Resource: Sample Non-Retaliation Policy

By Greg Radinsky,^[1] JD, MBA, CHC, CCEP


POLICY/GUIDELINE TITLE: Non-Intimidation and Non-Retaliation Policy	ADMINISTRATIVE POLICY AND PROCEDURE MANUAL
POLICY #: X	CATEGORY: Compliance and Ethics
System Approval Date: [DATE] Site Implementation Date: [DATE]	Effective Date: [DATE] Last Reviewed/Approved: [LAST APPROVAL DATE]
Prepared by: Office of Corporate Compliance	Notations:

GENERAL STATEMENT of PURPOSE

The purpose of this policy is to establish a policy for [ORGANIZATION NAME] prohibiting intimidation of and/or retaliation against anyone who participates in good faith in [ORGANIZATION NAME]’s Compliance Program.

POLICY

It is the policy of [ORGANIZATION NAME] to prohibit intimidation of and/or retaliation against any individual who participates in good faith in [ORGANIZATION NAME]’s Compliance Program. Good faith participation in the Compliance Program includes, but is not limited to, reporting potential issues, investigating issues, self-evaluations, audits and remedial actions, and reporting to appropriate officials as provided in sections seven hundred forty and seven hundred forty-one of the New York Labor Law. Retaliation against or intimidation of any individual associated with [ORGANIZATION NAME] also is prohibited by [ORGANIZATION NAME]’s Code of Ethical Conduct, [ORGANIZATION NAME] policy #[NUMBER] - Detecting and Preventing Fraud, Waste and Abuse, Human Resources policy V-3 - Conduct in the Workplace/Progressive Discipline and [ORGANIZATION NAME] policy #[NUMBER] - Compliance Help Line.

SCOPE

This policy applies to all [ORGANIZATION NAME] employees, as well as medical staff, volunteers, students, trainees, physician office staff, contractors, trustees and other persons performing work for or at [ORGANIZATION NAME]; faculty and students of [ORGANIZATION NAME] conducting research on behalf of the [ORGANIZATION NAME] School of Medicine on or at any [ORGANIZATION NAME] facility; and the faculty and students of the [ORGANIZATION NAME] School of Graduate Nursing and Physician Assistant Studies.

PROCEDURE/GUIDELINES

Any individual who believes that he or she has been subject to intimidation and/or retaliation for good faith participation in [ORGANIZATION NAME]’s Compliance Program must immediately report such intimidation and/or retaliation to the Corporate Compliance Officer, either in person at the Corporate Compliance Office, via telephone to the Corporate Compliance Office at [PHONE NUMBER] or by making a report to the Compliance Help-Line either by telephone at [PHONE NUMBER] or by visiting [WEBSITE] and filing a complaint online.
All reports of intimidation and/or retaliation relating to good faith participation in [ORGANIZATION NAME]’s Compliance Program will be investigated by the Chief Corporate Compliance Officer or his/her designee. Upon conclusion of the investigation, the Chief Corporate Compliance Officer will make a report and recommendation for discipline, where appropriate, to the Chief People Officer, or his/her designee. The Chief Corporate Compliance Officer and the Chief People Officer and/or their designees shall confer and agree upon the discipline to be imposed.
Pursuant to the Human Resources’ Employee Conduct Policy, the possible sanctions that may be imposed on any individual who is found to have intimidated and/or retaliated against another individual include, but are not limited to, termination of employment.

REFERENCES to REGULATIONS and/or OTHER RELATED POLICIES

Title 18, Part 521 of NYCRR

Human Resources Policy [NUMBER] – Conduct in the Workplace/Progressive Discipline

[ORGANIZATION NAME] Code of Ethical Conduct

[ORGANIZATION NAME] Policy #[NUMBER] - Detecting and Preventing Fraud, Waste, Abuse and Misconduct

[ORGANIZATION NAME] Policy #[NUMBER] – Compliance Help Line

CLINICAL REFERENCES/PROFESSIONAL SOCIETY GUIDELINES

N/A

ATTACHMENTS

N/A

FORMS

N/A


APPROVAL:
[ORGANIZATION NAME] Policy Committee	[DATE]
[ORGANIZATION NAME] Clinical Operations Committee	[DATE]

Standardized Versioning History:

*= [ORGANIZATION NAME] Policy Committee Approval; ** = [ORGANIZATION NAME] Clinical Operations Committee Approval

[DATE]*; [DATE]**