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 care facilities, to monitor regulations, and to oversee individual behavior within a care organization. These compliance programs provide principles and regulations within their operations to healthcare organizations that need to enforce patient privacy in order to foster better care outcomes. These programs are intended to provide the right patient care, ensuring that patient security is maintained very well in the facility. The officer of the Compliance Committee receives a report quarterly or annually to check that everything is being done correctly in the administration. The two healthcare organizations I researched and chose that have compliance programs similar to ours are the NYC Hospital System and Johns 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 our own organization evolve through certain alterations incorporated into our compliance program.
Matrix:
| Matrix Questions | Healthcare Compliance Program 1 | Healthcare Compliance Program 2 |
| Johns Hopkins Health System | NYC Hospital Systems | |
| How internal monitoring and auditing are conducted. | The compliance program in Johns 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, 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 the 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 Johns 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. | Johns Hopkins System has several personnel for monitoring the compliance program, including the Chief Compliance Officer (CCO), Vice President, Compliance and Insurance Committee, and the Sub-Committee of the Audit at the facility. The Chief Compliance Officer (CCO) reports directly to the Committee of the Board of Compliance and Insurance. | The Chief Compliance Officer is an employee who reports directly to the Chairperson of the Audit Committee and the Board of Directors and also reports to the President of NYC on selected matters such as reporting violations. |
| How employees are trained and educated to model compliant behaviors. | Johns Hopkins Health System offers an orientation for all newly hired employees. Testing is conducted for current employees as well as new employees on a regular basis. | The Health System of NYC provides education and on-the-job training for all employees from time to time, 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 in response to any offense. | Once an offense or violation is detected in the system, superiors immediately take action regarding any violation. |
| How lines of communication with employees are developed. | In Johns 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 may lead to disciplinary actions based on the severity of the violation, whether intentional or unintentional, including 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, Johns Hopkins Health System and NYC Hospital System, to explain how both healthcare organizations structure their compliance programs and how the programs are similar and different in their operations. Johns Hopkins System uses a Corporate Compliance program that preserves and protects levels of integrity while promoting adherence to the ethical and legal standards for which Johns Hopkins is known. On the other hand, NYC Hospital and Health System uses the Health Compliance program to improve the quality of care provided to patients within its facilities and cope with regulatory issues. Both healthcare systems constructed their compliance programs with particular emphasis on hierarchy, education, training, implementation, resolution, processing, and communication to provide full transparency regarding care laws and regulations. The NYC healthcare system uses an online care delivery system to meet the healthcare needs of 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 and is appointed by the hospital’s president. The CCO 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 researching, I selected certain processes, such as orientation and training for newly hired employees in the care facility from Johns Hopkins Health System and disciplinary actions for 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 senior management, or human resources if they are in need of advice regarding the compliance program. The disciplinary standard of the Johns Hopkins System is based on the severity of the violation. If an offense is reported, an investigation committee is launched according to the policies and procedures of the System, which may lead to termination, retraining, contract penalties, or removal of privileges (Butanis, n.d.). Both healthcare organizations have launched a communication line for employees to call and report compliance issues to the authorities concerned.
There were many similarities as well as differences in disciplinary standards that I think would be a great strategy for our healthcare organization to adopt from the compliance program hierarchy of the NYC Health and Hospitals System. Besides, the methods of auditing and monitoring can be adopted from the Johns Hopkins Health System, as the compliance program plan presents all aspects of the business for conducting 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 Johns Hopkins Health System, which does not have the authority to directly contact each member of senior management (NYC, Policies & Procedures, n.d.). On the other hand, I firmly believe that our organization should adopt the monitoring and auditing methods of Johns Hopkins, as questionnaires, interviews, and on-site visits can help the CCO gain a clear perspective on the regulations and principles implemented in the facility. The CCO will then promote the right practices while understanding the procedures and policies applicable to all locations within the care system. Johns 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 any and all offenses. This strict action encourages employees within the healthcare facility to properly educate themselves through the robust educational and training programs Johns 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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