7 Elements of an Effective Compliance Program

Villanova University has set forth policies and procedures that are housed in the Villanova Policy Library (VPL) that guide the University and the conduct of its employees in day-to-day operations.  The University Ethics & Compliance Officer oversees the University's policy repository to ensure University-wide policies and procedures are available to pertinent members of the University community, and that there are appropriate processes in place to identify and escalate policies and procedures that require periodic review and updates.

Code of Conduct

Although a clear statement of detailed and substantive policies and procedures is at the core of a compliance program, the University-wide Code of Conduct (Code) sets forth the basic standards of workplace behavior that are expected from all University employees, including but not limited to senior leadership, faculty, staff, student employees (undergraduate or graduate students), visiting faculty, and contractors; and states the University’s commitment to compliance with all applicable laws, regulations, and policies.  Compliance is a shared obligation across the University as each Community Member has a responsibility to ensure that their conduct complies with all University policies and procedures, including the Code; contractual obligations; and pertinent Federal, State, and local laws and regulations.

The Code includes references to certain relevant University policies, procedures, and other resources; however, these references are not exhaustive, and documents referenced may be updated as appropriate.

The Code may be used as an aid in the interpretation of University policies but does not change or expand the scope or coverage of any policy. Villanova Community Members are expected to review and be familiar with all handbooks, policies and procedures, and contractual obligations applicable to their employment with the University.

All Villanova Community Members are expected to uphold this Code. Violation of this Code will result in appropriate disciplinary action, up to and including dismissal from employment, or (in the case of outside contractors) severance of the relationship with the University.

The Villanova’s University Compliance Officer (CO) reports who reports to the Vice President and General Counsel, the President, and the Stewardship Committee of the Villanova University Board of Trustees and is responsible for implementing an annual risk-based compliance work plan. The CO leads the compliance program in accordance with the Federal Sentencing Guidelines and the University's strategic plan and mission.

• The CO serves as a resource to University leadership, and provides assistance, coordination, support, and oversight related to compliance and ethics efforts and matters, related to all federal, state, and local laws as well as internal policies, while encouraging the highest ethical standards of conduct for those who represent the University and act on its behalf.
• While the primary responsibility for compliance efforts remains in the individual units of the University, the CO works closely and collaboratively with each unit to guide and build on existing compliance practices, such as: reporting; establishing standard policies and procedures; developing and implementing training; conducting verification/monitoring processes; effectively partnering with the Chief Internal Auditor on risk and compliance items that may require audit reviews; and working with appropriate parties across the University to take corrective actions as necessary.
• The CO monitors and collaborates with other University leaders, compliance hotline submissions/other reported compliance/ethics concerns and related investigations, to ensure matters are timely and appropriately responded to and resolved.
• The CO leads a University-wide compliance council consisting of employees responsible for regulatory and compliance issues.
• The CO oversees the University's policy repository to ensure University-wide policies and procedures are available to pertinent members of the University community, and that there are appropriate processes in place to identify and escalate policies and procedures that require periodic review and updates.
• The CO participates in committees to enhance University controls/operations, identify areas of risk, and to ensure compliance with regulations/laws.
• The CO keeps abreast of changes to University policies and procedures; emerging risks/trends and regulatory changes pertinent to higher education; compliance profession related updates/changes; and changes in local, state, and federal laws, as applicable.
• The CO coordinates and interacts with entities performing external audits/assessments of the University.

Compliance Committee – University Council on Ethics & Compliance

As part of the design of the institutional ethics and compliance program for Villanova University, the University Council on Ethics & Compliance serves to provide guidance and oversight to the program itself. Composed of diverse representation, the members of this Committee lend their institutional knowledge, subject matter expertise, and dedicated efforts to the development of a program tailored to meet the university’s specific needs, which is proactive in its oversight of existing and emerging compliance risks. 

Compliance training refers to the process of educating employees on laws, regulations and company policies that apply to their day-to-day job responsibilities.  The University Ethics & Compliance Program ensures Villanova members understand what it takes for them to meet their compliance-related responsibilities. This is stressed by regulatory agencies:

• The United States Sentencing Commission’s Guidelines state that an organization must “take reasonable steps to communicate periodically and in a practical manner its standards and procedures, and other aspects of the compliance and ethics program…by conducting effective training programs and otherwise disseminating information.”
• The Office of Inspector General’s (OIG’s) updated General Compliance Program Guidance states “providing appropriate education and training is a vital component of an effective compliance program.”

The specific training should be tailored to make it as meaningful as possible for each group of participants. In addition to the University Ethics & Compliance Office’s training on FERPA, Minors on Campus, Title IX, and collaborating with faculty research and new employee orientations, the University Ethics & Compliance Office is conducting an Education and Training Gap Analysis in 2025-2026 fiscal year by assessing University departmental training in regard to regulatory requirements.

Access to Supervisors and/or the Compliance Officer

The University Ethics & Compliance Officer forms and maintains collaborative relationships with University leadership/ management to ensure timely communication of information related to compliance efforts, and compliance risk-related information. Villanova members are encouraged to reach out to their supervisors as a first line communication.  In order to encourage communications, confidentiality and non-retaliation, non-retaliation language is inserted in specific Villanova policies which are accessible through the Villanova Policy Library.

Hotlines and other forms of communication

Villanova encourages the use of the Report A Concern website, EthicsPoint hotline, e-mails, newsletters, suggestion boxes, and other forms of information exchange to maintain open lines of communication. In addition, an effective employee exit interview program could solicit information from departing employees regarding potential misconduct and suspected violations of company policy and procedures.

The University Ethics & Compliance Officer coordinates and monitors University-wide compliance activities within a decentralized environment, establishing a compliance monitoring framework, and ensuring that a University-wide Code of Conduct is in place and is kept current, in collaboration with other University leaders.

The University Compliance Officer documents this ongoing monitoring, including reports of suspected noncompliance, and provide these assessments to company's senior management and the compliance committee. The extent and frequency of the compliance audits may vary depending on variables such as the company's available resources, prior history of noncompliance, and the risk factors particular to the company. The nature of the reviews may also vary and could include prospective systemic review of the company's processes, protocols, and practices or a retrospective review of actual practices in a particular area.

As part of University Ethics & Compliance Officer’s initiative to evaluate periodically the effectiveness of the organization's compliance and ethics program, the office has conducted a Compliance Program Gap Analysis in 2025-2026 to increase the program’s effectiveness.

An effective compliance program should include clear and specific disciplinary policies that set out the consequences of violating the law or the Code of Code and policies and procedures. Villanova undertakes appropriate disciplinary action across the University in order for the disciplinary policy to have the required deterrent effect.

Villanova University promptly responds to credible evidence made aware to the University Ethics & Compliance Office from any source.  Prompt voluntary reporting demonstrates the University's good faith and willingness to work with governmental authorities to correct and remedy the problem.