MCW Policies and Procedures

Visitors to the Ombuds Office may find the following information useful. This section includes excerpts from a number of the official policies of the Medical College of Wisconsin as well as links to the full documents. Note that the full documents are available ONLY to internal viewers who have access to InfoScope, the Medical College's intranet.

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  Americans with Disabilities Act

In accordance with the Americans with Disabilities Act of 1990 and the Wisconsin Fair Employment Act, the Medical College of Wisconsin prohibits discrimination against qualified individuals with disabilities in all employment practices including: job application procedures, hiring, firing, advancement, compensation, benefits, classification, leaves of absence, training, and other terms, conditions and privileges of employment. The College is committed to providing accommodations for qualified employees, and/or applicants with documented disabilities.

To view information on the Americans with Disabilities Act, search "Americans with disabilities" from InfoScope (MCW network access required).

  Anti-harassment and Non-Discrimination

The Medical College of Wisconsin is committed to providing an environment free from all forms of harassment, discrimination and all other negative conduct that inhibits effective communication and productivity. MCW will take immediate and appropriate action when it determines that harassment and/or discrimination has occurred.

  Conduct and Conflicts

In addition to serving as a confidential resource for staff and faculty, the Office conducts exit interviews of faculty leaving the College and reports general trends and emerging issues to MCW leaders, while maintaining confidentiality of visitors to the Office.

The Ombuds provides an informal, alternate resource to air concerns and resolve conflicts for MCW faculty and staff. The Ombuds Office will be a place where staff and faculty can report concerns or seek guidance regarding disputes or concerns at no cost and at any stage in the resolution process.

The Ombuds will confidentially receive complaints, concerns or questions about alleged acts, omissions, improprieties, and/or broader systemic problems. The response of the Ombuds is tailored to the dynamics of the situation and the visitor’s concerns. The Ombuds will listen, make informal inquiries or otherwise review matters received, discuss resolution options, and make referrals. The Ombuds will assist parties in reaching resolutions that are consistent with the ideals and objectives of the College. Services of the Ombuds supplement, but do not replace, other more formal processes available to the College community.

In addition, the Ombuds will serve as an information and communication resource, consultant, and catalyst for institutional change for MCW. The Ombuds also will provide feedback to MCW when trends, patterns, policies or procedures generate concerns or conflicts.

Faculty and staff have the right to consult the Ombuds without reprisal. Retaliation against visitors to the Ombuds is prohibited.

To view the complete policy, search "AD.CC.070" on InfoScope (MCW network access required).

  Corporate Compliance

The Medical College of Wisconsin has a strong and abiding commitment to ensure its compliance with the regulatory requirements that govern our missions of Education, Research, Patient Care and Community Engagement. The main function of the Corporate Compliance Program is to create a comprehensive strategy to ensure that MCW is consistently complying with the federal and state regulations relating to our missions. The Division of Corporate Compliance has four offices that assist with this function: The Clinical Compliance Office, the Internal Audit Office, the Research Compliance Office and the Risk Management Office.

Clinical Compliance: The mission of the Clinical Compliance Office is to ensure the College and its faculty physicians comply with the regulatory requirements of a group practice including but not limited to documentation, coding & billing of professional fee reimbursement, HIPAA, Fraud & Abuse Laws, EMTALA, Stark, and Anti-Kickback regulations. This mission is accomplished through educational sessions, clarification of specific regulatory issues, and internal reviews/audits.

Internal Audit: The mission of the Internal Audit Office is to provide a wide range of quality audit services to our customers at MCW and to support their efforts in being an institution dedicated to leadership and excellence in: Education, Research, Patient Care and Community Service. The audits performed by the Internal Audit Office appraise the potential risks associated with various activities and the effectiveness and application of appropriate controls to limit those risks. The types of audits provided by Internal Audit fall into three main categories: Process Audits, Compliance/Regulatory Audits, and Financial Audits.

Research Compliance: The mission of the Research Compliance Office is to ensure that MCW and its Faculty Researchers comply with the regulatory requirements of conducting research including but not limited to financial management associated with NIH grants, Human Research Protection Regulations, Effort Reporting, Financial Conflicts of Interest, and Clinical Trial Billing. This mission is accomplished through Process Audits, Regulatory Audits, and Financial Audits.

Risk Management: The mission of the Risk Management Office is to provide consultation and assistance in patient care matters involving potential risks, potential litigation and litigation. The office works closely with the risk management offices of our affiliated hospitals.

To view more information on Corporate Compliance, search "corporate compliance" from InfoScope (MCW network access required).

  Employee Assistance Program (EAP)

The EAP is a confidential counseling and assessment program designed to address the emotional and mental wellbeing of MCW’s employees.

Consultation and professional services are covered under MCW's health plan under most circumstances. If you do not have coverage under MCW's health plan, please check with your current health care provider for coverage.

Services are provided on a strictly confidential basis. EAP is bound by state and federal laws and professional ethics. Confidential information is not shared with MCW management staff.

MCW expects to continue this policy, but reserves the right to interpret, alter, amend, or terminate any or all of its provisions in its sole discretion, retroactively or at any future time.

Employee Assistance Program (EAP)

  Equal Opportunity – Affirmative Action

The Medical College of Wisconsin is an equal opportunity and affirmative action employer. It is the policy of MCW to provide equal employment opportunities, consistent with applicable state and federal laws, to all qualified persons without regard to race, creed, color, sex, age, disability, marital status, veteran status, membership in the national guard, state defense force or any other component of military forces of the United States or Wisconsin, sexual orientation, national origin, ancestry, religion, arrest or conviction record or other pertinent legislation, judicial mandates and presidential executive orders designed to eradicate discrimination in all areas of employment. MCW is also committed to providing a work and academic environment free from all forms of harassment.

To view information on equal opportunity, search "equal opportunity" from InfoScope (MCW network access required).

  MCW Corporate Policy on the Ombuds Office

To view MCW's corporate policy regarding the Ombuds Office, search "ombuds office policy" from InfoScope (MCW network access required).

  Performance Evaluation

The Medical College of Wisconsin recognizes the performance of the employee's skills, knowledge and experience are fundamental to the mission of MCW. MCW encourages the performance review to be used as a tool to maximize performance and determine accountability. The performance review is the process of identifying, measuring and developing the potential of MCW employees within the work environment. It is intended to provide a communication link between the employee and immediate supervisor regarding job content, work standards, job satisfaction, work processes, and expected levels of performance. It is also intended to serve as an opportunity for continuous improvement as the result of open communication and mutual support, as well as to establish the work performance record in the personnel file.

To view information on performance evaluations, search "performance review" from InfoScope (MCW network access required).

  Release of Employee Information

Employee records are maintained by the Offices of Human Resources and Payroll and are confidential. Employees have the right to review and obtain copies of documents in their file, including those that are used or have been used in determining their qualifications for employment, promotion, transfer, additional compensation, termination and/or other disciplinary actions maintained by Medical College of Wisconsin in its capacity as an employer. Employees may request access to their file twice a year. An employee's representative may be allowed to receive copies of employee records upon written authorization of the employee at the expense of the requestor.

To view information on release of employee information, search "release of employee information" from InfoScope (MCW network access required).

   Rules of Employee Conduct

It is the policy of the Medical College of Wisconsin that disciplinary and/or corrective action are used when an employee engages in conduct that interferes with operations; performs poorly; violates work rules, policies or specific department regulations; discredits the organization; or is offensive to fellow employees, patients, customers or visitors. When a performance and/or behavior issue exists, it is a supervisor's responsibility to work toward correction of the problem and to communicate to the employee the consequences of uncorrected behavior. Disciplinary action must always be applied in a consistent manner, free of prejudice and bias, and without discrimination as outlined in the MCW EEO/Affirmative Action Statement.

MCW expressly reserves the right to terminate employment "at will". However, disciplinary or corrective action may be suggested whenever management believes that the employee's less than satisfactory performance or conduct could be improved through adequate counseling. Even if corrective or disciplinary action is implemented, the employment may be terminated at any step, at the discretion of management. Management, in its sole discretion, may warn, suspend or discharge any employee at will, at any time, after consultation with the Office of Human Resources.

To view information on rules of employee conduct, search "employee conduct" from InfoScope (MCW network access required).

  Staff Conflict Resolution

There are times when differences of opinion will arise from the interpretation of policies or matters relating to daily work responsibilities. All parties benefit from the prompt and orderly resolution of such concerns. The Medical College of Wisconsin promotes positive working relationships which depend on effective communication and understanding among people. Good relationships are easier to achieve when people feel that their problems and opinions can be discussed freely and honestly. The majority of misunderstandings can and should be resolved through open discussion between people.

Issues subject to the staff conflict resolution process (appeal process) may include such things as corrective actions, etc. The staff conflict resolution process may not be used to contest department guidelines or MCW policies, budgetary programs, benefit programs, or performance reviews. The appeal procedure below is provided to assist the communication and problem solving process and provide a prompt, orderly means of receiving and responding to employee concerns.

To view information on staff conflict resolution, "staff conflict resolution" from InfoScope (MCW network access required).