Transforming a Medical Center’s Fragmented Compliance Framework
See how Coker helped a client revolutionize its compliance framework and create a culture of accountability among its staff and board members.
Challenge
The Client had a fragmented and informal compliance program with only a handful of Office of Inspector General (OIG) Compliance Program elements in place. Their existing compliance function was ill-equipped and overextended, juggling multiple responsibilities and ultimately struggling to effectively manage compliance day-to-day. This presented a significant opportunity for growth and enhancement. The Client needed expert guidance to develop a cohesive, efficient, and fully equipped compliance program.
Solution
Our compliance experts identified areas of weakness in the Client’s existing compliance infrastructure using detailed gap and risk assessments. Together with the Client, we developed a new framework with streamlined processes and comprehensive policies aligned with industry standards. We helped the Client designate and deploy a dedicated virtual compliance officer to champion the new framework’s implementation. Additionally, we engaged the Client’s Board with tailored training sessions and helped fortify their commitment to compliance excellence. Finally, we developed a plan for audits, monitoring, and corrective action to keep the new framework running smoothly.
Approach
- Step 1Conduct a Compliance Program Gap Assessment
We conducted a comprehensive analysis of the existing compliance program, carefully aligning our findings with OIG Compliance Program guidance. This analysis, along with a detailed compliance risk assessment, helped us identify key areas for improvement. - Step 2Demonstrate Commitment to Regulatory Requirements
To demonstrate commitment to the regulatory requirements, we created an initial Compliance Program Manual that served as a roadmap for future efforts. - Step 3Appoint a Virtual Compliance Officer
At the Board’s request, we helped the Client designate and deploy a dedicated virtual compliance officer. This key appointment helped spearhead the development and implementation of the new compliance framework. - Step 4Engage and Fortify the Board
We helped the Client add compliance and oversight responsibilities to the Board’s Charter and By-Laws. This significant amendment underscored the Board’s commitment to fostering a culture of compliance excellence. To further bolster the Board’s capabilities, we collaborated with the Client to ensure active recruitment of new Board members with compliance expertise. Finally, we provided tailored, engaging training sessions for Board members, equipping them with an enhanced understanding of their roles and responsibilities. - Step 5Develop a New Framework
Together with the Client, we built out a robust compliance framework aligned with industry standards. Within that framework, we developed comprehensive policies that addressed potential compliance challenges. We also developed a Compliance Work Plan that outlined the steps and strategies necessary to address and mitigate high-risk areas. - Step 6Engage Employees
To encourage open communication and reporting, we helped implement a compliance hotline. This initiative fostered a safe and transparent environment in which employees could freely express concerns, leading to timely resolution of compliance missteps. - Step 7Develop a Sustainability Plan
To provide ongoing oversight and ensure continued alignment with compliance standards, we developed an audit and monitoring plan, along with a corrective action policy. To further bolster our Client’s compliance profile, we facilitated engagement with a reputable sanction screening vendor, ensuring all required stakeholders were screened against the LEIE and State Medicaid Sanctions List.
Conclusion
Through collaboration with our experts, the Client achieved a marked transformation of its compliance framework—metamorphosizing from fragmented and ill-equipped to cohesive and capable. Working together, we implemented a robust compliance program that not only met regulatory requirements but was also tailored specifically to the Client’s unique needs.
With our help, the Client established a solid foundation for a culture of compliance that will support their mission and strategic goals for years to come. High training completion rates indicate a significant improvement in staff awareness and understanding of compliance issues. New staff members are now completing their required compliance training during the onboarding process, ensuring that right from the start, they are equipped with the knowledge and skills they need to fulfill their personal responsibilities. The Client has also seen a substantial increase in completion rates for annual compliance training. All these successes indicate a growing culture of compliance and accountability.
Results At a Glance
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