You are the very first compliance officer at a hospital system comprised of four

Question

You are the very first compliance officer at a hospital system comprised of four hospitals and seven physician offices. The hospital system has a non-profit status. The chairman of the board wants to know more about your role and what you will be accomplishing for the hospital system. More importantly, he is very concerned about possible liability both enterprise wide and personal in nature. The Chairman also serves as the chief surgeon of the hospital system. Other members of the board include the COO, CEO, Attorney, an anesthesiologist, an oncologist, an accountant and a nurse manager. What are your duties as a compliance officer? Make the case that you should report to the Board of Directors.

Explanation / Answer

Duties of compliance officer:

Develops, initiates, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct. Manages day-to-day operation of the Program.

Develops and periodically reviews and updates Standards of Conduct to ensure continuing currency and relevance in providing guidance to management and employees.

Collaborates with other departments (e.g., Risk Management, Internal Audit, Employee Services, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the Corporate attorney as needed to resolve difficult legal compliance issues.

Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Develops and oversees a system for uniform handling of such violations.

Acts as an independent review and evaluation body to ensure that compliance Issues/concerns within the organization are being appropriately evaluated, investigated and resolved.

Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.

Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues, and provides general guidance on how to avoid or deal with similar situations in the future.

Provides reports on a regular basis, and as directed or requested, to keep the Corporate Compliance Committee of the Board and senior management informed of the operation and progress of compliance efforts.

Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.

Establishes and provides direction and management of the compliance Hotline.

Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.

Works with the Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees and managers.

Monitors the performance of the Compliance Program and relates activities on a continuing basis, taking appropriate steps to improve its effectiveness.

If someone tried repeatedly to persuade hospital executives to correct their noncompliant activity,a complaint officer can report to the board of directors.

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