Compliance Program Matrix Essay Discussion Paper
Assignment Directions
Your health care organization has had several small compliance incidents in the past two years, and the organization is now motivated to update
its compliance program. Your executive leadership team asked you to review two health care compliance programs from similar organizations to
determine how they constructed their compliance program and what aspects your organization should adopt.
Select the type of health care organization you want represented in this assignment (e.g., family practice, hospital, urgent care, or nursing home).
Locate two compliance program documents from comparable health care organizations using your internet search engine.
Read both compliance program documents and examine the similarities and differences between the two.
Create a matrix that compares how both organizations execute the following compliance components:
• How internal monitoring and auditing is conducted
• How compliance and practice standards are implemented
• The designated compliance officer (or person designated to be the contact for compliance matters), who that person reports to, and their
relationship to the organization’s governing board
• How employees are trained and educated to model compliant behaviors Compliance Program Matrix Essay Discussion Paper
• How violations or offenses are detected, reported, and corrected
• How lines of communication with employees are developed
• How disciplinary standards are enforced
Write a 525- to 700-word executive summary that informs your executive leadership about the matrix you created and offer your opinion as to
which best practices the organization should adopt for its own compliance program.
Cite your sources according to APA guidelines.
Submit your matrix and article.
Compliance with healthcare regulations is a profound aspect that enables healthcare organizations to thrive in ever-dynamic healthcare systems and avoid the legal implications of their actions. According to Dunbar et al. (2021), health authorities establish standards for benchmarking quality and assess the extent to which organizations comply with these regulations. In this sense, failure to adhere to healthcare regulations may result in sanctions, license revocation, intense scrutiny, and tarnished reputation. While our hospital has had several minor incidences of non-compliance with standards in the past two years, it is essential to reflect on compliance programs for reputable hospitals in the United States to inform a contextualized compliance matrix. Therefore, this paper elaborates on various aspects of a compliance program, using documents from Mayo Clinic and Dignity Health Clinic. Compliance Program Matrix Essay Discussion Paper
Compliance Components
Internal Monitoring and Auditing
Mayo Clinic and Dignity Health Clinic have internal mechanisms for monitoring and auditing to determine organizational compliance levels. Mayo Clinic sites have safety committees responsible for compliance with safety-related rules and regulations. The compliance office provides information and training regarding current laws, business partners, Code of Conduct, and organization representatives (Mayo Clinic, n.d.). On the other hand, Dignity Health Clinic has a Facility Compliance Liaison (FCL) employee who audits, monitors, and evaluates the implementation of the organization’s integrity program to ensure compliance with current regulations. The Dignity Health program entails various aspects, including the Standards of Conduct, employee education, follow-up, investigation, corrective and disciplinary actions, and auditing and monitoring programs.
The Implementation of Compliance and Practice Standards
In both organizations, compliance programs enshrine practice standards, Code of Conduct, and thresholds for regulatory compliance. At Mayo Clinic, the integrity and compliance program consist of a Code of Conduct and a Compliance Office. The Compliance Office train and educate healthcare professionals about ethical codes, operates a confidential, toll-free compliance hotline, investigates incidences of non-compliance, and provides resources for disciplinary actions. At Dignity Health Clinic, the Dignity Health Compliance function and the Facility Compliance Liaison (FCL) collaborate to implement elements of the integrity program, including employee education, program monitoring and auditing, communication mechanisms, investigation, and follow-up (Dignity Health, 2019). These strategies enhance compliance with ethical and legal standards. Compliance Program Matrix Essay Discussion Paper
Designated Compliance Officers
At Mayo Clinic, local compliance officers oversee compliance with the Code of Conduct and administrative regulations. Local compliance officers report to Mayo Foundation Compliance Committee that oversees the Integrity and Compliance Program. Dignity Health Clinic has a Facility Compliance Liaison (FCL) employee tasked to communicate, monitor, and evaluate the implementation of the Integrity Program. The FCL reports to the System Compliance Director (Dignity Health, 2019). Further, the System Compliance Director reports directly to the Dignity Health Corporate Compliance Officer.
Employee Training and Education to Model Compliant Behaviors
The two comparable hospitals have ethical codes encompassing various aspects, including confidential information and trade secrets, conflict of interest, safety, employee relations, honest communication, respect, and integrity. At Mayo Clinic, the Compliance Office trains and educates healthcare professionals about these elements of the Integrity Program to model compliant behaviors (Mayo Clinic, n.d.). On the other hand, the System Compliance Director collaborates with the Facility Compliance Liaison (FCL) employee and Dignity Health Corporate Compliance Officer to train employees in Dignity Health Clinic.
Detection, Reporting, and Correction of Violations and Offenses
Each of the two hospitals has a whistleblower protection agreement that fosters anonymous reporting and communication of potential violations of ethical and regulatory standards. Compliance Offices and designated compliance officers can detect and correct violations in good faith and ensure protection from any form of retaliation. Corrective measures adopted to correct violations are consistent with organizational policies and agreements. Compliance Program Matrix Essay Discussion Paper
Developing Lines of Communication with Employees
Effective, timely, and convenient communication is essential in promoting organizational compliance. At Mayo Clinic and Dignity Health Clinic, compliance offices operate confidential, toll-free compliance Hot Lines and E-mail addresses for inquiries and incident reporting. Also, these offices operate intranet sites as informational resources for staff. These options are available 24 hours to enable consistent communication and effective reporting.
Enforcing Disciplinary Standards
After investigating and ascertaining violations of ethical and legal standards, the Compliance Offices of the two comparable hospitals appropriately deal with perpetrators according to the organizational policy books. However, the two organizations provide opportunities for individuals to pursue an appeal if they have perceptions of unfairness. This aspect promotes dignity, fairness, impartiality, and respect.
Recommendations for the Best Practices
Undeniably, Mayo Clinic and Dignity Health are reputable healthcare organizations in the country. In this sense, their Integrity Programs enable them to comply with ethical and legal standards, including Codes of Conduct and regulations. Based on their compliance program documents, it is essential to note that an effective compliance program should entail various components, including proper auditing and monitoring, having designated compliance officers tasked to ensure contextual compliance, comprehensive staff training, and education programs for enhancing their knowledge and awareness of current laws, developing systems and communication lines that safeguarding anonymous reporting, and ensuring impartiality, respect, and fairness when delivering disciplinary actions toward violators. Compliance Program Matrix Essay Discussion Paper
References
Dignity Health. (2019). Standards of conduct: Dignity health’s guide to compliance and ethics. https://www.supportcaliforniahospital.org/file/volunteer-applications/standards-of-conduct.pdf
Dunbar, P., Browne, J. P., & O’Connor, L. (2021). Determinants of regulatory compliance in health and social care services: A systematic review protocol. HRB Open Research, 4, 13. https://doi.org/10.12688/hrbopenres.13214.3
Mayo Clinic. (n.d.). Mayo Clinic integrity and compliance program. https://kipdf.com/mayo-clinic-integrity-and-compliance-program_5ae50f1b7f8b9ab5258b4581.html Compliance Program Matrix Essay Discussion Paper
