The Compliance Program in Healthcare

(“PRACTICE”), the administration of the institution and the institution of government are committed to providing the most effective treatment for patients and to consider their rights as paramount. The task of the organization is to preserve and improve the health of the population, regardless of their age; to prevent their condition and improve the quality of life. At the same time, the organization fulfills and complies with all standards in ethical and professional aspects when communicating with clients (de Wit et al., 2018). Moreover, clients are provided with personalized care, including compliance with state-imposed federal laws and laws of the state in which medical services are provided and paid.

The purpose of the Compliance Program is to review and establish policies and procedures aimed at maintaining corporate culture and principles related to high quality patient care. The program reveals the behavior of employees that does not comply with the established rules; providing high ethical standards (Bishop et al., 2021). PRACTICE policy is implemented in accordance with the current legislation of the country and a certain state, programs and ethical standards of medical care for clients and the requirements of the payer in the process of providing paid medical services (Koehler, 2018). All members of the organization’s team must comply with the program, including the administration, board of directors, doctors, employees and involved volunteers and other persons providing medical services on behalf of PRACTICE.

The elements that are included in the Compliance Plan Manual are as follows:

1. PRACTICE standards enshrined in an official document, prescribing norms for compliance with the rules.
2. The implementation of the compliance program is led by a designated person and a compliance committee.
3. As part of the compliance plan, the organization conducts ongoing training aimed at training all personnel in accordance with their functions and improving the quality of service delivery.
4. To reduce the risk of problems in areas of patient care, the implementation of the plan is carried out to check and monitor compliance with established policies.

General Standards of Conduct

1. High ethical standards of employees. Each employee of the organization undertakes to follow the established ethical and professional standards. Patients cannot be subjected to disrespectful treatment from the staff. At the same time, the treatment is carried out with the help of high-tech equipment with complete honesty and openness regarding the diagnosis.
2. Evidence-based level of medicine in the treatment of patients. The organization policy and the compliance plan are a reliable guarantor of protection against medical manipulations that do not have an evidence base. Active physicians and other staff are committed to providing modern and effective treatments accepted by the scientific community.
3. Providing objective data and results in the process of diagnosis and treatment. The Compliance Plan focuses on a policy of proven efficacy for all prescriptions made by physicians. The organization’s standards are based on an approach focused on the safest possible care of each patient.
4. The financial relationship between the client and the organization or any healthcare professional. All financial transactions are carried out in accordance with the established laws of the State and the State.
   • Clinic personnel are strictly prohibited from establishing financial arrangements of any kind. They may not take anything of value from an outside physician or patient relatives, as without the approval of the Compliance Plan employee, this is considered a bribe.
   • In the case of a previously established financial relationship with a third party physician or a patient’s family member, staff may not issue Medicare bills provided the service was issued by the third party physician without confirmation of this action by the Compliance Officer.
   • By signing the financial agreement, the employee undertakes to strictly follow the implementation of the prescribed points. If the agreements are not fulfilled or partially fulfilled, the personnel may incur criminal or administrative liability in accordance with state policy.
5. No discrimination between staff and patients. Employees undertake not to show any signs of discreet attitude in the framework of communication with each other and customers. The reasons for this cannot be gender, race, age, sex, sexual orientation, religion, disability and others. In case of non-compliance with the rules, the employee may be subject to criminal or administrative form of liability and subsequent dismissal.

All members of the staff must confirm their familiarity with the above hospital standards and sign the appropriate paper on their understanding and acceptance of these rules.

Administrative Responsibilities

The Board of Governors is responsible for overseeing and establishing a successful Compliance Program. The Board of Governors takes responsibility for appointing a compliance committee and selecting members and a compliance officer to properly oversee the implementation of policies and standards within the organization.

In accordance with the policy, the Board of Governors establishes the following goals and opportunities for achieving the Compliance Plan:

1. Organizes a committee to evaluate the operation of the Compliance Plan and selects the appropriate members.
2. Persuasively insists on adherence to the plan among all personnel of the organization.
3. Assigns an officer to monitor the progress of the Compliance Plan.
4. For the successful implementation of the compliance plan, the Board of Governors determines the use of appropriate funding. Such a regulation is aimed at ensuring that employees can successfully and smoothly conduct their duties.
5. All employees of the organization, including Board of Governors, regardless of their position, are required to undergo periodic training in order to resolve problems related to the compliance program.
6. The Board undertakes to review and evaluate the reports provided by the managing designated compliance officer, if necessary.
7. The Board of Governors undertakes to maintain confidentiality in all matters related to difficulties in the implementation of the compliance plan.

Compliance Officer Responsibilities

In connection with the introduction of the Compliance Program, the Board of Governors appoints a Compliance Officer to monitor the success of the installed system. The designee is required to report to the Board of Governors any difficulties the staff or organization encounters in relation to the plan. Thus, in connection with the appointed position, the Compliance Officer must steadily perform the following duties:

1. Control the process of implementation of policies and standards in accordance with a given program.
2. Coordinate staff and explain the responsibilities of workers according to the system.
3. Report on the work done to the Board of Governors and report to the committee on the activities of the established system.
4. Conducting an audit and identification of the compliance structure throughout the organization and among all personnel.
5. In accordance with his position, the compliance officer interacts with external regulators acting as control and supervisory bodies.
6. Conduct joint work with the Human Resources Department, which is aimed at meeting the needs of the personnel and their subsequent training regarding the compliance program.
7. Identify and report to the Compliance Committee and Board of Governors regarding compliance risks in the application of the system.
8. Provide confirmation that any contracts and financial transactions concluded under the Compliance Plan are legal and cannot be labeled as fraudulent activities.
9. Establish with the Human Resources Department the rules for hiring and recording resumes of potential staff.
10. Compliance with State and State Law Regarding New Hiring.
11. Establish a relationship of trust with staff, devoid of nit-picking or any discriminatory attitude with respect to race, age, religion or gender.

Employee Responsibilities

Each member of the staff undertakes to comply with the established standards and bear responsibility for their observance. Everyone has the right to openly or anonymously report violations of the established system. In the event that a person openly reports a violation of the Compliance Program, he cannot be subjected to discriminatory and abusive treatment from other employees or superiors.

When applying the Compliance Program, each employee undertakes:

1. All employees sign an agreement to apply the Compliance System and act in accordance with the rules, policies and standards.
2. Each staff member must report their mistake or difficulty in the course of the program; at the same time, employees are obliged to report to the knowledge of the authorities or the committee about the mistakes of colleagues.
3. Participate in all training programs related to the implementation of the Compliance System and its adoption in the organization.
4. In case of violation of the established policies and standards of the Compliance Program, the employee is subject to various kinds of disciplinary action.
5. Penalty for violation of the program is determined by the Compliance Committee and the Board of Governors and may include the dismissal or demotion of an employee from his position.
6. An employee may not discriminate or denigrate his colleagues if they have reported to the Committee of the Council or the Board of Governors regarding the observed violations by other personnel.

Medical Staff Responsibilities

In the process of applying the Compliance Plan, responsibilities are assigned to medical workers, which they must steadily follow. In case of non-compliance with these standards, various fines may be imposed on employees, up to and including dismissal. Thus, the medical staff undertakes to comply with the following policies in accordance with the Compliance Plan:

1. The staff provides patients with all information regarding their illness and further treatment plan.
2. The medical staff in a clear and understandable form explains to the clients the data on their actual condition, possible deterioration and further prognosis of the state of health.
3. Attend any required training programs that include guidance on the implementation of the Compliance Program, professional development or briefing.
4. Report any minor or major violation of the Compliance Program by any employee.
5. Provide each patient with systematic suggestions aimed at strengthening their health and improving the current state of the disease.
6. Provide patients with documentation of their health with assessment data and suggested treatments and health maintenance.
7. Assess the needs of patients to better understand their cultural and social characteristics and provide proper treatment and preventive care.
8. Provide all necessary measures to maintain a satisfactory condition of the patient after a doctor’s appointment or discharge from a medical institution after treatment.

Education and Training

PRACTICE provides staff training and related training materials related to the Compliance Program, including policies and standards, payer requirements, and state laws and regulations. All staff of the facility, regardless of their position (Board of Governors, junior staff, medical staff, employees, volunteers and shareholders) receive initial training aimed at understanding and applying the Compliance Program. As part of the training, employees will be offered an initial orientation, which includes the following items:

1. Ethical standards and ethics of business and professional behavior in teamwork and in the treatment of patients.
2. Brief explanation of the Compliance Program, its standards, policies and key points.
3. Obtaining a copy of the training material, which takes into account all the policies and standards of the applicable program and possible penalties due to deviation from the regulations.
4. Penalties for refusing to report to the Compliance Officer and the Board of Governors that narcs have occurred.
5. During the application of the Compliance Program, the staff of the institution will undergo periodic training in order to strengthen and maintain knowledge. Periodic training will be divided among groups of personnel and take place in accordance with the positions held.
6. During periodic training, personnel will address issues and concerns that have arisen since the application of the Compliance Program, if these data do not conflict with confidentiality issues.
7. The frequency and regularity of the training programs associated with the Compliance Plan is determined and regulated by the Compliance Committee.
8. During training, employees can ask questions of interest and receive detailed answers to them, if the topics do not affect the privacy policy.
9. All personnel who have completed training are required to complete an official form confirming this. Employees sign a conclusion stating that in the course of education and training they disclosed all the violations that occurred and are ready to bear responsibility if this information is not confirmed.

Communicating Compliance Issues

As part of the implementation of the program, PRACTICE undertakes to establish a trusted line of communication with the staff for the successful implementation of the plan. No employee may be subject to disciplinary action or retaliation for reporting violations of policies and standards.

1. Personnel may ask questions and contact the Compliance Officer or any member of the Compliance Committee in the event of difficulties or unforeseen circumstances.
2. Members of the Committee are committed to responding to questions from staff in accordance with established policies and regulations.
3. Issues and difficulties should be documented and later developed and discussed by the committee members.
4. The personnel can report the violations and difficulties that have occurred to their immediate supervisor or members of the Compliance Committee.
5. In the event of a violation, the staff reports in writing on the reasons for the incident. These employees cannot independently initiate an investigation regarding the problem or hide it from superior employees.
6. The Compliance Officer undertakes to establish closed boxes designed to submit anonymous reports of violations or non-compliance with established standards.
7. In the event of receiving an anonymous or open complaint, the Compliance Officer must initiate an investigation into the causes of the incident. In doing so, he is obliged to keep as confidential as possible the person reporting the incident.

Auditing and Monitoring

During the implementation of the Compliance Plan, the organization supports employees in the implementation of self-assessment and evaluation in order to monitor and successfully apply the standards. Data on the current state of affairs is collected by the Compliance Officer and subsequently transmitted to the Administrative Body and the Board of Governors in the form of reports.

1. The Compliance Committee and the Officer provide each department with assigned responsibilities that ensure compliance with related policies.
2. Policies and processes within a department may vary slightly depending on the risks involved in implementing the plan and the needs of the individual department.
3. The committee works separately with each department to establish and ensure successful monitoring and audit processes.
4. The Committee establishes regular checks regarding the actions of departments on the application and regulation of the Compliance Plan.
5. The review includes verification of payment claims made by the department; the department’s proposals for advertising and marketing; the quality of care provided to patients; contracts created with patients and third-party shareholders.
6. The Committee periodically conducts interviews with employees regarding the possibility of identifying violations and difficulties that have occurred since the application of the program.

Investigation of Response

The Compliance Officer undertakes to carry out checks regarding the violation of the requirements agreed for the application of the plan. The staff member submits a report to the Committee and Board of Governors with appropriate and relevant findings.

1. Upon receipt of a notice of violation, the Compliance Officer must create an appropriate account. The entry should include the date and manner in which the complaint was received; a summary of the content of the letter; notes regarding the response and actions taken in response to the complaint.
2. Upon receipt of a complaint, the Officer, or his designated proxy, will immediately begin to investigate the facts of the violation.
3. During the investigation, the employee undertakes to study the documentation of the department in which the violation occurred; study of statistics and policies related to the problem to determine the degree of its severity; conducting interviews with employees.
4. After the investigation, the Officer provides a detailed account of what happened, provides statistics and the extent of the problem. The report briefly outlines the stages of the investigation and the actions that the Officer deems necessary to take in the current situation.

Billing Responsibilities

The organization acts as a guarantor that any financial transactions and payment requirements are legitimate and accurately identify the services provided by staff.

1. The organization cannot bill for services that were not rendered; for miscalculated service charges.
2. The organization bears criminal and administrative liability in case of dishonest performance of the services for which the bill was issued.
3. It is a criminal offense for an organization to attempt to profit financially from patients by misrepresenting a patient’s diagnosis or imposing unjustified services.
4. No employee performs unnecessary procedures without the knowledge and consent of the patient for financial gain.
5. The organization may not pass off previously performed analyzes as new ones for the purpose of economic benefit.
6. The organization has no right to use automatic diagnosis programs without accompanying studies and comments from the attending physician.
7. When billing a patient, the organization offers a detailed report with the current prices of each procedure, specialist consultation or provision of consumables.
8. An organization is prohibited from passing off false diagnostic information as valid when filing a claim for financial gain.

References

Bishop, B. W., Nobles, R., & Collier, H. (2021). Research Integrity Officers’ Responsibilities and Perspectives on Data Management Plan Compliance and Evaluation. Journal of Research Administration, 52(1), 76-101.

de Wit, K., Curran, J., Thoma, B., Dowling, S., Lang, E., Kuljic, N., Perry, J.J. & Morrison, L. (2018). Review of implementation strategies to change healthcare provider behaviour in the emergency department. Canadian Journal of Emergency Medicine, 20(3), 453-460. Web.

Koehler, M. (2018). Overseeing a compliance program. In Strategies for Minimizing Risk Under the Foreign Corrupt Practices Act and Related Laws. Edward Elgar Publishing.