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Development of Grace Memorial Hospital Compliance Program

Paper Type: Free Essay Subject: Health
Wordcount: 2306 words Published: 9th Jul 2021

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 I have recently been hired by Grace Memorial Hospital as their Corporate Compliance officer. This is a new hospital that is getting ready to open its doors in 3-4 months and I am working hard to ensure that their compliance program will be put in place before they open. I have been working with my team to put in place the following aspects of this compliance program. We had to first plan and implement the program from the beginning and ensure that we had all the necessary tools to move forward. Then, we had to begin the developmental phase of this compliance program and ensure that we would complete the project on time. This has been a long and arduous process but we firmly believe that we will be ready with our compliance program in 3 months.

Planning and Implementation

There is a great deal of work that goes into the planning and implementation of a new corporate compliance program. First, you need to select a project manager to help with the planning process. Second, you would need to select your team members who will help put the entire program together. Third, you would need resources to help ensure you are on the right track. Fourth, you will need to schedule regular planning meetings to ensure all team members understand their roles. Fifth, you will need to determine which tools you will use to effectively keep your program on track. Lastly, you will need to delegate tasks and responsibilities to your team members so everyone understands what their job entails.

Selection of Project Manager

 Project management is a major part of this compliance program and the project manager should have a strong background since their job is the driving force of the project and they may work alone or with their own team. It will be important to determine the extent of the project by dividing the project into smaller sections and create a track for each section. They should also identify any resources that will be needed, which will include people, money, and supplies and distinguish any resources which haven’t been accessed yet. It would also be beneficial to establish a timeline and record the steps that were taken as well as deadlines (Safian, 2009). There are many aspects that go into planning a compliance program, and an effective program would include identification of laws, regulations, and standards; creation of policies and procedures; effective education for staff members; methods for reporting violations without fear of retaliation; introduce monitoring methods; perform regular audits; investigate any instances of non-compliance; apply corrective action to policies. My team and I will need to conduct research to identify the laws, regulations, and official policies in which the hospital must adhere to. This may include searching government organization websites and making a list of important organizations and agencies (Safian, 2009).

Selection of Team Members

 The selection of my team members is an important process, and I must communicate effectively to all the members of the Health Information Management (HIM) department as well as other staff in various departments including clinical staff on the progress of the program. The compliance committee will be able to share responsibility for certain elements of the program such as creating and operating a hotline reporting system and conducting presentations at training seminars. The members of the board of directors will sit on the compliance committee along with the CEO, president, or board of trustees as well. Our compliance committee will be composed of internal and external company directors in addition to the committee of the department compliance officers and department heads. The committees will practice open and authentic communication with each other and the staff, the governing board, and the regulatory agencies (Safian, 2009). It is vital for us to schedule planning meetings with committee members on a regular basis to discuss any changes or improvements to the program.

Resources and Tools

 After research and deliberation, we have determined that it might be in our best interest to employ examples from developing a compliance program from the Federal Register, the Office of the Inspector General (OIG), and the Centers for Medicare and Medicaid Services, and other insurance providers (Safian, 2009). These will help to provide procedures for our organization and to ensure that we are working inside the rules of the law. One of the most important tools that we can use is to monitor and audit to discourage any fraud. Routine monitoring would be beneficial to use regularly and periodic monitoring which will occur at random. These will help to identify and discourage any fraud that might occur.

Delegation of Responsibilities

 Since we are working with a team of people, it would be beneficial to get to know the team and understand each person’s strengths and weaknesses. This will make it easier to assign tasks based on their strengths and increase our opportunity for quality and success. When working alongside each other it would be beneficial to make a list and sub-list in order to delegate tasks. We could create a report or use project management software to keep a close track of who is doing what. By keeping this record, it will help us to monitor each activity and its progress (Safian, 2009).

Design and Development of an Effective Compliance Program

 An effective compliance program is an ongoing process for everyone involved within the organization to follow the rules, laws, and policies that were set in place by the federal and state governments, as well as the organization as a whole. As the compliance officer, I am the core of the compliance program, and the image of the department as well as the organization along with its dedication to maintaining an honest and ethical business while standing by my obligation to care for patients (Safian, 2009). It is also a part of my job to understand the laws and ethics of the health information management business and to produce and communicate policies and procedures to ensure everyone is doing the appropriate thing in order to get the job done effectively. I will work alongside the clinical staff to ensure that any questions may be answered promptly and accurately which may be done by using an inbox, outbox or emails (Safian, 2009).

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 The main purpose of a compliance program is to interpret the laws accurately as well as providing every employee with an understanding of how to behave properly, prevent fraud and abuse, improve the quality of healthcare, control expenses, limit liability, and advance the organization’s mission. The benefits would include promoting organizational success, planning an approach in order to educate staff of important rules and regulations to promote quality care and decrease liability. It is also important to establish an environment of honesty, improve service to patients, minimize loss, reduce liability, and provide a mechanism to address issues in a timely manner. In order to have an effective compliance program, you must have a comprehensive plan such as clinical compliance, safety compliance and corporate compliance (Safian, 2009).

  The first portion of an effective compliance program is called the comprehensive plan, which consists of clinical compliance that promotes high-quality care to the patients within the organization. It also consists of safety compliance which focuses on the safety of the patients and maintaining a safe environment within the organization. Lastly, it consists of corporate compliance which is the main discussion of this section, and it focuses more on the billing and collections, contracts, and privacy laws. This program must maintain a constant effort on continuous quality improvement methods. An effective program must also be designed to detect and deter fraud, waste, and abuse. This program should be rationally planned, fully implemented, and fully enforced. The most important of all of these components is that in order for this program to be effective it must, at a minimum, be designed after the Federal Sentencing Guidelines Seven Step Due Diligence. This is the core and foundation of the compliance program (Safian, 2009).

8 Steps of Due Diligence:

  1. Standards of conduct, policies, and procedures- with the code of conduct, the organization sets itself into the expectations based on the organization’s vision, mission, and values. Documentation is important to prevent fraud and abuse, provide a clear expectation of what is expected and should be dispersed to all staff members. Every employee will be required to read and sign as an acknowledgment of the standards and will be kept in their employee file.
  2. The Compliance officer and compliance committee- the entity or agency that provides direction and support to this compliance program.
  3. Exercise due diligence to avoid delegation of authority to unethical individuals and individuals with a propensity to engage in illegal activities- this person must have high integrity, high ethics, trust, and respect by the employees. When a compliance officer is hired, it is important to complete a thorough background check and interview so that the compliance officer is someone with high ethics, values, and integrity. 
  4. Communicate and educate employees on Compliance and Ethics Programs- there should always be open communication among the leaders and staff. Staff should also be thoroughly educated on the program’s entirety and any changes currently being made. All employees will be required at least 1-3 hours of education per fiscal year.
  5. Monitoring and auditing-The efficiency of the program should be monitored. Using periodic auditing and monitoring is very important.
  6. Enforcement and discipline- If there are violations, you must answer the questions, how would you do the investigation and how will you report it back and how would you discipline the people who have executed the violation? The program must be fully enforced, and the consequences of the violations for staff should be well known.
  7. Respond appropriately to incidents and take steps to prevent future incidents- If someone reports a violation, then there must be an investigation. The investigation should be communicated and documented in writing so that any future violation is thoroughly investigated and an appropriate response is accompanied.
  8. Program review- To ensure the program is updated based on the changes, laws and regulations, policies and procedures as well as the expectations of the organization that the program is up to date. This should be readily available for anyone to review.

The program must also address high-risk areas since these areas are more prone to have fraud and abuse, make mistakes, or cause difficulties. These high-risk areas should be monitored extensively as well as formally audited and should be continuously improved, so compliance will remain effective. The program must also be a part of the daily operations of the organization, and a lifestyle for the organization in order to promote integrity, ethics, and expectations of being in compliance which promotes a culture of compliance. A program must have an executive oversight from the CEO, president, or board of trustees because these executives are ultimately the ones who are responsible for the organization’s performance. Lastly, a program must maintain a constant focus on continuous quality improvement and ensure that the policies are up to date and the laws are updated as changes are made (Safian, 2009).

Steps and Tools to Ensure Program Remains on Timely Schedule

 It is important for me and my team to work diligently to ensure that the program will remain on a timely schedule for the hospital. A reasonable amount of time must be identified for each task to be completed. The nature of this step of project management will help to reduce the stress created by unrealistic timelines (Safian, 2009). Ensuring that the deadlines and overall timeline of the project should create a constant movement of work flowing into the conclusion of this program’s timeline. The main tool that will be used to ensure that this project is implemented on time is the Gantt chart. This is a spreadsheet-based format that displays the schedule of the entire project. This chart lists the tasks that need to be completed and the timeline in which each task will be completed (Safian, 2009). It also lists the progress of each task as well as which staff member is assigned to each task in order to ensure that everyone is doing their part.

 There are many aspects that go into creating, implementing and sustaining a corporate compliance program. It takes a full team of people in order to get this program running and keep it flowing smoothly. This program is not one that can be thrown together in a month; the compliance officer must ensure that each legal and ethical aspect is reviewed once or twice before the policy will be implemented to its full extent. Once an effective compliance program is up and running and shows that it is making improvements and deterring any fraud or abuse, then the compliance officer can be rest assured that they are doing their job to the best of their ability.


Safian, S. C. (2009). Essentials of Health Care Compliance. Clifton Park, NY: Delmar/Cengage Learning.


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