“PACE” Yourself

Improving Compliance with Better

•Policies

• Awareness

•Committees

•Education

Lap 1: POLICIES

OIG Guidance:Element #1 –

written standards

(where it all begins) �

J. Stuart Showalter, JD, MFS

Atlanta, GA

FMOL Health System

Decentralized structure

Inconsistent policies

No central repository

No policy development process

“Who’s on first?”

Now moving to centralize

Whose

template?

Where do

I find …?

What is a policy, anyway?

Not a ‘practice’

A written principle to govern behavior� Fundamental rule

� The organization’s position on an issue

Different than a procedure, which is� A way of acting

� A series of steps

� “How to” “P&P”

Start your engines!

� Get buy-in from key influencers:� Senior management

� Policy “owners” (SMEs)

� Legal

� Compliance/Privacy/InfoSec

� Choose committee(s)

� Choose policy “librarian”

Choose format/template� Research says …

� Note headings & body

� See text box

NOTES:

1. A standard policy format-

•Forces the author to organize thoughts

more clearly

•Promotes the reader’s understanding

•Avoids the “Columbus method” of

readership

2. All sections must be completed. If n/a,

state “none”.

3. The footer should indicate file name and

path.

3. Delete this text box before printing.

Definitions

Scope

Purpose

Attachments

Procedure

Policy

References

Scope

�To whom does the P&P apply?� All employees?

� The Lab, the Pharmacy, the ED?

�When does the P&P apply?� At all times?

� During emergencies?

� Night shift only?

Purpose

What’s the policy about?

What’s its purpose?

� “To protect the confidentiality of patient information.”

� “To define conflicts of interest and how to deal with them.”

Bad example

Policy

Statement of standards

Fundamental principles

“It is the policy of ABC Corp. to prohibit smoking in the building.”

Procedure

Implementation:� Who� What� Where� When � How

Accountable?

Responsible?

Concerned?

Informed?

Who is:

“Employess who wish to smoke may do so outside on the rear patio during breaks.”

Abbreviations

Acronyms

Legalisms

Technical terms

Location?(See the “wheel”)

If it’s not defined, it might as well be written in:

Definitions

References

“Show me where it says we have to do that.”

Citations and links to laws, regulations, journal articles, etc.

Cross-reference other policies (rarely)

Any recognized authority or source

Use APA or other standard bibliographic style

Attachments

The place for more details

Convert a manual into a policy

What to do about forms?

Have a forms section online

How to publish?

Manuals are hard copies in more ways than one--� Hard to maintain

� Hard to find

� Hard to rely on

Online catalog is best

Online Catalog

“Compliance360”

Naming a Policy & Procedure

First word is important

Should indicate the exact topic of the P&P

Example:Routine Inquiry for Organ & Tissue Donation

Include key words for on-line searches

Style Tips

Why is style important?

• We speak to be understood,

but...

• We write to make it impossible to be misunderstood.

Rule #1

Know your audience!

Rule #2: Think!

Think about what you’re writing! � “a high rate of speed”� “Cincinnati’s population of 331,000 people”� “a former native of Missouri”� “height of the depression”� “historic figures from the past”� “she was limited by her mobility”

More tips �

Write … edit … rewrite … do it all over again

Print it out

Read it aloud or to others

Change venue or font

Don’t just rely on ‘spell check’

“There’s no such thing as writing; there’s only re-writing!”

Some common problems

Shall/will

Should/must

May/might

It’s/its

Lead poisoning

All right!

Lie/lay

Bill Clinton: “America’s

fallen soldiers laying

in the field.”

(Hens lay eggs. Presidents

should not!)

I.e. vs. e.g.

� I.e. (id est) ─ specific thing(s) • “The first three letters of the alphabet

(i.e., A, B, and C) …”

� E.g. (exempli gratia) ─ akin to etc.:• “Various letters (e.g., B, C and P) mean

different things in the Cyrillic alphabet

Affect and Effect

Affect

Verb Noun

Effect

To influence

To carry out

Mood; emotions

End result

Even Punctuation Counts�!- or – “The Panda Story”

“Large black and white mammal native to China and Tibet ...

… it eats, shoots and leaves.”

“When promulgating your esoteric cogitations, eschew all conglomerations of flatulent garrulity.”

The KISS method

“Utilization of the waste receptacles is preferred to the indiscriminate disposal of non-functional materials.”

(I.e., “Don’t litter!”)

Nathaniel Hawthorne--

“Easy reading is

damn hard writing!”

Lap 2: Awareness & Recognition

Linda Borges, Director of Compliance

MVP Health Care

Schenectady, NY

Building an Effective

Compliance Awareness

& Recognition Program

About MVP� Founded in 1982 as a not-for-profit health

insurer.� MVP’s 750,000-plus membership throughout NY,

VT, and NH continues to grow.� MVP cited for excellence by U.S. News & World

Report, Kodak, and IBM.

● MVP’s health plans feature innovative wellness programs and incentives.

� MVP employs a customer-centric philosophy.

� MVP focuses on health-care costs, proactive health management, and 21st-century technology.

Surveys

Results

Awareness

Recognition

Goal

Compliance Awareness

and

Recognition Program

� Create a schedule of the types of

messages

� Use varied delivery modes

� Leave room for unexpected

communications!

� Use a theme

Superhero Theme

� Be Proactive

�Compliance investigations and

issues

� Employee feedback

� Metrics

� Regulatory requirements

Compliance Inquiry Tracking Log

DRAFTDRAFT

� Make the hotline number more visible

� Create magnets with the hotline number

�More prominent presence on the company

Intranet

� More frequent compliance tips

Bulletins

Departmental

Meetings Captain Integrity

Magnets

SIU

Fraud &

Abuse

Task Force

Newsletter

articles

Training

Posters

Contests

Meet & Greet

Intranet

Brochures

Blogs

Picture Strips

User Friendly

Documents

Compliance Week

Magnets Word Search

Compliance is Everyone’s

Responsibility.Enough Said!

Compliance is Everyone’s

Responsibility.Enough Said!

DRAFT

Captain Integrity

Executive Profile

Scavenger HuntScavenger HuntScavenger HuntScavenger HuntAnswer questions to find MVP treasures

Drawing for Prizes!

And the hunt begins…

Scavenger HuntScavenger HuntScavenger HuntScavenger HuntWhat line of work did Captain Integrity

consider before becoming a Superhero?

Where is the information on Ethics

Point located on the new Intranet page?

What color is Captain Integrity’s cape?

To whom do you send Compliance

Superhero nomination Forms?

Create simple,

user friendly

documents

• Simple

• Colorful

• Pictures

• Examples

“Voicing

Your

Concerns”

Brochure

DRAFTDRAFT

Monitor your methodsMonitor your methodsMonitor your methodsMonitor your methods

…to determine what works

What is the best idea that you used to create awareness?

What great idea didn’t work?

Compliance

Superhero

Program

Department

Lunches

Reserved

Parking

“Classic”

MVP

prizes

Letters of Commendation

FeatureArticles

Certificates

of

Appreciation

DRAFTDRAFT

What ideas do you have for

recognition?

S U C C E S

S

Awareness + Recognition =

More Inquiries + Investigations

Save employee feedback!

“We need more

forward thinkers like

the compliance

team.”

“I think our Compliance

program is well known

and when it comes to

ethical behaviors, MVP is

on board.”

“You guys do a great job of keeping

us on the straight & narrow. In

today’s culture, what you do is

essential and you do it well.”

“You are doing a real

good job

communicating to us.

Thank you.”

Engaging Your Board of Directors

� Train BOD on your compliance

program

� Update frequently

� Share positive employee feedback

� Show examples of awareness &

recognition

� Demonstrate that your awareness

and recognition program is working

Discussion

Quick Pit Stop

Lap 3: COMMITTEES

“Driving” Compliance

Committee Effectiveness

Jim Passey, Director

Compliance & Internal Audit

Huntington Hospital

Pasadena, CA

Engaged, Involved, Excited?

How many of you feel that your compliance

committee is engaged, involved and excited about

the work of the compliance program?

How many believe that your compliance

committees could operate more effectively and

be more engaged?

Who should be on the compliance committee?

What does the OIG say?

� “Compliance committees benefit from having the

perspectives of individuals with varying responsibilities

in the organization…”

� “[Compliance committee members] should have

requisite seniority and comprehensive experience…to

implement any necessary changes in…policies and

procedures.”

Who should be on the compliance committee?

Functional areas suggested by the OIG through various

Compliance Program Guidance publications:

Who should be on the compliance committee?

Scale your committee to the operations of your organization

� The size, scope and complexity of your committee will

depend on the size, scope and complexity of your

organization.

� The make-up of your committee should resemble the

make-up of your organization, particularly where high

risk for compliance issues is concerned.

Who should be on the compliance committee?

How many have predominantly senior management

members on your compliance committee?

How many have predominantly middle managers?

How many have predominantly staff level employees?

How can I involve and motivate my

compliance committee?

Keep committee members educated on the latest

compliance issues – and have them educate each other

Invite committee members to participate in compliance

issues related directly, or indirectly, to their area of

expertise, as appropriate

Involve committee members in reviewing all compliance-

related policies and procedures

Involve committee members in routine risk assessment for

compliance concerns – key areas should have their own

compliance “dashboards” to report on each meeting

Involve committee members in committee action items –

everyone leaves with an assignment

Have committee members introduce or train on compliance

issues throughout the organization

How can I involve and motivate my

compliance committee?

Ask committee members to present compliance topics in

leadership arenas

Consider rotating committee members routinely (e.g., every

2-3 years)

Keep pumping the bellows! Maintain a high level of energy

and excitement – no one will ever be more excited about

compliance than the Compliance Officer!

Keep it fun!

How can I involve and motivate my

compliance committee?

Other Considerations

Timing and frequency of committee meetings – should

be scaled to the needs of the organization

Subcommittees of the Compliance Committee (lab, SNF,

billing, etc.)

Small organizations

Multi-site organizations

Interstate organizations

Reporting authority – who does the committee report

to? Senior management? Governing Board?

Other Good Ideas?

Lap 4: EDUCATION

D. Michelle Burford, RN, MSN, JD, CPHRM

Fort Madison Community Hospital

Fort Madison, IA

FMCH Educational Journey

Reasons for the Journey

Novice compliance officer

Time constraints

Reliability factor

Ease of use for staff

Constant flux of new information

Staff member requests

Seven Elements of Compliance

Appropriate training and education

� For the compliance officer

� For staff members

Adjust based on job function and

responsibility

Two Elements…

for the Price of One.

� The latest guidance requires us to audit

the education that is done.

� Outside vendor/webinar/speaker brought in by

someone other than my office

� They complete a checklist pre-purchase audit.

� Internally created may be more of a challenge

to audit

Why do we care about education?

� Beyond the guidance, the rules, and

the regulations...

� Employees represent our companies

� Reduce chances of errors & liability

� Morale can be affected positively

� Have a more knowledgeable workforce

Old habits

Assessment & Diagnosis

Surveys � Leadership-needs survey

� Policy changes and new processes

� Laws and regulations

Requirements� OSHA, Joint Commission, other

accrediting bodies, etc

� Concerns, previous audits, monitors

Planning & Implementation

Purchased products

� Fiscal year consideration

� Implementation timelines

Home grown

� Time to Create

� Scheduling

Planning & Implementation

OIG Guidance

Hot topic issues with press coverage� New laws, regulations, interpretive guidance

from accrediting agencies

Internal needs� New/changed processes, policies, or procedures

� Change of provider types

� Departmental request

Evaluation

Surveys

� After CBL and live sessions

� Leadership questionnaires

Knowledge-based questions during

audits

My own evaluation of the products,

possibilities

Adult Training is Different

Adults bring with them experience � This can be a double-edged sword for us as

employers

Diverse backgrounds of audience

Adults will commit to learning when the goals are important to them

They need concrete experiences to apply their work

Choosing the Format

Educational Options

Purchased products� Webinars

� Computer-based learning

Live sessions� The “Expert” traveler

� Local compliance officer

Written communications� Emails, brochures, website, and even pay

stub stuffers

Purchased Products

Potential Benefits Potential Drawbacks

Content from reliable

source

Information should be

up-to-date and accurate

Time saver

Wide variety of sources

Content too detailed for

variety of staff levels

Special effects may be

a challenge

Time eater

Due diligence prior to

purchase

Live Sessions & Home-Grown CBL

Potential Benefits Potential Drawbacks

Reliability based on your

research

Up-to-date and accurate

information

Topic selection is vast

Ability to customize for

target audience

Challenging special

effects

Time eater

Narrowing down course

topics

Effective Trainers

Enthusiasm for the topic

Experience

Set the tone up front

Incorporate various educational techniques � Case studies

� Role play

Computer Training

Some students prefer computerized

training, studies show

Computerized training can increase

active learning by the participant

Other studies focus more on the use of

computer training as an adjunct

Rules for the Road Ahead

Connect the training to the employees’actual job functions

Hold employees accountable for participation

Use pre-training materials � Stimulate thought

� Different learning needs of employees

� Save time

Other Considerations

Have the managers attend

Have the learners be active� Ask questions to stimulate thinking

Have a mechanism to communicate a follow-up for the attendees� Reinforce the change of practices

� Answer questions that were unanswered

Adding Something Memorable

Throughout the completion period for our training, a number of staff stopped me in the hallway to talk about the bear. It helps to put a personal touch on compliance.

The look of 2010

CBLs have been written and designed in-house.

Live sessions will be utilized to enhance the CBL course material� EMTALA will have a CBL offering with an EMTALA

Q&A live program scheduled

Live sessions will be used as an alternative to sensitive material� Managerial training on workplace discipline will be

live with the testing through CBL

The look of 2010

“Quips & Quotes”--our monthly newsletter

will have a submission from Compliance at

least quarterly

Emails will continue to be used for current

information sharing

If you promise not to tell, eye catcher: me holding a dolphin

Sample of 2010 Staff Requirements

Nursing & Clinical Services Leadership Team

HIPAA: CBL, but live is

optional

General compliance

training

EMTALA

Mental health commitment

process

HIPAA: CBL and live Q&A

General compliance training

Disciplinary process (live

with CBL testing)

EMTALA (for house

supervision and nursing/

clinical leadership)

The Finish Line

In Compliance, the finish line is a

moving target.

Education will always be dynamic and

in need of re-evaluation, re-design,

re-emphasis, and re-energizing.