An Employee's Role Under the Ethics and Compliance Program
Tenet's Ethics and Compliance Program plays an integral role in the company's operations. Tenet works diligently to ensure that its employees understand and comply with applicable laws and policies and adhere to the highest standards of ethics and integrity. Each employee plays a vital role in achieving this goal.
Employee involvement in the program may take many shapes, such as reading and acknowledging the company's Standards of Conduct, participating in ethics and compliance training, and adhering to relevant policies and procedures and the terms of Tenet's Quality, Compliance and Ethics Program Charter. Tenet also may rely upon an individual's cooperation to assist its Ethics and Compliance Department in the review and resolution of compliance issues.
Each employee and, depending on their function, many of our contractors are required to take an annual training session covering our Ethics and Compliance Program and general compliance policies and procedures. For employees and contractors involved in physician arrangements, billing, coding, cost reporting or providing care to patients, Tenet requires additional specialized training in these areas. New employees and certain contractors are required to take this training within their first 30 days of work and annually thereafter. These training sessions also are presented to our hospitals' governing boards and employed physicians.
Ethics Action Line
An Ethics Action Line (1-800-8ETHICS) is available to all employees, contractors, vendors, physicians, volunteers or students.
The Seven Elements of an Effective Compliance Program
Tenet's compliance program is comprised of unique components developed to address our specific business operations. The program is based on the seven elements of an effective compliance program described in the Office of Inspector General Compliance Program Guidance for Hospitals and the Supplemental Guidance.
These guidance documents make numerous recommendations regarding measures and specific activities that health care providers should implement to ensure that appropriate care is provided to federal health care program beneficiaries and that the claims submitted for such care are correct and accurate. Tenet's program is structured to address issues raised in both documents.
In addition, the Quality, Compliance and Ethics Program Charter contains specific requirements regarding training, clinical quality activities, screening for excluded parties, required policies and a review of the Ethics and Compliance Program.
Tenet also has implemented specialized programs designed to serve as checks and balances for areas of operations that may pose additional exposure for the organization. For example, Tenet has special audit programs for acute care hospitals, skilled nursing facilities, rehabilitation facilities and psychiatric operations. In addition, Tenet has incorporated the elements of the OIG's Model Compliance Plan for Clinical Laboratories by implementing recommended requisition forms, standard advance beneficiary notices, charge protocols, physician education and an audit process.
The seven major components of Tenet's Ethics and Compliance program include:
- High-level oversight provided by our senior vice president and chief compliance officer who reports directly to the Quality, Compliance & Ethics Committee of Tenet's Board of Directors;
- Written standards and policies;
- Auditing and monitoring;
- Open lines of communication through our Ethics Action Line;
- Response to detected deficiencies; and
- Disciplinary action as warranted.
The senior vice president and chief compliance officer provides regular reports to the Quality, Compliance & Ethics committee of Tenet's Board of Directors. Each Tenet hospital has a dedicated compliance officer. Regional compliance directors and other corporate departments provide additional support and resources.
Rules, Policies and Resource Materials
Tenet's Standards of Conduct are distributed to all Tenet employees, active staff physicians and certain contractors and vendors. The Standards of Conduct also are available on eTenet, Tenet's intranet communication system. The Standards of Conduct set forth Tenet's commitment to compliance with all federal health care program requirements. Regular updates to the Standards of Conduct are provided as necessary.
Tenet has a comprehensive set of policies and procedures that address a wide range of compliance-related issues including those addressing physician relationships, coding, specific billing and reimbursement topics, and compliance-related human resources policies.
General Training to All Tenet Employees
All new employees must attend a two-hour ethics and compliance training program. In addition, all employees receive an annual ethics and compliance refresher training. The Standards of Conduct, as described above, are used as the foundation for the training. Certain contract workers also are required to attend these training sessions. General ethics and compliance training materials, tailored to clinical personnel, are offered to active medical staff.
Specialized Compliance Training
Tenet's comprehensive training program provides relevant employees with customized compliance training, including HIPAA/information privacy and security. Additional training may be required when a new policy is adopted. Under the terms of the Charter, Tenet provides additional specialized training to the following groups:
- Senior management and hospital governing board members
- Selected coding, billing and reimbursement employees
- Clinical quality personnel
- Employees involved in contracting with physicians
- Employees whose job functions place them in identified risk areas
Training may be delivered through live sessions, computer-based training or pre-recorded CDs or DVDs.
Auditing and Monitoring
Tenet provides monitoring and auditing of its compliance activities by conducting an annual risk assessment and developing a compliance work plan. These audits include reviews of arrangements with physicians and other referral sources, coding compliance audits, clinical quality audits, privacy and security vulnerability reviews, and audits of acute care hospitals and specialty units (inpatient rehabilitation, psychiatric units and skilled nursing units).
Reporting and Communication
Tenet uses its hospital-based compliance officers to track the response and resolution of any issues identified through the Ethics Action Line, employee reports, external reports and internal or external auditing. The hospital compliance officers use a database to track their progress on the resolution of issues to ensure that Tenet has access to the documentation each time an issue is resolved.
As described throughout this summary, Tenet investigates reported allegations and takes appropriate corrective action. Elements of each corrective action plan include:
- Identification of the issue;
- Revisions to policies and procedures, if necessary;
- Training on those policies and procedures, or retraining on established policies and procedures;
- Monitoring to ensure compliance; and
- Appropriate disciplinary action in the event of non-compliance.
The hospital compliance officer and regional compliance directors manage development and implementation of corrective action plans for compliance-related issues. In addition, resources from other corporate departments may be utilized for investigation and/or implementation of corrective action. The objective of all corrective actions is to ensure that patients receive quality care and that all claims are correct and accurate.