POLICIES AND PROCEDURES POLICIES AND PROCEDURES 101101
HCCA ANNUAL COMPLIANCE INSTITUTECHICAGO, ILLINOIS
APRIL 22, 2007
Clive HortonRe-Soft International, LLC
New Canaan, CT
Al JosephsSenior Director, Policies And Training
Tenet Healthcare CorporationDallas, Texas
Heidi KocherDirector, Policy & Procedure Management
Tenet Healthcare CorporationDallas, Texas
WHAT ARE SOME OF THE WHAT ARE SOME OF THE QUESTIONS?QUESTIONS?
Where can I find that procedure?How do I know this is accurate and up-to-date? Did employees receive the policy?Has everyone read acknowledged, and understood?How can I prove to auditors that we are following our procedures?Is there a better, faster way to document procedures?
WHAT ARE SOME OF THE WHAT ARE SOME OF THE QUESTIONS?QUESTIONS?
Is this the most current version?
How do I get feedback to the procedure owner in a manner where it won’t get lost?
How can I manage my policies and procedures globally?
Has this procedure changed since the last time I used it? What is different?
POLICYPOLICY LIFE CYCLELIFE CYCLE
Author
Review
Evaluate
Communicate
Publish
Revise
Periodic Review
Comply
Train
POLICY AND PROCEDURE
MANAGEMENTArchive
CONTROL / OVERSIGHTCONTROL / OVERSIGHT
POLICY COMMITTEEPOLICY COMMITTEECONTROL/ISSUINGCONTROL/ISSUING
AUTHORITYAUTHORITY
SUBJECT MATTER SUBJECT MATTER EXPERTSEXPERTS
DevelopmentDevelopment
SUBJECT MATTER SUBJECT MATTER EXPERTSEXPERTS
DevelopmentDevelopment
SUBJECT MATTERSUBJECT MATTEREXPERTSEXPERTS
DevelopmentDevelopment
POLICY CYCLEPOLICY CYCLE
EVALUATE POLICY NEED• Laws, regs• Risk areas
AUTHOR• Designate • Train• Empower
REVIEW• Policy committee• Control
POLICY CYCLEPOLICY CYCLE
PUBLISH• Electronic• Paper
COMMUNICATE• Designate audience• Method
TRAIN• Method
COMPLY• Auditing & monitoring• Test
CONSIDERATIONSCONSIDERATIONS
• Keep It Simple• Involve Employees That Will Live By
The Policies And Procedures• Consistent Format• Allow For Feedback• Track Questions• Reference Materials• Forms
WHAT POLICIES?WHAT POLICIES?
BUILD A FOUNDATION• General Policies
BUILD WALLS• Industry / Area Policies
BUILD A ROOF• Policies For Risk Areas
SOURCES / REQUIREMENTSSOURCES / REQUIREMENTS
• OIG Disclosure Guidances• Deficit Reduction Act• Sarbanes-Oxley• US Sentencing Guidelines• Corporate Integrity Agreements• Laws – Stark, Anti-kickback, Civil Monetary
Penalties, etc.• CMS Manuals and publications• Fiscal Intermediary/Carrier billing
requirements• Other companies
BUILD A FOUNDATIONBUILD A FOUNDATION
Code Of Conduct• Commitment To Compliance• Expectation For Employee Compliance• Encourage Reporting Of Suspected Violations• Outline Consequences For Failure To Comply• Right Of Employees To Report Concerns Without
Retribution Or Retaliation
Deficit Reduction Act• Fraud Control Program Policies • Avoid False Claims• Describe Whistleblower Protections• Non-retaliation
BUILD A FOUNDATIONBUILD A FOUNDATION
OIG/GSA Screening• Pre-hire or -contract• Medicaid • Annual screening• Remove from position / ensure no harm to
patients• Self-report requirement• Outline consequences for failure to comply• Contracting ban!
HOT-LINE / REPORTING• Anonymity• Follow-up steps• Non-retaliation
BUILD A FOUNDATIONBUILD A FOUNDATIONPolicy Program• Policy conventions• Policy review cycle frequency• Policy responsibilities• Formatting and numbering conventions
Human Resources• Disciplinary action for compliance issues• Training requirements
Management Oversight• Board committees and charters• Compliance structure
BUILD WALLSBUILD WALLS
General compliance• Expand on DRA fraud control program• HIM documentation/chart completion• Accurate coding• Accurate billing• HIPAASpecific legal policies• Stark• Anti-kickback• Investigations
BUILD WALLSBUILD WALLS
Clinical Quality• JCAHO requirements• Medical Staff / Peer review• Inpatient / Outpatient• Service / Facility specificAuditing & Monitoring• Workplan responsibility• Auditing responsibility• Follow-up / resolution responsibility
BUILD A ROOFBUILD A ROOF
Specific Risk Areas Examples:• Service / unit specific
• Facility specific• Audit results• OIG Workplan• Compliance / legal issue• Identified billing system control issues• Contracts management• Documentation
GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS
• Know who your audience is• Begin with end in mind• Utilize systems approach
• Policy• FAQs• Training, educational materials• Required data gathering, forms
• Delegate, delegate, delegate• Clarity and simplicity in writing• Logical organization
GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS
• Documentation• Resources• Laws, rules and regs
• Centralized vs. distributed• Timely updates• Force periodic reviews• Acknowledgement vs.
comprehension• Don’t reinvent the wheel
DonDon’’t Reinvent the Wheelt Reinvent the WheelSamples of Other OrganizationsSamples of Other Organizations’’ PoliciesPolicies
• HCA - http://ec.hcahealthcare.com• University of Connecticut –
http://www.policies.uchc.edu/area/compliance.html• University of Texas Health Science Center at San Antonio -
http://www.uthscsa.edu/compliance/policies.html• Columbia University Med. Ctr. Billing Compliance Program -
http://cpmcnet.columbia.edu/dept/compliance/plan/index.html• Lourdes Health System - http://www.lourdesnet.org/compliance/• Jefferson Health System Corporate Compliance Program -
http://www.mainlinehealth.org/files/jeffersonhealthcorporatecomplianceprogra_8290.pdf
• University of California San Diego Health Sciences -http://health.ucsd.edu/compliance/index.html
• University of California Davis Health System -http://www.ucdmc.ucdavis.edu/compliance/
• University of Kentucky Medical Center Corporate Compliance Program - http://www.mc.uky.edu/compliance/manual.htm
• Vanderbilt University Medical Center -http://www.mc.vanderbilt.edu/compliance/
THE NEXT PHASE:THE NEXT PHASE:Active Policy Distribution Active Policy Distribution Measuring the acceptance Measuring the acceptance and understanding of and understanding of Corporate PoliciesCorporate Policies
CORE PROPOSITIONCORE PROPOSITIONThe Problem• a tidal wave of regulatory demands driving up the cost of
compliance• a sea change in individual accountabilities and responsibilities• ineffective current approaches give board little visibility of policy
compliance
The Solution: Active Policy Distribution• ensures staff read, understand and sign-up to key policies • in-depth policy life-cycle management, reporting and audit
trails
The Benefits• fundamentally reduces the risks of non-compliance• gives control back to management• demonstrates rigorous processes and drives down
administration costs
EXISTING METHODSRegular events emphasize theimportance of demonstrating sound Policyimplementation as:
• Policy acceptance becomes more important• Policies are changing more frequently
Many companies still use Paper DistributionTraditional Intranet/Email distributioninsufficient
• Effectiveness is not easily measured• Inflexible and Admin-intensive• Little Executive visibility of policy understanding,
acceptance or compliance auditability• Often overwhelming for the end user• Not time-sensitive• No way to demonstrate that a sound Company Policy
Distribution process is in place
Consequences of getting Policy Distribution wrong
ITInformation security breachLoss of service / networkRemedial action
LEGALCross enterprise liability THE BOARD
Governance obligations Stakeholder value Personal liability
COMPLIANCEIneffective processesUnauditable compliance
FINANCEAdmin costsDirect costs damages & fines
HRAdministrative burdenEmployee confidenceInternal investigation
BRAND/IPRRemedial action and restorative cost
POLICY POLICY MANAGEMENTMANAGEMENT
+ TIME!
WHAT IS WHAT IS ACTIVE POLICY DISTIBUTIONACTIVE POLICY DISTIBUTION
• Getting the right policies to the right person at the right time
• Monitoring and measuring their acceptance and understanding
Conventional and Alternative Shortcomings
Intranet CorpManual
Induction
No No Yes
No Yes Maybe
No No No
No No No
Yes Yes No
Yes Yes Yes
No No No
Maybe No No
Yes No No
E-learning
Workflow
Maybe Maybe
Yes No
Yes Yes
No Yes
No No
No No
No No
No Maybe
No No
Conventional Approaches Potential Alternatives
Active Policy
Distribution
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
The gap in existing approachesThe gap in existing approaches
Policy and compliance system requirements
Effective presentation and accessibility
Understanding and agreement
Detailed reporting and auditing
Automated policy life-cycle management
Ease of adaptability
Heterogeneous environment support
Agility of implementation
Functional integration with key systems
Scalable, sustainable cost
Benefits of Effective Benefits of Effective Active Policy DistributionActive Policy Distribution
• Reduced time and cost of managing policies across the organisation
• True measurement of policy effectiveness• Reduced risk arising from policy breaches• Demonstrable compliance• Management visibility of policy uptake• Positive employee behaviour• Measure clarity of Policy Content for
knowledge gaps• Adaptable to customer business and
technical environment
Who will benefitWho will benefitOrganizational profile
• Regulated organizations where non-compliance with policies has business-threatening consequences
• Compliance “pain sufferers”• Already have experience of the issues
surrounding creating and managing policies
Key FeaturesKey Features• Easy access for all users – no special training
• Easy access to all policies
• Search / cross-referencing facility
• Deliver relevant policies to right people at right time
• Support for users with no computer access
• Collaboration & Version management
• Testing of understanding
Policy Interception Options Policy Interception Options
At network login
Via Email
At Application Login
Actionable ConsequencesActionable ConsequencesSequences of Actions can be set based on the importance of the policy
All actions are logged
Policies Failure to Affirm Failing TestInternet Use Policy • Remove internet access
• Alert Line Manager• Alert Network Ops
• Represent with answers and retest• Alert HR for second fail and schedule retraining
Code of Conduct • Alert Line Manager• Alert HR• Issue First Warning
• Link to CBT Training intranet• Represent test without answers• Remove all network access on second fail
Receiving of Gifts Alert Policy Owner No test required
Support for Support for nonnon--computerised userscomputerised users
two dimensional barcode holds employee, clause and policy-specific data
employees sign and return policies
Contact InformationContact Information
Clive HortonReSoft International [email protected] 972 8462
Heidi KocherTenet Healthcare [email protected]
Al JosephsTenet Healthcare [email protected]