Summative Assessment: Compliance Programs
Hospitals around the globe implement compliance programs to encourage the use of internal controls because of many concerns that arise in the care facilities to monitor regulations and oversee individual behavior within a care organization. These compliance programs within their operations provide the principles and regulations to the healthcare organizations that need to enforce privacy for patients in order to foster better care outcomes. These programs are liable to provide the right patient care empowering the standards that patient security is calculated very well in the facility. The officer of the Compliance Committee receives a report quarterly or annually to keep check that everything is being done right in the administration. The two healthcare organizations I researched and chose which have similar compliance programs as ours are NYC Hospital System and John Hopkins Health System. I have designed a matrix that compares and contrasts the similarities and differences in their compliance programs as well as processes within both facilities. This matrix will help evolve our own organization with certain alterations incorporated into our compliance program.
Matrix:
| Matrix Questions | Healthcare Compliance Program 1 | Healthcare Compliance Program 1 |
| John Hopkins Health System | NYC Hospital Systems | |
| How internal monitoring and auditing are conducted | The compliance program in John Hopkins Health System expects that all personnel will attentively conduct their routine activities in the Health System in conformance with the regulations and principles set by such programs. Moreover, the personnel will be expected to take part in educational as well as training programs conducted in the healthcare facility for better care outcomes. The Director of Compliance and team will ensure compliance by monitoring all aspects of business for the completion of internal audits. | The CCO at NYC Health System will propose alterations to a corporate-wide compliance staffing plan, report on compliance activities in the facility quarterly, and submit the approved staffing plan annually to the president of the Health System. |
| How compliance and practice standards are implemented | The Chief Compliance Officer at John Hopkins will maintain a record-keeping system. The officer will establish the record in compliance with the Corporate Compliance program. | Reporting at NYC Health System will be made via the compliance helpline to the CCO to oversee and monitor patient accounts. |
| The designated compliance officer, who that person reports to, and their relationship to the organization’s governing board | John Hopkins System has several personnel for monitoring the compliance program including the Chief Compliance Officer (CCO), Vice President, Compliance and Insurance Committee, and Sub-Committee of the Audit at the facility. Chief Compliance Officer (CCO) reports directly to the Committee of the Board of Compliance and Insurance. | Chief Compliance Officer is an employee that reports directly to the Chairperson of the Audit, the Board of Directors who is also the President of the NYC on selected matters such as report violations. |
| How employees are trained and educated to model compliant behaviors | John Hopkins Health System offers an orientation for all new employees hired for advancement. Testing is done in place for current employees as well as new employees on regular basis. | The Health System of NYC provides education and onboard training for all the employees now and then along with educational certifications to foster employees’ growth. |
| How violations or offenses are detected, reported, and corrected | All violations are directly reported to the CCO and the anti-retaliation policy is followed properly against any offense. | Once an offense or violation is detected in the system, superiors immediately take action for all and any violation. |
| How lines of communication with employees are developed | In John Hopkins Health System, lines of communication with employees are developed through questionnaires, personal interviews, and on-site visits. | In NYC, communication lines are developed through annual reports, board presentations, instructions regarding business plans, and the system’s newsletters. |
| How disciplinary standards are enforced | Noncompliance with the disciplinary actions that may lead to severity of violation whether intentional or unintentional will result in contract penalties, removal of privileges, or termination. | Disciplinary standards are imposed in accordance with NYC’s procedures and policies. |
Executive Summary
In this assignment, I have researched and selected two healthcare organizations, John Hopkins Health System and NYC Hospital System to explain how both healthcare organizations come up with their compliance programs, similar and different in their operations. John Hopkins system uses a Corporate Compliance program that preserves and protects the levels of integrity for promoting adherence to ethical and legal standards John Hopkins is known for. On the other hand, NYC Hospital and Health System uses the Health Compliance program to improve the quality of care provided to the patients within facilities and cope with regulatory issues. Both healthcare systems constructed their compliance programs with particular emphasis on hierarchy, education, training, implementing, resolving, processing, and communicating full transparency of care laws and regulations. NYC healthcare system uses an online care delivery system to meet the healthcare needs of the patients through video visits with a care professional from the facility. The Chief Compliance Officer and the Board of Directors are accountable for developing, maintaining, directing, and reporting activities within an organization such as offenses and violations. In NYC, the CCO is part of senior leadership within the care facility appointed by the hospital’s president who reports to the Board of Trustees regarding the program’s adherence to the rules and regulations set forth by local, state, and federal laws or protocols (NYC, Policies & Procedures, n.d.).
Upon research, I have selected certain processes such as orientation and training for the new employees hired in the care facility from John Hopkins Health System and disciplinary actions for the compliance and practice standards from NYC that our own organization should adopt to evolve. Both healthcare organizations encourage their new and existing employees to contact the CCO, any member of the senior management, or human resources if they are in need of any piece of advice regarding the compliance program. The disciplinary standard of the John Hopkins System is based on the severity of the violation if an offense is reported, an investigation committee is launched according to the policy and procedures of the System that may lead to termination, retraining, contract penalties, or removal or privilege (Butanis, n.d.). Both healthcare organizations have launched a communication line for the employees to call and report compliance issues to the authorities concerned.
There were many similarities as well as different aspects of disciplinary standards that I think would be a great strategy for our healthcare organization to adopt from the compliance program’s hierarchy from NYC Health and Hospital System. Besides, the methods of auditing and monitoring can be adopted from the John Hopkins Health System as the compliance program plan presents all aspects of the business to conduct the internal audits of the organization. I believe that our organization should adopt compliance and practice standards implemented by NYC as its compliance program allows the CCO to be the sole authority while developing, monitoring, and correcting regulations within the healthcare organization, unlike John Hopkins Health System which does not have the authority to directly contact each member of the senior management (NYC, Policies & Procedures, n.d.) On the other hand, I firmly believe that our organization should adopt monitoring and auditing methods of John Hopkins as questionnaires, interviews, and on-site visits can help CCO gain a clear perspective about the regulations and principles implemented in the facility. The CCO will then promote the right thing understanding the procedures and policies applicable to all locations within the care system. John Hopkins Health System’s disciplinary standard should also be adopted because of its strict disciplinary actions such as the anti-retaliation policy to strictly deal with all and any offenses. This strict action encourages employees within the healthcare facility to properly educate themselves through the robust educational and training programs John Hopkins offers to promote better patient and employee outcomes (Butanis, n.d.).
References
Butanis, B. (n.d.). The Corporate Compliance Department | Johns Hopkins Medicine in Baltimore, MD. https://www.hopkinsmedicine.org/compliance/
Policies & Procedures. (n.d.). NYC Health + Hospitals. https://www.nychealthandhospitals.org/policies-procedures/
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