Description
Answer ALL guided questions under Part 1 and Part 2 in ONE post.
Review the document The Law, Compliance Tools, and Managerial Actions (ATTACHED)
Use only classroom materials to complete the discussion. This would include the textbooks, weblinks, and the Classroom law library, and Compliance library. (REFERENCES PROVIDED)
Part 1: Critical Analysis of the Law
Identify, cite the code, and give a short description of one health law found in the common health care statutes document (PROVIDED LAW-Advanced Directives -The law that gives people the right to establish a do not resuscitate order (DNR), living will, or Medical Order for Life Sustaining Treatment (MOLST) Maryland Advanced Directives
https://www.marylandattorneygeneral.gov/Health%20P…adirective.pdf -ATTACHED)
. For the health law selected, evaluate the following.
Evaluate whether the law is a federal or state law, civil or criminal, public or private. How do you know?
Why is it important to know when a statute has been modified by administrative regulation, court decision, or new statute? How can you find out about these changes?
What are the penalties associated with non-compliance with your law? Why would it be important to you and your organization to avoid these penalties? How could you comply with the law you described?
Evaluate the role of the health care administrator or health information technology administrator in legal compliance.
Why is your role important in preventing litigation and supporting legal compliance?
What tools are available for legal compliance? Name one compliance tool from the Week 12 Managerial Compliance Tools list (ATTACHED) and describe the tool. Evaluate how the tool would control the legal risk from the law you selected.
How can you take action to reduce legal risk? (Describe at least one managerial action you could take and how you would use the tool you just described to limit legal liability.)
Part 2: Strategic Compliance with the Law
You are an administrator for Big City Hospital Inc., a large medical center. Your medical center has just received a Summons indicating that a Complaint has been filed in the state district court in your city claiming that Dr. Quick, Nurse Sleep, and your medical center were negligent during a recent surgery.
The claim is that the doctor left before the surgical count, the nurse didn’t notice a missing sponge during the count, and the patient now has an x-ray showing that there is a sponge in the abdomen. The medical records do not reflect that a sponge count was even completed. Your state of Maryland has an arbitration process that has been completed and the lawsuit has started.
Tip: Make sure all part 2 responses evaluate the scenario and apply concepts to the specific scenario.
1. As part of the lawsuit, you receive a litigation hold letter requesting that all documents related to the lawsuit be preserved including electronically stored information (ESI).
Why is it important to preserve documents for litigation?
How would you do this? Describe three actions you would take to preserve documents (prevent destruction) for this lawsuit.
What key documents would need to preserve for this case because they relate to what happened?
2. When a case goes to court, good medical record documentation can make the difference in winning or losing a lawsuit.
1.
o How can medical record documentation limit or increase legal liability in this case ? What should a strong medical record in this case include?
o As a result of this lawsuit, what three actions would you take to prevent the problem and improve medical record surgical care documentation including adequate documentation of the sponge count?
References
Showalter, S. (2020). The law of healthcare administration. (9th ed.). Health Administration Press.Chapter 1 (pages 1 -19) and Chapter 3 (pages 111-123)
https://learn.umgc.edu/content/enforced/930557-004637-01-2242-GO1-9041/Introduction%20to%20American%20Legal%20System%20PDF.pdf
Litigation Holds – The Triggers and Consequences For Failing to Preserve Evidence
https://learn.umgc.edu/content/enforced/930557-004637-01-2242-GO1-9041/Risk%20Management%20in%20Executive%20Levels%20of%20Healthcare%20Organizations%20Insights%20from%20a%20Scoping%20Rview%20(2018)%20PDF.pdf
https://learn.umgc.edu/content/enforced/930557-004…
Unformatted Attachment Preview
Week 12: Managerial Tools for Compliance
Compliance and Risk Management Tools
Checklists
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AAFP Closing your practice checklist
https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/departing_physician.html
ACEP/PAI Physician Checklist for Appealing Audit Findings
http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/checklist-forappealing-audits.pdf
AcomHealth 2020 Coding and Billing Checklist https://acomhealth.com/wpcontent/uploads/2020/02/2020-Coding-Billing-Checklist.pdf
AHA Checklists to Improve Patient Safety https://www.aha.org/ahahretguides/2013-07-10-checklists-improve-patient-safety
CANDOR Disclosure Checklist https://www.ahrq.gov/patientsafety/capacity/candor/modules/checklist5.html
Central Line Insertion Checklist
http://www.ihi.org/resources/Pages/Tools/CentralLineInsertionChecklist.aspx
CURI Medical Record Check-List Assessment https://assets.hccainfo.org/Portals/0/PDFs/Resources/Conference_Handouts/Clinical_Practice_Co
mpliance_Conference/2019/Tuesday/602_Handout.docx.pdf
Employee Termination Checklist Employee Termination Checklist (25 tasks)
[PDF & Printable]
GDPR Checklist for data controllers https://gdpr.eu/checklist/
Greenway Health: Information sharing/Information Blocking Checklist
https://www.greenwayhealth.com/sites/default/files/files/202105/Greenway%20Health%20Information%20Blocking%20Checklist_2.pdf
HCCA: EMTALA Compliance Checklist https://assets.hccainfo.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/
2016/308handout2.pdf
HHS ONC HIT HIPAA Security Checklist
https://www.healthit.gov/sites/default/files/comments_upload/hipaa-securitychecklist.pdf
HHS OHRP Research Informed Consent Checklist
https://www.hhs.gov/ohrp/regulations-and-policy/guidance/checklists/index.html
Hiring Process Checklist https://www.hiresuccess.com/blog/hiring-processchecklist-step-by-step-guide
Holland and Hart HIPAA Privacy Checklist
https://www.hollandhart.com/pdf/HIPAA-Privacy-Checklist-HH.pdf
Holland and Knight: Affordable Care Act Compliance Checklist for Employers
https://www.hklaw.com/files/Uploads/Documents/Practices/EmployeeBenefits/AC
AComplianceChecklist.pdf
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HRET Checklist to Improve Patient Safety http://www.hpoe.org/ReportsHPOE/CkLists_PatientSafety.pdf
JCRINC Point of Care Medical Record Checklist https://info.jcrinc.com/rs/494MTZ-066/images/POINT-OF-CARE30.pdf?ref…
KYMA Sample Compliance Checklists for Electronic Health Records
https://kyma.org/shared/content/uploads/2015/12/ehr-compliance-checklist.pdf
Maryland Non-Profits: Starting a Nonprofit in Maryland Checklist
http://marylandnonprofits.org/wp-content/uploads/Start-a-Nonprofit-ChecklistMaryland.pdf
Medical documentation and checklists Medical Documentation and Checklists
(novitas-solutions.com)
Medicare Discharge Planning Checklist
https://www.medicare.gov/Pubs/pdf/11376-discharge-planning-checklist.pdf
National Staffing Credentialing Checklist Credentialing Checklist – Requirements
for Application (nationalstaff.com)
NSF 2019 Equipment Calibration Checklist
https://d2evkimvhatqav.cloudfront.net/documents/bsc_2019_equipment_annual_f
orm.pdf?mtime=20200716154310&focal=none
Premera Provider Credentialing Document Checklist
https://www.premera.com/documents/023163.pdf
RAC Preparedness Checklist https://assets.hccainfo.org/Portals/0/PDFs/Resources/Conference_Handouts/Clinical_Practice_Co
mpliance_Conference/2013/301-Handout2.pdf
SCRIBD Medical Records Audit Checklist
Termination Risk Assessment Checklist
https://www.hollandhart.com/presentations/Healthcare-Bootcamp_LETermination_Risk.pdf
WHO Surgical Safety Checklist
https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng.pdf?
sequence=1&isAllowed=y
Codes of Ethics
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ACHE Code of Ethics https://www.ache.org/about-ache/our-story/ourcommitments/ethics/ache-code-of-ethics
AHIMA Code of Ethics https://bok.ahima.org/doc?oid=105098#.YZMsDWDMKUk
AHRQ Health IT Evaluation Toolkit and Evaluation Measures Quick Reference
Guides Health IT Evaluation Toolkit and Evaluation Measures Quick Reference
Guides | Digital Healthcare Research (ahrq.gov)
AMA Code of Ethics https://www.ama-assn.org/delivering-care/ethics/codemedical-ethics-overview
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AMA Informed Consent Opinion 2.1.1 https://www.ama-assn.org/deliveringcare/ethics/informed-consent
AMA Medically Ineffective Interventions Code of Medical Ethics Opinion 5.5
https://www.ama-assn.org/delivering-care/ethics/medically-ineffectiveinterventions
ANA Code of Ethics https://nursing.rutgers.edu/wpcontent/uploads/2019/06/ANA-Code-of-Ethics-for-Nurses.pdf
John Hopkins Conflict of Interest Policy https://www.hopkinsmedicine.org/supplychain/policies-and-procedures/jhhs-conflict-of-interest-policy.html
Mayo Clinic Code of Conduct https://mcforms.mayo.edu/mc2500mc2599/mc2570.pdf
NAHQ Code of Ethics https://nahq.org/about/code-of-ethics/
Compliance Toolkits
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AHIMA Information Governance Toolkit 2.0
https://bok.ahima.org/doc?oid=301510
AHRQ Communication and Optimal Resolution (CANDOR) Toolkit
Communication and Optimal Resolution (CANDOR) Toolkit | Agency for
Healthcare Research and Quality (ahrq.gov)
ASHRM Active Risk Control Toolkit: Better Solutions After Risk Assessment
https://www.ashrm.org/resources/arc_toolkit
ASHRM Health Care Facility Workplace Violence Risk Assessment Tool
https://www.ashrm.org/resources/workplace_violence
ASHRM Root Cause Analysis Playbook
https://ams.aha.org/EWEB/DynamicPage.aspx?WebCode=ProdDetailAdd&ivd_p
rc_prd_key=111f753d-a277-4c89-8e38-4d1fd6289654
CMS Connected Care Toolkit Connected Care Toolkit – Chronic Care
Management Resources for Health Care Professionals and Communities
(cms.gov)
CMS Documentation Matters Toolkit https://www.cms.gov/Medicare-MedicaidCoordination/Fraud-Prevention/Medicaid-IntegrityProgram/Education/Documentation
CMS Hospice Benefit Toolkit https://www.cms.gov/Medicare-MedicaidCoordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Hospice
HHS OIG Compliance Toolkits https://oig.hhs.gov/compliance/compliancetoolkits/
Institute for Healthcare Improvement Patient Safety Essentials Toolkit Patient
Safety Essentials Toolkit | IHI – Institute for Healthcare Improvement
LEP Toolkit https://www.dol.gov/agencies/oasam/centers-offices/civil-rightscenter/external/limited-english-proficient/toolkit
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IRS Exempt Employer’s Toolkit https://www.irs.gov/charities-non-profits/exemptemployers-toolkit
MHS Indiana Medical record Documentation Audit Tool
https://www.mhsindiana.com/content/dam/centene/mhsindiana/medicaid/pdfs/Me
dical-Record-Audit-Tool-July-2015.pdf
NICU Toolkit: Transitioning Newborns from NICU to Home
https://www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/index.html
Texas Pediatric Society Palliative Care Toolkit https://txpeds.org/palliative-caretoolkit
Contract Clauses
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Law Insider – Mediation Sample Clauses https://www.lawinsider.com/clause/disputeresolution-mediation
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Good Faith Negotiation Clause Samples https://afterpattern.com/clauses/goodfaith-negotiation
Sample Arbitration Clause
https://www.adr.org/Clauses?gclid=EAIaIQobChMIjcaFgPKb9AIVwHxvBB2U2gq
VEAAYAiAAEgIelfD_BwE
Sample Data Protection Clause https://www.lawinsider.com/clause/dataprotection
Sample Limitation of liability Clauses
https://www.lawinsider.com/clause/limitation-of-liability
Sample Termination of Contract clauses
https://www.lawinsider.com/clause/termination-of-contract
Sample Managed Care Contract
https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%
20Management/Office%20Operations/sample_managed_care_contract.pdf
Forms and Templates
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Against Medical Advice Form Against Medical Advice (AMA) Form
https://www.thesullivangroup.com/risk_resources/ToolBox/AMA_form.pdf
AHIMA:A Model Contract for Health information Exchange
https://library.ahima.org/PdfView?oid=63657
Baylor Scott and White Health Electronic Medical Record Access agreement for
Non-Baylor Scott & White Health Users
https://www.bswhealth.med/Documents/physician-relations/emr-accessagreement.pdf
Cornell IRB Consent Form Templates
https://researchservices.cornell.edu/forms/irb-consent-form-templates
Hofstra IRB Informed Consent Form
https://medicine.hofstra.edu/pdf/research/sample-informed-consent-form-forhofstra-irb-proposal.pdf
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IRS 990 – Tax Form for Tax Exempt Organizations https://www.irs.gov/pub/irspdf/f990.pdf
IT Risk Assessment Excel Template
Living Will Forms https://eforms.com/living-will/
Maryland MOLST Form
https://marylandmolst.org/docs/MOLST%20MM3%202013%20FINAL%20PROP
OSED%2072613%20POSTED%2021714-no-instructions.pdf
Medication Error Reporting Form
https://jipmer.edu.in/sites/default/files/Medication-error-reporting-form.pdf
NLC Contracting Guidelines and Checklist for EHR Vendor Selection
https://www.healthit.gov/resource/nlc-contracting-guidelines-and-checklist-ehrvendor-selection
Maryland Application for a 1915 Home and Community Based Services Waiver
https://health.maryland.gov/mmcp/waiverprograms/SiteAssets/Pages/Home/Medi
cal%20Day%20Care%20Services%20renewal%202021%20CLEAN%2001.28.2
1.pdf
Maryland Certificate of Need (CON) Application Forms
https://mhcc.maryland.gov/mhcc/Pages/hcfs/hcfs_con/hcfs_con_applications.asp
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Medical Records Release Authorization Form/HIPAA
https://eforms.com/release/medical-hipaa/
Model Business Associate Agreement
https://www.hhs.gov/sites/default/files/model-business-associate-agreement.pdf
PHR Model Privacy Notice Template
https://www.healthit.gov/sites/default/files/phr-model-privacy-notice-final-2011.pdf
Responsible-Accountable-Consulted-Informed (RACI)Matrix in excel
Risk Register Template for Excel
Stoel Rives Sample Litigation Hold Notice
https://www.stoel.com/StoelRives/files/fa/fac01e84-5bad-48e6-9b1ffcb997d9ded2.pdf
Guidelines and Protocols
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AHRQ Quality and Patient Safety Programs by Setting: Ambulatory Care
https://www.ahrq.gov/patient-safety/settings/ambulatory/index.html
AHRQ Quality and Patient Safety Programs by Setting: Emergency Department
https://www.ahrq.gov/patient-safety/settings/emergency-dept/index.html
AHRQ Quality and Patient Safety Programs by Setting; Hospital
https://www.ahrq.gov/patient-safety/settings/hospital/index.html
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AHRQ Quality and Patient Safety Programs by Setting: Long-Term Care
https://www.ahrq.gov/patient-safety/settings/long-term-care/index.html
AMA Guides to the Evaluation of Permanent Impairment: an overview
https://www.ama-assn.org/delivering-care/ama-guides/ama-guides-evaluationpermanent-impairment-overview
ASAM National Practice Guidelines For the Treatment of Opioid Use Disorder
https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline
Clinical Practice Guidelines for Quality Palliative Care
https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPCNCPGuidelines_4thED_web_FINAL.pdf
CMS Guidelines for Teaching Physicians, Interns, and Residents
https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf
CMS Teaching Physicians, Interns, and Residents Guidelines
https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf
COSO Guidance https://www.coso.org/guidance-on-ic
Creighton Health Record Documentation Policies and Procedures
https://www.creighton.edu/fileadmin/user/GeneralCounsel/docs/2.5.4._Health_Re
cord_Documentation__2-1-2020.pdf
Department of Justice (DOJ) Horizontal Merger Guidelines
https://www.justice.gov/atr/horizontal-merger-guidelines-0
Guide to Reporting Abuse in Maryland https://cdn.ymaws.com/www.naswmd.org/resource/resmgr/imported/child%20abuse%20reporting%20checklist.pdf
HHS OIG Compliance Guidance Compliance Guidance | Office of Inspector
General | Government Oversight | U.S. Department of Health and Human
Services (hhs.gov)
HHS OIG Contractual Joint Ventures Special Advisory Bulletin
https://oig.hhs.gov/documents/special-advisorybulletins/885/042303SABJointVentures.pdf
HHS OIG Health Care Fraud Self-Disclosure Protocol
https://oig.hhs.gov/documents/self-disclosure-info/1006/Self-Disclosure-Protocol2021.pdf
Joint Commission Universal Protocol
https://www.jointcommission.org/standards/universal-protocol/
Maryland Guide to Legal Aspects of Doing Business in Maryland
https://www.marylandattorneygeneral.gov/Securities%20Documents/legalaspects
.pdf
Maryland 2022 Home Health Agency Certificate of need (CON) Guidelines
https://mhcc.maryland.gov/mhcc/pages/hcfs/hcfs_homehealth/documents/2022_
HHA_Guidelines.pdf
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NCQA Guidelines for Medical Record Documentation https://www.ncqa.org/wpcontent/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentatio
n.pdf
Newborn Critical Care Center (NCCC) Clinical Guidelines: Neonatal Palliative
Care Guidelines Newborn Critical Care Center (NCCC) Clinical Guidelines DocsLib
NIST Calibration Procedures https://www.nist.gov/pml/weights-andmeasures/laboratory-metrology/calibration-procedures
U.S. Preventive Services Task Force Preventive Service Recommendations
https://www.uspreventiveservicestaskforce.org/uspstf/recommendationtopics/uspstf-and-b-recommendations
Policies and Procedures
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American Hospital Association (AHA) Bill of Rights
CCHC Employee Handbook https://www.cchchealthcare.com/wpcontent/uploads/2014/10/CCHC-Employee-Handbook.pdf
Cleveland Clinic Policy on Do Not Resuscitate (DNR)
http://www.clevelandclinic.org/bioethics/policies/dnr.html
FSMB Policy on Physician Illness and Impairment
https://www.fsmb.org/siteassets/advocacy/policies/policy-on-physicianimpairment.pdf
FSMB Policy on Physician Impairment
https://www.fsphp.org/assets/docs/physician-impairment.pdf
ISO Procedure for Equipment Calibration and Maintenance https://projectlead.eu/2020/12/31/iso-9001-as-9100-calibration-requirements-and-procedure/
John Hopkins Policies and Employee Handbooks
https://www.hopkinsmedicine.org/human_resources/about/policies_handbooks.ht
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Memorial Hospital Peer Review Policy https://www.beaconhealthsystem.org/wpcontent/uploads/2018/08/Medical-Staff-Peer-Review.pdf
Renaissance Stonybrook Disruptive Provider Policy
https://renaissance.stonybrookmedicine.edu/sites/default/files/disruptive%20final
_0.pdf
UCLA David Geffen School of Medicine Resident Policies
https://medschool.ucla.edu/gme-resident-policies
University of Buffalo Impaired Physician Policy Impaired Physician Policy Jacobs School of Medicine and Biomedical Sciences – University at Buffalo
University of Maryland Medical System Policies
https://www.umms.org/about/policies
Risk Management and Assessment Tools
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ASQ Root Cause Analysis Tools https://asq.org/quality-resources/root-causeanalysis/tools https://asq.org/quality-resources/root-cause-analysis/tools
Plan–Do-Check-Act (PDCA) Model for Risk Management
https://simplifyiso.com/connect-the-dots-pdca-risk-based-thinking-and-theprocess-approach/
NIST Risk Assessment Tools https://www.nist.gov/itl/appliedcybersecurity/privacy-engineering/collaboration-space/focus-areas/riskassessment/tools
Security Risk Assessment (SRA) Tool https://www.healthit.gov/topic/privacysecurity-and-hipaa/security-risk-assessment-tool
UNNUS Strength-Weakness-Opportunities-Threats (SWOT) Analysis
https://unnus.com/medical/healthcare-swot-analysis/
Wolters Kluwer The Bowtie Method Risk Management Tool
https://www.cgerisk.com/knowledgebase/The_bowtie_method
Training Materials
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CDC NIOSH Training and Workforce Development
https://www.cdc.gov/niosh/training/default.html
CMS Evaluation and Management Services Guide
https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
eCQM and eCQI Educational resources https://ecqi.healthit.gov/ecqm-and-ecqieducation-resources
HHS ONC Security Risk Assessment Videos
https://www.healthit.gov/topic/privacy-security-and-hipaa/security-riskassessment-videos
HHS OIG A Roadmap for New Physicians: Physician Education Training
Materials https://oig.hhs.gov/compliance/physician-education/
HHS Training Materials on HIPAA https://www.hhs.gov/hipaa/forprofessionals/training/index.html
OSHA Training Tools https://www.osha.gov/training/library/materials
Evaluation and Analysis
HCAD 650
Course Goals
For you to gain skills in evaluating and solving problems that arise in the health care
workplace through strong critical thinking skills
For you to be empowered with risk management and compliance tools to resolve
problems that will arise in the health are workplace
For you have the opportunity to evaluate and solve problems and apply compliance tools
each week through discussions and assignments
Course resources are robust so that time does not need to be spent on research, but so
that you can focus on critical thinking and evaluation to resolve problems in ways that
comply with the law.
Use the Textbooks, Classroom law library, Internet Links in the Classroom to complete assignments.
There is no need for outside research.
Evaluation Steps
1. Understand the Problem
2. Know the law and consequences
3. Know Compliance Tools
4. Brainstorm Options/Evaluate ways to apply compliance tools to the specific problem
5. Choose the best managerial actions for compliance
6. Support your action plan with strong reasons
1. Understand the Problem
Describe the specific problem, why it is a problem, and how it relates to the law
Bad Example: The physician was not licensed.
Good Example: The lives in Maryland and is licensed in Maryland. She would like to provide
telehealth services in Florida, but is not licensed there. Florida does not participate with the
Interstate Medical License Compact.
This explains the specific details of what is happening.
It discusses the root cause of the problem or why it is happening.
It links the problem to the law, so that it is clear why it is a legal problem.
Questions to ask:
What happened ? What are the details of what happened?
Why did this problem happen?
How does this problem relate to the law?
2 Understand the Law and Consequences
Name, describe, and give a code citation to the law.
State the consequences of the law.
Explain what the law requires an organization to do.
Explain how the law applies to the specific problem.
Identify the legal risk from non-compliance as well as other risk ie financial, reputational,
clinical risk.
Implications of the law
2. Understanding the Law
Detailed
content
Bad Example: Florida has a physician licensing law.
on the
law Good Example:
State code
section
The Florida physician licensing law is found in Florida Code 458.313 which allows for
“licensure by endorsement”. In order to obtain licensure by endorsement, the medical
provider must pay a fee, pass the state medical licensing boards, show evidence to
practice medicine in another state, comply with any Medical Board rules for licensure,
and have not have prior legal violations. The Interstate Medical Licensure Compact
(IMLC) can speed up licensing between states, but is not the only way to become licensed
in a new state. If the provider wanted to expedite things with IMLC, she could apply to a
state which participated with IMLC such as Wester Virginia, Kentucky, Tennessee, Georgia,
etc. instead of Florida. If the physician is not licensed to practice in a state, then a
physician can not provide services in that state unless there is a telehealth specific
exception in the state. Florida also allows for out of state telehealth provider registration
with certain restrictions. (Florida Code 456.47)
The law is specific to the situation.
2 Understanding the Law
Questions to Ask:
What is the name of the law? What is the title to the law?
What is the federal or state code section?
What are the consequences of non-compliance?
What does the law say? What does the law require an organization to do?
How does the law apply to the problem?
What does the law say to do to become licensed?
If this is a state law, how would another state law impact things? Would it be better to do this in a different state?
How needs to be done to meet the requirements of the law?
What is the risk of non-compliance based on the legal consequences?
What other consequences impact risk to the organization?
3 Understand Compliance Tools
Know the compliance tools that are available.
Individual Discussions: You are given different tools to apply so that you get familiar with different tools.
Ethics Committee Group Discussion: The group selectsed the compliance tools to apply so you get
experience determining when to apply different tools
Know how to use the compliance tools
Adapt the compliance tool to fix the specific problem
Examples
Bad Example: A licensure checklist can be used to meet licensure requirements.
Good Example: A physician licensure checklist for telehealth services in Florida requires (1) an
application for telehealth provider registration (2) verification of an active license in another
state (3) no license discipline in the last 5 years (4) appoint a registered agent in Florida (5)
maintain liability insurance (5) not open a Florida office or provide in-person health care in
Florida (6) only use a Florida licensed pharmacy to dispense drugs to patients.
3 Understanding Compliance Tools
Questions to Ask:
If no tool is assigned ask: What tool could best be used to resolve this problem? Why would it be a
good tool to use?
What does the compliance tool I have been assigned to use do? What does it say? How does it
work? How would it apply? Are there other tools that would be useful to reach a solution?
How would I apply the tool to solve this specific problem? What options do I have? Which are
most realistic?
How could I adapt the tool to this specific problem?
4. Brainstorm Options
Evaluate Ways to Apply compliance Tools to the
specific problem
BRAINSTORM – Note your brainstorm is part of the process to complete the work, but does not
need to be submitted. It leads to your final solution.
Bad Example: A licensing checklist can be used to ensure license requirements are met.
Good Example/Options Generated
1. The physician will use the telehealth licensing checklist will match the telehealth provider registration
requirements and be updated annually to ensure continued compliance with state law.
2. The physician will comply with full licensure requirements in the state so that there is an easy option to
open an office there in the future. A license checklist based on full medical license will be used.
3. The physician will apply for licensure only in compact states because it is easier to obtain new state
licensure. The physician will use a checklist for the interstate compact to become licensed in a different
state from the one originally targeted.
4. The physician will use a generic medical licensing checklist to put required documentation in a cloud
based, securely protected area to facility licensing in any state, then add any state specific
documentation as needed.
4. Brainstorm Options
Evaluate Ways to Apply compliance Tools to the
specific problem
EVALUATION OF BRAINSTORMED OPTIONS
Bad Example: A licensing checklist will solve the problem.
Good Example/Consideration of how the specific action impacts compliance and
corrects the problem
1. The telehealth licensing checklist meets the specific need of becoming licensed for telehealth in
Florida.
2. The full licensure checklist would be more comprehensive and allow for more practice privileges
but may be burdensome to provide telehealth services.
3. Licensure in compact states is easier, but doesn’t meet the targeted objective of the physician’s
desired goal.
4. The use of a cloud based, securely protected generic medical licensing checklist with supporting
documentation would facilitate licensure in any state in the future. While not specific to the goal
of telehealth, it would be a good long range option.
4. Brainstorm Options
Evaluate Ways to Apply compliance Tools to the
specific problem
Questions to Ask/Brainstorming
How can I apply the compliance tool to correct this specific problem?
How can I apply specific components of the compliance tool to the specific problem?
What creative solutions can I come up with to resolve this problem based on the compliance
tool?
What can I do to address the root cause of the problem? How can I ensure long term solutions?
Questions to Ask/Evaluation
Is this option doable? Is it something that I as a manager can do or recommend?
Which options are the best solutions? Why?
Which option should be done first? Why?
What else needs to happen for this option to work? How do I do it?
5. Choose the Best Managerial Actions for
compliance
Make your recommendation based on your evaluation of the best options that would
work to resolve the specific problem.
Bad Example: Use a licensing checklist to meet licensing requirements.
There is no statement of what would be included in the tool.
There is no evaluation.
There is no evaluation of how to USE the tool to correct the problem.
The managerial tool is not applied in a specific way to resolve the problem.
There is no correction of a specific problem.
There are no reasons of why this would be the best tool.
5. Choose the Best Managerial Actions for
compliance
Good Example:
My recommendation is to first of all develop a telehealth registration checklist specific to Florida telehealth registration
requirements which would ensure that Florida telehealth requirements are met. This tool will be evaluated based on Florida
law and updated annually to ensure continued compliance with Florida telehealth registration requirements going forward.
In gathering information to support the Florida telehealth registration, the information will be saved in a cloud based secure
spot for use should further licensing in other states be needed. This information will be supplemented as needed with the
goal of having complete information to support new licensing on the cloud within one year of the Florida application. This
serves the long term goal of being able to efficiently meet licensing requirements in a new state.
5. Choose the Best Managerial Actions for
Compliance
Why this is good
The recommendation states specific actions to correct the specific problem. It is linked to the problem.
The recommendation is linked to the Compliance tool and adapts a licensing checklist tool to the specific need.
The recommendation states specific actions to take to correct the specific problem. It combines actions to create
a robust plan to correct the problem.
The recommendations focuses on long term solutions by improving the process for licensure which can be a
recurrent need.
The actions demonstrate understanding of the problem, the law, the compliance tool, and demonstrate
evaluation of ways to correct the problem to come up with a strong solution to the specific problem in a way that
complies with the law.
The solution sets priorities of what to do first and second.
6. Support the action plan with strong
reasons
Give reasons to justify your recommendation.
Tip: Your boss will want to know why you suggested what you did.
Bad Example: The licensing checklist solves the problem.
There is not specific reason why this specific action was taken.
It does not clearly link the solution to the specific problem.
It does not provide reasons to support specific actions.
It does not state why this was the most important action to take.
6. Support the action plan with strong
reasons
Good example:
These actions were the best actions to take because a telehealth registration checklist is
specific to the desired goal of providing telehealth services in Florida. In this case, a
general licensing checklist will be adapted to meet the registration requirements to
provide telehealth services in Florida. The cloud based secure storage of licensing
documentation provides a long term solution to facilitate and expedite any future
licensing needs.
Why this is a good example:
It states how it corrects the specific problem.
It states how it uses the compliance tool.
It states how it complies with the law.
It states how this is a long term solution for something that may be a recurrent need.
What NOT to Do
Don’t simply summarize information about the law and compliance tools
Don’t base conclusions on your opinion. Your opinion might violate the law
Don’t state conclusions without talking about the problem and the law and compliance
and risk management tools
Don’t state “comply with the law” as a solution. This is too general.
Don’t be general. Problem solving and legal compliance must be specific.
Don’t state conclusions without supporting reasons
You should be able to defend your recommendations to a health care executive
Be Strategic in Doing Coursework
Use textbook readings as a foundation to understand the law
Do the reading with the purpose of answering discussion or assignment questions
Use the Classroom Law Library resources and classroom links.
Resources are provided so that your time can primarily be spent on evaluation and analysis
Look for innovative solutions
Remember the ability to resolve problems in ways that comply with the law by applying
compliance and risk management tools is what makes you promotable!
The course is set up to give you experience to evaluate real life problems you will face as a
manager and opportunities to apply risk management and compliance tools to solve these
problems
The course goal is for you to be empowered with skills and tools to solve real world problems
and comply with the law as a health care manager.
Final Tips
Learning to understand problems, the law, and how to use compliance tools can be hard.
Evaluating and applying the law and tools to correct specific problems can be hard. This
is why people who can do this are highly paid!
Expect it to be hard. Keep practicing and it will get easier. When you are able to do this
well, you will be the one who is promotable and highly paid.
Don’t just state conclusions. Write out the steps to evaluate things.
Remember, there isn’t one right way to solve a problem. There are lots of ways. Look for
creative ways to solve problems by using compliance and risk management tools.
If you have questions – ASK!
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