Speaker 1: Welcome to the Corporate Compliance Tip, Seven Steps to an Effective Compliance Program by the American Institute of Healthcare Compliance. The content of this compliance tip should not be considered as legal or consulting advice. The Office of the Inspector General, or the OIG, has developed a series of voluntary compliance program guidance documents that are directed at various segments of the healthcare industry, such as hospitals, nursing homes, third-party medical billers, durable medical equipment suppliers, small group practices, and individual solo practices. The purpose is to provide a guideline for the development and use of internal controls to monitor adherence to applicable statutes, regulations, and program requirements. Our best advice for you, whether you are a new organization developing a compliance program for the first time, whether you are organizations that are merging together and trying to merge the complexities of two different organizations into one, or if you are simply reviewing and updating your compliance program, consult two primary resources. Talk to your risk attorney, which is free, through your malpractice insurance company. They can provide you with an outline to mitigate risk for your type of healthcare organization. They can also come in and review your current compliance program and give you an idea of what the weaknesses are and how to improve it. And also include the seven steps that are recommended by the Office of the Inspector General. Now, all the guidances that they have published contain seven steps. Some of them are in different order, but these compliance tips that we're about to review covers the seven main steps, which can be found under compliance on the OIG website, oig.hhs.gov. At a minimum, the government states a comprehensive compliance program needs to include written policies and procedures, having a compliance officer, having training, a complaint process, knowing how to respond to complaints, conducting auditing and monitoring, and knowing how to investigate and enforce compliance in your organization. So let's talk about step one, written policies and procedures. This is for the development and distribution of written standards of conduct, as well as written policies and procedures that helps to promote the healthcare organization's commitment to compliance. Be sure to address stark anti-kickback statutes, False Claims Act, and other areas which pose high risk of noncompliance. The designation of a compliance officer is required. Also address other appropriate bodies, such as developing a corporate compliance committee charged with the responsibility of operating and monitoring the compliance program and who reports directly to the CEO and the governing body. Having a compliance officer with the appropriate authority is critical to the success of the program because the compliance officer needs to be able to have access to high-level proprietary pieces of information to do their job. And necessitates the appointment of a high-level official in the hospital with direct access to the hospital's governing body and the CEO. Included in this, the officer needs to have sufficient funding and staff to perform the responsibilities fully. Coordination and communication are key functions of the compliance officer with regard to planning, implementing, and monitoring the compliance program. There must be a commitment from the CEO and the governing board on down to allow sufficient funding, time, and resources. Number three, training. The development and implementation of regular, effective educational and training programs for all affected employees is required. Now, this could be beyond your workforce if necessary to business associates and other contractors and subcontractors. But don't forget to go up with your training as well as down the chain of command. This includes the board of directors and C-suite executives, management, new and established members of your workforce should all be included in the program. Having a good complaint process that works is going to help your employees and workforce to feel that they have somewhere that they can go to express concerns. We need to develop and maintain an effective process such as a hotline to receive complaints and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation. Responding to complaints is important. You need to develop a system to respond to allegations of improper, suspicious, and illegal activities and it's a critical aspect for an effective compliance program. Document enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations, or federal healthcare program requirements. Number six, audit and monitor your program. That is the only way you're going to know if it's working effectively. The use of audits and other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas is the only way you can produce documentation that your organization is measuring the effectiveness of the program and have the ability to investigate and enforce the investigation and remediation of identified systemic problems and the development of policies addressing non-employment or retention of sanctioned individuals should be documented. Detected but uncorrected misconduct can seriously endanger the mission, reputation, and legal status of your organization. And depending upon the nature of the alleged violations, an internal investigation will probably include interviews and a review of relevant documents. Obtain appropriate training to learn how to conduct such investigations. Consider enrolling in the American Institute's Internal Forensic Healthcare Auditing Program which is designed for compliance officers to learn how to be part of a formal investigative team and earn your certified internal forensic healthcare auditor credential. Also consider our Corporate Compliance Officer web-based training program to become a certified officer of corporate compliance or go to our website for more information. I hope you enjoyed today's program.