General Compliance Topics

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  • 1.  Hotline Report Updates to Senior Leadership

    Posted 09-21-2022 09:28 AM
    Like many of you, the majority of our hotline reports are anonymous and investigated by the appropriate department - whether it be compliance, human resources, risk management, or patient relations.  Approximately 40% of our reports are deemed substantiated.  At our quarterly administrative compliance committee, we report on the number of hotline reports received and if substantiated, we will share highlights of the reports and what action was taken to address the issue, etc. If the report was substantiated, however, the allegations were NOT critical or of high priority, this may be the first time a senior leader is hearing of a report in their respective area.

    If a report alleges a significant risk, the senior leader is notified in real-time and may be provided updates during the course of the investigation to keep them apprised of the outcome, substantiated, unsubstantiated or unfounded, etc. In this case, they are not caught off guard at the quarterly compliance committee if highlighted. Some of my senior leaders have recently expressed real-time transparency regardless of level or outcome.

    I'm interested in how other organizations operate?
    Thank you in advance!

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    Cheryl Rasbach
    Chief Compliance Officer
    Regional One Health
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    SCCE Membership


  • 2.  RE: Hotline Report Updates to Senior Leadership

    Posted 09-21-2022 09:54 AM
    I do the same thing as you do.  I have not had any concern from the other Leaders on how things are reported.

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    Ann Dunham
    MBA, SPHR, CHC, CHRC
    Compliance Officer
    Hannibal Regional Healthcare System
    Hannibal, MO
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    SCCE Membership


  • 3.  RE: Hotline Report Updates to Senior Leadership

    Posted 09-21-2022 03:54 PM
    Prior to the compliance committee meetings, our Chief Compliance & Privacy Officer meets individually with each member of Senior Leadership (it is short, usually 30 minutes or less) to review anything that was within their areas that is going to be reported - so hotline cases, other reported issues, internal monitoring/auditing results, etc. for the reason you state - so they are aware, and it gives them the opportunity to talk to their staff and get additional information that they might then want to share with committee if pertinent.

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    Marie Wagner, CHC, CHRC
    Operations Manager, Corporate Compliance
    The Queen's Health Systems
    Honolulu, HI
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    SCCE Membership


  • 4.  RE: Hotline Report Updates to Senior Leadership

    Posted 09-22-2022 08:20 AM
    Thank you for your responses thus far, this is extremely helpful!

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    Cheryl Rasbach
    Chief Compliance Officer
    Regional One Health
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    SCCE Membership


  • 5.  RE: Hotline Report Updates to Senior Leadership

    Posted 09-22-2022 12:54 PM
    This does not respond to your question but I was wondering if you define what is a "major compliance violation" that must be reported.

    There are different variations of this (for example, material, substantial or important compliance violations) but I am looking to see if there is a good working definition of this term. Thank you.

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    John Baker
    Kasai North America
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    SCCE Membership


  • 6.  RE: Hotline Report Updates to Senior Leadership

    Posted 09-28-2022 08:28 AM
    Jon -
    Unfortunately I don't have a set definition.  I work for a healthcare organization therefore anything that could cause patient harm or a significant financial hit to the organization would be considered a high risk.  Interested to see if others have something documented as a starting point for others.

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    Cheryl Rasbach, CHC, CPC-P, PAHM
    Chief Compliance Officer
    Regional One Health
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    SCCE Membership