HCCA Compliance Institute April 2013

Road to a Compliant Culture1

The Road to a Compliant Culture through the Bridge of Communication and the Vehicle of Education

Interactive Session

Deann M. Baker, CHC, CHRC, CCEP.

Compliance Officer, Sutter Health, Fairfield, CA

Danna Teicheira, CHC, CCEP, CHPC,

System Privacy Officer, St Luke’s Health System, Boise, ID

Thefollowing scenarios are designed to discuss compliance communication and education strategy. As we review some of these scenarios, consider how to communicate and address:

  • The audience (application)
  • The best delivery (method)
  • How to appeal to adult learning
  • The ethical Implications (culture)
  • Key Policies, procedures and regulatory standards

Scenario 1:

You receive a compliance hotline complaint. The anonymous caller says: “Dr. Jones is not billing correctly. “ What do you do?

  1. Nothing, there is not enough information to act upon.
  2. Initiate an audit of Dr. Jones’s billing and look for potential problems.
  3. Respond back to the caller through the hotline asking for more detail and inviting the caller to contact the Compliance Office.

Scenarios such as this one can be used to educate senior leaders and managers/supervisors on best practices when reports come in.

Scenario 2:

You receive a report that an employee has taken a picture of a patient and has shown it to coworkers. The picture is on the employee’s cellphone. When you interview the employee the employee says, “This is not a HIPAA issue, the picture was non-identifying.” What do you do?

  1. Do nothing; the employee is right – the picture is non-identifying
  2. Explore this as a confidentiality and ethics violation.
  3. The employee is wrong; it is a HIPAA violation.

Scenarios such as this allow discussion with senior leaders, manager/supervisors, and front-line employees. What education would you be considering for employees after an incident such as this one?

Hint: This sort of incident may indicate a gap in training – what elements of compliance must be blended to educate employees?

Scenario 3:

You receive a report that a clinic manager was told by more than one of her employees that a coworker was accessing records of an employee and of her own family members, who are not patients in the clinic. The manager reports that he/she has already run an access audit and found access. The manager also reports that the employees who reported this incident told their coworker of the access and the employee has run his/her own access report. . This is one her best employees and the manager states the employee was counseled and was “remorseful. “The manager says he/she is reporting just so this will be “on the record” and indicates that the matter is closed. What do you do?

  1. Rejoice; the manager has done your work for you. No further action is needed.
  2. A single issue has just “morphed” into four issues – what are the four issues?
  3. What elements of compliance are involved here?
  4. What sort of remedial action is needed? What corrective (individual action) may be required. Hint: What do your policies say?

Scenario 4:

A clinic director (several clinics under his/her scope of authority) makes a presentation on a new clinic initiative for the organization. The information is received favorably. As the director is leaving, a board member asks for a minute to discuss an issue. The director is pleased to know that the presentation inspired further discussion. However, once the director and the board member are out of earshot of the rest of the group, the board member asks about the status of a complaint filed by a good friend of his. The board member expresses frustration that the incident has not yet been resolved and asks for details on the actions being taken to address the issue. What should the director do?

  1. Give the board member the information requested; after all, the request is from a board member.
  2. Explain that patient complaints can only be discussed with the patient or a patient’s personal representative and that director knows the board member will understand and support that response because regulations and organizational policy limit discussion of such incidents.
  3. Tell the Board Member to contact the Administrator of the organization’s clinic operations.

What gaps in education and/or education do detect? What opportunities do you see?

Scenario 5:

A physician has been working directly with a particular Medical Device Manufacturer Sales Representative. The physician has strongly communicated the request to the purchasing staff in Central Supply to only purchase medical device products for his surgeries through this manufacturer because he prefers their product and prefers the assistance of this specific sales representative. The physician explains that these particular surgeries are complex and to use any other product would not be in the best interest of his patients. Are there any issues to evaluate with this request? Who should approve this? What is the possible best way to address this with the physician?

  1. Call the hotline immediately to report a conflict of interest.
  2. Talk directly with the physician and tell him you cannot do this based on the Conflict of Interest policy.
  3. The purchasing agent should just complete the transactions as they are told since they have no authority.

Are there other better solutions to share and what are the opportunities to address culture with this situation? (Hint: is it possible for on the job training and guidelines to be in place for new employees in this role?)

Scenario 6:

During a lunch break with co-workers, one of which is your supervisor, a discussion takes place about a new free clinical service being provided to patients. The discussion is about how to control the systems from billing the services because the grant doesn’t permit billing, the marketing methods, and the data necessary to collect to evaluate the expected improvements. You inquire whether this is a research study and are told it is not and that because it was a quality improvement project it didn’t require IRB review. You inquire further and your supervisor tells you its above your pay grade and not to worry about it. What, if any action should be taken, since your supervisor didn’t seem to have any concerns?

  1. Call the hotline to investigate this concern due to fear of retaliation.
  2. Talk further with your supervisor in a private setting about your concerns about this project.
  3. Conduct an evaluation of this matter yourself and then provide the results to your supervisor’s direct manager.
  4. Tell others about your concerns to see if they share them.

Are there specific standards you could use to discuss resources available to anyone encountering a like situation? How might you use this with different audiences and what are the ethical dilemmas that could be discussed with this scenario?