Your health care organization has had several small compliance incidents in the past two years, and the organization is now motivated to update its compliance program. Your executive leadership team asked you to review two health care compliance programs from similar organizations to determine how they constructed their compliance program and what aspects your organization should adopt.
Select the type of health care organization you want represented in this assignment (e.g., family practice, hospital, urgent care, or nursing home).
Locate two compliance program documents from comparable health care organizations using your internet search engine.
Read both compliance program documents and examine the similarities and differences between the two.
*****Create a matrix that compares how both organizations execute the following compliance components:********* ( This part)
- How internal monitoring and auditing is conducted
- How compliance and practice standards are implemented
- The designated compliance officer (or person designated to be the contact for compliance matters), who that person reports to, and their relationship to the organization’s governing board
- How employees are trained and educated to model compliant behaviors
- How violations or offenses are detected, reported, and corrected
- How lines of communication with employees is developed
- How disciplinary standards are enforced******
Write a 525- to 700-word executive summary that informs your executive leadership about the matrix you created and offer your opinion as to which best practices the organization should adopt for its own compliance program.
Cite the 2 compliance program documents and any additional references that support your opinion (e.g., trade or industry publications, government or agency websites, scholarly works, or other sources of similar quality).
Wk 1 Individual Assignment
The compliance programs being compared for this assignment are for St. John’s Medical Center (in the matrix referred to as the first organization) and the St. Joseph Healthcare System (Referred to in the matrix as second organization).
A compliance program can be defined as a set of internal policies and procedures that an organization has but in place to ensure that the company complies with laws, rules and regulations and or to uphold the reputation of the business. The matrix created about is a comparison/contrast matrix juxtaposing compliance programs for two heath care organizations. The matrix will form a basis for the recommendations offered to the executive leadership team.
For both organizations, the first step should be hiring a Chief Compliance Officer. This individual will be responsible for overseeing every aspect of the company’s compliance as well as ensure that new members of the staff are trained and the rest of the employees are kept up to date with compliance rules both for the safety of the organization legally but also to ensure that the reputation of the organization is maintained. It is important that the Chief Compliance Officer report to someone in the management position of the organization and this is most preferably the CEO. This is because the CEO sits on the governing board of the organization and is in a position to make decisions that impact the entire organization promptly.
When it comes to auditing and monitoring, the framework put in place by the St. John Medical Center seems ideal. The auditing and monitoring plans should be conducted by the CCO at the beginning of every fiscal year based on the previous year’s assessment as well as other identified risks. This will be vital for the company considering that regular auditing and monitoring will help detest areas of non-compliance that may result in non-compliance. It will also ensure that any potential risks that the organization may face are kept at a bare minimum. During the monitoring process, some of the issues that might be checked include and is not limited to internal risk assessments as well as federal healthcare regulatory updates that will ensure compliance.
When it comes to violations and offences and how they can be detected, reported and corrected, regular monitoring as well as open lines of communication would suit the company the best as it has multiple advantages. With regular monitoring, the Chief Compliance Officer will be able to tell any problem or risk areas and address the issues accordingly. In the case that it is a member of the staff that is responsible for the violations, the Chief Compliance Officer as well as the head of Human Resources will determine the appropriate corrective actions. This will range from being the offender being asked to retake mandatory training, to suspension and even termination depending on the violation and its effect to the organization. Further, keeping open lines of communication will allow all the employees to feel free to report any violations they might notice to the Chief Compliance Officer privately and confidentially without fear of being reprimanded or facing some sort of stigma from the rest of the employees. The Chief Compliance Officer will also take the necessary measures to ensure that all his decisions with regards to taking corrective action are not biased against any of the employees. Such measures can include the formation of a disciplinary committee that will help in the investigation and decision making process.
The recommendations above are by no means exhaustive but they can fit into the organization as they have in both the organizations whose compliance reports have been analyzed in the matrix. The executive committee should therefore consider them carefully for implementation into the organization.