HCA Healthcare has developed compliance monitoring and auditing programs designed to assess the effectiveness of the ethics and compliance program.

Monitoring systems are designed to be incorporated into day-to-day processes. Auditing efforts typically use a retrospective approach. Responsible executives develop monitoring programs, and the internal audit department develops compliance audit plans and conducts audits.

Compliance Process Reviews (CPRs)

In addition to the auditing efforts, the program assessment team of the ethics and compliance department conducts on-site Compliance Process Reviews (CPRs). A CPR is a comprehensive assessment of a facility’s ethics and compliance program through conducting an extensive desktop review followed by an onsite visit. A random sample of HCA Healthcare facilities is selected each year to undergo a CPR to ensure the appropriate processes and procedures are in place and that these processes and procedures are providing the desired results.

From a facility perspective, the review provides the ethics and compliance officer (ECO) with valuable guidance to assist in strengthening process controls and improving the overall performance of the facility's program. From a company perspective, the reviews allow for the gathering of large volumes of ethics and compliance program data collected from multiple facilities throughout HCA. The analysis of this data assists in identifying both trends and opportunities for improvement to our company-wide ethics and compliance efforts.

“The CPR process was a learning experience for me being the interim ECO. The process has engaged me even more to make sure that the program is effective and working well. My reviewer was not only articulate and well-informed of the areas being reviewed but also very helpful and supportive in the success of the facility’s ethics and compliance program. It was a pleasure working with the reviewer.”

Ethics and Compliance Officer

The CPR serves two objectives: to assess the performance and level of engagement of the facility’s ECO, and to provide the ECO with additional guidance, training and best practices to assist in the implementation and monitoring of required processes and procedures.

The CPR is conducted by reviewers from the HCA Healthcare ethics and compliance department. Before the on-site visit, the reviewer sends the ECO an extensive document request and a compliance process questionnaire (CPQ) covering more than 30 compliance topics. In addition to the ECO CPQ, key facility personnel must complete CPQs for several other specific compliance areas (e.g., privacy, security, pharmacy and records management).

After examining the CPQs and documents, the reviewer visits the facility to assess additional documents, conduct a tour and further discuss any questions from the desktop review. The on-site portion of the review includes meetings with key personnel involved in specific compliance areas to provide them with guidance and best practices as well.

Upon completion of this visit, the reviewer provides the facility with a comprehensive report of findings outlining the issues identified along with recommendations for appropriate corrective action for each issue. The findings are also provided to the facility CEO, the division ECO, the division president and the group president. The facility has three weeks to complete and submit a corrective action plan for approval. The plan must identify a root cause and provide the detailed corrective action planned to remedy each issue. Once approved, the reviewer follows up with the facility until all issues are properly resolved.

“I appreciated the opportunity to speak candidly concerning specific issues the facility faces and brainstorming solutions that fit the facility needs and constraints.”

Ethics and Compliance Officer

The aggregate findings of the CPRs are analyzed on an ongoing basis for indications of trends. As they are identified, trends and findings are reported to the senior vice president and chief ethics and compliance officer. Trends and findings are communicated to our facilities via the issuance of reports, email communications and annual presentations. An analysis of annual aggregate findings and identified trends is presented each year to the audit and compliance committee of the board of directors.

If you would like to receive additional information regarding the compliance process review program, please email Rachel Mead, Director of Ethics and Compliance Program Assessment.

“I was so impressed with how helpful the reviewer was and how helpful this review will be to our program as we strive to get it completely up and running as it should be… I now feel like I have someone I know in Nashville who I can reach out to with compliance questions. It is so helpful to spend time with the reviewer and to get to know them. Even though the review process requires so much time, I feel it was definitely a worthwhile exercise.”

Ethics and Compliance Officer

If you would like to receive additional information regarding the compliance process review program, please email Rachel Mead, Director of Ethics and Compliance Program Assessment.