2009 compliance institute - hcca official site · 2009 compliance institute public entity provider...

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2009 Compliance 2009 Compliance

InstituteInstitute

Public Entity ProviderPublic Entity Provider’’s s

RoundtableRoundtable

April 26, 2009April 26, 2009

22

Session FacilitatorsSession Facilitators

�� Bob Borntrager, CHCBob Borntrager, CHC

Assistant Deputy Director/Compliance Officer Assistant Deputy Director/Compliance Officer

County of San Diego Health and Human ServicesCounty of San Diego Health and Human Services

AgencyAgency

�� Cheryl Dekker Esters, CHC, BSCheryl Dekker Esters, CHC, BS

Compliance OfficerCompliance Officer

Solano County, CaliforniaSolano County, California

�� Linda GarretLinda Garret

Partner, Risk Management ServicesPartner, Risk Management Services

�� Jeffrey A. Nagel, PhD., CHCJeffrey A. Nagel, PhD., CHC

Chief Compliance OfficerChief Compliance Officer

County of Orange, Health Care AgencyCounty of Orange, Health Care Agency

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33

Rules for the Round TableRules for the Round Table

�� First First –– Informal, flexible.Informal, flexible.

�� Second Second –– You decide, we can talk at You decide, we can talk at

you or we can talk with you.you or we can talk with you.

�� Third Third –– Please, please put cell phones Please, please put cell phones

and pagers on vibrate or turn them off. and pagers on vibrate or turn them off.

�� Fourth Fourth –– Hopefully you can stay for the Hopefully you can stay for the

entire session, but if you need to leave entire session, but if you need to leave

we understand. Please do so quietly.we understand. Please do so quietly.

44

Proposed AgendaProposed Agenda

�� Public Entity ChallengesPublic Entity Challenges

�� Public Entity Risk ManagementPublic Entity Risk Management

�� Elected Boards and Public OfficialsElected Boards and Public Officials

�� HIPAA HIPAA –– one size does not fit allone size does not fit all

�� Contracting for ComplianceContracting for Compliance

�� Application of SOX to Application of SOX to PEsPEs

�� Measuring & Monitoring EffectivenessMeasuring & Monitoring Effectiveness

�� Ethics Challenges in Public ServiceEthics Challenges in Public Service

�� Budgetary concerns in Budgetary concerns in PEsPEs

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55

We have our proposed We have our proposed

agenda, BUT what agenda, BUT what

topics do you want to topics do you want to

talk about? talk about?

66


InstituteInstitutePubic Entity ProviderPubic Entity Provider’’s s


April 26, 2009April 26, 2009Linda J. Garrett, JDLinda J. Garrett, JD

Risk Management ServicesRisk Management Services

Cotati, CACotati, CA

(707) 792(707) 792--49804980

[email protected]@rmscotati.com

4

77

Where are you?Where are you?

88

Places where I have found Places where I have found

compliance officers:compliance officers:

�� Board of Supervisors OfficeBoard of Supervisors Office

�� AdministrationAdministration

��Human ResourcesHuman Resources

��Office of the County Office of the County CouselCousel

��Risk Management DepartmentRisk Management Department

�� AuditorAuditor’’s Offices Office

5

99

What What ““hatshats”” do you wear?do you wear?

1010

Titles ITitles I’’ve encounteredve encountered

(at one desk!)(at one desk!)

�� Compliance OfficerCompliance Officer

�� Risk ManagerRisk Manager

�� Privacy OfficialPrivacy Official

�� Security OfficerSecurity Officer

�� Safety OfficerSafety Officer

�� QA/QI CoordinatorQA/QI Coordinator

�� Infection Control Infection Control

NurseNurse

�� Grievance OfficerGrievance Officer

�� Patient Rights Patient Rights

AdvocateAdvocate

6

1111

What are your responsibilities?What are your responsibilities?

1212

Roles/duties IRoles/duties I’’ve seen include:ve seen include:

Protect the assets of the Protect the assets of the

organizationorganization

�� Money Money

�� PeoplePeople

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1313

�� PropertyProperty

�� ReputationReputation

1414

What do peopleWhat do people

thinkthink you do?you do?

8

1515

What do you REALLY do?What do you REALLY do?

1616

Specific responsibilities may Specific responsibilities may

include:include:

�� Purchase insurance Purchase insurance ––WorkersWorkers’’ CompensationCompensation

––General LiabilityGeneral Liability

–– PropertyProperty

–– AutoAuto

––DirectorDirector’’s and Officerss and Officers

––Medical MalpracticeMedical Malpractice

––Miscellaneous (e.g., aviation, Miscellaneous (e.g., aviation, bond/crime, pollution, special events, bond/crime, pollution, special events, watercraft)watercraft)

9

1717

Responsibilities Responsibilities -- continuedcontinued

��Review ContractsReview Contracts

––including:including:��VendorsVendors

��SuppliersSuppliers

��EmployeesEmployees

��ContractorsContractors

––carefully check:carefully check:��Insurance clauses Insurance clauses

��Hold harmless agreementsHold harmless agreements��Renewal dates (and track them!)Renewal dates (and track them!)

1818


��Claims AdministrationClaims Administration

––Incident trackingIncident tracking

––Conduct investigationsConduct investigations

––Claims rejectionsClaims rejections

––Negotiate settlementsNegotiate settlements

––Manage litigationManage litigation

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1919


�� Loss Prevention & SafetyLoss Prevention & Safety

–– Employee TrainingEmployee Training

–– Record keepingRecord keeping

–– Employment practicesEmployment practices

–– Policies and ProceduresPolicies and Procedures

–– Staff competenciesStaff competencies

2020

Duties Duties -- continuedcontinued

��Quality Assurance/Quality ImprovementQuality Assurance/Quality Improvement

11

2121


�� Public relationsPublic relations

2222


��ComplianceCompliance

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2323

““ComplianceCompliance”” duties may duties may

include:include:

��Write and develop policies and Write and develop policies and

proceduresprocedures

�� TrainingTraining

�� AuditsAudits

�� Incident reportingIncident reporting

��Response/investigation/mitigationResponse/investigation/mitigation

��Correction/disciplineCorrection/discipline

2424

Examples of additional items Examples of additional items

that may land on your desk:that may land on your desk:

�� Medical malpractice lawsuitMedical malpractice lawsuit

�� BloodborneBloodborne pathogen exposurepathogen exposure

�� Licensing auditLicensing audit

�� CMS audit CMS audit –– Conditions ofConditions of

ParticipationParticipation

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2525

�� HIPAA violationHIPAA violation

�� Fraud and abuse issueFraud and abuse issue

�� Misuse of equipmentMisuse of equipment

�� Pollution claimPollution claim

�� Media eventMedia event

2626

��Wellness programs in high schools Wellness programs in high schools

and middle schools and middle schools -- angry parents!angry parents!

��Discrimination and harassment Discrimination and harassment

claims to investigateclaims to investigate

14

2727

Are you appreciated?Are you appreciated?

2828

What are some of the topics you What are some of the topics you

are expected to train on?are expected to train on?

15

2929

What meetings are you What meetings are you

expected to regularly attend?expected to regularly attend?

3030

What are your challenges?What are your challenges?

16

3131

For exampleFor example……..

��Dependence on other departments Dependence on other departments

for advice (e.g., County Counsel) or for advice (e.g., County Counsel) or

directiondirection

�� Budget cuts (e.g., using less staff Budget cuts (e.g., using less staff

and less trained staff)and less trained staff)

�� Protecting the organization from Protecting the organization from

fines and penalties that canfines and penalties that can’’t be t be

covered by insurancecovered by insurance

3232

��Dealing with elected/appointed Dealing with elected/appointed

officialsofficials

––e.g. the Judge who favored young e.g. the Judge who favored young

female defendants and nickfemale defendants and nick--named named

another judge another judge ““BuckwheatBuckwheat””

––e.g., members of the Board of e.g., members of the Board of

Supervisors who may have an Supervisors who may have an

““agendaagenda””

17

3333

��Handling the mediaHandling the media

�� Freedom of Information Act and Freedom of Information Act and

State laws, e.g., California Public State laws, e.g., California Public

Records Act vs. employee and Records Act vs. employee and

patient privacy issuespatient privacy issues

3434

and, a very common and, a very common

challengechallenge……

too much to too much to

do!do!

18

3535

What strategies have worked for What strategies have worked for

you?you?

3636


InstituteInstitutePubic Entity ProviderPubic Entity Provider’’s s


April 26, 2009April 26, 2009

Cheryl Dekker Esters, BS, CHCCheryl Dekker Esters, BS, CHC


County of SolanoCounty of Solano

Fairfield, CAFairfield, CA

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3737

Publically Elected BoardsPublically Elected Boards

��How is your Board comprised? How is your Board comprised?

Appointed individuals or publically Appointed individuals or publically

elected officials?elected officials?

��How many officials make up your How many officials make up your

board?board?

��What is the primary responsibility of What is the primary responsibility of

the Board?the Board?

3838

��How often does your Board meet?How often does your Board meet?

��What are your challenges in working What are your challenges in working

with a publically elected Board?with a publically elected Board?

20

3939

What are your challenges?What are your challenges?

�� Education and training for the Board Education and training for the Board

of Supervisors and elected officialsof Supervisors and elected officials

�� Private agendas, public needs, or Private agendas, public needs, or

compliancecompliance

�� Federal/State funding sources and Federal/State funding sources and

budget impactbudget impact

�� BuyBuy--in and accountability at the top in and accountability at the top

to bottomto bottom

4040

��ReRe--election and bad presselection and bad press

��Constituents versus shareholdersConstituents versus shareholders

��Chain of commandChain of command

��Operating in a Operating in a ““hybridhybrid”” environmentenvironment

��Rotating assignments within county Rotating assignments within county

counselcounsel

��Working in a Working in a ““supersuper--agencyagency””

combined with social services, EMS, combined with social services, EMS,

child welfarechild welfare

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4141

�� Brown Act/Freedom of Information Brown Act/Freedom of Information

Act/California Public Records ActAct/California Public Records Act

��Union issuesUnion issues

��No representation of clinical staff or No representation of clinical staff or

medical director on Boardmedical director on Board

�� Political tonePolitical tone

4242

HIPAA Nuances InHIPAA Nuances In

Public EntitiesPublic Entities

��What do we know?What do we know?

��One size does not fit all!One size does not fit all!

�� Public agencies perform both covered Public agencies perform both covered

and nonand non--covered functionscovered functions

�� The covered component must limit The covered component must limit

information shared with the rest of information shared with the rest of

the organizationthe organization

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4343

What are the barriers and/or What are the barriers and/or

challenges we face in a public challenges we face in a public

entity?entity?

�� Lack of formal agreements between Lack of formal agreements between

departments/programs/agenciesdepartments/programs/agencies

�� More stringent contract language More stringent contract language

regarding the use or disclosure of regarding the use or disclosure of

informationinformation

4444

What barriers has your What barriers has your

organization identified and how organization identified and how

do you address these barriers?do you address these barriers?

23

4545

Words weWords we’’ve heard!ve heard!

�� But we all work for the same But we all work for the same

employeremployer…………

�� I canI can’’t do that because of t do that because of

HIPAAHIPAA………………....

��My supervisor sent my return to My supervisor sent my return to

work clearance to the managerwork clearance to the manager……..my ..my

privacy was violatedprivacy was violated…………..

��HIPAA says we must tint our HIPAA says we must tint our

windows because of privacy issueswindows because of privacy issues

�� Because of HIPAA, I canBecause of HIPAA, I can’’t talk to yout talk to you

4646

��Real or perceived confidentiality Real or perceived confidentiality and/or regulatory restrictionsand/or regulatory restrictions

�� State law preemption State law preemption -- HIPAA is not HIPAA is not the only game in townthe only game in town

�� Varying breach reporting Varying breach reporting requirements requirements

��Competing areas of responsibilities Competing areas of responsibilities between the Compliance Officer, between the Compliance Officer, Privacy Officer, and Security Officer.Privacy Officer, and Security Officer.

24

4747


InstituteInstitutePublic Entity ProviderPublic Entity Provider’’s s


April 26, 2009April 26, 2009Bob Borntrager, CHCBob Borntrager, CHC


County of San DiegoCounty of San Diego

April 26, 2009 April 26, 2009

4848

Contracting Contracting

for for

ComplianceCompliance

25

4949

Why does contractor Why does contractor

compliance matter?compliance matter?

�� FlowFlow--down conditions and down conditions and

responsibilityresponsibility

�� Prime/sub principlePrime/sub principle

�� Public perceptionPublic perception

��Deep pocketsDeep pockets

5050

Contracting services out Contracting services out

does not relieve the does not relieve the

public entity of its public entity of its

responsibility for responsibility for

complying with COGAs complying with COGAs

and COPs and COPs

26

5151

Areas of Potential Exposure Areas of Potential Exposure

for Contracted Servicesfor Contracted Services

��Claiming and ReportingClaiming and Reporting

�� Exclusion and DebarmentExclusion and Debarment

�� Professional LicensingProfessional Licensing

��Quality of CareQuality of Care

��CostCost--shifting shifting

�� Stark I/Stark II Stark I/Stark II

�� AntiAnti--kickback Statuteskickback Statutes

�� EMTALAEMTALA

5252

What does all this mean to me What does all this mean to me

as a contracting person?as a contracting person?

27

5353

FEDERAL FALSE CLAIMS ACTFEDERAL FALSE CLAIMS ACT

(31 USC 3729)(31 USC 3729)

Enacted in 1863 to stop Enacted in 1863 to stop

procurement fraud duringprocurement fraud during

the Civil War the Civil War

5454

FEDERAL FALSE CLAIMS ACTFEDERAL FALSE CLAIMS ACT

(31 USC 3729)(31 USC 3729)

““Any person who knowingly presents, Any person who knowingly presents, or causes to be presented, to an officer or causes to be presented, to an officer or employee of the United States or employee of the United States GovernmentGovernment……a false or fraudulent a false or fraudulent claim for payment or approvalclaim for payment or approval……is liable is liable to the United States Government for a to the United States Government for a civil penalty of not less than $5,500 civil penalty of not less than $5,500 and not more than $11,000, plus three and not more than $11,000, plus three times the amount of damages which times the amount of damages which the government sustains because of the government sustains because of the act of that personthe act of that person……....””

28

5555

FEDERAL FALSE CLAIMS FEDERAL FALSE CLAIMS

ACT (cont.)ACT (cont.)

““KnowinglyKnowingly”” is defined as:is defined as:

Actual knowledgeActual knowledge of the falsity of the falsity

of the informationof the information

(Shaw V. AAA Engineering & Drafting)(Shaw V. AAA Engineering & Drafting)

5656

So no news is good news, So no news is good news,

right?right?

29

5757

FEDERAL FALSE CLAIMS ACT FEDERAL FALSE CLAIMS ACT

(cont.)(cont.)

Under the Act, fraud is alsoUnder the Act, fraud is also……

�� Deliberate ignoranceDeliberate ignorance of the truth of the truth

or falsity of the informationor falsity of the information(United States ex rel. Giles V. (United States ex rel. Giles V. SardieSardie))

�� Reckless disregardReckless disregard of the truth of the truth or falsity of the informationor falsity of the information(United States v. (United States v. KrizekKrizek))

5858

# 1 Rule for # 1 Rule for

Contracting for Contracting for

ComplianceCompliance

(ignore at your own peril)(ignore at your own peril)

30

5959

Compliance/contracting Compliance/contracting

folks and program folks folks and program folks

think differentlythink differently

=

6060

Risk for public entity Risk for public entity

contracted services is contracted services is

deliberate ignorance deliberate ignorance

and willful disregardand willful disregard

31

6161

What you can do to What you can do to

prevent false claims in prevent false claims in

contracted servicescontracted services

6262

PrePre--Award Budget ReviewAward Budget Review

32

6363

One wayOne way……....

6464

Some better waysSome better ways……

��Does the budget match what you Does the budget match what you

think youthink you’’re buying?re buying?

��Does the budget make sense?Does the budget make sense?

33

6565

Cost Allocation PlansCost Allocation Plans

�� Are you paying for more than 100% Are you paying for more than 100%

of a position?of a position?

�� Are we paying multiple times for the Are we paying multiple times for the

same piece of equipment? same piece of equipment?

��WhoWho’’s reviewing across contracts?s reviewing across contracts?

6666

Invoice ReviewInvoice Review

��Do the billed amounts match the Do the billed amounts match the

levels of service?levels of service?

�� Is there accelerated spending?Is there accelerated spending?

�� Are the amounts actuals or Are the amounts actuals or

percentages?percentages?

�� Are there spending anomalies?Are there spending anomalies?

�� If consultants are used, have you If consultants are used, have you

seen their contracts?seen their contracts?

�� If hardware was purchased, have you If hardware was purchased, have you

seen it?seen it?

34

6767

Progress ReviewsProgress Reviews

��Do the levels of service make sense Do the levels of service make sense

when compared to the dollars spent?when compared to the dollars spent?

––Do they fall short of target?Do they fall short of target?

––Do they exceed target?Do they exceed target?

6868

Cost ReportsCost Reports

��Who monitors for completion?Who monitors for completion?

��Who monitors for accuracy?Who monitors for accuracy?

��Who tracks across years?Who tracks across years?

�� Is there a viable working relationship Is there a viable working relationship

between contracting, fiscal, between contracting, fiscal,

purchasing and support units?purchasing and support units?

��WhoWho’’s the s the ““wait a minutewait a minute”” voice?voice?

35

6969

Client Satisfaction SurveysClient Satisfaction Surveys

��Do clients report that theyDo clients report that they’’re getting re getting

what youwhat you’’re paying for?re paying for?

��Do clients report hours different from Do clients report hours different from

what is being contracted for/posted?what is being contracted for/posted?

��Do clients report quality of care Do clients report quality of care

issues?issues?

7070

Do clients have a way Do clients have a way

to talk directly to to talk directly to youyou??

36

7171

Two most important clausesTwo most important clauses

�� Audit and InspectionAudit and Inspection

��Record retentionRecord retention

7272

Provider ComparisonProvider Comparison

�� If you have multiple contractors If you have multiple contractors providing the same service to the providing the same service to the same client population, are they same client population, are they getting paid relatively the same?getting paid relatively the same?

�� Are there faster, better, or cheaper Are there faster, better, or cheaper ways of providing the services?ways of providing the services?

��Do you keep awarding contracts to Do you keep awarding contracts to nonnon-- or lowor low--performers?performers?

37

7373

What about direct What about direct

monitoring of quality of monitoring of quality of

care?care?

7474

What do you do about What do you do about

disallowed costs?disallowed costs?

38

7575

Is there political will?Is there political will?

7676

Case StudiesCase Studies

39

7777

Is there a problem?Is there a problem?

What do you do?What do you do?

7878

#1#1

You receive a call from one of your You receive a call from one of your

contractors who tells you they found contractors who tells you they found

the name of one of their employees on the name of one of their employees on

the exclusion list. the exclusion list.

40

7979

#2#2

A contractor budgets $5,000 in the A contractor budgets $5,000 in the

““OtherOther”” line item for the year. The line item for the year. The

amount actually invoiced for this line amount actually invoiced for this line

item averages $400/month over the item averages $400/month over the

course of the year. In the last month of course of the year. In the last month of

the contract the contractor invoices the contract the contractor invoices

$24,000 for the $24,000 for the ““OtherOther”” line item. There line item. There

is enough money left in the overall is enough money left in the overall

contract budget to cover this amount.contract budget to cover this amount.

8080

#3#3

A contractor reports serving 36 clientsA contractor reports serving 36 clients

last month. At your next scheduledlast month. At your next scheduled

site visit, you can only find 28 files.site visit, you can only find 28 files.

41

8181

#4#4Your contract requires criminal Your contract requires criminal

background checks for everyone before background checks for everyone before

employment and prohibits people with employment and prohibits people with

certain criminal convictions from being certain criminal convictions from being

employed. You receive a phone call employed. You receive a phone call

from a disgruntled former employee from a disgruntled former employee

that one of the current employees has that one of the current employees has

a conviction that violates this a conviction that violates this

requirement.requirement.

8282

#5#5

While reviewing client case files, youWhile reviewing client case files, you

notice some dates have been notice some dates have been ““whitedwhited--

outout”” and changed. There is nothing inand changed. There is nothing in

your contract that says they canyour contract that says they can’’t uset use

““whitewhite--outout””..

(Warning (Warning –– semisemi--trick question)trick question)

42

8383

#6#6

You find out that a nurse has beenYou find out that a nurse has been

charting that medications have beencharting that medications have been

given, when in fact they havengiven, when in fact they haven’’t t

been. This appears to havebeen. This appears to have

happened over a onehappened over a one--week periodweek period

when they were under a lot of familywhen they were under a lot of family

stress.stress.

(Definitely a trick question)(Definitely a trick question)

8484

#7#7

While reviewing a contractorWhile reviewing a contractor’’s s

invoice, you verify the amounts invoice, you verify the amounts

charged to the County for the charged to the County for the ““OtherOther””

line item. You find out that $3,800 of line item. You find out that $3,800 of

the charges are for cigarettes.the charges are for cigarettes.

43

8585

#8#8

While reviewing a contractorWhile reviewing a contractor’’s claim s claim

for reimbursement, you check the for reimbursement, you check the

invoices to verify the amounts charged invoices to verify the amounts charged

to your contract for the to your contract for the ““SuppliesSupplies”” line line

item. You notice that $1,500 of the item. You notice that $1,500 of the

charges are for car wash supplies. The charges are for car wash supplies. The

car washes raised over $60,000, which car washes raised over $60,000, which

the contract requires be used to offset the contract requires be used to offset

contract costs. The money went to the contract costs. The money went to the

contractorcontractor’’s general fund instead.s general fund instead.

8686

Why do we care?Why do we care?

Besides potential FCA exposure, everyBesides potential FCA exposure, every

dollar that is wasted, misspent, ordollar that is wasted, misspent, or

spent inappropriately is one lessspent inappropriately is one less

dollar available for client and patientdollar available for client and patient

services.services.

44

8787

Closing ThoughtsClosing Thoughts

��Contracting personnel Contracting personnel are the are the public entitypublic entity’’s first line of defense s first line of defense against inappropriately spent against inappropriately spent contract fundscontract funds

�� They know the programs and They know the programs and contracts better than any one elsecontracts better than any one else

�� The best prevention is their The best prevention is their awareness and diligenceawareness and diligence

8888

SOX SOX

for for

Public EntitiesPublic Entities

45

8989

Why do we care?Why do we care?

�� SOX for Public entities and nonSOX for Public entities and non--

profits is on the wayprofits is on the way

�� Elements already at the federal Elements already at the federal

levellevel

�� Public perceptionPublic perception

9090

What are we expecting?What are we expecting?

�� Investigation procedureInvestigation procedure

��Whistleblower protectionWhistleblower protection

��Record retention policyRecord retention policy

�� Audit committees with defined Audit committees with defined responsibilities and communications responsibilities and communications expectationsexpectations

��Rotating auditorsRotating auditors

�� Financial report certificationsFinancial report certifications

�� Assurance certificationsAssurance certifications

�� Auditing of internal controls and their Auditing of internal controls and their effectiveness over financial reporting effectiveness over financial reporting

46

9191

OMB Circular AOMB Circular A--123 123

ManagementManagement’’s s

Responsibility Responsibility

for for

Internal Control Internal Control

9292

What is RISK?What is RISK?

47

9393

““Significant weaknesses Significant weaknesses

in the design or operation in the design or operation

of internal control that of internal control that

adversely affect the adversely affect the

agencyagency’’s ability to meet s ability to meet

its objectives.its objectives.””

9494

Also known asAlso known as……..

What could keep us from doing what What could keep us from doing what

we need to do?we need to do?

48

9595

What are What are

Management Management

Controls?Controls?

9696

““Management controls are the organization, Management controls are the organization,

policies, and procedures used by agencies to policies, and procedures used by agencies to

reasonably ensure that (i) programs achieve reasonably ensure that (i) programs achieve

their intended results; (ii) resources are used their intended results; (ii) resources are used

consistent with agency mission; (iii) consistent with agency mission; (iii)

programs and resources are protected from programs and resources are protected from

fraud, waste and mismanagement; (iv) laws fraud, waste and mismanagement; (iv) laws

and regulations are followed; and (v) reliable and regulations are followed; and (v) reliable

and timely information is obtained, and timely information is obtained,

maintained, reported and used for decision maintained, reported and used for decision

making.making.””

49

9797

Five focus areasFive focus areas

9898

Control EnvironmentControl Environment

““The control environment is the The control environment is the

organizational structure and culture organizational structure and culture

created by management and created by management and

employees to sustain organizational employees to sustain organizational

support for effective internal support for effective internal

control.control.””

50

9999

Risk AssessmentRisk Assessment

““Management should identify internal Management should identify internal

and external risks that may prevent and external risks that may prevent

the organization from meeting its the organization from meeting its

objectives.objectives.””

100100

Control ActivitiesControl Activities

““Control activities include policies, Control activities include policies,

procedures and mechanisms in place procedures and mechanisms in place

to help ensure that agency objectives to help ensure that agency objectives

are met.are met.””

51

101101

Information and CommunicationsInformation and Communications

““Information should be communicated Information should be communicated

to relevant personnel at all levels to relevant personnel at all levels

within an organization.within an organization.””

102102

MonitoringMonitoring

““Monitoring the effectiveness of Monitoring the effectiveness of

internal controls should occur in the internal controls should occur in the

normal course of business.normal course of business.””

52

103103

Management Controls 101Management Controls 101

�� Set the tone for the controlsSet the tone for the controls

�� Identify the needed controlsIdentify the needed controls

�� Set policies and procedures to Set policies and procedures to

memorialize the controlsmemorialize the controls

��Communicate the controlsCommunicate the controls

��Monitor the adequacy of the controlsMonitor the adequacy of the controls

104104

All risks are created equal, but All risks are created equal, but

some are created more equal some are created more equal

than others. than others.

53

105105

What needs to be controlled?What needs to be controlled?

106106

54

107107

Where do you start?Where do you start?

108108

Risk categoriesRisk categories

�� FinancialFinancial

�� PersonnelPersonnel

�� ProgrammaticProgrammatic

�� PublicPublic

�� Political Political

55

109109

110110

Now that youNow that you’’ve identified and ve identified and

prioritized the risksprioritized the risks……

56

111111

Inventory time!!!Inventory time!!!

112112

Common control pitfallsCommon control pitfalls

�� Too many controlsToo many controls

�� Ineffective controlsIneffective controls

�� Bookshelf controlsBookshelf controls

��DoubleDouble--secret controlssecret controls

�� Somebody elseSomebody else’’s controlss controls

�� ““Do as I say, not as I doDo as I say, not as I do”” controlscontrols

57

113113

Is it ok not to care?Is it ok not to care?

114114

When do you have one too When do you have one too

many controls?many controls?

58

115115

Adversely affect the agencyAdversely affect the agency’’s s

ability to meet its objectives.ability to meet its objectives.

116116

Five keys to a successful Five keys to a successful

management controls assessment management controls assessment

�� Tone at the topTone at the top

�� Everybody playsEverybody plays

�� ItIt’’s a part of everyday lifes a part of everyday life

��Know what you donKnow what you don’’t knowt know

��Now that youNow that you’’ve done something, ve done something, dodo

somethingsomething

59

117117

The $1,000,000 QuestionThe $1,000,000 Question

118118

Is there political will?Is there political will?

60

119119

Closing ThoughtsClosing Thoughts

�� Figure out the expectationsFigure out the expectations

�� Set the expectationsSet the expectations

�� Share what you expectShare what you expect

�� Inspect what you expectInspect what you expect

120120


InstituteInstitutePublic Entity ProviderPublic Entity Provider’’s s


April 26, 2009April 26, 2009

Jeffrey A. Nagel, Ph.D., CHCJeffrey A. Nagel, Ph.D., CHC

Chief Compliance OfficerChief Compliance Officer

County of Orange, Health Care AgencyCounty of Orange, Health Care Agency

61

121121

Practical Methods for Practical Methods for

Measuring Compliance Measuring Compliance

Program Effectiveness, Program Effectiveness,

Evaluating Evaluating

Organizational Culture, Organizational Culture,

and Nurturing Ethicsand Nurturing Ethics

122122

Why Measure EffectivenessWhy Measure Effectiveness

Section III of the OIG Supplemental Section III of the OIG Supplemental CPG for Hospitals addresses CPG for Hospitals addresses effectiveness: effectiveness:

“…“…Hospitals should regularly review the Hospitals should regularly review the implementation of their compliance implementation of their compliance program program elementselements……and should and should include an assessment of each of include an assessment of each of the basic elements individually, as the basic elements individually, as well as the overall success of the well as the overall success of the program.program.””

62

123123


Federal Sentencing Guidelines (1991) :Federal Sentencing Guidelines (1991) :

““An effective program to prevent and detect An effective program to prevent and detect violations of law means a program that has been violations of law means a program that has been reasonably designed, implemented, and enforced reasonably designed, implemented, and enforced so that it generally will be effective in preventing so that it generally will be effective in preventing and detecting criminal conduct and detecting criminal conduct …… The hallmark The hallmark of an effective program of an effective program …… is that the is that the organization exercised due diligenceorganization exercised due diligence in in seeking to prevent criminal conduct by itseeking to prevent criminal conduct by it’’s s employees employees …… Due diligence requires at a Due diligence requires at a minimum that the organization must have taken minimum that the organization must have taken the following types of steps: (followed by the the following types of steps: (followed by the seven elements).seven elements).””

124124


Proposed Amendments to U.S. Proposed Amendments to U.S. Sentencing Guidelines:Sentencing Guidelines:

Language states that the high level person Language states that the high level person responsible for the compliance program has the responsible for the compliance program has the responsibility to responsibility to ““ensure the implementation and ensure the implementation and effectiveness of the program.effectiveness of the program.””

Clearly the impetus is on the compliance officer to Clearly the impetus is on the compliance officer to demonstrate effectiveness.demonstrate effectiveness.

63

125125

Why Effectiveness is ImportantWhy Effectiveness is Important

�� Internal Audiences:Internal Audiences:–– Board of DirectorsBoard of Directors

–– Executive ManagementExecutive Management

–– Functional Area ManagersFunctional Area Managers

–– EmployeesEmployees

–– StakeholdersStakeholders

–– ShareholdersShareholders

–– PatientsPatients

126126

Why Effectiveness is ImportantWhy Effectiveness is Important

�� External Audiences:External Audiences:–– GovernmentGovernment

�� HHS/OIGHHS/OIG

�� DOJDOJ

–– Payer SourcesPayer Sources

�� CMS/FI/CarrierCMS/FI/Carrier

�� Other payer sourcesOther payer sources

–– MediaMedia

–– PublicPublic

64

127127

Barriers to EffectivenessBarriers to Effectiveness

��Compliance OfficerCompliance Officer

–– Lack of authority to enforce Lack of authority to enforce standards, policies and proceduresstandards, policies and procedures

–– Lack of support by Board or Executive Lack of support by Board or Executive ManagementManagement

–– Inadequate skills to perform the Inadequate skills to perform the essential functions of the jobessential functions of the job

–– Lack of resources or commitment Lack of resources or commitment from employerfrom employer

128128


��Code of Conduct / Policies and Code of Conduct / Policies and ProceduresProcedures

––Well written policies or Code that is Well written policies or Code that is not available to workforcenot available to workforce

––Well written policies that are not Well written policies that are not enforcedenforced

–– A poorly written Code or policies that A poorly written Code or policies that are outare out--ofof--date, are not specific to date, are not specific to organization, are inaccurateorganization, are inaccurate

65

129129


�� Training and EducationTraining and Education

–– Inaccurate training materialsInaccurate training materials

–– Limited access to trainingLimited access to training

–– Poor quality of training (e.g., dull, Poor quality of training (e.g., dull, technical, too long)technical, too long)

–– Poor quality of delivery of training Poor quality of delivery of training (e.g., unqualified trainers, boring (e.g., unqualified trainers, boring narration)narration)

–– Limited variation in trainingLimited variation in training

130130


��Open lines of CommunicationOpen lines of Communication

–– Lack of culture of opennessLack of culture of openness

–– Lack of awareness of mechanisms to Lack of awareness of mechanisms to report violationsreport violations

–– Lack of anonymous reporting Lack of anonymous reporting mechanismmechanism

–– Fear of retaliationFear of retaliation

–– Limited action on reported issuesLimited action on reported issues

66

131131


��Disciplinary GuidelinesDisciplinary Guidelines

–– Poorly communicated guidelinesPoorly communicated guidelines

–– Preferential or limited enforcement Preferential or limited enforcement

of guidelinesof guidelines

–– Lack of progressive disciplineLack of progressive discipline

––Working effectively with Labor OrgsWorking effectively with Labor Orgs

132132


�� Auditing and MonitoringAuditing and Monitoring

–– Lack of an auditing and monitoring Lack of an auditing and monitoring schedule based on organizational schedule based on organizational risksrisks

–– Limited resources to perform functionLimited resources to perform function

–– Auditors not trained wellAuditors not trained well

–– Lack of independence/objectivity or Lack of independence/objectivity or conflict of interest of the auditorsconflict of interest of the auditors

67

133133

PurposePurpose

Effectiveness is determined by the Effectiveness is determined by the purpose of the program. So, what is purpose of the program. So, what is

the purpose of a compliance the purpose of a compliance program?program?

134134

Purpose: (OIGPurpose: (OIG’’s Compliance s Compliance

Program Guidance forProgram Guidance for

Hospitals 1998)Hospitals 1998)

��Adherence to applicable lawsAdherence to applicable laws

““[to] develop effective internal [to] develop effective internal controls that promote adherence to controls that promote adherence to applicable Federal and State law, applicable Federal and State law, and the program requirements of and the program requirements of Federal, State and private health Federal, State and private health plans.plans.””

68

135135

Purpose: Purpose: ( CPG continued)( CPG continued)

�� Further quality of careFurther quality of care

““significantly advance the prevention significantly advance the prevention

of fraud, abuse and wasteof fraud, abuse and waste……while at while at

the same time furthering the the same time furthering the

fundamental mission of fundamental mission of allall hospitals, hospitals,

which is to provide quality of care to which is to provide quality of care to

patients.patients.””

136136

Purpose: Purpose: (CPG continued)(CPG continued)

��Create a culture of complianceCreate a culture of compliance

““Fundamentally, compliance efforts are Fundamentally, compliance efforts are

designed to establish a culture within a designed to establish a culture within a

hospital that promotes prevention, hospital that promotes prevention,

detection and resolution of instances of detection and resolution of instances of

conduct that do not conform to Federal and conduct that do not conform to Federal and

State lawState law…… as well as the hospitalas well as the hospital’’s ethical s ethical

and business policiesand business policies..””

69

137137

What is the value of What is the value of

an effective an effective

compliance program?compliance program?

138138

Value of EffectivenessValue of Effectiveness

The U.S. Sentencing guidelines are The U.S. Sentencing guidelines are designed for two key purposes (the designed for two key purposes (the stick and the carrot):stick and the carrot):

PunishmentPunishment: This model corresponds : This model corresponds to the degree of blameworthiness of to the degree of blameworthiness of the offender.the offender.

DeterrenceDeterrence: This model provides : This model provides incentives for organizations to detect incentives for organizations to detect and prevent crime.and prevent crime.

70

139139

Value: U.S. Sentencing Value: U.S. Sentencing

GuidelinesGuidelines

An organization can mitigate the An organization can mitigate the

potential fine range potential fine range –– in some cases up in some cases up

to 95% to 95% -- if an organization can if an organization can

demonstrate that it had put in place an demonstrate that it had put in place an

effective compliance program. This effective compliance program. This

mitigating credit under the guidelines is mitigating credit under the guidelines is

contingent upon prompt reporting to contingent upon prompt reporting to

the authorities and the nonthe authorities and the non--

involvement of high level personnel in involvement of high level personnel in

the actual offense conduct.the actual offense conduct.

140140

ValueValue

Audit Frequency

Co

st

Total relevant Costs Audit Cost

ExpectedLosses

71

141141

Tools for Measuring Tools for Measuring

EffectivenessEffectiveness

HCCA Resource DocumentHCCA Resource Document::

�� ““Evaluating and Improving a Compliance Evaluating and Improving a Compliance Program: A Resource for Health Care Board Program: A Resource for Health Care Board Members, Health Care Executives and Members, Health Care Executives and Compliance OfficersCompliance Officers””

�� Available on home page of HCCA website: Available on home page of HCCA website: http://www.hccahttp://www.hcca--info.orginfo.org

142142

Measuring Effectiveness: Measuring Effectiveness: HCCA Resource DocumentHCCA Resource Document

�� Structural (Effort)Structural (Effort)

–– The seven basic elements of a The seven basic elements of a compliance programcompliance program

–– Easy to measure presence or Easy to measure presence or absenceabsence

�� SubstantiativeSubstantiative (Outcome)(Outcome)

–– Compliance with the specific body of Compliance with the specific body of substantiativesubstantiative lawlaw

–– More difficult to measureMore difficult to measure

72

143143


�� Effort: the time, money, resources and Effort: the time, money, resources and

commitment that an organization puts commitment that an organization puts

into building and improving a compliance into building and improving a compliance

program.program.

�� Outcomes: the impact that our efforts Outcomes: the impact that our efforts

have on our level of compliance.have on our level of compliance.

144144



HCCA Resource DocumentHCCA Resource Document::

�� Indicators:Indicators:•• Policies and ProceduresPolicies and Procedures

•• Ongoing Education and TrainingOngoing Education and Training

•• Open Lines of CommunicationOpen Lines of Communication

•• Ongoing Monitoring and AuditingOngoing Monitoring and Auditing

•• Enforcement and DisciplineEnforcement and Discipline

•• Investigation, Response and PreventionInvestigation, Response and Prevention

73

145145

�� Indicator areas of discussion:Indicator areas of discussion:

1.1. RationaleRationale

2.2. Relevant IssuesRelevant Issues

3.3. ImplementationImplementation

4.4. Role of Compliance Officer, Role of Compliance Officer, Management and BoardManagement and Board

5.5. Evaluation and MeasurementEvaluation and Measurement


146146

74

147147



OIG Supplemental CPG for OIG Supplemental CPG for HospitalsHospitals::

��Developed a monitoring tool based Developed a monitoring tool based on supplemental guidanceon supplemental guidance

�� Benchmarked status of program Benchmarked status of program against new standardsagainst new standards

��CPG Available on OIG website: CPG Available on OIG website: http://http://oig.hhs.gov/fraud.aspoig.hhs.gov/fraud.asp

FACTORS YES NO COMMENTS

COMPLIANCE OFFICER AND COMMITTEE

Does the compliance program have a clear, well-crafted mission?

Does the compliance program have sufficient resources (staff/budget),

training, authority and autonomy to carry out its mission?

Is the relationship between the compliance function and general counsel

function appropriate to achieve the purpose of each?

Is there an active compliance committee, comprised of trained

representatives of each relevant function department as well as senior

management?

Are ad hoc groups or task forces assigned to carry out special missions,

such as conducting an investigation or evaluating a proposed

enhancement to the compliance program?

Does the compliance officer have direct access to the governing body, the

Director, all senior management, and legal counsel?

75

149149

Other Methods forOther Methods for

Measuring EffectivenessMeasuring Effectiveness

�� Employee SurveysEmployee Surveys

�� Interviews or Focus GroupsInterviews or Focus Groups

��Document ReviewsDocument Reviews

�� Benchmarking against providersBenchmarking against providers

��Denial ManagementDenial Management

�� Existing MeasuresExisting Measures

��Compliance Training QuizzesCompliance Training Quizzes

150150

Measuring Effectiveness and Measuring Effectiveness and Organizational Culture:Organizational Culture:

Survey MethodSurvey Method�� Easy application to your own organizationEasy application to your own organization

�� Measuring your program allows comparisons Measuring your program allows comparisons to national benchmarks: KPMG and ERC to national benchmarks: KPMG and ERC

�� Measuring different business units allows Measuring different business units allows comparisons of culture across your comparisons of culture across your organizationorganization

�� Longitudinal studies allow you to target a Longitudinal studies allow you to target a measured area of concern and then remeasured area of concern and then re--assessassess

76

151151

Local Compliance Survey Local Compliance Survey ––

20072007

�� Fourth in a longitudinal survey of local Fourth in a longitudinal survey of local government healthcare setting starting in government healthcare setting starting in 20042004

�� 2007 survey polled 2,767 employees, with 2007 survey polled 2,767 employees, with 1,190 responses (43% response rate)1,190 responses (43% response rate)

�� Benchmarks level of understanding of Benchmarks level of understanding of compliance program and specific compliance program and specific measures of organizational ethicsmeasures of organizational ethics

�� Tracks the views of employees across Tracks the views of employees across departments within organizationdepartments within organization

152152

COUNTY OF ORANGE

HEALTH CARE AGENCY

2007 COMPLIANCE PROGRAM SURVEY

Please select the most appropriate answer to the following statements Agree Agree Disagree Disagree

Completely Somewhat Somewhat Completely

1 I understand the purpose of a

Compliance Program.

��

2

My management team supports the

goals and objectives of the Compliance

Program and the Code of Conduct.

��

3 The Code of Conduct is clear and easy to understand.

��

4 I am aware of the policies & procedures

related to my job.

��

77

153153

C O U N T Y O F O R A N G E

H E A L T H C A R E A G E N C Y

2 0 0 7 C O M P L IA N C E P R O G R A M S U R V E Y

P lea se se le c t th e m o st a p p ro p ria te a n sw er to th e fo llo w in g s ta te m e n ts A g re e A g ree D isa g ree D isa g re e

C o m p le te ly S o m ew h a t S o m ew h a t C o m p le te ly

5

If a c o m p lian c e c on c ern c o m es to m y

a tten tio n , I w o u ld rep o rt i t to a

su p erv iso r /m an a g er, th e O ffic e o f

C o m p lian c e, o r o th e r ap p ro p ria te a rea .

��

6

If a c o m p lian c e c on c ern c o m es to m y

a tten tio n , I w o u ld b e c o m fo rtab le

rep o rtin g it to :

M y S u p erv iso r /M a n a g er

T h e O ff ic e o f C o m p lian c e

H C A H u m a n R eso u rc es

O th e r (e .g . S a fe ty O ff ic e r,

In te rn a l A u d it)

��

7 F ea r o f re ta lia t io n w o u ld p rev en t m e

fro m rep o rtin g a c o m p lia n c e p ro b lem .

��

8

T h e C o m p lian c e P ro g ra m h a s a ffec ted

th e w a y I p erfo rm m y d a y-to -d a y

resp o n s ib ilitie s .

��

154154



2 0 0 7 C O M P L I A N C E P R O G R A M S U R V E Y

Y e s N o

9

I a m f a m i l i a r w i th t h e H C A C o m p lia n c e P r o g r a m .

��

1 0

I h a v e c o n s u l te d o r r e f e r r e d to t h e C o d e o f

C o n d u c t .

��

1 1

I k n o w w h e r e t o lo c a te H C A p o lic ie s a n d

p r o c e d u r e s .

��

1 2

I k n o w th e n a m e o f th e C h i e f C o m p lia n c e

O f f ic e r .

��

1 3

I k n o w h o w to c o n t a c t th e C h i e f C o m p li a n c e O f f ic e r .

��

1 4

I a m a w a r e o f th e E m p lo y e e C o m p lia n c e

H o t l i n e a n d h o w t o a c c e s s i t .

��

78

155155




Y e s N o

1 5 I a m a w a r e o f t h e C o m p l i a n c e P r o g r a m w e b

s i t e o n th e In t r a n e t .

��

1 6 I a m a w a r e o f t h e H IP A A w e b s i t e o n t h e

I n t r a n e t

��

1 7 I h a v e a c c e s s e d th e C o m p l i a n c e P r o g r a m w e b

s i t e o n th e In t r a n e t .

��

1 8 I h a v e a c c e s s e d th e H IP A A w e b s i t e o n th e

I n t r a n e t .

��

1 9

1 9 a

1 9 b

I h a v e o b s e r v e d w o r k p la c e b e h a v i o r th a t I f e l t

v i o l a t e d th e C o d e o f C o n d u c t .

I f y e s , d id y o u r e p o r t t h e v i o l a t i o n t o a n y o n e ?

P le a s e t e l l u s w h y y o u d id n o t r e p o r t t h e

o b s e r v e d v i o l a t i o n .

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

��

��

156156




2 0 A s s i g n e d

S e r v i c e A r e a

� A d m i n ( i n c l u d e s I T , Q M a n d H R ) � B e h a v io r a l H e a l t h

� F i n & A d m S v c s ( i n c l H C A / A c c t g . ) � M e d ic a l & I n s t . H e a l t h

� P u b l ic H e a l t h S v c s � R e g u la t o r y H e a l t h

2 1

A r e y o u

S u p e r v i s o r y /

M a n a g e m e n t ?

Y e s � N o �

2 2

Y e a r s w i t h

H C A o r H C A

A c c o u n t i n g

L e s s t h a n 1 y e a r � 1 - 2 y e a r s � 3 - 5 y e a r s �

6 - 1 0 y e a r s � 1 0 o r m o r e y e a r s �

2 3

P l e a s e p r o v i d e a d d i t i o n a l c o m m e n t s o r s u g g e s t i o n s y o u m a y h a v e

r e g a r d i n g t h e C o m p l i a n c e P r o g r a m :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

79

157157

Reporting Potential ConcernsReporting Potential Concerns

Reporting a Compliance Concern

83%

13%

2% 2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Agree Completely Agree Somewhat Disagree

Somewhat

Disagree

Completely

158158

Observing ViolationsObserving ViolationsObserved Code of Conduct V iolation

25%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Yes No

80

159159

Reporting of ViolationsReporting of Violations

If Yes, Did You Report The Violation To Anyone?

64%

36%

0%

10%

20%

30%

40%

50%

60%

70%

Yes No

160160

Ethics Resource CenterEthics Resource Center

National Government Ethics Survey

2007

81

161161

�� Fourth in a longitudinal survey of U.S. Fourth in a longitudinal survey of U.S.

Workplaces starting in 1994Workplaces starting in 1994

�� 2007 report polled 3,452 employees in 2007 report polled 3,452 employees in

business, government and nonprofit business, government and nonprofit

sectorssectors

�� The 774 respondents from the The 774 respondents from the

government sector analyzed government sector analyzed

separatelyseparately

�� Provides national benchmark on Provides national benchmark on

government ethicsgovernment ethics

��National distribution of surveysNational distribution of surveys

NGES NGES -- 20072007

162162

NGES NGES -- 20072007

The Bad NewsThe Bad News

��Prevalence of misconduct is the highest of all Prevalence of misconduct is the highest of all

Industry Sectors measured in KPMG study (81%)Industry Sectors measured in KPMG study (81%)

��National Government Ethics Survey reports that National Government Ethics Survey reports that

misconduct across government is very high misconduct across government is very high

(57%)(57%)

��The strength of ethical culture in government The strength of ethical culture in government

workplaces is declining, while pressure to commit workplaces is declining, while pressure to commit

misconduct is growing (NGES)misconduct is growing (NGES)

��Only 8% of government workplaces have strong Only 8% of government workplaces have strong

ethical culturesethical cultures

82

163163

164164

NGES NGES -- 20072007

The Good NewsThe Good News

��More that 80% of employees say that they feel More that 80% of employees say that they feel prepared to handle situations inviting misconduct prepared to handle situations inviting misconduct (NGES)(NGES)

��70% of government workers who observe 70% of government workers who observe misconduct report it to management (NGES)misconduct report it to management (NGES)

��When a strong ethical culture is in place within a When a strong ethical culture is in place within a government organization, misconduct is reduced government organization, misconduct is reduced by 52%, retaliation is reduced by up to 89% and by 52%, retaliation is reduced by up to 89% and reporting rises by 40% (NGES)reporting rises by 40% (NGES)

83

165165

The whole is greater than the sum The whole is greater than the sum

of the partsof the parts

�� Coupling a Strong Ethical Culture with a Strong Coupling a Strong Ethical Culture with a Strong Ethics and Compliance Program is the path to the Ethics and Compliance Program is the path to the Greatest Reduction in Ethics Risk.Greatest Reduction in Ethics Risk.

�� The strength of a companyThe strength of a company’’s compliance program s compliance program has the greatest impact on encouraging employee has the greatest impact on encouraging employee reporting.reporting.

�� The strength of a companyThe strength of a company’’s ethical culture has the s ethical culture has the greatest impact on misconduct.greatest impact on misconduct.

�� Together, culture and program maximize ethical Together, culture and program maximize ethical behavior and appropriate reporting in the workplace.behavior and appropriate reporting in the workplace.

1 + 1 = 3

166166

Measuring Effectiveness Measuring Effectiveness

Lessons Learned and ExamplesLessons Learned and Examples

��Utilize your compliance committee Utilize your compliance committee to assist in measuring your to assist in measuring your program.program.

��Use the tool as a benchmark of Use the tool as a benchmark of your effectiveness.your effectiveness.

��ReRe--administer the tool annually to administer the tool annually to measure improvement.measure improvement.

�� Address areas of deficiency.Address areas of deficiency.

84

167167

How do you create an How do you create an

ethical culture in your ethical culture in your

organization?organization?

AKA: Nurturing AKA: Nurturing

workplace ethicsworkplace ethics

168168

Benefits of an Ethical Benefits of an Ethical

OrganizationOrganization

�� Ability to recruit & retain topAbility to recruit & retain top--quality staffquality staff

�� More satisfying & productive working More satisfying & productive working environmentenvironment

�� Building & sustaining credibility for programBuilding & sustaining credibility for program

�� Open discussion of ethical issuesOpen discussion of ethical issues

�� Clear guidance to employeesClear guidance to employees

�� Less misconductLess misconduct

�� Greater willingness to reportGreater willingness to reportmisconduct and correct itmisconduct and correct it

�� Greater satisfaction Greater satisfaction

85

169169

Building an Ethical OrganizationBuilding an Ethical Organization

�� Managers and Supervisors provide tools to Managers and Supervisors provide tools to

staff to make daily decisions to enhance staff to make daily decisions to enhance

the ethics of the organization. the ethics of the organization.

170170

Creating an ethical

environment spreads across your organization

86

171171

Case StudyCase Study-- CommunicationCommunication

�� A manager encourages staff to give input on how to make A manager encourages staff to give input on how to make their program a better place to work. their program a better place to work.

�� X decided to get something off his chest. He tells the X decided to get something off his chest. He tells the manager that it seemed to him that people are getting manager that it seemed to him that people are getting promotions and plum assignments based on who liked promotions and plum assignments based on who liked them and not the quality of their work. The manager them and not the quality of their work. The manager politely replied that this was not acceptable in her unit. politely replied that this was not acceptable in her unit.

�� The next morning X was summoned by the managerThe next morning X was summoned by the manager’’s s secretary to her office for a meeting. The manager looked secretary to her office for a meeting. The manager looked X in the eye and said, X in the eye and said, ““ Yesterday you told me about Yesterday you told me about some unacceptable practices. I want you to tell me the some unacceptable practices. I want you to tell me the names of the employees you were referring to.names of the employees you were referring to.””

172172

Case StudyCase Study-- CommunicationCommunication

1.1. What are the implications of the What are the implications of the

managermanager’’s response?s response?

2.2. How would you feel as the employee? How would you feel as the employee?

3.3. What are the possible effects on the unit? What are the possible effects on the unit?

4.4. How could this have been handled How could this have been handled

better? better?

87

173173

Open CommunicationOpen Communication

�� ListenListen

�� Keep an open mindKeep an open mind

�� Be respectful, Be respectful,

patient and honestpatient and honest

�� Be availableBe available

�� Understand that Understand that

delivering bad to delivering bad to

news is toughnews is tough

�� Be aware of your Be aware of your

tone & body tone & body

languagelanguage

�� Be discreteBe discrete

�� Avoid ambiguityAvoid ambiguity

�� DonDon’’t make t make

promises that you promises that you

cancan’’t keept keep

174174

Case StudyCase Study-- Star EmployeeStar Employee

�� A supervisor has a intelligent and capable A supervisor has a intelligent and capable

employee. This person performs his job very employee. This person performs his job very

well, has excellent statistics, is always cheerful well, has excellent statistics, is always cheerful

and ready to take on new assignments. In fact and ready to take on new assignments. In fact

he is so efficient that he routinely completes all he is so efficient that he routinely completes all

of his assigned duties early. The supervisor of his assigned duties early. The supervisor

allows this person to leave early when his work allows this person to leave early when his work

for the day is done. Since he completed a full for the day is done. Since he completed a full

dayday’’s worth of work, the supervisor gives him s worth of work, the supervisor gives him

credit for working the entire day. credit for working the entire day.

88

175175

Case StudyCase Study-- Star EmployeeStar Employee

1.1. Is this supervisor's decision acceptable? Is this supervisor's decision acceptable?

Why or why not? Why or why not?

2.2. What message does this send to other What message does this send to other

staff?staff?

3.3. What can be done differently? What can be done differently?

176176

Eliminate Pressure to Eliminate Pressure to

CompromiseCompromise

�� Identify practices or situations that create Identify practices or situations that create

pressure on employees to compromise ethicspressure on employees to compromise ethics

�� DonDon’’t focus on short term resultst focus on short term results

�� Examine really high performing staffExamine really high performing staff

�� Actively discourage manipulation of clients, Actively discourage manipulation of clients,

vendors or others for an advantagevendors or others for an advantage

�� Immediately address any and all forms of Immediately address any and all forms of

retaliation by coretaliation by co--workersworkers

�� Avoid supervisory conduct that could be Avoid supervisory conduct that could be

perceived as retaliatory.perceived as retaliatory.

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Build Ethical TeamsBuild Ethical Teams

��Recruit based on job content and Recruit based on job content and skillsskills

�� Select for candidates whose values Select for candidates whose values and character are consistent with and character are consistent with HCA values, mission and goals. HCA values, mission and goals.

��Offer opportunities for staff to Offer opportunities for staff to strengthen organizational ethicsstrengthen organizational ethics

�� Emphasize ethics in performance Emphasize ethics in performance reviews reviews

��Model the conduct that you want to Model the conduct that you want to see in your employeessee in your employees

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Case StudyCase Study-- Setting the Setting the

ExampleExample

JJ is a busy manager. One of her employees BB has an JJ is a busy manager. One of her employees BB has an innovative idea that can change the unitinnovative idea that can change the unit’’s workflow and s workflow and significantly increase productivity. BB took the initiative andsignificantly increase productivity. BB took the initiative anddrafted a proposal, hoping that her idea will bring her some drafted a proposal, hoping that her idea will bring her some positive attention and improve her chances for promotion. positive attention and improve her chances for promotion.

Meanwhile JJ has been asked by her boss to develop a strategy Meanwhile JJ has been asked by her boss to develop a strategy to increase services in her area without adding staff or increasto increase services in her area without adding staff or increasing ing costs. JJ Has been too busy with the daily demands of her job tcosts. JJ Has been too busy with the daily demands of her job to o set aside enough time to really develop this concept. As the set aside enough time to really develop this concept. As the deadline approaches, JJ decides to present deadline approaches, JJ decides to present BBBB’’ss proposal to her proposal to her boss as her own idea. JJ feels justified because BB reports to boss as her own idea. JJ feels justified because BB reports to her her and she plans to give a BB good evaluation and a raise. and she plans to give a BB good evaluation and a raise.

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Case StudyCase Study-- Setting the Setting the

ExampleExample

1.1. What type of message does this send? What type of message does this send?

2.2. How will this action affect the program? How will this action affect the program?

What are possible consequences? What are possible consequences?

3.3. How the employee feel? How the employee feel?

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Your IdeasYour Ideas……

��How can you apply the ideas to your How can you apply the ideas to your

program? program?

�� Suggestions?Suggestions?

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Cultivating CultureCultivating Culture(Partial credit to Josephson Institute of Ethics)(Partial credit to Josephson Institute of Ethics)

�� Communication is a good thingCommunication is a good thing

�� Take it seriously/handle it carefullyTake it seriously/handle it carefully

�� Encourage by words and deedsEncourage by words and deeds

�� Establish ground rulesEstablish ground rules

�� Respect how hard it is for employee to deliver bad Respect how hard it is for employee to deliver bad newsnews

�� Listen with open mindListen with open mind

�� Avoid negative tone/body languageAvoid negative tone/body language

�� Do not allow tirades or yellingDo not allow tirades or yelling

�� Be honest and avoid ambiguityBe honest and avoid ambiguity

�� Provide closureProvide closure

�� Be careful of what you say or do afterwardsBe careful of what you say or do afterwards

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ReferencesReferences

�� Amendments to the U.S. Sentencing Amendments to the U.S. Sentencing GuidelinesGuidelines

��OIG Compliance Program GuidanceOIG Compliance Program Guidance

��OIG Supplemental CPG for HospitalsOIG Supplemental CPG for Hospitals

��HCCA: Evaluating and Improving a HCCA: Evaluating and Improving a Compliance ProgramCompliance Program

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