Compliance and Quality

1. Compliance and Quality Bringing It Together for Your Board Kristin Jenkins, J.D., FACHE October 2008

2. Explaining the Ties • All Disciplines Related to Healthcare Delivery Actually go Back to, well…Healthcare Delivery • Compliance Deals with the Board’s Fiduciary Duties to a Healthcare Organization, including the duty of care for the accuracy of reimbursement and rendering care to patients • Without a high quality of care, there can be no “compliance” with healthcare reimbursement or utilization rules, because care rendered incorrectly means care reimbursed incorrectly • The Board has the highest fiduciary responsibility for the care rendered to patients in its organization, for without this, the business doesn’t fulfill its ultimate purpose • Garbage in, garbage out

3. The OIG – Our Educational Partner • Corporate Responsibility and Corporate Compliance • Corporate Responsibility and Healthcare Quality

4. Goals/Metrics/Benchmarksand Accountability • Strategic Plan • Organization’s Commitment to Excellence, Safety and Clinical Quality • Organization’s Commitment to Transparency and Accountability • Defining Excellence • Use and Meaning of Benchmarks • Annual Plan/Goals • Tied to Strategies • Pervasive and Meaningful • Alignment • Pay for performance, gain sharing, outcomes management arrangements

5. Structures/Processes for Quality Oversight • Combining Medical Staff Clinical Quality and Systemic Performance Improvement • Coordination of Compliance Officer and Department with Quality and Risk Functions

6. Policies and Operations – Implementation, Enforcement and Internal Controls • Policy Design and Management • Front Line Management Accountability • Trending Reports • External Reviews and Audits

7. Formal Board Orientation and Membership • Membership on Board • Orientation to Strategic Plan, Annual Plan, Compliance and Performance Improvement Plans, structure of programs and Committee reporting structures

8. Board Reporting • Timing • Identifying What is Important and When • Data Rich, Information Poor • Events, Monitoring, Systemic Improvement Efforts • Elements of Compliance

9. Integration with Compliance and Risk Assessments • Information Sharing between functions • Committee Relationships • Membership on committees • Management Structure considerations

10. Promotion of Reporting Issues/Transparency • Resources for promotion • Cultural Environment • Reacting to Reporting • Coordination of Multiple Reporting areas for meaning/information • Sentinel Event Alert – Never Behavior

11. Resources for quality program • Electronic Records • Well trained staff • Adequate staff • Medical Staff leadership • Budget season

12. Medical Staff Credentialing and Competency • Medical Staff Leadership • Event Reviews • Professionalism Reporting • Training programs • Regular Reporting and discussions with Board • Sentinel Event Alert – Never Behaviors

13. Adverse Event Learning and Information Sharing • See Transparency • Guidance from Compliance experiences • Encouragement from Regulatory Agencies • Internal Trust • Seeing the Bigger Picture

14. Getting It Together – All Have Elements of Compliance and Quality • Safety: Licensure/Medicare Participation/Patient Treatment • Infection Control, Hand Offs, Written and Verbal Communications, Correct Site, Correct Patients, Medications, seclusion and restraints • Transparency: Reporting Safety, Treatment, and Compliance Concerns • Accessibility: EMTALA and Timeliness of Care • Medical Assessment and Treatment of Patients: Core Measures, Best Practice Comparisons in service lines; • Medication Management: Patient Safety, FDA guidelines, DEA guidelines, State Pharmacy Boards • Staffing Effectiveness: Nursing Ratios per Level of Care, Fall and Decubitus Rates • Efficiency/Utilization: Length of Stay, Readmissions, Observation Status, Medical Necessity • Risk Management Activities: Evaluating and Planning Minimization of compliance and quality of care risks through systems and best practice adoption; appropriately addressing problems internally and externally • Environment of Care: Licensure and patient and employee safety, OSHA • Satisfaction and Clinical Outcome Measures

15. Reporting to Your Board (will be posted to NTHCPA.org) • Monthly Reporting • Core Measures • Credentialing • Medical Staff Activities/Policies • Systemic Performance Improvement Efforts

16. Reporting to Your Board (will be posted to NTHCPA.org) • Quarterly Reporting • Safety • Patient Satisfaction (HCAPS and Other) • Grievances/Reporting Trends • Compliance Monitors/Reports • Clinical Outcomes • Efficiency and Access • Environment of Care • Med Management • Staffing Measures

17. Reporting to Your Board (will be posted to NTHCPA.org) • As needed reporting • Adverse Events • FMEAs • Disruptive Behaviors • At Least Annual Reports • PI Plan • Compliance Plan • Staffing Effectiveness Plan • Budget/Resource Allocation Plans