Integrity and Compliance Program

Integrity and Compliance Program
System Office
New Hire Orientation
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http://media.trinity-health.org/Nexus/OIAS/serenade_code.wmv
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The Context for ‘The Sacred Work’ We Do
Mission
We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and
transforming healing presence within our communities.
Vision
As a mission-driven innovative health organization, we will become the national leader in
improving the health of our communities and each person we serve. We will be the most
trusted health partner for life.
Core
Values
Reverence
We honor the sacredness and dignity of every person.
Commitment to Those Who are Poor
We stand with and serve those who are poor, especially those most vulnerable.
Justice
We foster right relationships to promote the
common good, including sustainability
of Earth.
Stewardship
We honor our heritage and hold ourselves
accountable for the human, financial and
natural resources entrusted to our care.
Integrity
We are faithful to who we say we are.
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Working in the Health Care Industry
• Working in the health care industry is extremely complex
• Sometimes the right course of action is unclear. Some
examples:
A patient on my unit has
expressed racial
preferences with regard to
particular care providers.
How should I proceed?
When I was delivering meals to
patients, I saw my neighbor’s
name on the patient list for the
oncology unit. Is it okay if I
call her husband to see how
I can help?
Medicare notified us of billing
inaccuracies. The specific bills
have been resolved. But we
haven’t changed what caused the
errors in the first place. What’s
my responsibility?
I overheard a coworker
making jokes about the
elderly with other
coworkers. What should
I do?
Is it okay if I let a
vendor buy lunch for
our department a few
times a month?
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Purpose of Today’s Introduction
• Introduce the Integrity & Compliance Program
• Discuss your responsibilities in supporting the Integrity &
Compliance Program:
Speak up/
ask questions
Escalate
issues
about which
you have
concerns
Read and follow
the Code of
Conduct
Complete
assigned
training
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Today Is Just An Introduction…
As a new hire, you are also required to:
• Review and understand the Code of Conduct
• Complete the HealthStream course assigned to you:
o Annual Integrity and Compliance Education
o Other online learning assigned by your department
• Read and sign the Confidentiality and Network
Access Agreement
• Read and sign the Conflict of Interest form
• Review other handouts
• Participate/complete department any additional
education requirements
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What Is The Integrity and Compliance Program?
• Trinity Health’s commitment to act with integrity and make decisions
based on the highest standards of ethical behavior, following all laws and
regulations
• Key Integrity and Compliance Program resources include:
Trinity Health
Code of
Conduct
Education and
Training
Programs
Policies and
Procedures
Resources to
answer
questions and
to report issues
and concerns
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Code of Conduct: Overview
Describes behaviors and conduct expected of all
in Trinity Health:
•
•
•
•
Colleagues, volunteers and contractors
Medical staff
Board members
Suppliers and other business partners
Describes our commitment to maintaining “right
relationships” with:
•
•
•
•
•
Our patients/residents and their families
Co-workers and others serving with us
Suppliers and other business partners
Government and others that pay for our services
Our communities
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Code of Conduct: Key Topics
Fraud and Abuse
Conflicts of Interest
Privacy and
Confidentiality
Respectful Work
Environment
Reporting Issues and
Concerns
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Fraud and Abuse – Key Points
What is fraud?
• An intentional act of deception or misrepresentation
• Acting with actual knowledge or in “reckless disregard” of the laws or regulations
What is abuse?
• Improper or excessive use of a program or service
(e.g., Medicare or Medicaid)
Examples in health care:
• Falsifying medical records
• Submitting inaccurate or misleading claims for services
• Submitting claims for services never provided
• Submitting claims that don’t meet payer requirements
• Lying to obtain payment for services
• Offering or paying money, goods, or anything of value for patient referrals
• Offering or giving something of value to patients to encourage them to use or
purchase health care services
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Fraud and Abuse – What’s Expected of You?
• Act with honesty and integrity in all Trinity Health activities.
• Follow all laws and regulations that apply to your work and ask
for assistance if you have questions.
• Follow all requirements of government (e.g. Medicare and
Medicaid) and other third-party payers that pay for health care
services.
• Participate in training and education on laws and regulations
that apply to your work responsibilities.
• Cooperate with any government investigation. Never destroy or
alter documents or make false statements in connection with a
government investigation.
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The False Claims Act – Key Points
•
Federal law that makes it a crime to knowingly falsify a record or file a false
claim involving federal health care programs (e.g., Medicare, Medicaid)
•
Many states with Trinity Health operations have similar false claim laws
•
Refer to the False Claims Act information in the Code of Conduct for more
information on:
-- Penalties for violating the False
Claims Act
-- Protections for individuals who file a
lawsuit under the False Claims Act
Scenario: You believe
services are being billed
incorrectly. What should
you do?
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Conflicts of Interest – Key Points
What is a Conflict of Interest?
•
A situation when outside activities or relationships
influence - or could appear to influence - decisions
you make in your work for Trinity Health
Example Conflicts of Interest
•
Accepting gifts, entertainment, meals, sporting
event tickets, etc., from Trinity Health suppliers
•
Having a financial interest (e.g. employment,
compensation arrangement, ownership) in
companies doing business with Trinity Health
•
Using confidential business information for
personal gain
•
Accepting outside employment with a company
that competes with Trinity Health
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Conflicts of Interest – What’s Expected of You?
•
Maintain objectivity and avoid Conflicts of Interests in relationships
with suppliers and other business partners
•
Disclose and obtain advance approval from your supervisor of any
situation that could represent a potential Conflict of Interest with your
work for Trinity Health
•
Make decisions in the best interest of our patients and Trinity Health
Scenario: If a supplier
offers to buy lunch for
your department, what
should you do?
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Privacy & Security – Key Points
•
Right Relationships with Patients: Respect for, and
protection of, patient information is CRUCIAL for
maintaining trust
•
Patient information (a.k.a. Protected Heath
Information or PHI) is more than just patient
names—it’s any information, used alone or in
combination, that could identify a patient
•
Trinity Health collects PHI from patients, residents
and others in our care in order to provide effective,
high quality care
•
PHI includes electronic, paper, films and digital
images, even verbal conversations!
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Privacy and Security – What’s Expected of You?
•
Safeguard and protect all patient information you
encounter – follow department policies and procedures
•
Notify your supervisor immediately if you become
aware of lost, stolen or unprotected patient information
•
Raise any concerns about
the privacy and security of
patient information with
your supervisor or your
Privacy Official
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Examples of Mishandled Patient Information
•
Patient information in a public trash dump reported on 5:00 pm news
•
Patient’s HIV information is disclosed, child shunned
•
Mental health report left at copier and mistakenly included in a
mailing
•
Identifiable patient information used in a community education
presentation
•
Fax number entered incorrectly and information on100 patients sent
to local day care center
•
Colleague discloses patient information on Facebook
•
Nurse discusses pregnancy results while other patients and visitors
are present
•
Colleague sees neighbor’s name on a surgery list and asks spouse
about surgery
•
A patient receives another patients discharge orders
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Accessing Patient Information
•
Do not use, access or disclose patient information unless for a legitimate
business or clinical purposes
•
Trinity Health regularly monitors access to information systems containing
patient information for appropriateness
•
Consequences of inappropriate access include:
• Disciplinary action up to and including termination of employment
• Potential civil monetary fines or even jail time if intentional and for personal gain
•
Confused about the line between your “work” life and “personal” life as it
relates to patient information? Discuss with your supervisor or Privacy
Official
Scenario: A co-worker tells you
she looked up your supervisor's
birthday in the billing system. What
should you do?
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Safeguarding Patient Information – Verbal
•
Don’t discuss with family, friends or others
•
Don’t talk about patients in public spaces
•
Don’t discuss patients on social media sites such as
Facebook™ or Twitter™
Scenario: One of your
coworkers is a “friend” on
Facebook. He shares
information about a patient at
your hospital that is being
reported by a local TV station.
What should you do?
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Safeguarding Patient Information – Electronic
Keep all passwords confidential
• NEVER share your password or use someone
else’s password
• Passwords must be secured at all times
• Don’t write passwords down or post them where
others might easily find
Use system access codes/security badges
appropriately
•
•
•
•
Use access codes only for work purposes
Never share your access code/badge with others
Make sure office doors and work areas are secured
Do not let outsiders into a building/department with
your access code/badge
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Safeguarding Patient Information – Electronic
•
Emails containing patient information sent to recipients outside the
Trinity Health network must be encrypted
•
Secure laptops, mobile devices, reports and other materials
containing patient information in locked offices or cabinets when not
in use
•
When in transport, secure items and materials in car trunk
•
Do not save patient information on portable USB devices and
CDs/DVDs
Scenario: You lose a flash
drive that contains patient
information. What should
you do?
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Safeguarding Patient Information – Other
•
Verify fax numbers, mail and interoffice addresses
•
Do not remove patient information from the facility
•
Be responsible for any documents you print or copy
•
Use the “print locked copy” feature when sending patient information
to a printer
•
Shred documents containing patient information or dispose in a
locked confidential trash bin
Scenario: You find documents
left at the copier containing
patient information. What
should you do?
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Privacy and Security – Summary
•
You are accountable for protecting the privacy and security of
patient information you encounter in your work
• Read the Confidentiality and Network Access Agreement carefully
before signing
•
Review any additional privacy and security procedures that
may be applicable to your department with your supervisor
•
Complete the annual Integrity & Compliance HealthStream
course assigned to you
•
Review Trinity Health’s Privacy and Security policies online
(http://intranet.trinity-health.org/web/privacy-compliance/privacyprocedures-standard)
•
Ask if you have any questions!
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Resources to Answer Your Questions
Many resources are available to assist in answering
your questions or to report an issue or concern:
•
•
Your supervisor or manager (usually the best place to start)
•
Higher-level manager or leader in your department or area
•
Human Resources
•
Your Integrity and Compliance Officer
•
Privacy and Security Officials
•
Trinity Health Integrity & Compliance Line
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Integrity & Compliance Officers
Mike Holper
Kristin Carroll
Senior Vice President,
Integrity and Audit
Services, System Integrity
and Compliance Officer
Vice President, PMO, TIS,
Integrity & Compliance Officer
[email protected]
[email protected]
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Privacy and Security Officials
Monica Lareau
Preston Jennings
Director, HIPAA Compliance,
Privacy Official
Vice President, Information
Security & Chief Information
Security Officer
[email protected]
[email protected]
Trinity
Health
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Trinity Health
Integrity & Compliance Line
866-477-4661
•
Staffed 24/7/365 by an outside service on behalf of Trinity
Health
•
When you call the Integrity & Compliance Line you will speak
to an individual trained to listen to your concerns and gather
as much information as possible
•
You may also submit a report online at
www.mycompliancereport.com, using access code “THO”
•
Callers may remain anonymous, if they choose; all reports
are treated confidentially
•
Calls are not traced or recorded, the Integrity & Compliance
Line does not use caller ID
•
Investigations are generally conducted within 30 days, and
responses made available to the caller
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Your Obligation to Speak Up!
•
Trinity Health promotes an environment that encourages all to seek
answers to questions and to report issues and concerns
•
You have a right and duty to report any activity you believe may
violate applicable laws, regulations, professional standards of
practice, or the Code of Conduct using the resources discussed
Trinity Health Non-Retaliation Policy
•
Trinity Health policy prohibits retaliation, in any form, against
individuals who report issues and concerns in good faith
•
Retaliation is subject to discipline, up to and including termination of
employment
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MI
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Thank You!
“We are all accountable”
Remember your responsibility to:
Speak up/
ask questions
Escalate
issues
about which
you have
concerns
Read and follow
the Code of
Conduct
Complete
assigned
training
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2016AllTrinity
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