Compliance Services
Does your hospital have the seven key elements of an effective compliance program in place?
Does your compliance program address high risk areas in your organization?
Do you want to reduce the potential for sanctions, fines, and penalties?
Here’s How QHR Can Help
QHR helps you dissect your program, determine gaps, and take your program to the next level!
NEW! Compliance Assessment
This assessment is a desktop analysis of compliance documents including, but not limited to charter, code of conduct, policies, procedures, training material, organizational charts, committee minutes, and job descriptions.
NEW! Compliance Education (On Site)
This comprehensive education program targets the key elements of a compliance program, HIPAA Privacy and Security rules, and the key elements of a broad range of other compliance topics, will demonstrate the compliance industry’s best practices through the use of case studies, round table discussion, as well as question and answer sessions.
NEW! Board of Trustees Education (On Site)
This comprehensive education program provides an in depth analysis of the board member’s oversight responsibilities related to hospital compliance activities. Fiduciary duties, including duty of care are explained along with information outlined by the Office of the Inspector General and American Health Lawyers Association, and current case law describing board member liability.
NEW! Compliance Implementation Assistance
Compilation of a comprehensive compliance program includes: drafting of a facility code of conduct, policy and procedure manual, job descriptions, training materials, forms, auditing plans, and communication logs specific to the organization.
The Office of Inspector General (OIG) has outlined in its Hospital Guidance and Supplemental guidance the seven key elements of an effective compliance program. Within these seven elements, includes the compilation of polices, procedures, auditing tools, training programs, and communication tools.
We know you have limited resources and here’s how QHR can help.
Let us develop your policies, procedure, tools, and forms based on your organization’s needs. Whether that is a code of conduct, fresh training material, or an annual auditing plan, QHR can develop and train your staff on your new material.
NEW! Compliance Program Review (On Site)
The on site compliance program review includes three phases:
Phase I – Review of compliance documents prior to on-site visit including, but not limited to charters, committee meeting minutes, and job descriptions.
Phase II – On site interviews with the compliance committee, executive team, board members, and key staff members. Review of business processes and compliance program objectives to determine gaps, weaknesses and strengths of the program.
Phase III – Record of findings and formal report to management, Board, or legal counsel as appropriate, by means of an Executive Summary, Findings and Recommendations Report, and Management Action Plan.
The Office of Inspector General (OIG) model compliance plan recommends that hospital’s have an external review of their compliance program every three years.
Our senior consultants will provide a comprehensive on site compliance program review that will identify areas of improvement and will determine whether the policies and procedures that you have in place are “put into process” in your organization. Is there a culture of compliance across your organization that is driven from the top down? Are the high risk areas identified in the OIG’s Annual Work Plan being adequately addressed? Your report will include an evaluation of each the elements of an effective compliance program as identified in the OIG’s Hospital and Supplemental Hospital Guidances.
