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Developing a Meaningful Compliance Work Plan

3/17/20151 Developing a Meaningful Compliance work PlanMargaret HambletonVice President, Chief Compliance OfficerDignity HealthHCCA Compliance InstituteApril 20, 2015 Lake Buena Vista, FLAgenda work Plan Objectives Elements used to develop a work Plan Awareness Survey Effectiveness Evaluation Risk Assessment Coordinating with audit, education, policy, and other activities Stakeholder engagement3/17/20152 work Plan Objectives To direct Compliance and operations staff efforts in the work most critical to eliminate potential areas of vulnerability and to improve Compliance program effectiveness To determine the adequacy of resources (staff, technology, services) used to address areas of vulnerability To ensure structural and substantive assessment of the Compliance programThe work Plan is The OIG s work Plan Vendor developed plans results of your Risk Assessment alone Static Developed in a vacuum3/17/20153 The work Plan Reflection of the Organization Mission Strategy Operations Risk Tolerance Dynamic EngagingWork Plan Components Awareness Survey Effectiv

Formal mechanism exists to evaluate compliance program effectiveness. Process for evaluation is documented and the assessment is completed in accordance with established process. 1.04 Does the compliance office communicate the results of prior annual compliance effectiveness evaluations to the Board and other stakeholders?

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