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How To Keep Up Awareness Of Compliance

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“Compliance

--Keeping up Awareness”

Corporate Compliance

Department

Carolinas HealthCare System

Charlotte, North Carolina

Sherri De Shazo, RN MBA MHA

Director, CHS Corporate Compliance

(2)

Discussion Points

A. What is the OIG expectation of compliance awareness

as an element of effectiveness?

B. As compliance professionals, do we routinely “make the

connection” with staff and daily operations?

C. What are some approaches to promoting “Compliance

Awareness” initiatives to reach all levels of staff?

(3)

Carolinas Healthcare System (CHS)

Carolinas HealthCare System--Overview

Carolinas HealthCare System The mission of the Carolinas HealthCare System is to create and operate a comprehensive system to provide health care and related services,

including education and research opportunities, for the benefit of the people it serves.

‹23 owned, managed or leased hospitals and healthcare delivery facilities in two

states

‹Over 24,000 employees

‹Combined gross patient revenues in excess of $2.5 billion ‹Largest health care system in the Southeast

‹Third largest public, multi-hospital system in the nation

‹500 physician provider organization with over 100 offices in 11 counties

‹GME Program, includes 10 Specialties, 135 faculty physicians and 200

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Mission

Vision

Commitment

Integrity

Caring

Teamwork

Carolinas HealthCare System—Core Values

(5)

CHS Corporate Compliance--Overview

Director Corporate Compliance Assistant VP Corporate Compliance Director Corporate Compliance Director Audit Services Director Corporate Compliance Privacy

Chief Compliance Officer Chief Privacy Officer

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1. Written standards of conduct, including policies and

procedures

2. Designation of a Chief Compliance Officer & appropriate

bodies

3. Conduct regular, effective education and training programs

4. Process for complaint reporting and procedures for

complainant protection.

5. System of response and discipline related to allegations of

improper activities

6. Use of audits and/or other evaluation techniques to monitor

compliance

7. Investigation and remediation of systemic problems, and

policies regarding sanctioned individuals.

Compliance Awareness and the

Effective Compliance Program

Carolinas HealthCare System Fed Register / Vol. 63 No 35

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Conducting Effective Training and Education

“The proper education and training of corporate officers,

managers, employees, physicians and other health care

professionals, and the continual retraining of current personnel

at all levels, are significant elements of an effective compliance

program.”

Fed Register / Vol 63 No 35

Compliance Awareness and the

Effective Compliance Program

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Carolinas HealthCare System

1. Fundamentally compliance efforts are designed to

establish a culture that promotes prevention, detection

and resolution..

2. In practice the compliance program should effectively

articulate and demonstrate the organization’s commitment

to the compliance process

3. The existence of benchmarks that demonstrate

implementation and achievements are essential to and

effective program.

4. Eventually a compliance program should become a part of

the fabric of routine hospital operations

Compliance Awareness and the

Effective Compliance Program

(9)

How does the compliance professional answer these “how

aware are your staff” questions—?

x Is your compliance program “working” for all levels of the organization?

x Have you done enough to communicate the compliance message to all employees?

x Does the average employee find compliance relevant to their daily responsibilities?

x Are you keeping the compliance message fresh to promote ongoing staff and leadership interest?

Compliance Awareness and the

Effective Compliance Program

(10)

CHS Compliance Awareness Initiative

Compliance Staff Buy-in: Support for the Awareness Initiative

¾

Gather feedback regarding the compliance program

¾ Talk with those who support the compliance program within and outside the compliance department.

¾ Survey staff perception of the compliance department and compliance culture

¾Identify internal Program goals to address compliance awareness

deficits

¾ Enhance compliance consistency among all Compliance Directors ¾ Greater Facility Administrator involvement

¾ More education from Compliance Department

¾ Improve departmental accountability for compliance

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CHS Compliance Awareness Initiative

Leadership Buy-in: The Awareness Initiative Vision

¾Discuss the value and opportunities for renewed staff awareness ¾ Focus on compliance as a daily individual responsibility

¾ Share benchmarks from Employee Compliance Effectiveness Survey ¾ Provide new System of Integrity books to all employees

¾ Promote confidentiality and appropriate HelpLine use

¾ Opportunity to educate staff on updated or new Corporate Compliance Policies

¾ Address data and issues noted in HelpLine calls

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CHS Compliance Awareness Initiative

Compliance Awareness “Theme”: Making the anticipated

event familiar.

¾ Select a “catch phrase” to educate and remind all staff on the goal

for the awareness initiative

¾ “Compliance is everyone’s job!” ¾ “Compliance is our Culture!”

¾ “You are the CHS System of Integrity!” ¾ “Compliance—is it in you!”

¾ Get leadership commitment to support planning and to participate ¾ CMC President letter to all facility employees announcing the event

date.

¾ Sr. VPs sponsored the “prize” for the department with the highest

level of participation

¾ Sr. Vice Presidents presence during the events

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CHS Compliance Awareness Initiative

Carolinas HealthCare System

Compliance Awareness: Marketing the Initiative

¾Ensure event hosts are advised to get the word out early and often ¾Build internal and external enthusiasm to make the work fun—pizza

party for the planning and event team

¾Publicize the upcoming event on the intranet and internal newsletters

¾Use quotes from the leadership announcement letter to post around the event areas and facility

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CHS Compliance Awareness Initiative

Carolinas HealthCare System

Compliance Awareness: Marketing the Initiative (continued)

¾….. get the word out early and often

¾Select the first sponsoring facility or department— volunteers first! ¾Ensure the event activities are covered by Marketing for future

(15)

CHS Compliance Awareness Initiative

Carolinas HealthCare System

Compliance Awareness: Planning the Initiative

¾Ensure event hosts are educated on available resources for support

and planning

¾Develop a project plan for the event and assign responsible

parties

¾Develop basic tools and templates for other facilities or

departments to easily duplicate activities

¾Tap into other planned events that will elicit large numbers of

employee participants—employee fairs and socials

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CHS Compliance Awareness Initiative

Carolinas HealthCare System

Compliance Awareness: Planning the Initiative (continued)

¾Plan event activities and times that are staff and facility friendly

¾Build in an element of competition for participation—reward

departmental participation

¾Decide on the focus of your awareness efforts—specific policies,

compliance industry events, compliance personnel to know,

basics of compliance effectiveness, identified helpline trends,

survey data, frequently asked questions

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CHS Compliance Awareness Initiative

Carolinas HealthCare System

Compliance Awareness: Implementing the Initiative

¾Ensure event hosts are educated on event activities and desired

outcomes

¾Get assistance from other department’s---Administration, Human

Resources, Marketing/Public Relations, HIPAA participants, High Risk Departments, Compliance Staff

¾Tap into other planned events that will elicit large numbers of employee participants

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CHS Compliance Awareness Initiative

Carolinas HealthCare System

Compliance Awareness: Implementing the Initiative (continued)

¾…. event activities and desired outcomes

¾Select the event set-up—displays, videos, one-one interactions, games ¾Make sure the activity area is inviting and exciting—high traffic zones ¾Reward employee efforts to learn and participate

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CHS Compliance Awareness Initiative

Compliance Awareness: During the Initiative

¾ Make each employee feel like a personal guest of compliance! ¾ Elicit employee feedback regarding their experience with the

compliance program

¾ Introduce staff to members of the compliance team and Facility Administration

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CHS Compliance Awareness Initiative

Compliance Awareness: During the Initiative (continued)

¾ …. employees are guests of compliance!

¾ Track Participation Rates—registration by name and department

¾ Offer commemorative “gimmees” for the educational experience—key chains, pens, logo items and FOOD!

¾ Provide recognition and incentive for staff participation in the compliance education process

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CHS Compliance Awareness Initiative

Carolinas HealthCare System

Compliance Awareness: Following the Initiative

¾Ensure event hosts are educated on desired post-event outcomes

¾Be prepared to show your outcomes in terms of participation and increased awareness

¾total participants,

¾number of participants per shift,

¾participation rate by department or employee classifications, ¾“prize winners” by department or employee category,

¾number of non-helpline calls and consultation requests,

¾survey response and results by department and employee classification ¾Elicit employee feedback post event—post event survey

¾Be available for follow-up meetings with staff regarding survey comments and questions asked during the event.

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CHS Compliance Awareness Initiative

Compliance Awareness: Taking the initiative beyond the event

New Manager Orientations— Program for all staff transitioning into

managerial roles.

Have conducted 13 Compliance Responsibility programs and educated approximately 330 new or recently promoted managers in past year. 9 Compliance program structure and policies

9 Elements of effectiveness

9 How to conduct and/or participate in audits and investigations 9 How to assist employees with various compliance issues

9 Case scenarios for decision-making

9 Ongoing compliance education requirements

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CHS Compliance Awareness Initiative

Compliance Awareness: Taking the initiative beyond the event

Other awareness initiatives:

¾ Compliance teleconferences— recorded to allow department managers and staff to check-out of the compliance library.

¾ Compliance link on intranet--for employee access and questions

¾ Compliance Program “User Website”—online compliance tools and documents for compliance staff outside the Compliance Department. ¾ Compliance Newsletter— updates on current compliance issues ¾ Compliance E-mail Groups— routine compliance reminders for

managers of line staff to provide “compliance moments”

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Carolinas HealthCare System

CHS Compliance Awareness Initiative

Taking the initiative beyond the event…..encourage HCCA to

endorse

National Compliance Awareness Week--Is compliance worth it—

yes!

Sherri De Shazo, RN MBA MHA Carolinas HealthCare System (704) 355-5628

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