The HYPOTHESISDeveloping a Compliance Program

at a Small Higher Education Institution

Sheila Lockwood, CHMMChemical Hygiene and Biosafety Officer

31st CUHWC August 5, 2013

Create. Sustain. Support.

My Background

1990 Israel Research

1991-2013

1982-1990

One of 28 Jesuit Institutions

16 Colleges & Universities 34 Community & Technical Colleges

WA

Bill Ehmann PhD.Associate Provost Research and Graduate EducationExecutive Champion

Seattle University-Quick Facts

Established 189154 BuildingsMaster Plan Build UpUrban 50 Acres

EH&S Team 2 FTENo Compliance OfficeNo Risk Management OfficeLimited Internal Auditor Capabilities

Enrollment 7,755Undergraduates 4,631Graduates 3,124Academic Staff 653

Largest Independent Institution in the Northwest8 Colleges

Private Independent Jesuit Catholic

Service Learning Curriculum

Endowment $178.8 Million Environmental Sustainability Program

Research Enterprise $12 Million

Undergraduate Tuition ~$29,000/yearCollege Scorecard-High

A Journey of Discovery

1. Need to identify where we are

2. Plan where we want to be 3. Determine how we want to get there

Five is our Magic NumberProactive Universities

Build the Foundation• Executive Oversight Compliance Committee• Defining and documenting the structure• Compliance Gap Analysis• Responsible parties• Multi-year timeline

SU Compliance InventoryADA Healthcare Procurement Waste

Management

Crime Statistics Human Subjects Research Administration

Emergency Preparedness

Conflicts of Interest

Animal Subjects Securities Exchange

HazMat Transport

Donor GiftRestrictions

Human Resources

Taxes Records Privacy

EEOC/AffirmativeAction

Immigration Technology Licensing

Global Ops.

EH&S Land Use/Investment Property

Intellectual Property Sustainability

Financial Aid NCAA Workers Compensation

Export Control

Compliance Gap AnalysisCriteria

• Ask the Question• Establish the Regulatory Structure• Assign Ownership of the Issue/Topic• Corrective Actions that Fill the Gap(s)• Prioritize Actions and Define a Timeline

• Identify others with successful outcomes

Gap Analysis ModelsPerson

Interviewed Risk Owner Department Area of Concern Issues Affect On Other Departments

Probability of Occurrence H = >70%

M = 30-70% L = <30%

Impact

2. Project Update

Current Status List completed action items and project successes thus far.

Remaining Tasks List the remaining tasks/action items which are needed for the successful completion of the project.

1. General Project Information Project Title:

Project Sponsor/Department:

Project Summary:

Gap Analysis ScoringNot Known No Procedure Documented but

not implementedImplemented but not documented

Implemented and Documented

No Evidence Very little evidence

Some evidence Moderate level of evidence

A lot of evidence

Not Applicable

Nonexistent Low Medium High

Little to no evidence

Perfunctory Statement

Some discussion and some documentation

Analysis with at least one BMP

Complete Analysis and multiple BMPs

Growth Pains Subject Area Resource Gap Data Gap InformationInfrastructure Gap

Could I answer the question Y/N

Could I find an Answer Y/N

Could I define an Action Y/N

Could the Action be Achieved Y/N

Could I Prioritize the Action Y/N

SU-Two Tiered Mechanism

Priority Level Value

Level 1 = Compliance RiskGroup ASafety

Level 2 = Best PracticeGroup B

Stewardship/Sustainability

Level 3 = Future ConsiderationGroup C

Future Consideration

In Place

Developing or Requested

Needed

Multi-Year Implementation Plan

EmpathyVulnerabilityComplex UndertakingAvoiding Burnout

Resources

• NACUA http://www.nacua.org• Society for Corporate Compliance and Ethics• NACUBO http://www.nacubo.org/ • Research and Scholarly Integrity in Graduate Education 2012 third publication

(Project for Scholarly Integrity)• Higher Ed Compliance Alliance

http://www.higheredcompliance.org

• CITI Programhttps://www.citiprogram.org/

Thank You

Sheila Lockwood, CHMMChemical Hygiene and Biological Safety Officer

Seattle University 901 12th Avenue P.O. Box 222000

Seattle, WA 98122-1090

Tel: (206) 220-8273lockwoos@seattleu.edu

March 18, 2013

FORUM

Questions & Answers