Chief Compliance and Ethics Officer Health Care

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  • 1.  Exceptions to policy

    Posted 05-18-2022 12:26 PM
    If exceptions to policy (not Compliance policies) are consistently made or the policy is not being followed, when does it become a Compliance issue? Or, doesn't it? For example, the appearance policy including wearing a name badge, or an attendance policy not being adhered to and not followed up on.

    Thank you so much,
    Rachel Anderson

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    Rachel Anderson, MSN, RN, CHC
    Chief Compliance Officer
    Boone County Hospital
    Boone, Iowa
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  • 2.  RE: Exceptions to policy

    Posted 15 days ago

    I think the answer varies depending on your organizational structure, but to me this is a Human Resources Issue first.  When policies have exceptions for some folks that is fodder for discrimination/favoritism claims,which would be a risk I would put on my work plan and work with HR to resolve.  Compliance would/could be involved but through HR, as they would be the group responsible for ensuring those policies and discriminatory practices were resolved.  


    That may include working with them to review/revise those policies, if they no longer make sense, or to enforce them as written uniformly to ensure we are not functioning in an organization that discriminates.

    We periodically struggle with  dress code policies being ignored in our agency and I continually circle us back around to the risk of not universally enforcing policies regardless of the nature of the policy.  I am in a small agency though so I am more involved in the minutia.



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    Cecelia Havens, MBA, CHC
    Project and Compliance Director
    APO
    Springfield, MO
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  • 3.  RE: Exceptions to policy

    Posted 15 days ago
    I would also hold HR accountable to monitor the employee adherence to those types of policies.  If accountability is not happening, I would take it up the chain as a concern, even all the way up to the CEO if necessary.  Part of our Compliance role is to promote the culture of following policies.


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    Ann Dunham
    MBA, SPHR, CHC, CHRC
    Compliance Officer
    Hannibal Regional Healthcare System
    Hannibal, MO
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  • 4.  RE: Exceptions to policy

    Posted 13 days ago
    A couple thoughts in addition to what has already been shared:

    1) Policy exceptions should be documented. I like to have a form for the policy owner to use to document each exception (which can help ensure all the right information is captured, including for how long the exception is approved and why). Depending on your situation, you might have the Compliance Office agree to maintain a file of all the exceptions, or you might have a Policy Office do that, or you could leave it in the hands of the policy owners but then you have no central data on trends...

    2) Once exceptions are documented, you can keep statistics or dashboards and report to the Policies Committee (or whatever governance group is over policies) with a standard agenda item on the status of exceptions. This can highlight policies that seem to have too many exceptions or can prompt an audit of a policy and its exceptions to see if the policy is being followed and if exceptions are appropriate. This allows the Compliance Officer not to be the only one expressing concerns about too many exceptions, or exceptions that are turning into discrimination, etc. This is an excellent monitoring activity for the governance group over policies.

    3) If no one else is taking responsibility for policies organization-wide in this way, start a Policies Committee! Try not to just have Compliance do all the monitoring, but instead make it a business governance function, owned by the business. The business runs on policies and needs to be sure they are being followed and that exceptions are being granted appropriately.

    I hope that provides a few ideas to help!
    Merri Beth

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    Merri Lavagnino
    Executive Director, Compliance & Privacy
    Indiana University Health Plans
    Indianapolis,IN
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  • 5.  RE: Exceptions to policy

    Posted 12 days ago
    Personally I don't think that sounds like a compliance function and I wouldn't agree to have compliance take on that responsibility for other departments / non-compliance policies. If there is an exception process for a policy that should be detailed in the policy and whoever owns that policy should own that process. I think compliance's role is in terms of the 7 elements with respect to the monitoring and auditing functions, not day-to-day operations.

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    Brenda Manning JD, CIPP/US, CHC, CHPC
    Senior Privacy Counsel
    Maximus, Inc.

    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.
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  • 6.  RE: Exceptions to policy

    Posted 14 days ago
    In-person staff wear badges is a safeguard to help identify who belongs in a facility / particular area and who doesn't. While a policy to wear a badge may be part of a Corporate Appearance Policy because that makes overall sense as to wear to put it, it's really rooted in privacy and security, not HR, so I would suggest your privacy team reach out to HR if adherence is an issue. I'd also be concerned with where the badges are if the workers aren't wearing them.


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    Brenda Manning JD, CIPP/US, CHC, CHPC
    Senior Privacy Counsel
    Maximus, Inc.

    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.
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  • 7.  RE: Exceptions to policy

    Posted 7 days ago
    Thank you all for your responses.

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    Rachel Anderson, MSN, RN, CHC
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