1. © Aurora Health Care, Inc. Programming Your Program Nancy Vogt, CHC, CHP, RHIT Director of Compliance Aurora Health Care

2. © Aurora Health Care, Inc. Agenda Sharing our: Use of technology to track all compliance program activities Insights into designing a compliance information system Journey into data mining Low-tech solutions for training, awareness and risk assessment

3. © Aurora Health Care, Inc. Aurora Health Care Private, not-for-profit integrated health care provider 13 hospitals (15 campuses) 172 clinic sites >1,500 employed physicians Largest homecare organization in WI Commercial laboratory >70 retail pharmacies 30,000 caregivers 94,000 inpatient discharges 2 million hospital and outpatient visits 4 million ambulatory care visits Revenues greater than $4.0 billion

4. © Aurora Health Care, Inc. Aurora’s Compliance Department

5. © Aurora Health Care, Inc. Compliance Information System Purpose: To track and report compliance program activities To retain a readily available, searchable reference library To create workflow efficiencies

6. © Aurora Health Care, Inc. Designing the System Identified what we wanted to report –Examples: hotline calls, exit interviews, voluntary repayments, regulatory activities Identified what we wanted to track –Examples: hotline call turnaround time, annual work plan status, 60-day repayment window, age of open issues and investigations, regulatory surveys

7. © Aurora Health Care, Inc. Designing the System (cont.) Identified what we wanted to retain –Examples: legal opinions, Compliance Committee meeting minutes, responses to questions, department procedures Identified workflow opportunities –Examples: hotline calls, exit interviews, repayments

8. © Aurora Health Care, Inc. Reporting Examples Quarterly summary to Audit Committee, CEO, and all compliance committees Each summary tailored to committee’s interest and scope Annual summary of activities to System Compliance Committee and Audit Committee Monthly regulatory activities to CCO

9. © Aurora Health Care, Inc. Audit Committee Qtrly Summary

10. © Aurora Health Care, Inc. Hotline Example

11. © Aurora Health Care, Inc. Outcomes Reporting Example

12. © Aurora Health Care, Inc. Annual Summary of Activities

13. © Aurora Health Care, Inc. Tracking Activities Designed categories/fields to support tracking and reporting Examples: –Annual Work Plan status –Hotline call turnaround time –60 day repayment window –Aging of issues

14. © Aurora Health Care, Inc. Annual Work Plan Status 4 categories of activities –Auditing/Monitoring –Education –Policies –Projects Annual Work Plan subcategory allows tracking across categories All Work Plan items entered/assigned at beginning of year

15. © Aurora Health Care, Inc. Custom Field Example

16. © Aurora Health Care, Inc. Retain Reference Information Library Topic Field Library Categories

17. © Aurora Health Care, Inc. Workflow A work in progress Examples: –Focus on Compliance (intranet) article management –Task assignments –Hotline call procedure –Repayment tracking via recurring e-mail reminders

18. © Aurora Health Care, Inc. Article Management Annual calendar of weekly articles E-mail reminders created in Compliance Information System (CIS) Compliance officers write, then post as an attachment in CIS Week prior, Director reviews/edits and submits to Communications Department Articles made available again via management newsletter

19. © Aurora Health Care, Inc. Article Management (cont.)

20. © Aurora Health Care, Inc. Article E-mail Reminders

21. © Aurora Health Care, Inc. Tasks

22. © Aurora Health Care, Inc. Hotline Call Procedure Create activity in system Attach transcribed call Create task for appropriate compliance officer –Task includes deadline for starting the investigation –System generates e-mail to CO Create e-mail follow-up reminder

23. © Aurora Health Care, Inc. Data Mining

24. © Aurora Health Care, Inc. Risk Assessment Rate probability and impact Rate adequacy of controls –For each set of controls, delete the 2 ratings that do not apply –See “EXAMPLE OF SCORING (FINAL) for score Sort Risk Score highest to lowest Identify 80% of risk (Pareto principle)

25. © Aurora Health Care, Inc. Annual Training (2012) No! If we promise to keep a secret, we can’t tell anyone. If your friend told you he was sick and asked you to keep it a secret (and you promised you would), would you tell your sister anyway? Let’s get a couple first graders to answer this one…

26. © Aurora Health Care, Inc. Quiz Questions D.Reporting compliance concerns is voluntary, not mandatory. Reporting compliance concerns is mandatory. Our Code of Ethical Conduct requires all Aurora caregivers to report concerns. They can be reported to a leader, a compliance officer, or via the Compliance or Privacy Hotlines. Which of the following is a false statement about reporting compliance concerns?

27. © Aurora Health Care, Inc. Annual Training (2013)

28. © Aurora Health Care, Inc. Links and Hard Stops

29. © Aurora Health Care, Inc. Weekly Intranet Articles

30. © Aurora Health Care, Inc. Compliance & Ethics Website

31. © Aurora Health Care, Inc. Sample Guidance Document Hospital Signature/Co-Signature Grid

32. © Aurora Health Care, Inc. Website FAQ’s

33. © Aurora Health Care, Inc. Questions nancy.vogt@aurora.org