1
Advanced
Principles
of
Compliance
Programs:
Bringing
it
All
together
Presented by:
Dawnese Kindelt, System Compliance Director Lisa Silveria, System Compliance Director
2
• Gain an understanding of the planning, execution, and
reporting processes
• Discuss different means for obtaining buy‐in from leaders in
facility operations
• Consider different mechanisms for creating accountability • Share Dignity Health’s business model to administer and
oversee compliance, in a complex organization, with only seven
directors
3
• 38 Hospital • 100+ “Clinics “
• 12 Distinct Part Skilled Nursing and Long Term Care • 22 Home Health/Hospice agencies
• 7 Behavioral Health programs • 6 Inpatient Rehab. Facilities
• 1 Approved ACO
• For‐profit managed service organization with third party billing
services
• Numerous Joint Ventures
Dignity
Health
Background
4
• VP Compliance & Internal Audit
• 7 System Compliance Directors (Facility, Clinics, Facility
Coding/HIM, Research, Privacy, Data Security) • Hospital Resource Allocation:
– Facility Compliance Liaisons (FCL)
– Clinic Director
– Facility Privacy Officials (FPO)
– Accountable Executive (AE)
– IT Site Managers
3
Corporate
Compliance
•Program Development •Effectiveness •Expertise
Operations
•Local Compliance
Committee •Implement
Program •Record Retention
Board
Oversight
•Governance •Culture •Accountability •Resource
Allocation
External
Experience
•OIG Work Plan •CMS/Federal Reg. •Medicaid
•HCCA
•Trade Associations
Audit and
Monitoring
•Internal Audit •Compliance Audits •Self Assessments
6
• Risk Assessment
• Work Plan
• Scorecard
• Desk Top Reference (detailed in post session)
7
• Begins in October with publication of OIG Work Plan
• Develop electronic survey
– OIG Industry Guidance (all)
– OIG WP
– Internal Experience
– Industry Experience
• Audit and Evaluation Reports
• Distribute electronic survey to facilities (FCL)
– Gather information from facility senior leaders and/or staff
• Electronic survey of clinic directors
• Identify items that are operational in nature, as opposed to compliance risk
– Send to specialty councils (Revenue Cycle, Lab, Human Resources, etc)
• Separate surveys for privacy, data security and Research
Risk
Assessment
Process
(January
– February)
8
Host
the
Annual
Compliance
Summit(Feb)
• Identify trends within responses • FCL Score the RA
• Provide Education
– Internal and external presenters
– Example: What/why Accountable Care Organizations, and what
compliance oversight is needed
• Network to determine how Corporate can better support
operations
– New program development
– Develop self assessments for risk areas • Share best practices
5
9
HCCA
Institute
(April)
• Diverse session attendance • Network with peers
• Reconvene as a team following the event
– Share ‘take‐aways’
– Identify topics for work plan considerations (Risk Assessment)
• Summarize specific topics/learning to share with service line
leaders
10
Risk
Assessment
Scoring
Process
(May)
• Identify topics with high scores during Compliance Summit • Add risk areas identified during HCCA
• Score by Compliance Department
11
• Toss out a risk you learned about this week • Define the risk
• Use the score matrix
– Speaking point: you might need to define “slight, moderate” for your
organization.
Risk
Assessment
Exercise
– Group
Participation
– Toggle
to
example
workbook
12
Work
Plan
Development
(May)
• From the workbook
• Develop Work Plan and Point Person/Owner
– Prioritize topics
• Approval by Audit and Compliance Sub‐committee of the Board • Communicate to Operations (July)
– FCL Group
– Clinic Directors
– FPO
– AE
7
13
High
Level
Oversight
– Board
Report
14
Scorecard
Development
(Feb/March)
• Based on OIG Guidance elements
– Facility Compliance Meetings
– Policy distribution
– Hotline response
– Audit/Corrective Action Plans (internal and RAC)
– Employee/Vendor Screening
– Education
• Includes elements from HIPAA, Data Security and Research • Other risk areas (Revenue Services, CM, Risk/Patient Safety)
15
Scorecard
Approval
(June)
• Draft document is communicated to Presidents and the FCL
– Memo from Compliance Officer detailing each element and the rationale
– Describe which elements were removed and with what they were replaced • Feedback is compiled, reviewed and considered for possible
edits
• Final draft is approved by Audit and Compliance Board sub‐
committee (June)
• Communicated to stakeholders (July) • Publish in the Compliance Desk Reference
16
9
17
High
Level
Oversight
• Ask Lisa Joy to make this slide with an example of board
summary (scores and graphs) redacted, and watermarked as
sample
• Executive Leadership Team
• Published to all SALs which creates internal competition • Compliance Oversight Committee
• A&C
18
19
High
Level
Oversight
– Board
Report
(2)
20
Compliance
Desk
Reference
Last Updated on: January 11, 2013
This Excel file is an easy paperless way to provide useful information at your fingertips. The reference file is designed like a website with hyperlinks for easy navigation. Listed below are the main pages (worksheet tabs) of the Desktop Reference with hyperlinks to each page. Use the "Home" link at the top of each page to return here.
For changes or corrections to this document please contact: Lisa Paige or Bill Snyder. (See Compliance Department Contacts)
Topic Updated Topic Updated
Highlighted items have been updated within the last 30 days
Acronyms 04/26/2012 N Guidance Documents 01/07/2013 N
Additional External Resources 10/17/2012 N HIPAA Desktop Reference Monthly N
Audit Tools 03/15/2012 N Hotline / Alertline 02/10/2012 N
Calendar (Meetings and DUE DATES) 01/07/2013 Y Joint Ventures 01/09/2013 Y
Clinic Compliance Desk Reference N NCDs / LCDs 08/27/2012 Y
CMS Program Transmittals 04/10/2012 N New Service Lines / Phys Supervision 12/16/2012 Y
Compliance Department Contacts 12/02/2012 N OCEP 01/11/2013 N
Contacts by Topic 01/07/2013 Y OIG Compliance Program Guidance Documents 04/13/2012 N
Education & Presentations 05/25/2012 N Orientation Materials 04/26/2012 N
DeMinimus 12/16/2012 Y Org Chart Audit and Compliance 11/10/2012 N
EMR 01/11/2013 Y Patient Inducements 05/24/2012 N
Facility Compliance Contacts 01/07/2013 Y Physician Transaction Training 05/24/2012 N
Please review facilities list for accuracy N Policies 04/14/2012 N
FCL Meetings 12/06/2012 N President's Scorecard (Service Area Leader's Scorecard) 11/10/2012 N
Fiscal Year Work Plans 11/10/2012 N Provider Based Clinics 04/14/2012 N
Government Payer Refund Logs 01/11/2013 Y Standards of Conduct
The information contained in this workbook is intended as a resource, but the application to specific facts and circumstances can easily impact our risk and liability; unless you are sure of the application, please contact your FCL, Compliance or Legal
