Evolution of Metrics December 6, :30 1:30 p.m.

Transcription

1 Evolution of Metrics December 6, :30 1:30 p.m. Lynda Hilliard, MBA, RN, CHC, CCEP Compliance Consultant Deidre Ramsey, MBA, RN, CHC Managing Director, TPMG Compliance Learning Objectives 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. 2 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. 3 1

2 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? 4 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. 5 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. 6 2

3 Examples Compliance Program Metrics Focus Area Process Metric Outcome Metric Code of Conduct/ Standards of Practice New Employee Signed Acknowledgements On File Number of Substantiated Hotline Incidents (related to Code) Total New Employees Total Number of Substantiated Hotline Reports Distribution of Code of Goal = 0% Conduct to New Employee Oversight (Governing Body) Board Level Compliance Meetings Quorum Achieved Identified Risk Mitigation Reports Discussed and Approved Scheduled Meetings Total Number of Reports of Risks with Request for Mitigation Monies Governing Board and Senior Goal =100% Leadership Involvement Education and Training Employees Completed Annual Training Amount of Fines/Attorney Fees Paid to Resolve (Education-Focused) Violations General Compliance Total Relevant Employees Total Amount of Fees/Fines Paid for All Violations Education Goal = 0% Communication/Hotline Number of Issues Triaged within Policy Timeframe Number of Potential Issues Reported Reports of Potential Compliance Concerns Enforcement/Screening Pre-Hire Sanction Check Completed Hiring At-Risk Positions Total New Employees without Checking Sanctioned List Number of Audits Conducted & Finalized Audit & Monitoring Number of Audits Per Workplan Audit Plan Effectiveness 7 Number of External Whistleblower Reports Total Number of Reports through Internal Reporting System Goal = 0% Fines/Penalties Paid for Employing Disbarred/Sanctioned Individuals Total Amount of Fees/Fines Paid for All Violations Goal = 0% Number of Follow-up Audits Indicate Issue Resolution Total Number of Follow-up Audits Completed A Case Study: Kaiser Permanente Who We Are Executive Compliance Committee Structure and Reporting Risk Assessments 8 Kaiser Permanente Integrated Delivery System Kaiser Foundation Health Plan (KFHP) Kaiser Foundation Hospitals (KFH) The Permanente Medical Group (TPMG) 9 3

4 Kaiser Permanente Northern California Region 3.4 million members 22 medical centers 7,000 physicians 66,700 employees 10 Medical Center Organizational Structure 11 Executive Compliance Committee Reporting Structure 12 4

5 STEP 1: Survey Stakeholders 8. Communicate Highest Risks to TPMG Leaders and ECC 2. Collect Survey Results 7. Develop a Work Plan Develop an Audit Plan How TPMG Conducts a Risk Assessment 3. Analyze Survey Results 6. Develop a Risk Profile for Each Risk 4. Prioritize the Risks Review Prioritized Risks with Stakeholders TPMG Compliance Work Plan Development of Work Plan Risk Identification Revisions to Plan 14 TPMG Compliance Audit Program Develop Audit Plan Conduct the Audit Create Executive Summary Provide Medical Center Audit Results Compile Annual Audit Results 15 5

6 Executive Compliance Committee Risks are identified and reported to ECC Report includes: Summary Key Accomplishments Actions Needed Top Risks and Challenges 16 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 Contact Information: Lynda Hilliard Compliance Consultant Deidre Ramsey Managing Director, TPMG Compliance (510)

7 HCCA Conference Evolution of Metrics December 6, 2013 APPENDIX Appendix: Report Examples 1. Regional TPMG ComplianceWork Plan Regional TPMG Compliance Audit Plan Individual Medical Center Audit Results Audit Executive Summary Annual OverallAudit Results Executive Compliance Committee ReportingTemplate.. 8 Regional TPMG Compliance Work Plan - Example 3 7

8 Regional TPMG Compliance Audit Plan Example 5 4 Individual Medical Center Results 5 Regional TPMG Compliance 6 8

9 7 ECC Reporting Template 8 9