Jefferson University Hospitals

Whistleblower Protections (Policy Number: 122.10)

Policy No: 122.10
Original Issue Date:2/1/2005
Review Date:7/27/2012 Revision Date:7/27/2012

Category: Administration
Title: Prohibition Against Retaliation for Good Faith Reporting of Noncompliance (Whistleblower Protections)
Applicability: Jefferson Health System and its Controlled Affiliates (Jefferson)


The purpose of this policy is to outline the protections available to the employees of Jefferson, who in good faith, report possible misconduct, violations of law or regulation or violations of Jefferson policy. Jefferson recognizes the value of having its employees and medical staff members report concerns about any real or potential non-compliance with applicable federal, state and local laws and internal policies and procedures. Jefferson provides its employees and medical staff members with various ways through which they may communicate compliance issues and prohibits retribution or retaliation against anyone who in good faith reports such concerns.


Through new employee orientation, in-service training, Jefferson newsletters and other methods of internal communication, Jefferson informs its employees and medical staff members of their responsibility to report their concerns about actions taken by Jefferson which may be inconsistent with applicable federal, state and local laws, accreditation agencies and Jefferson policies and procedures.

Policies related to the Jefferson Code of Conduct (Jefferson Policy No.102.26) and Preventing Fraud, Waste and Abuse and the federal False Claims Act (“FCA”) (Jefferson Policy No.122.11) state that individuals are free to report any information about possible misconduct or inappropriate business practices. In fact, our Standards of Conduct require that employees who know about misconduct to report the misconduct using any of the reporting mechanisms available:

  • To their supervisor, manager, or team leader;
  • To other Jefferson management (Human Resources, General Counsel, etc.)
  • To the Corporate Compliance Office: or
  • Using Jefferson’s confidential and anonymous reporting hotline, the Jefferson Alert Line, via 833-ONE-CODE (833-663-2633) or  (Jefferson Policy No. 122.09).

Jefferson recognizes that some employees and medical staff members may be reluctant to report compliance issues if they are concerned that they may be subject to retaliation, retribution or harassment. Therefore, Jefferson prohibits anyone from engaging in retaliation, retribution or harassment directed against an individual who in good faith reports a concern directly to Jefferson management, the Corporate Compliance Officer or an appropriate government agency or via Alert Line. Our Non-retaliation Policy protects employees from any adverse action if they report in good faith. Once an employee makes a disclosure, Jefferson will:

  • Investigate any complaints of retaliation or interference made by employees/Whistleblowers;
  • Take immediate steps to stop any allegations of retaliation; and,
  • Discipline any person associated with Jefferson found to have retaliated against or interfered with an employee/Whistleblower.


1) Definitions

  • Adverse Action: Any action taken or threatened by a Jefferson employee that would negatively impact the terms and conditions of the Whistleblower’s employment including but not limited to: continued employment, promotion, demotion, loss of status, or negative change in day-to-day responsibilities.
  • Allegation by Whistleblower: Any disclosure, written or oral, to a responsible Jefferson administrator, the Chief Compliance Officer or to ComplyLine.
  • Conflict of Interest: A conflict of interest exists where the interests of the individual, employment financial or otherwise, might impair or might reasonably appear to impair an individual’s independent judgment in the discharge of his or her duties as an employee of Jefferson.
  • Good Faith Disclosure of Misconduct: For a disclosure to be made in good faith, the Whistleblower must make the allegation with a belief in the truth of the allegation based upon the known facts. Allegations made with reckless disregard or in willful ignorance of facts that would disprove the allegation are not made in good faith.
  • Interference: Any attempt by Jefferson or any person associated with Jefferson to prevent an individual from reporting an allegation of misconduct or to influence the nature of the report.
  • Misconduct:  Any activity in violation of any state, federal, local law or regulation or Jefferson undertaken by any Jefferson employee in the performance of the individual’s duties. Misconduct includes but is not limited to: bribery, coercion, conversion, corruption, fraud, fraudulent conduct, malicious prosecution, malfeasance, misuse of Jefferson property or facilities and theft of Jefferson property.
  • Qui Tam: “Qui Tam” is a provision in the False Claims Act that allows a private individual, or Whistleblower, with knowledge of a fraud on the United States government to bring suit on behalf of the government. “Qui Tam” is an abbreviation for a Latin phrase that loosely translated means, “he who sues for the king as well as for himself.”
  • Retaliation: Any adverse action or credible threat of an adverse action taken in response to a Whistleblower’s good faith allegation of misconduct.
  • Whistleblower: A person or entity making the protected disclosure is commonly referred to as a Whistleblower. A Whistleblower can be an employee, former employee or member of an organization who reports misconduct. Generally the misconduct is a violation of a law, rule or regulation.

2) Reporting Process

  • All suspected or alleged cases of retaliation, retribution and/or harassment will be referred to the Chief Compliance Officer (“CCO”), who is responsible for the investigation of such matters. If the investigation shows that an adverse action has been taken against a Jefferson employee or medical staff member in retaliation for a good faith disclosure of information to Jefferson management or an appropriate government agency, the adverse action will be reversed and any individual involved in the prohibited behavior will be disciplined in accordance with Jefferson policies and procedures.
  • Filing a Report: Employees who want to report a problem under this policy should contact the Compliance Office immediately. In the event the alleged retaliatory action involves the CCO or the CCO has a conflict of interest as defined in this policy, the complaint should be filed with the Office of General Counsel.
  • Contents of Report: The report must be in writing and should include specific information documenting and supporting the Whistleblower’s complaint. The following information should be included if available:
    a. A copy of the initial report filed by the Whistleblower  alleging the misconduct;
    b. An explanation of the alleged interference with the filing of the report or the related to the retaliation including the person involved in the retaliation, dates, specific actions, etc.;
    c. Contact information including name, address, telephone and e-mail address and contact information for the Whistleblower’s representative, if any; and,
    d. A statement signed by the Whistleblower that the contents of the initial complaint are true or are believed by the Whistleblower to be true.
  • Initial report review and acknowledgement to Whistleblower: The CCO will investigate and respond to the Whistleblower within 10 business days. This initial review will only assess the nature and seriousness of the retaliatory action. The CCO will take the following actions:
    a. Review the Whistleblower’s report of retaliation and determine whether or not an investigation is warranted.
    b. If an investigation is not warranted, the CCO will inform the Whistleblower in writing and provide a justification for the decision. The Whistleblower may appeal the decision of the CCO to the Office of General Counsel.
    c. If an investigation is warranted, the CCO will be responsible for initiating and conducting the investigation.
    d. If additional information is required for the CCO to make a determination related to the need for an investigation, the CCO will request the additional information from the Whistleblower in writing specifying what information is needed and when. Failure to comply with the CCO request may result in a discontinuation of the investigation.

3) Interim Protections

At any point prior to resolution of the Whistleblower’s complaint, the Whistleblower may request that interim action be taken to protect the Whistleblower against an existing adverse action or credible threat of an adverse action. Based on the available evidence, the CCO will consult with the appropriate department administrators and make a determination related to the existing or perceived adverse action. The CCO will make a recommendation to the appropriate Vice-President regarding interim protective actions. The CCO will document the facts related to the decision and share the results of the decision with the Whistleblower in writing. When the investigation is concluded and the Whistleblower allegation is fully resolved, the temporary measures taken to protect the Whistleblower will be discontinued and may be replaced with permanent remedies.

4) Resolving Allegations of Retaliation or Interference

Credible allegations will be investigated according to the following process:

  1. Role of Compliance Office: The Chief Compliance Officer will initiate the investigative process and be responsible for coordinating the investigation. The CCO will determine if an investigation panel is required or if the issue can be resolved through less formal measures such as individual interviews. 
  2. Investigation Process: The investigation process will include interviews with the Whistleblower, the alleged retaliator and any other individuals relevant to the investigation who can provide material information regarding the allegation. Jefferson employees are expected to cooperate fully with any investigations. Documents and any other materials relevant to the investigation will be collected and reviewed.
  3. Timeliness: All investigations of Whistleblower retaliation must be timely and in no case take longer than 180 days unless the Whistleblower agrees to an extension.
  4. Confidentiality: Confidentiality will be maintained to the extent possible.
  5. Final Report: The findings and conclusions of the investigation will be documented in a written report. The report will include a description of the investigative process, findings of fact, a list of individuals interviewed, an analysis of the evidence and recommendations. The report will be maintained in the Compliance Office.
  6. Determination of Retaliation: The final determination as to whether or not retaliation or interference has occurred will be made by the Chief Compliance Officer in consultation with the Senior Vice President and General Counsel.

5) Sanctions for Retaliation or Interference in the Reporting Process

  • An employee or medical staff member may not use this policy as a defense against a disciplinary action if that action has been taken for legitimate reasons and in a manner that is consistent with Jefferson’s policies and procedures. Disciplinary action against an employee or medical staff member whose conduct or performance warrants such action will not be deemed a violation of this policy. Additionally, an individual who knowingly and intentionally makes false allegations of non-compliance will be subject to disciplinary measures, up to and including discharge, in accordance with Jefferson policies and procedures.
  • If it is determined that retaliation or interference has occurred, the CCO will recommend to the appropriate Vice President, remedies and sanctions to satisfy Jefferson’s obligation to protect the Whistleblower. Remedies and sanctions will include disciplining and sanctioning the retaliator and may include dismissal if the retaliator’s actions are considered serious in nature.
  • The Whistleblower protection provisions of the FCA provide for reinstatement, twice the amount of back pay with interest, and litigation costs and attorneys fees if an employer discriminates against an employee for taking action under the FCA.


  1. Deficit Reduction Act of 2005 (S. 1932) §§ 6031 6034 (DRA)
  2. The False Claims Act, 31 U.S.C. § 3729-3733
  3. Administrative Remedies 31 U.S.C. § 3801, et seq
  4. 43 P.S. § 1421et seq
  5. 62 P.S. § 1407, 1408
  6. Code of Conduct, Jefferson Policy#.132.01
  7. Preventing Fraud, Waste and Abuse and the federal False Claims Act, Jefferson Policy # 122.11

Original Issue Date: 2/1/2005
Revision Date(s): 11/04/2005, 11/27/2006, 06/30/2009,7/27/2012
Review Date(s): 11/27/2006, 6/30/2009,7/27/2012

Responsibility for maintenance of policy: Compliance and Privacy Officer