Managing Compliance Risks within a Small Organization or with a Smaller Compliance Team

By | December 3, 2018

In the current, ever-changing regulatory environment, smaller compliance teams face unique changes. The OIG’s supplemental Compliance Program Guidance[1] published in 2005 states that ‘there is no single “best” hospital compliance program. Some hospital entities are small and may have limited resources to devote to compliance measures; others are affiliated with well-established, large, multi-facility organizations with a widely dispersed work force and significant resources to devote to compliance.’

As such, knowing where to focus the limited resources is one of these challenges. LindaJo Spencer, System Chief Compliance and Privacy Officer at Middlesex Health System says ‘reviewing the OIG workplan is one way of narrowing in on the potential risk areas’. The OIG no longer publishes an annual workplan instead publishes an organic workplan which is updated on a monthly basis meant to ensure that it aligns better with the work planning process. Donna Schneider, Vice President, Corporate Compliance and Internal Audit at Lifespan says that there may be many priorities and knowing what needs to get done is important.

Yesenia Contreras, Chief Compliance Officer and Executive Director of Compliance, Privacy and Internal Audit at a hospital system operating out of Massachusetts and Rhode Island says, ‘sometimes you need outside help to get started on a new audit or risk area’. After an initial audit of a particular risk area with the help of an external party, ongoing monitoring can be carried on by internal resources. ‘It’s important to get creative with resources’ says Donna. Jennie Henriques, Chief Compliance & Audit Officer at Southshore Hospital believes compliance is a team effort. ‘I often try to leverage different expertise and engage the leaders on the front line; you may have a small team and you can’t do it without them.’

Keeping up to date with the regulatory environment is a challenge that organizations of all sizes face. Understanding newer risk areas and business areas which may be subject to regulatory audit is challenging. Jennie opines that having an individual in the department tasked with keeping watch on newer regulations helps tremendously along with subscribing to regulatory listservs. ‘Checking the OIG workplan on a monthly-basis helps’ she says.

‘Knowing what energizes you to come in everyday is important’ says Donna. LindaJo says it’s all about keep it ‘fresh’. ‘I try to do things a little differently and am always looking at newer ways to engage with our workforce’ she says. Per Yesenia, the secret lies in building strong relationships. ‘Try to get to know people, talk about topics other than work. There is a personal side to every relationship and understanding that is important’.

If you are interested in learning more about this and other compliance issues, please join us on December 13th at the HFMA MA-RI Compliance Conference. Registration is available here.

[1] Federal Register / Vol. 70, No. 19 / Monday, January 31, 2005 / Notices