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• Policy and Procedures
• Education and Training
• Compliance Officer and Governance
• Corrective Action Planning
• Open Modes of Communication
• Auditing and Monitoring
• Enforcement Through Well- Published Guidelines
I’d like to outline how technology has been incorporated into our program to facilitate our effectiveness and compliance with federal, state and accreditation requirements.
Policy and Procedures: Currently, Compliance uses software solutions to store policies and procedures, replacing the old binders full of paper. This allows for timely access, review and revision by multiple stakeholders across the organization. Through this electronic option, searches for specific information are possible and this also facilitates cross- referencing of extra-departmental policies that are linked to Compliance, such as Human Resources or Legal policies.
Education and Training: In addition to in-person compliance education in the onboarding of all new employees, there is a requirement for annual compliance education as well. Through our education software tool, we provide annual compliance training which is reviewed and updated annually. It can be completed on most PCs around the organization at the employee’s convenience. The software helps track the completed mandatory and elective modules of education by department, and these completions are incorporated into the annual performance appraisals for staff.
Compliance Officer and Governance: We have a Compliance Committee of the Board of Trustees that oversees the Compliance Officer and program of the organization. A charter for the committee has been developed and approved by the board committee. This charter outlines the membership and annual education requirements, quorum and frequency of meetings, approval of compliance workplan, oversight for investigations, review and approval of the risk assessment plan along with other tasks. Preparation for the quarterly meetings involves review of an abundance of documents and presentations. Replacing hard copies, each member now receives a tablet that is configured for review of documents for each meeting.
Corrective Action Planning: In the past, Compliance used binders, folders and storage cabinets for storing paper documents that outlined investigations, concerns and complaints, inspections, audits and records of other related issues.
The documents would need to be accessible for follow- up by outside entities to verify documentation of any issues that required correction. Currently, we now have a compliance software database that stores our investigations, risk assessments, concerns and other issues. This tool has a resolution section where we document corrective action plans, progress and completion as needed for management or external agency review.
Open Modes of Communication: Our organization has a compliance hotline, web report and direct to Compliance contact (email, phone call or in-person) that we strongly encourage our employees to use for reporting concerns. Our hotline vendor provides intake of information, via call or web report and electronically transfers that information into our software solution that we also use for corrective action planning. This way, we can offer anonymous reporting for timely follow-up and resolution. Once the information has been transferred to our software database, we can track and trend compliance calls and issues for reporting purposes to management and the Compliance Committee of the Board and document the corrective action planning.
Auditing and Monitoring: For our workplan, we align with the Office of Inspector General areas of focus in hospital, ambulatory and other healthcare settings each year. This includes risk assessments of Medicare Conditions of Participation, compliance with contract payments, policies and procedures, documentation requirements, rules and regulations and other ad-hoc audits. If there is any need for corrective action is identified, we devise a plan, implement and monitor to ensure compliance. For our audits, we provide an executive summary which outlines the purpose of the audit, corresponding laws and regulations, review a sample, share the findings and make recommendations. Once the recommendations are received by management and corrective action planning is implemented, we will monitor and resolve. Replacing hard copies and in- person meetings, we use electronic documentation and correspond via teleconference to open and close an audit.
Enforcement Through Well- Published Guidelines: All established organizations should have a Code of Conduct to provide guidelines for ethical and legal business operations. Compliance uses our Code of Conduct as a body of standards for which compliance violations can be measured against with corresponding disciplinary actions and corrective action planning. We have our Code of Conduct readily accessible to our staff and the public via our intranet and public webpage. We also have a printed edition for distribution.
In summary, Compliance has incorporated technology, which has facilitated operation of an effective program. We eagerly look forward to new technology that will help us continue to improve.