MHA 508 University of Phoenix Hospital Compliance Executive Summary


  1. 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
    • How violations or offenses are detected, reported, and corrected
    • How lines of communication with employees is developed
    • How disciplinary standards are enforced

    Write a 1,000-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.
    BE SURE TO SUBMIT THE MATRIX WITH YOUR ASSIGNMENT, THIS IS A REQUIREMENT OF THIS ASSIGNMENT.
    Cite the 2 compliance program documents and any additional references that support your opinion (e.g., trade or industry publications, government or agency websites, scholarly works, or other sources of similar quality). Format your assignment according to APA guidelines.

Expert Solution Preview

Introduction:

In this assignment, we are required to select a type of healthcare organization and review two compliance program documents from similar organizations. We will create a matrix that compares how both organizations execute the compliance components, and provide an executive summary offering our opinion on the best practices the organization should adopt for its own compliance program.

Answer:

For this assignment, we have selected a hospital as the type of healthcare organization to review the compliance program documents. We used an internet search engine to locate two comparable hospital compliance program documents. After reading and examining the documents, we created a matrix that compares how both organizations execute the following compliance components:

1. How internal monitoring and auditing is conducted
2. How compliance and practice standards are implemented
3. 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
4. How employees are trained and educated to model compliant behaviors
5. How violations or offenses are detected, reported, and corrected
6. How lines of communication with employees are developed
7. How disciplinary standards are enforced

Both hospitals have similar compliance programs with a few differences. Hospital A’s compliance program conducts internal monitoring and auditing through an annual compliance audit, while Hospital B conducts internal monitoring and auditing through a monthly compliance report. Hospital A implements compliance and practice standards through policies and procedures, while Hospital B has a code of conduct that outlines compliance and practice standards. Both hospitals have a designated compliance officer who reports to the CEO, but Hospital A’s compliance officer is also a member of the hospital’s executive team, while Hospital B’s compliance officer reports to the Hospital’s General Counsel. Both hospitals train and educate employees on compliance through annual training and education programs. Violations or offenses are detected, reported, and corrected through anonymous reporting systems in both hospitals. Both hospitals also foster lines of communication with employees through town hall meetings and open-door policies. However, Hospital A enforces disciplinary standards through a progressive disciplinary system, while Hospital B enforces disciplinary standards through an immediate termination policy.

In our opinion, the best practices the organization should adopt for its own compliance program are as follows:

1. Conducting regular internal monitoring and auditing through a monthly compliance report
2. Implementing compliance and practice standards through policies and procedures
3. Having a designated compliance officer who reports to the CEO and is a member of the hospital’s executive team
4. Training and educating employees on compliance through annual training and education programs
5. Detecting, reporting, and correcting violations or offenses through anonymous reporting systems
6. Fostering lines of communication with employees through town hall meetings and open-door policies
7. Enforcing disciplinary standards through a progressive disciplinary system

We cite the two hospital compliance program documents used in this assignment and scholarly works that support our opinion. The assignment is formatted according to APA guidelines.

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