Ministry launches system-wide compliance plan
Ministry Healthcare of Marshfield, WI, didn't wait for the federal Office of the Inspector General (OIG) to release its hospital guidance before developing its wide-ranging corporate compliance plan. It started almost two years ago, and although the process was arduous, Ministry's early efforts are beginning to pay off.
"With the publication of the OIG guidance, I feel far more confident now than ever before that we had the foresight to develop a compliance plan that reflects the culture of our organization," says Denny Thomas, director of risk management at St. Joseph's Hospital in Marshfield, WI, and a key member of Ministry's compliance team.
The system, which comprises 18 facilities in Wisconsin and Minnesota, began developing its compliance plan in 1996, when federal inspectors made it clear through Operation Restore Trust and the PATH initiative that health care fraud was high on their list of priorities. "We looked at this and said, up front, this is the way we want to do business anyhow," Thomas says.
Ministry's first step was to retain a full-time compliance expert and, under his guidance, examine the full scope of compliance issues within the system. That meant looking not just at Medicare and Medicaid but at environmental and safety issues, employment practices, tax exemption issues, copyright and software licensing, physician contracting issues, and patient treatment and quality of care.
Based on an initial assessment, Ministry officials formed a compliance committee that included representatives from risk management, human resources, and corporate finance, as well as top administrators. "There was a lot in the initial analyzing phase," Thomas says. "We asked, 'What really is the scope of this project? What do we really hope to accomplish?' And as we researched and learned from one another, we slowly all became experts."
The next step was to install compliance officers in each facility and educate Ministry's 6,500 employees about the plan. Compliance officers were drawn from existing hospital administration. The compliance team then developed a one-page code of conduct that each employee was asked to read and sign off on.
Because not every employee had an equal understanding of the issues involved in compliance, the team also developed two booklets outlining more thoroughly the issues involved in effective compliance. One booklet gave a detailed summary of regulatory compliance issues and Ministry's expectations of proper conduct. The second, shorter booklet, was a streamlined guide to business and personal conduct for system employees.
Thomas stresses simplifying the language of any educational materials you issue. "It should be understandable to your audience, but the reading level shouldn't be so low that it changes the meaning of the information," he says.
The team particularly focused on educating employees in "at risk" disciplines, such as accounting, utilization review, and medical records. These groups received inservice training and additional educational material. In addition, each manager in the system received a prepared script and videotape to help educate them on how to train their staffs. "For a few of us to go out and teach 6,500 employees ourselves would have been an enormous task," Thomas notes.
Employees were also shown a videotape, and managers received an additional script to help them answer any questions the employees might have. "And then of course, if the manager isn't able to answer a question, the employee can certainly turn to one of the committee members who developed the compliance plan."
Although establishing a compliance plan well in advance of the OIG's hospital guidance was a difficult process, Thomas is glad Ministry didn't wait. At a recent conference attended by in-house legal counsel, risk managers, and utilization review personnel from facilities across the country, Thomas "got a sense that there's a scrambling, a fear that they may have a plan forced on them versus voluntarily developing one because they're waiting until the 11th hour."
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