“Compliance is always a process that you can improve on.” That’s the belief of John Wallace, Chief Compliance Office for Rutland Regional Medical Center. Serving rural Vermont for over a century, the hospital maintains 100 acute care beds and employs about 1,300 people.
For Wallace and Rutland Regional Medical Center, the ComplyTrack Suite solution from Wolters Kluwer Law & Business enabled them to start a journey to better compliance management processes by saving time during risk assessment, and providing the detail required to enable effective action plans and process improvements across the enterprise.
Challenge - Rutland Regional Medical Center lacked a comprehensive enterprise risk assessment process. Although detailed, Rutland’s process did not include all relevant compliance topics. Additionally, it was taking valuable time away from other duties.
Solution - ComplyTrack modules: Activity & Event Manage Contract & Relationship Manage, and Risk Assessment Manager.
Results - The Rutland compliance team has started the journey to better compliance management by leveraging ComplyTrack’s greater specificity across an array of health care compliance issues. With links to full regulatory texts, the ability to track compliance functions in a secure and accessible workspace, and manage contracts in a single location, the team is maximizing time and efficiency.
The Journey to Effective Compliance Management
When Wallace joined the organization and performed his first risk assessment, he recognized that Rutland had two problems – risk assessment was not detailed enough to cover all relevant compliance topics, and the process took too much time away from other compliance duties. With the old process, Wallace was required to engage in the time-consuming task of compiling a long list of risks in an Excel spreadsheet based on past Office of the Inspector General (OIG) work plans and other issues. He then carefully identified the regulations and references that applied to each issue, a painstaking process that took many hours. After learning about the ComplyTrack Suite, Wallace believed that with it Rutland could increase effectiveness and reduce the cost of enterprise risk assessment.
The Power in Question Sets
Rutland began to generate electronic departmental compliance surveys using the ComplyTrack Risk Assessment Manager module, with customizable question sets designed specifically for health care compliance covering a comprehensive array of topics. The company started with the core revenue cycle departments, including patient accounting, medical records, registration and finance, and is gradually adding ancillary departments.
Question sets in the Risk Assessment Manager module contain links to allow for easy, instant review of the underlying regulatory requirements. After Wallace began sending question sets out to the department directors, he noticed that filling out the survey was becoming a valuable educational opportunity. With links to the actual regulations, those responsible for specific issues are now seeing them in context and understanding the importance of the information they are being asked to provide. The ability to read the actual requirements and connect them with their own internal processes has created a unique learning experience.
For example, when Wallace began to work with each department during survey administration, it became clear that ComplyTrack was helping to drive compliance throughout the organization. “With the nursing Conditions of Participation question set, I sat down with all of the nursing directors and went through the questions, recalls Wallace. They understood what the issues were, but they hadn’t spent much time reading the State Operation Manual. By working with the data provided by ComplyTrack, Rutland has taken compliance management to another level, with its staff realizing they are an integral part of the process.
The Drive to Compliance Process Improvements
With ComplyTrack, Wallace is able to export recommended actions from in Microsoft Excel format, using the resulting spreadsheet to create a prioritization matrix. This document is presented to the compliance committee, composed of representatives from every department participating in the risk assessment, which uses the matrix to discuss and prioritize work needed in each department. The process is facilitating greater understanding across the organization.
In addition to in-depth risk assessment, Rutland uses ComplyTrack’s Activity & Event Manager to track open issues such as investigations and incident reports. As a single, central thread across an entire incident, it supports documentation and simplifies activity tracking. Contract & Relationship Manager is also used, helping Rutland track and manage the terms and conditions of hospital contracts. The company is transitioning over to it as its primary contract management software, using it to store physician agreements. Rutland is also phasing in all contracts, beginning with vendor agreements.