4/9/2015. Large Hospitals and Health Systems HCCA 19 th Annual Compliance Institute. Session Goal. Discussion Facilitators: PREAM1 APRIL 19, 2015

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1 Large Hospitals and Health Systems HCCA 19 th Annual Compliance Institute PREAM1 APRIL 19, 2015 Session Goal This session is the opportunity for Large Hospital and Health System compliance officers to engage in a collaborative discussion of both emerging and chronic challenges to effective compliance programs unique to such organizations, share model practices and practical solutions. A panel of experienced large system compliance professionals will introduce and speak to such topics, engage the audience in an interactive exchange of perspectives and approaches and solicit additional issues of concern. You should take away from this session an enhanced understanding of challenges common to compliance programs in large organizations, new approaches to these challenges and the wisdom of your colleagues. Discussion Facilitators: Suzie Draper VP, Business Ethics and Compliance Intermountain Healthcare John Steiner Chief Compliance and Privacy Officer and Associate General Counsel Cancer Treatment Centers of America Cheryl L. Wagonhurst Law Office of Cheryl Wagonhurst 1

2 Overview I. Compliance Best Practices II. Subject Matter Challenges III. Emerging s Evolution of a Compliance Program Complexity Regulatory Agency Enforcement and Oversight 2

3 Evolution of a Compliance Program Proliferation 2014, Intermountain Healthcare 19 websites checked daily 3,287 regulations reviewed (> 32,000 pgs) 451 Prime assignments 2,090 FYI Communications Regulatory Agency Enforcement and Oversight Evolution of a Compliance Program Regulatory Agency Enforcement and Oversight Federal Compliance Program Guidances stipulates the need for an Effective Compliance Program Silent on how to measure effectiveness Emphasizes that to be effective, the program must Be fully implemented Be adequately resourced Have an annual independent audit of effectiveness (select programs) Have effective board oversight Increased push for outcomes and performance measures Evolution of a Compliance Program Solo Practitioner or Large Integrated Delivery System o s facing a healthcare entity Regulatory Financial Patient Safety Reputational Scalability 3

4 Evolution of a Compliance Program Scalability Solo Practitioner or Large Integrated Delivery System o Assessing the environment in which your Program exists Size and diversity of business lines Available expertise and budgetary resources Leadership / organizational structure Compliance Program Evolution Initial Establish Program Elements Basic Metrics Maturing Activity Metrics Demonstrate Elements of Compliance Program Monitor Compliance Program Elements Mature Performance Metrics Demonstrate Effectiveness & Consistent Improvement Benchmarking and Trending Elements of an Effective Compliance Program High Level Commitment Policies and Standards of Conduct Training and Education Effective Lines of Communication Auditing and Monitoring Response and Prevention Discipline Assessment 4

5 Element: High Level Commitment High Level Commitment Which of the following has been the most challenging for your organization? Culture of Compliance Tone at the Top Compliance Program Performance Metrics Partnering Internal Audit/Quality/ Management Employee Engagement High Level Commitment Culture Element: High Level Commitment 5

6 Cultural Maturity High Level Commitment Culture What is the maturity of your culture? Are you an advisor or an afterthought? Do they run to you, or from you? Do you have routine access to Senior Management and the Board of Directors? Do you partner with Internal Audit? Auditing and Monitoring Element: Auditing and Monitoring Element: Auditing and Monitoring Auditing and Monitoring In which area do you think your organization has the best Auditing and Monitoring infrastructure? Clarity of Roles: 3 Lines of Defense Data Mining Proactive Regular Dashboard Reporting Routine Process Monitoring System-wide Learning 6

7 Auditing and Monitoring Clarity of Roles 3 Lines of Defense Element: Auditing and Monitoring Compliance Program Three Lines of Defense Board of Directors and Audit Committee Senior Management Operations Management Monitoring Processes and Procedures Training Issue Reporting Issue Correction Compliance Issue Management Regulatory Analysis Assessment Process Operational Oversight Tools and Resources Internal Audit Independent Audits Collaboration with Compliance Based Audits Issue Correction Verification Improvement Opportunities External Auditors Regulators Response and Prevention Element: Response and Prevention 7

8 Response and Prevention Shift from reactive to proactive Element: Response and Prevention Compliance Program Evolution Detect / Identify Effective / Identify Next Issue Reactive Investigate Sustain Proactive Assess CAP Payback Sanction Penalties CAP Process Standardization Education Controls Monitors Evolution of ERM and GRC GRC o Governance o Management o Compliance RACI o Responsible o Accountable o Consultation o Information 8

9 Element: Response and Prevention Response and Prevention Even with extensive resource infusion, which area in your organization continues to have the most problems/errors? Ethics in Patient Referral Act (Stark Law) Government Payor Audits Reimbursement Denials Information and Data Security Privacy and Data Breaches Limited English Proficiency / ADA Assessment Element: Assessment Assessment Assessment Moving from checking-the-boxes Prioritization Strategies Identification Mitigat Identification Mitigation Prioritization 9

10 Assessment Process Strategies Mitigation Identification Prioritization Identification Mitigation Prioritization Strategy Assessment All risks are not equal Moving from checking-the-boxes 10

11 Subject Matter Challenges I. Compliance Best Practices II. Subject Matter Challenges III. Emerging s Moving from checking-the-boxes Assessment Which regulatory area is creating the most activity within your organization? Quality / Joint Commission OIG Workplan CoPs Agency Surveys Certifications / Best of Class Status Evolving Organizational Response to 11

12 Healthcare Outlook Changes in Corporate Structure o Clinical System Integration o Zero Harm Reporting and Escalation Changes in Physical Plant o Smaller facilities o Expanded delivery of services Changes in Delivery Structure o Accountable Care Organizations Systems Improvement Agreements New and Effective means of preventing termination and closure One year Use of IRO Focus on Conditions of Participation Systems Improvement Agreements Allows for process improvements Integrates quality and compliance Promotes sustainable compliance 12

13 Emerging s I. Compliance Best Practices II. Subject Matter Challenges III. Emerging s Assessment In which area do you feel your organization is the least mature? Electronic Health Record Information Systems Security Business Innovation Mergers and Acquisitions Stakeholders Added Value Contracts Moving from checking-the-boxes Assessment Identification Monitoring Audits Regulatory updates Compliance issue and risk trends CMS/OIG identified risk areas Gaps in controls Functions / activities with high impact 13

14 Moving from checking-the-boxes Assessment Emerging s Clinical Documentation EHR copy and paste Adjustment Coding ACO/ Shared Accountability Population Health Management LA County 350,000 NASDA Q unknown Ebay 145,000,000 Nintend o 240,000 Advocate Medical Group 4,000,000 Wallgreens 100,000 Adobe 152,000,000 Touchston e 300,000 Florida Courts 100,000 South Africa Police 16,000 Korea Credit Bureau 20,000,000 Sony 145,000,000 SnapCha t 4,700,000 Drupal 1,000,000 Texas DHHS 2,000,000 Hudson Gas 110,000 Internationa l Bank Heist $1 billion stolen Target 70,000,000 LexisNexis 1,000,000 AOL 92,000,000 Montana DDHS 1,300,000 Boston Children s unknow n Macrumor s.com 800,000 WA State Courts 160,000 Premier 11,000,000 CHS 45,000,000 Nieman Marcus unknown Anthem 80,000,000 Cross industry Breaches

15 Intermountain Healthcare Suzie Draper Vice President, Business Ethics and Compliance Intermountain Healthcare Salt Lake City, UT (801) Intermountain Healthcare Serves Utah and southeastern Idaho Not-for-profit healthcare system 22 hospitals >185 clinics o 24 community clinics for low-income, homeless and uninsured; 6 owned,18 receiving financial support 1,100 physician multi-specialty Intermountain Medical Group Health insurance SelectHealth o 750,000 covered lives Homecare and Hospice Clinical Quality Board Goals 36,000 employees Total assets of $6.3 billion Total operating revenues of $5.5 billion Cancer Treatment Centers of America John Steiner Chief Compliance and Privacy Officer and Associate General Counsel Cancer Treatment Centers of America Schaumburg, IL (847) John.Steiner@ctca-hope.com Cancer Treatment Centers of America National network of cancer hospitals founded in 1988 Serves patients from all 50 states, at specialty hospitals located in Chicago, Tulsa, Philadelphia, Phoenix and Atlanta Focuses on complex and advanced-stage cancer Offers fully integrated approach to cancer treatment o Traditional treatments like surgery, radiation and chemotherapy, and complementary therapies like nutrition, acupuncture and mind-body medicine to manage side effects, all under one roof Known for delivering the Mother Standard of care and Patient Empowerment Medicine 4,500 employees (called stakeholders at CTCA) Partners with nearly 300 different organizations to educate, support local communities and improve health and wellness Cheryl L. Wagonhurst Cheryl Wagonhurst Attorney at Law Law Office of Cheryl Wagonhurst Santa Barbara, CA (805) cwagonhurst@wagonhurst.com 15

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