patrick sulzberger, cpa, chc compliance & the board a guide to excellence

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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psulzberger@tsphealthcare.com

816.916.4989

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