Chief Compliance and Ethics Officers Health Care

Compliance Department Operations Manual

  • 1.  Compliance Department Operations Manual

    Posted 7 days ago
    Hello,

    ​​In the HCCA-OIG "Measuring Compliance Program Effectiveness: A Resource Guide" document published in January 2017, the guidance talks in 1.58 about maintaining a "compliance department operations manual"

     

    Could you share with me what your thoughts are about what an operations manual consists of, other than compliance department policies?

     

    The section in the HCCA-OIG document is Compliance Plan:

     

    1.57 Maintain compliance plan and program

     

    1.58 Maintain compliance department operations manual

    Thank you as always for your guidance.



    ------------------------------
    Brian Harley CHC,CHPC
    Sr Dir Compliance & Ethics
    Nemours
    Orlando,FL
    ------------------------------


  • 2.  RE: Compliance Department Operations Manual

    Posted 7 days ago
    ​Hi Brian:
    I would suggest the Compliance Manual would have copies of Forms used to conduct:
    Risk Assessments
    Monitoring (Walkthrough Checklists)
    Audit forms
    Complaint Forms
    NPP
    Authorization for the Release of PHI forms
    AoD Logs
    Forms for Access, Amendment (as well as denial of same) of PHI

    There are many more forms to include, but I tend to think of it as: If I left tomorrow could someone come in and be able to resume my duties.

    ------------------------------
    Dr. Randy Lewis, LMFT, CHPC
    HIPAA Privacy Officer
    Orange County Government
    Orlando, FL
    ------------------------------



  • 3.  RE: Compliance Department Operations Manual

    Posted 7 days ago

    My operations manuals (not just for the compliance department) have been, depending on organization size, the how-to overview at least, the comprehensive knowledge base at most. My compliance department ops manual captures how to fulfill the compliance department's needs for reliability, is a basis for continuous improvement, and of course business continuity. Kind of the meta-P&P, in a sense. Includes processes, forms, history/justification for processes susceptible to changing course mid-stream; mine includes a rough calendar outline that helps define what "regular monitoring" means in practice and that is updated at least annually for system / process changes / work plan focus areas. I believe it needs to be maintained for accuracy to allow the team using it to shift along with changes in strategy over time with integrity. An operations manual's upkeep is a signal of the value of that activity by the leadership and which in turn drives a rules-based compliance culture.






  • 4.  RE: Compliance Department Operations Manual

    Posted 7 days ago

    We are writing Standard Work s for all of our processes such as, investigations, exclusion checks, conflicts of interest, etc.  There are two goals in this: one is to reduce variation/improve efficiency and also to provide a very concise process steps for anyone in our department or new to our department.

     

    Jim

    Jim Bowman, CHC

    Regional Compliance Manager

     

    Description: <a href=image001.jpg@01D1632B.910962B0">

     

    Office of Compliance and Integrity

    80 Seymour Street

    Hartford, CT 0610

    860-972-4093 Office

    860-214-6147 Cell

    860-545-3550 Fax

     

    If received in error, please notify me by

    e-mail and delete this message

     


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  • 5.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    LOL I wrote a book like that once Jim. The day after I finished it I didn't have a job.

    ------------------------------
    Brenda Manning J.D., C.H.C., C.H.P.C.
    Compliance Director, Privacy
    Carilion Administrative Services Building, Ste. 1201
    213 S. Jefferson Street
    Roanoke, VA 24011
    (540) 224-5757
    Fax: (540) 510-224-5787
    Integrity Help Line Compliance: (844) 732-6232
    bkmanning@carilionclinic.org

    Our Mission: Improve the health of the communities we serve.


    The views expressed herein are my own and do not represent those of my employer. They are not meant to constitute legal advice or create an attorney-client relationship.
    ------------------------------



  • 6.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    Jim,

    On a somewhat related note...what is your use, if any, on the use of flowcharts or other tools to help visualize the steps in the processes that you are reviewing and defining?

    I am a long time proponent of the use of flowcharts.

    A well constructed flowchart is priceless...as is often the process of creating it...as these both help define easy to follow, practically based work processes, in my opinion.

    ------------------------------
    ◘ August - Reread HIPAA Rules Subparts C, D, and E ◘
    -----------Frank Ruelas------------
    ------------------------------



  • 7.  RE: Compliance Department Operations Manual

    Posted 6 days ago

    Yes.  We use flow charts.  One of the best that I've seen is a flow chart used to determine whether authorization is needed in order to disclose PHI upon request.  Thanks.

     

    Jim

    Jim Bowman, CHC

    Regional Compliance Manager

     

    Description: <a href=image001.jpg@01D1632B.910962B0">

     

    Office of Compliance and Integrity

    80 Seymour Street

    Hartford, CT 0610

    860-972-4093 Office

    860-214-6147 Cell

    860-545-3550 Fax

     

    If received in error, please notify me by

    e-mail and delete this message

     


    This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, or an employee or agent responsible for delivering the message to the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message, including any attachments.





  • 8.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    Nice.

    One of the flowcharts (and sample policies and procedures) that I've posted here that has gotten a lot of mileage is that related to a request for the amendment of PHI.  After posting the flowchart, I received emails from folks of the "Oops...I just realized we were missing a few steps!".

    Flowcharts can really help in identifying not only key steps, but also identify steps that might be getting overlooked!

    ------------------------------
    ◘ August - Reread HIPAA Rules Subparts C, D, and E ◘
    -----------Frank Ruelas------------
    ------------------------------



  • 9.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    Dumb question - I know - but if I need a flow chart I have to have an administrative person who has "a program" to do this.  What do you need to do this yourself?  Any suggestions on learning how to do this?

    Thanks!
    Kris

    ------------------------------
    Kris Anderson, RHIT, CCS
    Quality/Privacy Officer
    Tri-County Health Care
    Wadena, MN 56482
    ------------------------------



  • 10.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    Kris,

    I must have missed something in your post as I didn't come across anything that I would remotely consider a "dumb question".  ☺

    Now to your very good question about "HOW TO" (anytime I read someone asking about "HOW TO" they get my attention because it my view so many people can speak to a version of the 5WH1 model which is 5WH1 - H1...in that they do not explain HOW)...did you know you can create very effective flowcharts in Excel?  You can also create these in Word.  With a little practice...flowcharts can be done rather quickly and easily.

    For some reason, I find using Excel much easier because it is easier to manipulate the shapes.  I use a number of programs for flowcharts but of all of the programs I've used to show people how to create flowcharts with tools they already have without having to go out and buy a flowcharting program....Excel does the trick.

    Would a brief video going through the steps of creating a flowchart in Excel be helpful for you Kris?

    ------------------------------
    ◘ August - Reread HIPAA Rules Subparts C, D, and E ◘
    -----------Frank Ruelas------------
    ------------------------------



  • 11.  RE: Compliance Department Operations Manual

    Posted 6 days ago

    Hi Frank,

     

    Not to cut in on Kris, but if you decide to do this, I hope you share (as you so often do).  I would definitely find it helpful!

     

    Thank you,

    Brenda

     

     

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  • 12.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    I'll make you and others interested a deal...let's think of it as a Flowchart Friday idea.

    If there's interest...let's see it by those onlist within this eGroup...AND...here's the kicker...if someone can provide a flowchart they've been using that maybe they can't edit because it was created in long lost software...or even has a hand drawn flowchart we can use as an example (for example they can scan and post)...then I say I am all for providing an instruction video on the HOW TO.

    Let's see where this goes, if anywhere...as I'm glad to help.

    ------------------------------
    ◘ August - Reread HIPAA Rules Subparts C, D, and E ◘
    -----------Frank Ruelas------------
    ------------------------------



  • 13.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    I’d be interested.... I didn’t even know Excel could be used for this!

    Thanks for offering to teach!

    Best,
    Meggie
    Sent from my iPhone




  • 14.  RE: Compliance Department Operations Manual

    Posted 6 days ago

    Count me in!



    ------------------------------
    Jennifer Carpenter, CHC, CCEP
    Director of Compliance
    Lone Star Community Health Center
    Conroe, Texas
    ------------------------------



  • 15.  RE: Compliance Department Operations Manual

    Posted 5 days ago
    I am interested. Thanks Frank

    ------------------------------
    Cindy Hart LPN, CPA, CPC, CHC
    Horsham, PA & Port Charlotte, FL
    ------------------------------



  • 16.  RE: Compliance Department Operations Manual

    Posted 4 days ago

    I am interested!  I had no idea you could do flow charts in excel.  Thank you, Frank.

    Please be green and think before printing this email, thank you.

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  • 17.  RE: Compliance Department Operations Manual

    Posted 15 hours ago

    I'm interested.

    Thanks,

    Julie

     

    Julie Tucker, MA, RN,CHC

    Compliance department

    220 Campus Blvd.

    Winchester, Va 22601

    jtucker@valleyhealthlink.com

    540 536-7823

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  • 18.  RE: Compliance Department Operations Manual

    Posted 4 days ago
    I'm interested in this...

    Thanks
    Jackie

    ------------------------------
    Jackie Robertson-Gutshall, CHC,CHPC
    Compliance Officer
    Advanced Regional Center for Ankle and Foot Care
    Altoona,PA
    ------------------------------



  • 19.  RE: Compliance Department Operations Manual

    Posted 3 days ago
    Thanks Jackie...I should know more about a date and time once I have a sample flowchart that someone would like to offer that we can use.

    Stay tuned...

    ------------------------------
    ◘ August - Reread HIPAA Rules Subparts C, D, and E ◘
    -----------Frank Ruelas------------
    ------------------------------



  • 20.  RE: Compliance Department Operations Manual

    Posted 3 days ago
    ​I, too, am interested. Thank you!

    Courtney

    ------------------------------
    Courtney Blau Esq.
    Adm Dir of Risk Management & Compliance
    Norman Regional Health System
    Norman,OK
    ------------------------------



  • 21.  RE: Compliance Department Operations Manual

    Posted 3 days ago
    Frank,

    I'm definitely interested.

    ------------------------------
    Tammi Worrell, RHIA, MHA
    Compliance Coordinator
    Reno, NV
    ------------------------------



  • 22.  RE: Compliance Department Operations Manual

    Posted 2 days ago
    Frank, Never used Excel for this, I've always been a Visio guy...but would love to see "How" to do it in Excel.

    ------------------------------
    Scot Lovejoy RPh CHC
    Chief Pharmacy Officer, Privacy Officer
    Agadia Systems, Inc.
    Parsippany,NJ
    ------------------------------



  • 23.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    A video would be great if it's not too much trouble!!!  I didn't know you could do this with Excel.  I would like to be able to do them myself.  When I have someone else do them,  I usually have to take it back to them many times for revisions.  Slow process.

    Thank you for your offer.

    Kris

    ------------------------------
    Kris Anderson, RHIT, CCS
    Quality/Privacy Officer
    Tri-County Health Care
    Wadena, MN 56482
    ------------------------------



  • 24.  RE: Compliance Department Operations Manual

    Posted 6 days ago

    I would guess...and let's see from our colleagues...that people were not aware.

    Question:

    How many folks both knew AND have created flowcharts in Excel?

    If you want to post offlist...no problem...I am guessing 75% or more did not know that Excel can be used to create flowcharts.



    ------------------------------
    ◘ August - Reread HIPAA Rules Subparts C, D, and E ◘
    -----------Frank Ruelas------------
    ------------------------------



  • 25.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    I would join in, to participate in a How To Friday.

    Carly Borenkind, LCSW

    Director of Compliance, Privacy & Quality
    Compliance Officer- JASA
    247 W. 37th Street 9th Floor
    New York, NY 10018
    Ph: 212.273.5296
    eFax: 929.299.1132

    Compliance Concerns can be reported anonymously, if desired, through the Compliance Hotline at 212-273-5288 or click here.  Concerns can also be emailed to complianceconcerns@jasa.org

    Compliance: Here to help



    On Fri, Aug 10, 2018 at 10:03 AM, Frank Ruelas via Society of Corporate Compliance and Ethics






  • 26.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    ​I did not know you could create flow charts in Excel.  I create my flow charts in Word by adding text boxes and inserting the lines myself.  When I try to use Word's flowcharting, I can never get it the way I want it.  I would also love to create my own organization chart!

    ------------------------------
    Cinda
    Compliance/Ethics & Privacy Director
    Ohio
    ------------------------------



  • 27.  RE: Compliance Department Operations Manual

    Posted 6 days ago

    I generally do mine in word.  I have not done one in excel. 

     

    I would be interested in a Friday learning session.

     

    Joseph Zielinski, JD, CHC, CHRC

    Corporate Compliance Program Director

     

    4logos-01

     

    3838 North Rural Street

    Indianapolis, IN 46205

     

    720 Eskenazi Ave

    Fifth Third Bank Building, Fifth Floor

    Indianapolis, IN 46202

     

    P: 317-221-2478

    C: 317-766-1838

    E: Joseph.Zielinski@eskenazihealth.edu

     

    Hotline-Logo-Transparent

    P: 1-855-895-8555

    O: www.hhc.ethicspoint.com

     

    "To achieve mutual understanding you must understand what information your colleagues need from you to perform their function, and they must understand what you need from them." Peter Drucker

     


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  • 28.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    ​I have seen other people have flow charts in excel, but I've only made them in Visio.

    ------------------------------
    Analicia Burnett CHC
    Corporate Compliance/Privacy Officer
    Santa Rosa,CA
    ------------------------------



  • 29.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    I made a flowchart in Excel just yesterday, capturing the A&M elements we're studying no less! For now, it's just for me. But I see a day in my future when it may be useful to use it to train others in my organization.





  • 30.  RE: Compliance Department Operations Manual

    Posted 3 days ago

    Had no idea and would love a video to understand how it's possible!  J  Mind officially blown!

     

    Thanks,

     

    Ashlee Walden, J.D., CHC

    Manager, HIPAA/Compliance

    TOA – Central Billing Office

    615-278-1682 phone

    615-695-1483 fax

     




    TOA Disclaimer: This transmission may contain privileged and confidential information, including patient health information protected by federal and state privacy laws. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message. Thank you for your cooperation.






  • 31.  RE: Compliance Department Operations Manual

    Posted 2 days ago
    You can create ​Flowcharts in Excel?  Who knew?   Not me.  Yes I'd love to learn how

    ------------------------------
    Josita deHaan-Kicmal CHC
    CPO/Asst Compliance Officer
    Surgery Partners
    ------------------------------



  • 32.  RE: Compliance Department Operations Manual

    Posted 2 days ago

    I would like to learn as well. Thanks!

     






  • 33.  RE: Compliance Department Operations Manual

    Posted 3 days ago

    Frank,

     

    I am aware that flowcharts can be created in Excel but I never have had much luck doing so. A video would be great.

     

    Charlie

     

    Charles E. Colitre, BBA, CHC, CHPC

    Compliance and Privacy Officer

    Crystal Clinic Orthopaedic Center

    3925 Embassy Parkway, Ste 250

    Akron, OH 44333

    330 670-6123

     




    Note: The enclosed information is STRICTLY CONFIDENTIAL and is intended for the use of the intended recipient only. Federal and Ohio laws protect any patient information that may be disclosed in this e-mail. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, use, dissemination, distribution, disclosure, or copying of the contents is prohibited. If you have received this email in error, please notify the sender immediately and return all printed copies by US Mail to: Crystal Clinic Orthopaedic Center, 3925 Embassy Parkway, Suite 250, Akron, OH 44333, Attention, HIPAA Privacy Officer.





  • 34.  RE: Compliance Department Operations Manual

    Posted 2 days ago
    ​I would be interested in a video on creating flowcharts in Excel. Thanks, Frank!

    ------------------------------
    Dr. Randy Lewis, LMFT, CHPC
    HIPAA Privacy Officer
    Orange County Government
    Orlando, FL
    ------------------------------



  • 35.  RE: Compliance Department Operations Manual

    Posted 2 days ago
    ​I love flowcharts!! And yes, I knew that Excel and Word can be used to create flowcharts but I am not very good at it!
    Thank you

    ------------------------------
    Rhonda Garber CHC,CPC
    Compliance Manager
    ------------------------------



  • 36.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    ​Frank, your videos are always very helpful to me, thank you!!

    ------------------------------
    Cinda
    Compliance/Ethics & Privacy Director
    Ohio
    ------------------------------



  • 37.  RE: Compliance Department Operations Manual

    Posted 11 hours ago
    I would love to see a training video on how to use/construct flowcharts in Excel.

    ------------------------------
    Carl Russell
    Compliance Analyst
    Delta Dental of Idaho
    Boise,ID

    Anything I say is my sole opinion and not of my company.
    ------------------------------



  • 38.  RE: Compliance Department Operations Manual

    Posted 2 days ago
    I am interested in learning about flowcharts in Excel as well!

    ------------------------------
    J. Lauren H. Savory, JD
    Director of Corporate Compliance
    Cabell Huntington Hospital
    1340 Hal Greer Blvd.
    Huntington, WV 25701

    Office Location:
    517 9TH Street, Suite 2A
    Huntington, WV 25701

    Office: (304) 399-4687
    Email: lauren.savory@chhi.org

    ------------------------------



  • 39.  RE: Compliance Department Operations Manual

    Posted 6 days ago

    I agree with all of the above.

    Add a policy which explains the Auditing & Monitoring process; (both E&M and HIPAA Privacy)

    ·         Define the difference between an audit & monitoring

    ·         How you perform the audit & monitoring

    ·         How you determine who needs to be monitoring  (routine vs. focused )

    ·         Potential Corrective Action Plans (CAP) for over-billing & under-billing (leaving money on the table).

    ·         Potential disciplinary actions for"chronic issues", so to speak.

     

    If you are really detail oriented; (sorry it is the nurse in me coming out, we had a P & P for everything)

    ·         Time & Effort reports for contracted providers/Medical Directors (if applicable).

    ·         Process for Contract review and "Auto renewals"

    ·         What is your process in assessing Fair Market Value (FMV) & how often do you re-assess FMV.

     

    I hope this helps you.

     

    Patrick R. Guilfoyle BA, RN, BSN, CHPC, CFE

    Compliance Manager

    Office of Compliance & Corporate Integrity

    42 East Laurel Road

    Suite # 1300

    PO Box 1011

    Stratford, NJ 08084

    T-856-566-6490

    F-856-566-6492

    guilfopr@rowan.edu

     

    "Right is right, even if everyone is against it, and wrong is  wrong even if everyone is for it."

    William Penn

    http://www.acfe.com/assets/0/73/4294984697/4294991127/324/c7c03ae7-a6c4-4e6d-a50a-66f782d7bdb0.jpg

     

     

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  • 40.  RE: Compliance Department Operations Manual

    Posted 6 days ago
    VIdeo would be great!  I had printed out some instructions awhile back on how to do flowcharts in Excel but never took the time to work thorugh the steps.  A video would push me to actually try to absorb the information and use it!

    ------------------------------
    Marie Wagner CHC,CHRC
    Sr. Corp Compliance Coord
    The Queen's Health Systems
    Honolulu,HI
    ------------------------------



  • 41.  RE: Compliance Department Operations Manual

    Posted 3 days ago
    ​Absolutely interested in Flowchart Fridays. I've used other office programs for flowchart construction and didn't know excel could do this too! Thanks Frank.

    ------------------------------
    Karin Pitt CHC
    Compliance Auditor
    Byram Healthcare

    ------------------------------



  • 42.  RE: Compliance Department Operations Manual

    Posted 3 days ago
    ​I am very interested Frank!  I don't like to miss any chance to learn from you!  Thank you!

    ------------------------------
    Gayla Smith
    HIM Manager/Compliance
    ------------------------------



  • 43.  RE: Compliance Department Operations Manual