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Evolution of MetricsDecember 6, 2013
12:30 – 1:30 p.m.
Lynda Hilliard, MBA, RN, CHC, CCEP
Compliance Consultant
Deidre Ramsey, MBA, RN, CHC
Managing Director, TPMG Compliance
Learning Objectives
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1. Understand the evolution of metrics in measuring
compliance;
2. List and understand types of metrics;
3. Outline operational steps to develop relevant metrics that
help to measure compliance program impact.
Why Use Metrics to Measure Impact?
� Indicate potential trends in a specific operational area
� Provide an outcomes-oriented view of compliance
� Assist in focusing limited resources to higher priority
areas
� Focus on reviewing the “root cause” of an identified systemic
issues versus “fault-finding”
� Contributory impact on a culture of compliance within an
organization.
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Decisions, Decisions…
� What kind of metrics should be developed?
� What are the key elements, at that point in time, in your
program that need to be monitored – such as timeliness of triage
and follow-up to hotline calls, LEIE screening, management
corrective action plans?
� What data demonstrate value and effectiveness of compliance
program to both senior leadership and government regulators?
� How many, how often should they be reviewed?
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Definitions
� Performance Management
� Ongoing assessment of employee and operational processes to
gauge progress towards pre-defined goals. For success, it requires
the integration of initiatives, alignment of organization units and
resources to improve processes across all “silos” of a
business.
� Metric
� Specific description at a given point in time of how a
quantitative and periodic assessment of performance should be
measured. Structure, process and outcome metrics can be used
effectively.
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Definitions
� Key Performance Indicators
� Metrics used to quantify performance objectives that reflect
strategic activities of an organization typically
process-oriented.
� Scorecard/Dashboards
� Compilation of key indicators noting progress towards
mitigation of risks that are unique to an individual organization
–provides a “common goal” across a diverse organization.
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Focus Area Process Metric Outcome Metric
Code of Conduct/
Standards of Practice
Distribution of Code of
Conduct to New Employee
New Employee Signed Acknowledgements On File
Total New Employees
Goal = 100%
Number of Substantiated Hotline Incidents (related to Code)
Total Number of Substantiated Hotline Reports
Goal = 0%
Oversight (Governing Body)
Governing Board and Senior
Leadership Involvement
Board Level Compliance Meetings Quorum Achieved
Scheduled Meetings
Goal =100%
Identified Risk Mitigation Reports Discussed and Approved
Total Number of Reports of Risks with Request for Mitigation
Monies
Goal = 100%
Education and Training
General Compliance
Education
Employees Completed Annual Training
Total Relevant Employees
Goal = 100%
Amount of Fines/Attorney Fees Paid to Resolve
(Education-Focused) Violations
Total Amount of Fees/Fines Paid for All Violations
Goal = 0%
Communication/Hotline
Reports of Potential
Compliance Concerns
Number of Issues Triaged within Policy Timeframe
Number of Potential Issues Reported
Goal = 100%
Number of External “Whistleblower” Reports
Total Number of Reports through Internal Reporting System
Goal = 0%
Enforcement/Screening
Hiring At-Risk Positions
without Checking Sanctioned
List
Pre-Hire Sanction Check Completed
Total New Employees
Goal = 100%
Fines/Penalties Paid for Employing Disbarred/Sanctioned
Individuals
Total Amount of Fees/Fines Paid for All Violations
Goal = 0%
Audit & Monitoring
Audit Plan Effectiveness
Number of Audits Conducted & Finalized
Number of Audits Per Workplan
Goal = 100%
Number of Follow-up Audits Indicate Issue Resolution
Total Number of Follow-up Audits Completed
Goal = 100%
Examples –
Compliance Program Metrics
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A Case Study: Kaiser Permanente
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Who We Are
Executive Compliance Committee Structure and Reporting
Risk Assessments
Kaiser Permanente Integrated Delivery
System
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Kaiser Foundation Health Plan (KFHP)
The Permanente Medical Group (TPMG)
Kaiser Foundation Hospitals (KFH)
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Kaiser Permanente
Northern California Region
3.4 million members
22 medical centers
7,000 physicians
66,700 employees
Medical Center Organizational Structure
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Executive Compliance Committee Reporting Structure
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STEP 1:
Survey Stakeholders
2. Collect Survey Results
3. Analyze Survey Results
4. Prioritize the Risks
5. Review Prioritized Risks with Stakeholders
6. Develop a Risk Profile for Each Risk
7. Develop a Work Plan
Develop an Audit Plan
8. Communicate Highest Risks to TPMG Leaders
and ECC
How TPMG
Conducts a
Risk
Assessment
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TPMG Compliance Work Plan
�Development of Work Plan
� Risk Identification
� Revisions to Plan
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TPMG Compliance Audit Program
� Develop Audit Plan
� Conduct the Audit
� Create Executive Summary
� Provide Medical Center Audit Results
� Compile Annual Audit Results
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Executive Compliance Committee
� Risks are identified and reported to ECC
� Report includes:
� Summary
� Key Accomplishments
� Actions Needed
� Top Risks and Challenges
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TPMG Compliance Wiki
� Included on Compliance Wiki:
� Program descriptions
� Links to important internal and external resources
� Contact lists for your compliance questions
� Training links
Questions
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Contact Information:
Lynda Hilliard
Compliance Consultant
[email protected]
Deidre Ramsey
Managing Director, TPMG Compliance
[email protected]
(510) 625-3885
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APPENDIX
HCCA Conference – Evolution of Metrics
December 6, 2013
Appendix: Report Examples
1. Regional TPMG ComplianceWork Plan . . . . . . . . . . . . . .
. . . . 3
2. Regional TPMG ComplianceAudit Plan . . . . . . . . . . . . .
. . . . . 4
3. Individual Medical CenterAudit Results . . . . . . . . . . .
. . . . . . 5
4. Audit Executive Summary . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 6
5. Annual OverallAudit Results . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 7
6. Executive Compliance Committee ReportingTemplate . . 8
Regional TPMG Compliance Work Plan - Example
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Regional TPMG Compliance Audit Plan Example
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Individual Medical Center Results
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Regional TPMG Compliance
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ECC Reporting Template
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