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Patrick Sulzberger, CPA, CHC
Compliance & The BoardA Guide to Excellence
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My background
My connection to YOU
My Background
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A Culture of Ethics or Compliance?
Compliance is rules based
Ethics is value based
Ethics vs. Compliance
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Culture of Compliance / Ethics
Compliance Ethics
Quality
CPI
Patient Experience
Employee Experienc
e
Cash Flow
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Rapidly changing environment
External environmental pressures (regulatory guidelines, competitive landscape, etc.)
Implications exist for all health care organizations
Health Care Today ….….
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Conducting monitoring and auditing
Implementing compliance and practice standards
Designating a compliance officer
Conducting appropriate training and education
Compliance Program Elements
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Responding appropriately to detected offenses and developing a corrective action plan
Developing open lines of communication
Enforcing disciplinary standards through well publicized guidelines
Compliance Program Elements
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Duty of Care
Primary Fiduciary Responsibility
Duty of Care
Act in Good FaithAct as an ordinary prudent person would actAct in the “best interest” of the Organization
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Act in Good FaithA Director has a duty to act in good faith to assure that:
1. A corporate information and reporting system exists
2. The reporting system is adequate • The Board receives information in a timely
manner as a matter of normal operations.
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Embedded in the Duty of Care requirement is “reasonable inquiry”
Do you understand the questions you should be asking to exercise duty of care?
Duty of Care
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OIG indicates the Board does not necessarily have to “ferret out” corporate wrongdoing or “red flags”
Reasonable Inquiry
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Once the Board is presented with information that causes (or should cause) concerns to be aroused
Obligated to pursue further until the issues are satisfactorily addressed
Reasonable Inquiry
Structural & Operational Considerations
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Structural Compliance Issues Understanding the scope of the compliance program
Operational◦Understanding the operations of the program
Areas of Focus
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What are the goals of the compliance program?
What are the inherent limitations? How does the Organization address these limitations?
Structural Questions
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Does the compliance program address the significant risks of the Organization?
How were those risks determined?
How are new risks identified and incorporated into the compliance program?
Structural Questions
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How has the code of conduct been incorporated into corporate policies across the Organization?
Has management taken affirmative steps to publicize the importance of the Code to all employees?
Operational Questions
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How are “at risk” operations assessed from a compliance perspective?
Does the organization evaluate the effectiveness of the compliance program?
Operational Questions
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What is the scope of compliance related education across the Organization?
Has the effectiveness of the training been evaluated?
Board kept apprised of significant Regulatory developments impacting risk?
Operational Questions
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April 20, 2015
◦Practical Guidance for Health Care Governing Boards on Compliance Oversight
New Guidance
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The Office for Civil Rights enforces the following;
o HIPAA Privacyo HIPAA Securityo HIPAA Breach Notificationo Confidentiality Provisions of Patient
Safety Rule
HIPAA Compliance
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Has your organization formally included quality / patient safety into it’s compliance program?
Poll Question
The Board and Quality
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The OIG has issued guidance:Corporate Responsibility and HealthCare Quality
The driver is components such as EMR, meaningful use, pay for performance, gain sharing arrangements, PQRS, etc.
Oversight of Quality
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Institute of Medicine (IOM) six part definition of quality:◦Safe◦Effective◦Patient-centered◦Timely◦Efficient◦Equitable
Defining Quality
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What is the goal of the Hospital / Clinic’s quality improvement program?
What metrics and benchmarks are used to measure progress toward the established quality goals?
Quality / Patient Safety
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Who are the key management and clinical leaders responsible for quality and patient safety programs?
What internal controls exist to monitor and report on quality metrics?
Quality / Patient Safety
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What information is essential to the Board’s ability to evaluate the Clinic’s quality performance improvement program?
How frequently does the Board receive reports about the quality improvement program?
Quality / Patient Safety
Risk Reality An Environment of Rapid Change
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Health care is changing rapidly, driven by several factors, including;
◦ACA payment reform◦Meaningful use, PQRS ◦Value-based modifier◦EMR, patient portals
Change Catalysts
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How would Medicare or other Regulators get to your organizations?
Whistleblowers is a key way◦Underscores the importance of our “culture”
Whistleblowers
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Patient Complaints to the State Board of Healing Arts
Data aberrations
Patient Complaints
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Patient complaints will become an increased risk with EMR
Patient Portals – what is in the medical record?
Price transparency can create confusion and complaints
Transparency – Patient Risk
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The Board has a key role in assessing organizational culture
When compliance issues arise
Board is accountable
Tone at the Top
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Board Leadership / Mgmt
Oversight Operations Duty of Care Effectiveness
Defining Roles
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Does your Board receive information from the compliance officer regarding specific risk areas identified each year?
Poll Question
Board Educationand Configuration
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Increasingly complexity & higher accountability
Strong orientation program for new Board members
◦OIG◦HIPAA◦Quality ◦Reimbursement
Orientation
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Affordable Care Act (ACA) payment reform◦Value based purchasing◦ACO’s◦PCMH◦Collaborative models
Orientation
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Board should include representatives with expertise in quality and patient safety
◦Clinical quality measures◦Understand quality scorecards◦Identify “red flags”
Board Configuration
Resources
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OIG Resources for Boards◦www.OIG.HHS.Gov Compliance Compliance 101 and Provider Education Education Material for Health Care Boards
Office of Inspector General
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Hospital Governing Boards and Quality of Care: A Call to Responsibility◦www.ihi.org Resources Publications
Institute for Healthcare Improvement
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