Agenda. Regulatory Foundation 3/16/2016 AUDITING, MONITORING & VALIDATING:

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1 AUDITING, MONITORING & VALIDATING: Leveraging Resources & Relationships to Assess and Reduce Risk Agenda Define validation, monitoring and auditing and discuss examples Review the advantages and disadvantages of each approach Discuss partnerships with other risk management units Develop some validation activities based on the sample law Group brainstorming on monitoring for compliance Begin development of an audit tool based on the sample law Recap Questions Regulatory Foundation Federal Sentencing Guidelines Implementation of auditing, monitoring and reporting systems to ensure and foster compliance Essential element of an effective compliance program OIG Compliance Guidance Need for a system for auditing and monitoring Ongoing evaluation process is critical Corporate Integrity Agreements Requirement to perform regular monitoring and auditing at least annually 1

2 Operational Justification Assist in identifying risk to business Identify if controls put in place to remediate a risk are working and risk mitigated Assist with preventing a real or potential risk from escalating Early detection Shows good faith Ultimately guides and changes behavior Definitions Validation Substantiation or confirmation activities in place to protect the organization Examples Pros Cheap Adaptable Anyone and everyone Time benefits Cons Not objective Documentation isn t thorough Only as good as source No long term reliability Definitions Monitoring: Day to day reviews. Not necessarily independent of the business unit under review. This is part of doing business and the approach may be informal. process involving ongoing checking and measuring, more consistent than validation Examples From Institute of Internal Auditors (IIA) 2

3 Monitoring (continued) Pros Can be handled by department SMEs Lower resource dedication Workflow incorporation Business partner ownership Cons Possible non objectivity Often not formal Some process/oversight Burden on business partner Trend visibility Definitions Auditing: Formalized approach, independent, objective. Audits are performed by someone who has no vested interest in the outcome or the business area being reviewed. Audits use an established approach and methodology for sampling. Examples Sample Audit Process 3

4 Auditing (continued) Pros Cons Objective Can identify unmitigated risk *** Risk based Well documented Findings and corrective actions Leadership awareness Burden on auditor Slower process Internal/external politics Reputational risk Who are your AMV resources? Quality Coordinators Leaders SMEs Informatics/Analysts Engineering And more In summary = RMUs Example of monitoring swap Hand washing v. phi Deciding your approach How big is the risk? What is the priority? What does your budget look like? What does your labor pool look like? Relationship with operational partners and leaders? Compliance committee engagement? How big is the job? External pressures and obligations? Is it a one time item or is it on going? Board or leadership direction? Other? 4

5 Validation and Monitoring APPLICATION Validation Americans with Disabilities Act (ADA) Validation: Signs, parking Validation Continued ADA Checklist Interpreter certification/training Many others 5

6 Monitoring A continuous process Duration Short term: support proactive management of potential issues before they become widespread Long term: ongoing, use data analytics/analysis, reporting Examples Safety Walkthroughs Purchasing / Contracting checklists Compliance or Licensing tracers Scheduled recurring validations furniture, signs, etc. Government Provided checklist Complaint based activity Looking at next 30 visits for compliance Sampling Auditing APPLICATION Auditing Focused on Limited English Proficiency compliance from the ADA Included other regulatory requirements Don t forget, there are 50 states Pull out the ADA excerpt and the grid titled Audit Tool Worksheet Disclaimer THIS IS NOT THE ONLY WAY TO DO THIS 6

7 Audit Tool Worksheet Sec Prohibition of discrimination by public accommodations Citation Text Evidence Findings (a) General rule No individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations of any place of public accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation. (b)(1)(a)(i) Denial of participation It shall be discriminatory to subject an individual or class of individuals on the basis of a disability or disabilities of such individual or class, directly, or through contractual, licensing, or other arrangements, to a denial of the opportunity of the individual or class to participate in or benefit from the goods, services, facilities, privileges, advantages, or accommodations of an entity. Findings and Follow Up Formal audits involve an opportunity for the operational partner to review any preliminary findings. Use your findings to plan your work and see where partnerships may be available. Process revision Education Additional AMV Disciplinary action Learning Objectives Understand the processes of auditing, monitoring and validation with a focus on the benefits and pitfalls of each activity. Apply principles of resource allocation based on assessed risks for both auditing and monitoring functions, based on the size of the organization. Real time application of principles to develop a sample validation tool, a monitoring plan and the foundation of audit criteria, based on common inpatient and outpatient rules and protocols. 7

8 Questions? Aurae Beidler, MHA, RHIA, CHC, CHPS Director of Compliance/Assistant Professor Pacific University Monica R. Freedle, CHC, C LHP Hospital Compliance Program Manager Kaiser Permanente Northwest monica.r.freedle@kp.org 8