Statement of Compliance Commitment
Driscoll Children’s Hospital has a proud tradition of ethical conduct and service. Driscoll Children's Hospital assures its absolute commitment to the highest standards of ethics and compliance. It is the policy of Driscoll Children's Hospital to fully comply with all applicable federal and state laws and regulations related to the delivery of health care products and services. Driscoll Children's Hospital further expects all employees, contractors, and consultants to conduct themselves in an ethical and compliant manner. To help all those who participate in providing services at Driscoll Children's Hospital understand and abide by these rules, Driscoll Children's Hospital has developed a Corporate Compliance Program which includes organizational policies and procedures for preventing and detecting suspected or potential compliance issues.
Driscoll Children's Hospital
Corporate Compliance Infrastructure
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Role of Driscoll Children's Hospital Corporate Compliance Committee
The 26 members of the Driscoll’s Corporate Compliance Committee (CCC) meet on a monthly basis to provide oversight to Driscoll’s Compliance Program. The membership of this lead committee includes Driscoll’s top corporate executives and many of our key department heads and organizational leaders. DCH’s Corporate Compliance Officer, Rick Villarreal, is the committee’s chairperson. Any issue or problem related to compliance with state and federal laws and regulations is deemed appropriate for review by the committee and its five hardworking subcommittees.
Each year, the members of the CCC develop an “Annual Compliance Work Plan” which provides focus for the committee, its members and subcommittees, for the entire 12 month period.
In addition to its overall responsibility for monitoring and improving the organization’s formal compliance program, it also provides quarterly reports, through the committee chairperson, to Driscoll’s Board of Directors via the Board’s own Compliance Committee.
THE FIVE SUBCOMMITTEES OF THE CORPORATE COMPLIANCE COMMITTEE
POLICY & PROCEDURE
The purpose of the Policy and Procedure subcommittee is to assist DCH in the drafting, reviewing, standard formatting, approval, dissemination and education for all policies and procedures impacting DCH from a clinical, patient care or administrative standpoint. Driscoll’s Corporate Compliance Program works closely with the Driscoll “Standards Committee” in order to ensure, to the extent possible, that all DCH administrative policies comply with appropriate and relevant state, federal and accrediting agency laws, regulators and standards. (Note: This key compliance function has been assumed by DCH’s Administrative “Standards Committee” chaired by DCH’s CNO.)
- “Standards Committee” is working to place all reviewed and approved policies on Driscoll’s intranet.
- “Standards Committee” has spent time weeding out old, out dated and redundant hospital policies.
- A new Standards “policy template” has been added to policy drafting mechanism… Directors and Managers are now asked to ensure that proposed new policies comply with applicable state and federal laws and regulations.
INFORMATION PROTECTION - HIPAA
- Develop a security and privacy program that addresses physical safeguards, administrative procedures, technical services to protect “PHI” information stored in databases, and technical mechanisms to protect data during transmission.
- Assessment of the risks and major threats to security and privacy of Protected Health Information.
- Identify the application Transaction and Code Sets Standards.
- Certification of the effectiveness of existing or new security controls.
- Assessment of privacy policies and procedures that cover specific requirements.
- Staff education on HIPAA rules and regulations (this must encompass all PHI, privacy and security issues)
- Establishing an audit and monitoring process to assess compliance.
CONTRACT MANAGEMENT
Develop policy and procedures to ensure accountability and consistency in the contract management process. At a minimum, such policies and protocols shall:
- Ensure that compliance becomes a requisite for every contract with independent contractors, physicians and vendors.
- Ensure appropriate review, monitoring and management of contracts.
- Ensure that Hospital Legal Counsel has revised all contracts prior to execution.
- Ensure that background checks are performed for all outside vendors and independent contractors.
- Ensure that contract terms and related information is communicated to the appropriate parties.
- Work closely with executive counsel to establish timelines for completion of the contract management inventory process.
- Develop, in conjunction with Hospital Legal Counsel and the Compliance Officer, protocols to monitor adherence to contract management policies and procedures.
BILLING & DOCUMENTATION
- Develop specific policy, procedure and protocols regarding billing, coding, documentation and charge description master maintenance guidelines.
- Work with various admitting, clinical and billing departments to help confirm that their current practices are in conformance with relevant state and federal regulations.
- Ensure that information regarding denials and rejections is shared among the billing, medical records and admitting staff. Develop and oversee yearly compliance audit program.
EDUCATION
The purpose of the Education Subcommittee is to facilitate the implementation of Compliance Training. This process includes (1) initial hospital-wide distribution and education of new programs; (2) new hire orientation; and (3) ongoing education via computer base training (CBT), teleconference, special guest speakers, employee compliance education through “Compliance Fairs”, etc.
Role of Driscoll Children's Hospital Board Compliance Committee
Driscoll Children's Hospital’s Board of Directors takes corporate compliance very seriously. In order to encourage the free flow of information concerning the compliance program and its activities, the DCH Board of Directors established the Board’s Corporate Compliance Committee nearly three years ago. The DCH Board of Directors Compliance Committee is chaired by Board member, Murray Bass, with Board members C. Ivan Wilson and Rick Merrill representing the total of three board member committee representatives. Each quarterly meeting of this board committee is attended by Driscoll’s COO, CFO, CIO and CNO. The committee is staffed by Rick Villarreal, Director Compliance & Governmental Reporting.
It is the board committee’s responsibility to accept, on a quarterly basis, detailed reports as to activities taking place at the CCC and the various compliance subcommittees. Reports are given regarding progress made in compliance activities as well as issues identified as needing additional attention. It is through this board level committee that the overall activities of the compliance program are communicated to the Driscoll Board of Directors.
Statement of Compliance
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