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One of the keys to maximizing the effectiveness of a compliance program is to maximize the different skill sets each team member brings to your process and function, says Jane Conard, senior counsel at Intermountain Healthcare (IHC) in Salt Lake City. That begins with effective internal organization, she says.
IHC is a nonprofit integrated health care delivery system with 22 hospitals predominantly located in Utah and Idaho. The systems has more than 100 physician clinics, managed care plans including more than 500,000 lives, and 23,000 employees.
Suzie Draper, compliance administrator at IHC, says that when the IHC Board of Directors established a compliance department several years ago, it was intent on vesting one person with sufficient "scope of influence" to bring about real change within the organization. That person, who quickly decided to hire a compliance administrator to operationalize the program, still chairs the compliance committee, which includes internal audit, legal, and clinical support.
According to Draper, another important part of IHC’s organizational structure is its advisory committee, which includes regional vice presidents and clinical vice presidents. "Whenever we have an enterprisewide initiative, it is important that we bring them on board," she says.
The compliance team is divided into compliance subcommittees, which are further divided by legal subject matter. "The areas where we found the most success are those where we have our facility or operations coordinators working closely with compliance workgroups," says Draper. Conard adds that human resources, managed care, environmental issues, and information security all are part of the comprehensive compliance program as well.
Another key to success is to make sure that every area has clear accountability. Facility and operations have line accountability, Draper says. "We also emphasize that is the first line of communication," she adds. "We don’t want to have anyone feel they need to circumvent those organizational structures and go to the hotline or central compliance if they can have those issues solved first within the organization or operation."
Those areas also are accountable for training. "Because we have different types of operations, they are accountable for different risk assessments," Draper reports. For example, the risks facing the children’s hospital are very different from some of the full-payer acute facilities. Likewise, the home care operation has 10 different agencies. "Each of these facilities must be looking at the different risks and making site-specific risk assessments," she says.
In addition, IHC has more than 30 workgroups that are focused on various functional areas. "They are the ones looking at the OIG guidance specifically written for the different areas," explains Draper. "We also have found that this is an important area to link compliance to quality."
Draper says it also is important to link quality in clinical programs with compliance. That begins with documentation and understanding conditions of participation. "I can’t stress enough how essential it is to have the clinician on board," she asserts.
In addition to monitoring operations and discovering and logging compliance issues, hospitals must execute corrective action plans appropriately, Draper says. That means that the staff that oversee employees and budgets must make sure these processes have been implemented.