Compliance 360
®GRC Solutions
Introductions
Ø Brent Jones Managing Consultant, Compliance 360 678-778-8996 [email protected] Ø Erin Mejeris Managing Consultant, Compliance 360 679-527-2467 [email protected]Introductions
Ø Cindy Todd Excellus, A Lifetime Healthcare Company Ø Anne Bisch BJC HealthCare Ø Dianne Jones Our Lady of Lourdes Memorial HospitalObjective
Ø Discuss our favorite Tips, Tricks and Best Practices for getting the most out of Compliance 360
Agenda
Ø Cindy Todd Introduction Ø Anne Bisch Introduction Ø Dianne Jones Introduction Ø Cindy’s Tips and Tricks Ø Anne’s Tips and Tricks Ø Dianne’s Tips and Tricks Ø Questions, Discussion and Tips and Tricks from the AudienceCindy Todd
CHP, HIPAAP, PAHM7
About The Lifetime Healthcare Companies
The Lifetime Healthcare Companies is a family of companies that provide health coverage and health care services to 1.8 million people. Our $5 billion nonprofit company is headquartered in Rochester, N.Y., and employs more than 6,000 workers throughout Upstate New York.
Excellus BlueCross BlueShield - New York State's largest not-for-profit health plan
Univera Healthcare - Managed care, indemnity and dental plan options to groups and individuals.
MedAmerica Insurance Company – Long-term care insurance for individuals and employer groups.
EBS-RMSCO, Inc. - Employee benefit programs with consulting, administrative services and risk management solutions.
Lifetime Care - Home health services, hospice, durable medical equipment, and nursing services.
Lifetime Health Medical Group - Comprehensive health care services through health centers and medical offices.
Support Services Alliance, Inc. - Group insurance products and business services for small businesses.
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Personal Background
Ø Joined BlueCross BlueShield of CNY in 1987 (later became part of The Lifetime Healthcare Companies) Ø Held several management positions including Customer Service, Quality Assurance & Training, Strategic Planning & Business Integration Ø Joined the Office of Corporate Ethics and Compliance in 2002 Ø Compliance 360 System Administrator since 2004 Ø Additional Certifications • PAHM – Professional, Academy for Healthcare Management (America’s Health Insurance Plans - AHIP) • HIPAAP – HIPAA Professional (AHIP) • CHP – Certified HIPAA Professional (HIPAA Academy)9
How We Use Compliance 360
Regulatory Compliance (Incidents, Documents) ØRegulatory Inquiry Ø Surveillance/Risk Identification Ø Implementation/Corrective Action Ø Monitoring and Examination
Ethical Compliance (Incidents)
ØEthics Inquiry/Investigation Contract Management (TPRM, Documents) Ø Vendor/Business Associate Ø Administrative Services Ø Templates
Privacy Office (Incidents, Policy, Documents, Compliance Workspace) Ø Privacy Tracking • Accounting Of Disclosure • Inquiries • Breach Investigation (Incidents) Ø Policy Development Ø Process Oversight & Attestation Ø Organizational Education (In Other
Ø Corporate Policy (Policy, Documents)
Ø Employee Handbook & Acknowledgement
(Policy, Survey)
Ø Legal Documents (Documents)
Ø System Admin Troubleshooting (Projects)
About BJC HealthCare
Ø BJC HealthCare is one of the largest nonprofit health care organizations in the United States, delivering services to residents primarily in the greater St. Louis, southern Illinois and mid-Missouri regions. Ø Net revenue of $3.2 billion Ø BJC serves urban, suburban and rural communities; and includes 13 hospitals and multiple community health locations. Ø Services include inpatient and outpatient care, primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long-term care and hospice.Personal Background
Ø Clinical process leader of the Standardization project which through process improvement, use of lean process techniques and through research of best practice, is standardizing adult medical/surgical and ICU nursing policies and procedures across 9 hospitals Ø In addition design, implementation and on-going education to Compliance 360 portal which provides an electronic workflow for policy and procedure review, reporting and survey capabilities to monitor regulatory readiness and compliance with policy and procedure review and provides one location for staff to access documentsHow We Use Compliance 360
Ø BJC HealthCare implemented the Policies module to manage Policies and Procedures (PnP’s) Ø University and Children’s hospitals went live separately • Children’s hospital utilized same workflows and set up as Community hospitals Ø 9 Community hospitals went live with nursing PnP’s in 13 weeks (initial goal was 8 weeks) Ø Currently • Migration of all local facility PnP’s by end of 2012 • Migrating corporate PnP’s to Compliance 360About Our Lady of Lourdes Memorial Hospital
Ø Lourdes began in 1925 as a 25-bed hospital and managed by the Daughters of Charity Ø Today Lourdes is a member of Ascension Health, the nation's largest Catholic and nonprofit health system and is licensed for 197 beds Ø Lourdes is also proud to be a Magnet designated healthcare system. Our care extends beyond the walls of our hospital and in to our community, including a 17-practice Primary Care Network, Mobile Mammography Van, Dental Services Van, Hospice Program, Center for Mental Health, Youth & Family Services, At Home Care, and much morePersonal Background
Ø Joined the Lourdes family in 1999 Ø Roles at Lourdes • TQM Specialist / Administrative Professional • Patient Satisfaction – Primary Contact – Administrator of Application (PRC) • Policies and Procedures – Administrative Support – Administrator of Application (Compliance 360) • Forms – Primary Contact – Administrator of Application (Zynx)How We Use Compliance 360
Ø Policy Module for Policies, Procedures and Forms • 49 Policy Manuals • 246 Sections (Chapters) • 2,564 searchable working documents • 646 non-searchable working documents Ø Third Party Risk Management Module for Contracts • 1,081 Active Contracts • 502 Expired Contracts Ø Claims Auditor module for Audit Management • ~4,814 claims • 1,673 RAC Medicare Claims under Audit • 3,141 Other External Audits Ø Meetings Module for Agenda and Meeting ManagementCindy’s Tips and Tricks
User Notices Ø Add to or create a new user notice that provides direction. Provide login information, the URL, and password information. Ø We have different user notices dependent upon the situation: • New User Notice • Contracted Employee Notice (limited-time access) • Lockout Reset ExampleCindy’s Tips and Tricks
Employee Imports from Human Resources
Ø I wish I knew that importing Job Title has no edits against it. There is inconsistency in how our job titles were entered so using Job Code is a better option for us (easier to create an edit). We had hundreds of invalid titles due to duplication based on slight variances: • Acct Service Rep II • Account Svc Rep II • Acct Svc Rep II • Account Service Rep II Ø Moving forward, we will have an edit of the job code when we extract the information from our HR files and before we upload it to Compliance 360. This will minimize our addition of duplicates.
Cindy’s Tips and Tricks
Collaboration Notification Messages
Ø In your collaboration request message, tell the user exactly what they need to do. Our message states: Please log into Compliance 360 and locate this policy on your Home Page "To Do" list. You may check-out the policy and, using track changes, identify any revisions or additions you would like to make. The document is then saved to your desktop so that you may subsequently check the document back in. You will also be offered an opportunity to provide comments, i.e. summary of your changes, which we encourage you to do for auditing purposes. After checking the policy in, be sure to indicate you are complete by clicking on the "Collaboration Complete" icon. If this is a revision to an existing policy, the reason for change will be listed here: [REASON_FOR_CHANGE]. If you require additional assistance, please contact [RESP_PARTY]. Thank you
Cindy’s Tips and Tricks
Overarching Incidents Ø Create a single incident to: • Relate other incidents for trend identification (Related Incidents) • Track regulatory awareness efforts (Attachments) • Track staff training and education (Actions) Ø The overarching Incident is identified as a Favorite for easy access. ExampleCindy’s Tips and Tricks
Cross-Divisional Access Ø Be sure to put a lot of thought into creating Divisions Ø A user in one Division does not have access to another Division unless specifically granted. Therefore, if you have a large number of people that require cross-divisional access, it could become burdensome.Cindy’s Tips and Tricks
Folder Structure Ø Having nested folders can help out with reporting or organizational needs, but it is very easy for users to get carried away with folder creation Ø Keep folders to the minimum amount needed and consider other options, e.g. custom fields for reporting needs.Cindy’s Tips and Tricks
Leveraging HTML Tags Ø HTML is the language that describes what a web-page looks like. Compliance 360 is a web-based application, and under the covers every screen is ultimately a web page. HTML uses “tags” to tell your web browser how to display the text of the page. Basic HTML “tags” can be used in some places in the application where you type in data. This can be very helpful in emphasizing information in item descriptions, incident summaries, notifications, etc. Some basic HTML Tags are: • <b>This text will be bold</b> • <i>This text will be italic</i> • <u>This text will be underlined</u> • <font color=Red>This text will be Red</font> Note that HTML tags do not necessarily translate on reports and cannot be used in all areas of the application. Google “HTML tags” for more information on use.Cindy’s Tips and Tricks
Leveraging HTML Tags Example: Incidents with a higher priority were getting lost in the Home Page Plug-in list. So, using an HTML tag, the name of the Incident is put in red font to make it stand out as a priority:Anne’s Tips and Tricks
Workflow: Keep It Simple
Ø Don’t change current processes which are already in place • University Hospital-on going struggles: multiple complex workflows built for each department resulting in several redesigns and end user dissatisfaction • Community and Children’s Hospital-successful: 2 workflows to manage local process and 2 workflows to manage system processes Ø Be prepared to encounter current process which may not “flow” • Avoid building a new “dream” state workflow
Anne’s Tips and Tricks
Standardization and Change Management
Ø Individual icons and logos: supports uniqueness of facilities while at the same time allowing for standardization of
Anne’s Tips and Tricks
Set up a Training Area
Ø Facility “Training & Testing”
Anne’s Tips and Tricks
Defining Workflow Actions
Ø Take the time to think about layout Ø Keep the Action in the same location across workflows • What and where you see an action is mirrored across all workflows Ø Organize actions together • Editing, Revising actions at the top • Starting workflow steps in the middle • Managing actions such as Audit Trail, History, Workflow History, Announce • Consider “hiding” the Delete action
Anne’s Tips and Tricks
Design for the Future
Ø Initial project was related to nursing PnP’s
Ø One year later loading all facility PnP’s and beginning to load corporate PnP’s too
Ø During initial implementation set up your workflows templates with the future in mind
Ø System Steering Committee: Decision makers to maintain
Dianne’s Tips and Tricks
Formatting Policies using Tables
Ø When viewed from our intranet via an ExternaLink, many of our polices are twisted due to tab characters placed in the title portion of the document Ø As I review/revise the policies I am now inserting a table of two columns and six or seven rows to keep the policy neat and tidy. The yields a more professional looking document
Dianne’s Tips and Tricks
Other Best Practices for Formatting Policies
Ø Remove page numbers Ø Remove attached documents • We have historically had the referenced forms referenced or attached to the policy document. • When migrating to Compliance 360 we made them a linkable document but did not remove from the policy itself. So the end user may be looking at an older version of the associated form if they are reviewing what is included in policy document. I hope they are pulling the actual form, not the form within the policy
Dianne’s Tips and Tricks
Leverage Editable PDF Forms
Ø I have converted many of my Word documents to editable PDF forms Ø This produces easy to read forms – I’m no longer trying to decipher hand written forms and it provides a more professional looking document Ø In practice, a staff member opens the editable form from Compliance 360 and completes the form by typing directly into it from their computer. They can then print and/or save the document and forward it to appropriate staff. Ø This has been a huge hit. Everybody wants PDF forms!
Dianne’s Tips and Tricks
Leverage Editable PDF Forms – Details
Ø This solution requires the Adobe Pro software Ø Starting with a word document, enter the data element piece (check box, text field & radio button) where needed. Ø Print or Save the document in PDF format Ø Open the Word document and the PDF version using Adobe Pro. The Word version allows you to see all the data entry pieces within the document Ø Edit the PDF by adding data entry pieces to the document • You can also copy and paste data entry pieces from one PDF to another Ø Upload the data entry PDF as a Document or Policy in Compliance 360, selecting “User Supplied PDF File”
Before starting – Must haves
Ø Adobe Pro
Ø Save word document as Adobe (PDF format) Ø Open with Adobe Pro Ø Add text fields Ø Add check boxes Ø Add radio buttons Ø Edit properties as you go
Customizing Fun
Ø Text fields • Multi-line, change font/font size, add border/ shading Ø Check boxes & Radio buttons • Add border and fill • Yes – border & fill in green • No – border & fill in redReady for Upload
Questions and Discussion
Tips, Tricks and Best Practices
from the Audience
Other Tips, Tricks and Best Practices
Appendix – Other Tips and Tricks
Workflow Ø Be as specific as possible with the Status Text for Workflow steps. If people become involved with more than one area of the business, a status text that isn’t specific can lead to confusion in the To-Do List, Message Digest, and other areas Ø Workflow Groups is a wonderful tool to really get out to users. This can be a timesaver for the System Administrator Reports Ø Other than those running on the new Reporting platform, run reports in HTML, right click, select all, copy and paste into Word and manipulate as desired. The HTML report can also be printed to Adobe PDF if changes are not neededAppendix – Other Tips and Tricks
Maintenance
Ø Utilize Message Digest for users overwhelmed by email. This can enhance the user experience for those users, and can make managing of their “To-Do” items easier
Appendix – Other Tips and Tricks
Use Surveys for Policy Attestations
Ø Use to send out surveys to multiple employees or groups to show proof of Policy Acknowledgement
Appendix – Other Tips and Tricks
Workflow Delegation Action
Ø This action displays a dialog that enables users to delegate workflow assignments to other employees Ø If this function is enabled, the employee can, at the appropriate workflow step, select the Actions button for an assignment and select Workflow Delegation. The Workflow Delegation window is displayed, and an employee can be selected and tasked with the delegated assignment
Additional Tips and Tricks from Cindy
Requests for Assistance
Ø Create Assistance Request forms that users complete and submit for troubleshooting or requests for guidance Ø Using the forms streamline the many requests and gathers preliminary information without the need to continually ask for more information Ø Eventually, the forms will be incorporated with the “Contact Us” button to streamline it even further Ø Additionally, the Project Module is used to track these requests and is able to provide status update notifications to the requestor and the use of “To Do” provides a dashboard view of open items
Additional Tips and Tricks from Cindy
Lookup Codes Ø Coordinate across business areas/Divisions for consistency Ø Anything used by all Divisions should be created globally Ø Within each Division, be sure that there is no redundancy as it will distort reportingAdditional Tips and Tricks from Cindy
Partnership Agreement Ø At the beginning of a new relationship/implementation, we issue a Partnership Agreement which clearly outlines the roles and responsibilities of each party involved in the relationship between the business process owners and the System Administrator Ø Renewed every two yearsAdditional Tips and Tricks from Cindy
ExternaLinks Ø If you store documents in an intranet or internet, use ExternaLinks instead of service requests to IT Caution: Just don’t send that link to too many people because of the open access it could provideAdditional Tips and Tricks from Cindy
Foundation Workflow Ø Create a workflow to be used as a foundation for all other workflows Ø Let business owners know that this basic, generic-type workflow can be used by them, but is subject to change at any time Ø As we grow in the application, the generic workflow can be tweaked, but custom workflows will not be impacted unless business owners want it to change Ø Having a workflow that serves as a foundation also ensures consistency in the name of workflow steps, color coding, etc. to make it easier for users that work across multiple business processes that use workflowAdditional Tips and Tricks from Cindy
Workflow (generic) Groups
Ø This is another wonderful tool to push out to users. We recently started using this more often and it really is a
timesaver for the System Administrator (for clients who chose to limit access to Maintenance)
Additional Tips and Tricks from Cindy
Using Closed for WF Status
Ø Put a “Z” in front of the word “Closed” (or Complete). This allows a user to sort alphabetically by workflow status and have all objects considered “open” to be listed first
Additional Tips and Tricks from Cindy
Regular Reports Ø If you have reports that need to run on a regular basis but each report has a slight variation in criteria, rather than set up multiple reports you can set up the report once, and describe the different criteria options in the report’s description so that it can be cut-and -pasted into the appropriate filter areas. The description area can also hold instruction for how to run that particular reportAdditional Tips and Tricks from Cindy
User Training and Documentation
Ø Write generic training documents based on how your company is using a specific module Ø As the module is pushed out for implementation by different business areas, they can use the generic document and customize it based on their specific business process Ø This also ensures consistency and accuracy in desktop procedures as related to the application
Additional Tips and Tricks from Cindy
Managing “Generic” Users
Ø We have several generic user IDs (employee records) created that are used for ExternaLinks, contractors, mailboxes, etc. These “users” appear in the Employee Divisional list Ø If the divisional list is used to issue an all employee survey or in other areas, these generic user IDs are included in that list which can cause problems with objects being considered “complete” (Survey) or can skew reports. Ø To resolve this, create a separate Division to house these generic user IDs so that they are not part of mass issuance of surveys, notifications or reports.
Additional Tips and Tricks from Cindy
Corporate Email Groups
Ø If you have groups created for purposes of routing notifications, and they change regularly, you might be able to create a group in your corporate email system. • Use that email address to create a generic user in Compliance 360. • The “owner” of that corporate email group can maintain the membership him or herself in the email system. Caution: Be mindful of the previous point regarding generic user IDs.
Additional Tips and Tricks from Cindy
Using Survey Proxies
Ø When using the Proxy functionality for surveys, by default, the survey notification message does not include the respondent name Ø Be sure to include the respondent token in your workflow messages. This will allow the proxy to identify the intended recipient.
Additional Tips and Tricks from Cindy
Managing Security for Attachments
Ø You can establish security access for an Attachment that is different from than the object to which it is attached. • First, enter the attachment as a document in the Documents module. • Assign security to the document • Attach the Document to the object, i.e. Policy
