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Reporting Systems

Effective compliance programs must have a system that provides employees and others the opportunity to report issues and concerns, including potential violations of laws and regulations on an anonymous basis, without fear of retaliation or harassment.

How Trinity Health addresses this standard:

  • Trinity Health contracts with Compliance Line Inc.™ ("CLI") to provide 24/7/365 hotline reporting services. In addition to the CLI supported telephone call center, the Trinity Health also uses CLI's online (MyComplianceReport.com) internet reporting service.
  • Trinity Health maintains a single hotline with reports sent to the System Office for review and assignment for investigation. In most cases, investigations are conducted by the Ministry Integrity & Compliance Officer and other local resources. However, certain types of issues are investigated by the System Office with or without Ministry assistance.
  • Trinity Health uses the MediRegs ComplyTrack System™ for case management of CLI reports. 
    1. Individuals filing reports may choose to remain anonymous and are provided a case ID number to call back to obtain a status report and resolution of their issue.
    2. Both Divisions maintain non-retaliation policies strictly prohibiting retaliation against individual for reporting an issue in good faith. Retaliation is subject to discipline, up to and including termination of employment.
    3. The availability and purpose of the hotline reporting systems is regularly communicated to colleagues via the Code of Conduct, posters, newsletters, intranet sites, and training programs.
  • In addition to hotline reporting systems, colleagues have multiple other options to raise issues and concerns in the workplace including:
  1. The Voice Organization Incidents, Complaints and Events
  2. Human Resources departments for workplace related concerns;
  3. Mission/Pastoral Care/Clinical Ethics – for issues such as advanced directives, end-of-life, patient rights, etc.;
  4. Medical Staff Affairs – for medical staff issues and concerns;
  5. Privacy and Security Officials – for issues related to the use and protection of patient or business confidential information;
  6. Ministry Integrity & Compliance Officers; and 7.Trinity Health System Office.