as well as to enhance the understanding of various compliance obligations. Those units include, but are not limited to, Human Resources, the Offices of Research and Sponsored Programs, and University Information and Technology Services.

Compliance training and education provides UWM employees with the knowledge they need to understand compliance obligations that apply to them during their employment.  All UWM employees receive mandatory training on the following topics upon hire:  sexual harassment (Title IX), information security awareness, and Executive Order #54 (state requirement on the reporting of child abuse and neglect).  Employees are required to repeat information security training every year and sexual harassment (Title IX) training every three years. Completion of mandatory training is required by UWs policy and must be completed to be eligible for a pay plan wage increase.

In addition to mandatory training, UWM offers additional training opportunities, including on research, information technology, fiscal misconduct, and human resources, for employees depending on their role and/or job duties at UWM. Employees with specific compliance obligations receive regular internal and external training on those requirements and best practices. The Office of Compliance and Ethics regularly hosts internal compliance trainings for compliance partners across campus. Training hosted by the Office of Compliance and Ethics offers opportunities to learn best practices, receive updates on emerging compliance issues, and network with other compliance professionals on campus. UWM’s Compliance and Ethics Officer also seeks input from compliance stakeholders about additional training and resource needs.

4. Monitoring and Auditing

UWM has a robust testing and monitoring program designed to ensure its compliance program is effective.  This includes regular audits by the Wisconsin Legislative Audit Bureau, the UWs Office of Internal Audit (which centralized the system wide audit functions), and annual financial aid audits. UWM leaders, at the campus, divisional, and unit level invest the time and resources to determine that controls are adequately designed and operating effectively. Employees who perform compliance functions also monitor controls and communicate issues to supervisors and/or unit/divisional leaders.  When compliance gaps are identified, whether through internal mechanisms or by audit findings, campus leadership, along with compliance staff, work to revise or implement new controls to mitigate risk.

5. Culture of Accountability, Ethics, and Integrity

UWM’s Compliance Program reinforces a culture and community of compliance and ethics at UWM. As discussed above, UWM’s Guiding Values and Code of Conduct incorporate principles such as compliance, stewardship, and integrity. Through an annual message each fall, UWM’s Chancellor highlights UWM’s commitment to compliance, ethics, and integrity and informs staff of key compliance policies, and each semester, UWM’s Provost informs and reminds all instructional staff of compliance and academic policies that apply to their work.

UWM employees are subject to ethics rules covering the use of university resources, conflicts of interest, and acceptance of gifts.[1]  UWM employees may not use their university position to gain private financial or other benefits for the employee, the employee’s immediate family, or organizations with which they are associated.  As required by Wis. Admin. Code § UWS 8.035, UWM has institutional ethics committees whose function is to provide employees with consultation and advice on applicable ethics rules. UWM’s Code of Conduct also encourages employees to seek guidance when faced with ethical dilemmas.

Depending on the employee’s role at UWM, employees also have additional reporting requirements that are intended to address potential conflicts of interest and encourage ethical behavior. UWM staff are required to report conflicts of interest to a supervisor or other appropriate administrator.  Faculty, academic staff, and limited appointees with half-time appointments or more and UWM research personnel are required to report annually on outside activities and interests related to their area of professional responsibility and for which they receive remuneration.   Employees with contract signatory authority and/or certain high-level positions at UWM are required to file annually a Statement of Economic Interest with the Wisconsin State Ethics Commission.

Accountability is a key component of UWM’s compliance program.  Reports of suspected or actual misconduct are taken seriously and investigated by appropriate units at UWM, as discussed further below. 

[1] The standards for UW System employees who are state public officials (generally high-level administrators) are found in Chapter 19 of the Wisconsin statutes. The rules for unclassified employees (generally faculty and academic staff, and limited appointees) are in Ch. UWS 8, Wisconsin Administrative Code and SYS 1290. The rules for university staff (generally most other UW System employees) are found in Regent Policy Document 20-22.

6. Reporting and Investigation

Detecting misconduct is a critical component of UWM’s compliance program. 

UWM’s Code of Conduct directs employees to report Code of Conduct violations to supervisors and supervisors must take appropriate action upon receiving a report.  When reports are substantiated, employees found in violation of laws, regulations, or policies are subject to disciplinary action up to and including termination. 

UWM employees are protected from retaliation for reporting suspected misconduct in accordance with applicable UWM and UW System policies as well as state and federal law.

To encourage the reporting of suspected misconduct, UWM created a Fraud Reporting Form for UWM community members to use to report suspected or actual misconduct. The UWM fraud report form is accessible anytime via an online reporting form.

Also, UWM monitors and responds to reports of suspected misconduct received from the UW System Integrity Hotline. The UW System Integrity Hotline is accessible anytime by phone or via the online reporting form. A person filing a report via the Hotline may choose to remain anonymous. Any person who reports suspected misconduct via the UW System Integrity Hotline or via the UWM fraud reporting form will not be subject to retaliation. Records of reports received via the UWM Fraud Reporting Form or UW System Integrity Hotline are maintained by the UWM Office of Compliance and Ethics.

Per UWM’s Fiscal Misconduct policy, employees who suspect or encounter an incident of fiscal misconduct are directed to inform their supervisor. Supervisors are required to immediately notify the Vice Chancellor for Finance and Administrative Affairs. Alternatively, if an employee is uncomfortable reporting the suspected misconduct to the employee’s supervisor or is unsatisfied with the supervisor’s response, the employee is directed to report the suspected misconduct directly to the Vice Chancellor for Finance and Administrative Affairs. Reports of suspected fiscal misconduct are investigated promptly and according to UWM’s Fiscal Misconduct Policy (See SAAP 8-2).

If misconduct is reported or detected, an appropriate unit on campus will investigate the matter fully and fairly. If misconduct is substantiated, corrective action will be taken. Actions include coaching, training, policy creation and revision, reviews and remediations of internal controls, and disciplinary actions. Employees engaging in misconduct may be subject to progressive discipline up to and including termination.

7. Risk Assessment

UWM identifies and evaluates compliance risks regularly at all levels of the institution and both formally and informally.  In 2023, UWM participated in a UWs pilot of the Risk, Compliance, and Audit (RCA) program.  As part of that program, UWM engaged in a risk assessment process. UWM evaluated 10 risks, five chosen by UW System and five chosen by UWM and evaluated all 10 risks using a UWs risk assessment tool. The UWs pilot will continue during the 2024-2025 academic year. The process will enhance and improve the manner, method, and timeline under which UWM identifies, manages, and mitigates high-level risks. 

UWM Compliance Framework – Appendix A

Executive Committee for Compliance – Chancellor and Senior Leadership

Working Groups

  • Academic & Research Compliance
  • Financial Aid & Student Rights
  • Health & Safety
  • Information Security
  • Human Resources
  • Fiscal Management
  • Records & Meetings