Patrick Sulzberger, CPA, CHC Compliance & The Board A Guide to Excellence

TSP HEALTHCARE2  My background  My connection to YOU

TSP HEALTHCARE3 A Culture of Ethics or Compliance?  Compliance is rules based  Ethics is value based

TSP HEALTHCARE4 Compliance Ethics Quality CPI Patient Experience Employee Experience Cash Flow

TSP HEALTHCARE5  Rapidly changing environment  External environmental pressures (regulatory guidelines, competitive landscape, etc.)  Implications exist for all health care organizations

TSP HEALTHCARE6  Conducting monitoring and auditing  Implementing compliance and practice standards  Designating a compliance officer  Conducting appropriate training and education

TSP HEALTHCARE7  Responding appropriately to detected offenses and developing a corrective action plan  Developing open lines of communication  Enforcing disciplinary standards through well publicized guidelines

TSP HEALTHCARE8 Primary Fiduciary Responsibility Duty of Care Act in Good Faith Act as an ordinary prudent person would act Act in the “best interest” of the Organization

TSP HEALTHCARE9 A 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.

TSP HEALTHCARE10  Embedded in the Duty of Care requirement is “reasonable inquiry”  Do you understand the questions you should be asking to exercise duty of care?

TSP HEALTHCARE11  OIG indicates the Board does not necessarily have to “ferret out” corporate wrongdoing or “red flags”

TSP HEALTHCARE12  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

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TSP HEALTHCARE14  Structural Compliance Issues  Understanding the scope of the compliance program  Operational ◦ Understanding the operations of the program

TSP HEALTHCARE15  What are the goals of the compliance program?  What are the inherent limitations?  How does the Organization address these limitations?

TSP HEALTHCARE16  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?

TSP HEALTHCARE17  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?

TSP HEALTHCARE18  How are “at risk” operations assessed from a compliance perspective?  Does the organization evaluate the effectiveness of the compliance program?

TSP HEALTHCARE19  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?

TSP HEALTHCARE20  April 20, 2015 ◦ Practical Guidance for Health Care Governing Boards on Compliance Oversight

TSP HEALTHCARE21 The Office for Civil Rights enforces the following; o HIPAA Privacy o HIPAA Security o HIPAA Breach Notification o Confidentiality Provisions of Patient Safety Rule

TSP HEALTHCARE22 Has your organization formally included quality / patient safety into it’s compliance program?

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TSP HEALTHCARE24  The OIG has issued guidance: Corporate Responsibility and Health Care Quality  The driver is components such as EMR, meaningful use, pay for performance, gain sharing arrangements, PQRS, etc.

TSP HEALTHCARE25  Institute of Medicine (IOM) six part definition of quality: ◦ Safe ◦ Effective ◦ Patient-centered ◦ Timely ◦ Efficient ◦ Equitable

TSP HEALTHCARE26  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?

TSP HEALTHCARE27  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?

TSP HEALTHCARE28  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?

An Environment of Rapid Change TSP HEALTHCARE29

TSP HEALTHCARE30  Health care is changing rapidly, driven by several factors, including; ◦ ACA payment reform ◦ Meaningful use, PQRS ◦ Value-based modifier ◦ EMR, patient portals

TSP HEALTHCARE31  How would Medicare or other Regulators get to your organizations?  Whistleblowers is a key way ◦ Underscores the importance of our “culture”

TSP HEALTHCARE32  Patient Complaints to the State Board of Healing Arts  Data aberrations

TSP HEALTHCARE33  Patient complaints will become an increased risk with EMR  Patient Portals – what is in the medical record?  Price transparency can create confusion and complaints

TSP HEALTHCARE34  The Board has a key role in assessing organizational culture  When compliance issues arise Board is accountable

TSP HEALTHCARE35  BoardLeadership / Mgmt  OversightOperations  Duty of CareEffectiveness

TSP HEALTHCARE36  Does your Board receive information from the compliance officer regarding specific risk areas identified each year?

and Configuration TSP HEALTHCARE37

TSP HEALTHCARE38 Increasingly complexity & higher accountability Strong orientation program for new Board members ◦OIG ◦HIPAA ◦Quality ◦Reimbursement

TSP HEALTHCARE39  Affordable Care Act (ACA) payment reform ◦ Value based purchasing ◦ ACO’s ◦ PCMH ◦ Collaborative models

TSP HEALTHCARE40  Board should include representatives with expertise in quality and patient safety ◦ Clinical quality measures ◦ Understand quality scorecards ◦ Identify “red flags”

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TSP HEALTHCARE42  OIG Resources for Boards ◦  Compliance  Compliance 101 and Provider Education  Education Material for Health Care Boards

TSP HEALTHCARE43  Hospital Governing Boards and Quality of Care: A Call to Responsibility ◦  Resources  Publications

TSP HEALTHCARE44  LinkedIn  partners partners  Facebook   Twitter

TSP HEALTHCARE45    tsphealthcare.com