1. Compliance and Quality Bringing It Together for Your Board Kristin Jenkins, J.D., FACHE October 2008

2. 2 Explaining the Ties  All Disciplines Related to Healthcare Delivery Actually go Back to, well…Healthcare Delivery  Compliance Deals with the Board’s Fiduciary Duties to a Healthcare Organization, including the duty of care for the accuracy of reimbursement and rendering care to patients  Without a high quality of care, there can be no “compliance” with healthcare reimbursement or utilization rules, because care rendered incorrectly means care reimbursed incorrectly  The Board has the highest fiduciary responsibility for the care rendered to patients in its organization, for without this, the business doesn’t fulfill its ultimate purpose  Garbage in, garbage out

3. 3 The OIG – Our Educational Partner  Corporate Responsibility and Corporate Compliance  Corporate Responsibility and Healthcare Quality

4. 4 Goals/Metrics/Benchmarks and Accountability  Strategic Plan Organization’s Commitment to Excellence, Safety and Clinical Quality Organization’s Commitment to Transparency and Accountability  Defining Excellence Use and Meaning of Benchmarks  Annual Plan/Goals Tied to Strategies Pervasive and Meaningful  Alignment Pay for performance, gain sharing, outcomes management arrangements

5. 5 Structures/Processes for Quality Oversight  Combining Medical Staff Clinical Quality and Systemic Performance Improvement  Coordination of Compliance Officer and Department with Quality and Risk Functions

6. 6 Policies and Operations – Implementation, Enforcement and Internal Controls  Policy Design and Management  Front Line Management Accountability  Trending Reports  External Reviews and Audits

7. 7 Formal Board Orientation and Membership  Membership on Board  Orientation to Strategic Plan, Annual Plan, Compliance and Performance Improvement Plans, structure of programs and Committee reporting structures

8. 8 Board Reporting  Timing  Identifying What is Important and When  Data Rich, Information Poor  Events, Monitoring, Systemic Improvement Efforts  Elements of Compliance

9. 9 Integration with Compliance and Risk Assessments  Information Sharing between functions  Committee Relationships  Membership on committees  Management Structure considerations

10. 10 Promotion of Reporting Issues/Transparency  Resources for promotion  Cultural Environment  Reacting to Reporting  Coordination of Multiple Reporting areas for meaning/information  Sentinel Event Alert – Never Behavior

11. 11 Resources for quality program  Electronic Records  Well trained staff  Adequate staff  Medical Staff leadership  Budget season

12. 12 Medical Staff Credentialing and Competency  Medical Staff Leadership  Event Reviews  Professionalism Reporting  Training programs  Regular Reporting and discussions with Board  Sentinel Event Alert – Never Behaviors

13. 13 Adverse Event Learning and Information Sharing  See Transparency  Guidance from Compliance experiences  Encouragement from Regulatory Agencies  Internal Trust  Seeing the Bigger Picture

14. 14 Getting It Together – All Have Elements of Compliance and Quality  Safety: Licensure/Medicare Participation/Patient Treatment Infection Control, Hand Offs, Written and Verbal Communications, Correct Site, Correct Patients, Medications, seclusion and restraints  Transparency: Reporting Safety, Treatment, and Compliance Concerns  Accessibility: EMTALA and Timeliness of Care  Medical Assessment and Treatment of Patients: Core Measures, Best Practice Comparisons in service lines;  Medication Management: Patient Safety, FDA guidelines, DEA guidelines, State Pharmacy Boards  Staffing Effectiveness: Nursing Ratios per Level of Care, Fall and Decubitus Rates  Efficiency/Utilization: Length of Stay, Readmissions, Observation Status, Medical Necessity  Risk Management Activities: Evaluating and Planning Minimization of compliance and quality of care risks through systems and best practice adoption; appropriately addressing problems internally and externally  Environment of Care: Licensure and patient and employee safety, OSHA  Satisfaction and Clinical Outcome Measures

15. 15 Reporting to Your Board (will be posted to NTHCPA.org)  Monthly Reporting Core Measures Credentialing Medical Staff Activities/Policies Systemic Performance Improvement Efforts

16. 16 Reporting to Your Board (will be posted to NTHCPA.org)  Quarterly Reporting Safety Patient Satisfaction (HCAPS and Other) Grievances/Reporting Trends Compliance Monitors/Reports Clinical Outcomes Efficiency and Access Environment of Care Med Management Staffing Measures

17. 17 Reporting to Your Board (will be posted to NTHCPA.org)  As needed reporting Adverse Events FMEAs Disruptive Behaviors  At Least Annual Reports PI Plan Compliance Plan Staffing Effectiveness Plan Budget/Resource Allocation Plans